Jco 1976

JANUARY 1976, VOL.
10 / ISSUE 1
THE EDITOR'S CORNER 9

Orthomatic— a computerized approach to managing an orthodontic office 25
Technique Clinic: Direct Bond Maxillary Retainer 43
JCO Interviews: Dr. Jack G. Dale on Serial Extraction 44
Full-Scale Color Transparencies of Cephalometric Tracings 62
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Jan(9 - 9): THE EDITOR'S CORNER
the editor's corner

The start of the Bicentennial Year offers us the opportunity to indulge in some patriotic
sentiment. There has been so much emphasis lately on what is wrong with America, that the youth
of our country may well grow up thinking everything is wrong and nothing is right about it. Most
orthodontists I know are the personification of the American Dream. Most of us were not born to
wealth. Many of us were born to poverty. Yet, all of us were able to achieve a measure of personal,
professional, social and economic accomplishment by dint of the inheritance of sound minds and
bodies, by sacrifice on the part of our families and ourselves and by plain hard work.
This formula may not be available to everyone, but to everyone to whom it is available, the
American Dream still lives and no one knows it better than we. So, what an unparalleled opportunity
for orthodontists on the occasion of a year-long celebration of this country's bicentennial, to
influence young people about the good things in America. Let us communicate our thoughts to our
patients and their families using all of the devices with which we are familiar. Some of these things
may become available commercially, but we can also create our own, expressing our own
sentiments. These can be in the form of short messages inserted with bills and other
communications, posters in the office, periodic letters to patients throughout the year, buttons,
tee-shirts, all kinds of ways of expressing the message and stimulating the thought that this is a great
and beautiful country whose citizens have a degree of freedom and an opportunity for health and
happiness unparalleled anywhere in the world.
Article Text 1
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Jan(25 - 42): Orthomatic a computerized approach to managing an orthodontic office
ORTHOMATIC
a computerized approach to managing an
orthodontic office
R. S. CALLENDER, DDS
A doctor's income results from the difference between payment received and office expenses. As
it is with other professions, today's economy is squeezing the orthodontist's income. Practice
percentages used to be 30% overhead, 70% profit. The conditions are now reversing toward 70%
overhead and 30% profit. In today's economy, information that used to be nice to know, is now
necessary to know.
Previously, it was not necessary to have accurate accounting of overhead expenses. Variations in
overhead made little significance in the doctor's income During the last five years, the cost of
supplies has increased 62% and salaries 68%. Rent has doubled in cost. Delinquencies are
increasing. Nationally, the number of new patient starts in some practices has declined nearly 50%.
Fees have increased only slightly. The inflated dollars of the doctor's income are worth only 40% of
what they were five years ago. There has already been a drastic increase in taxes, and probably more
increases are to come. Clearly, cost accounting is essential to manage an orthodontic practice.
The orthodontist needs to know the gross income of his practice every month and the number of
delinquent accounts properly aged in 30, 60, 90 and 120 days or more. It is necessary to know
overhead expenses and have these divided into proper categories. How much is spent on salaries,
fringe benefits, office space, equipment, supplies, and taxes? What is the net income? It is important
to know the referring doctors and how many patients they refer. A good recall system is essential to
avoid the loss of future patients because of failure to reevaluate them during the growth and wait
period. The doctor should have all this information on a month and year-to-date basis.
The number one cost is the doctor, number two is the auxiliary personnel, number three is
facilities, number four is supplies. The cost squeeze is on. Overhead has increased dramatically. The
number of orthodontists graduating each year has increased; there are fewer children born each year;
and economic conditions have reduced the number of patients seeking treatment. Competition is
making it hard to raise fees, and it may not be possible to increase patient load much because
doctors are all competing for the same patients. In response, doctors can raise fees, increase their
patient load, or cut costs through efficient operation. The orthodontist can use his time more
effectively by assigning certain tasks to well-trained auxiliaries, and to the lowest salaried auxiliary
who can perform that task in a satisfactory manner.
Orthomatic System
These problems have been recognized and dealt with in a system called Orthomatic. Orthomatic
is a system designed for the orthodontic practice, which I have worked on for over ten years. It is a
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Article Text 1
very thorough system and easy to operate. Easy input is one key. Another is that it is programmed
for variables. Exceptions to the rule immediately become apparent. Who missed an appointment?
Who did not make his payment? Who is falling behind in treatment? Who is not cooperating? All of
the delinquents, the variables, and the changes are identified on reports each month. All of the
transactions in the treatment and bookkeeping areas are reported, and are available for checking.
The reporting of the exceptions versus normal point out the things that need special attention to keep
the practice functioning effectively and efficiently. The cost of Orthomatic is at the bottom of the
cost hierarchy of wages, facilities, equipment, supplies, and materials.
In many instances, the practice runs the doctor. The Orthomatic System puts the orthodontist in
control of his practice. It provides a complete accounts receivable system, a general ledger system, a
practice promotion system, and a patient monitoring system based on the treatment cycle.
Treatment Cycle
In order to understand my practice. I have found it necessary to outline patient care into a
treatment cycle (Fig. 1). The Orthomatic System is based on this patient treatment cycle. From the
time a patient enters the office for the initial examination until they terminate retention, their
progress is monitored. The treatment cycle includes eight steps referred to as status: 1. examination,
2. pre-treatment records, 3. diagnosis, 4. instructions, 5. active treatment, 6. retention, 7.
post-treatment evaluation, and 8. termination. At any status in the treatment cycle, a patient may
progress in one of three directions. He may progress to the next status, he may be placed in recall, or
he may be terminated.
By utilizing the treatment cycle, we are able to identify the number of patients in each step;
personnel are able to utilize our recall system more effectively; and personnel are more able to
increase the efficiency throughout the office by keeping everyone informed. The office has the
ability to monitor all patients from the time of the first appointment until retention is completed.
This can be done for single or multiple doctor practices and multiple offices. Orthomatic can
organize the information about a practice so that you know who, where, when, why, how long, and
how much.
Patient Master Record.
Basic information is contained in the Patient Master Record. It includes names, addresses,
telephone numbers, responsible party, dentist, insurance, banking, the eight steps in the treatment
cycle, the length of projected active treatment and retention, progress reports required, contract
information (the terms are flexible so that any method of payment can be utilized — monthly,
quarterly, semi-annually, annually, balloon), date of last payment, date of last treatment, recall,
payments to date, and unpaid balance. If desired, a bank draft can be prepared. All this basic
information needed on a day-to-day basis in any practice is now easily accessible to everyone in the
office on microfilm or in computer language, microfiche (Fig. 2).
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Article Text 2
Treatment Slip
The treatment slip (Fig. 3) is an important input document, it is individualized for each doctor's
practice. Each practice determines what it will need out of the computer and establishes the
treatment steps and the codes they will use. The treatment slip has been organized and segmented so
that it can be used to report any information that might occur on a patient from the first visit to the
last. It follows the treatment cycle and records bookkeeping, communication, termination, recall, lab
information, and treatment procedures. The form is designed to enter information simply by drawing
a line through the appropriate description of treatment and code number. Also, it has the ability to
determine a charge or no charge on a particular service. Example: If an x-ray is to be charged for, a
line is drawn through 2223 on the treatment slip. If it is included in the contract, the same x-ray
would be marked with a line drawn through 2224 on the treatment slip which would indicate no
charge. This information will automatically be posted on the patient's history and will generate a
statement at the end of the month. Maintenance fees or special charges such as a broken retainer are
recorded in the same manner. Work has been significantly reduced in keeping up with the records
keeping and clerical needs with a heavy patient load on a given day. If the number of patient days
per month is multiplied times the data accumulated, there is a great deal of information to control
and organize to produce accurate reports at the end of the month. The treatment slip is the way this
is done.
The top portion of the treatment slip is an optional tear-off appointment slip. In my practice, the
next appointment is controlled in the operatory. The number of units and the time interval for the
next appointment are indicated. When the treatment slip arrives at the front desk, the receptionist
enters the appointment in the appointment book, tears off the top slip and gives it to the patient. The
slip tells parents when the next appointment is and notes any special charges that might have been
incurred at that visit.
The treatment slip permits monitoring of a great deal of information. It does this by recording
each procedure performed for the patient and is reported on the Analysis of Services Rendered
report. The doctor may want to know how many missed appointments occurred in any time interval
by office. By recording each time it occurs, the computer picks up and stores the information.
The Flow Analysis Report identifies the number of patients who are starting and finishing from
each status on the treatment cycle monthly and year-to-date. It tracks all exceptions and reports a
complete accounting of all patients within the practice. The Analysis of Services Rendered Report is
helpful in scheduling the number of patient days needed per month, and the required inventory of
archwires, bands, and supplies needed. This may also provide insight as to the number of auxiliaries
needed, and the amount of office space and equipment required.
Practice Promotion
The Patient Source Analysis Report is particularly valuable. It lists the referring party, who may
be the family dentist, shows the date of first referral, date of last referral, and the number of patients
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Article Text 3
referred during the month and year to date. The patients are listed alphabetically showing the date of
last treatment, status, office visited, date treatment was initiated, and projected completion date.
With this information, the orthodontist is better able to communicate with the dentist.
Recall
Orthomatic provides an excellent recall system. It prepares a monthly list of patients who need to
be reviewed. Various reasons are identified for recall and might include: financial problems,
treatment progress, growth evaluation, eruption of teeth, parent consultations, retainer adjustments,
palatal expansion appliance, cuspid retraction, and records for study cases. The doctor might want to
see one patient for tongue thrust or toothbrushing in one month and every three months thereafter, or
another patient in six months or twelve months for extraction. The information is stored in the
computer and in the time interval desired it will list all the patients wanted to be seen during the
month and for what reason.
One of my auxiliaries has stated it well. She said that Orthomatic has taken over her busy work,
eliminating much detail work that she used to do manually. The program remembers and notifies her
when appropriate action should be taken. The computer prepares the working reports. She can now
spend her time usefully resolving problems.
Patient Information
The Patient Master Record and the Patient History, appear on micro fiche each month for easy
access and viewing. The rest of the reports are printed on paper as working lists. Instead of large
volumes of paper, each microfiche contains the master records or patient histories of over 400
patients. All reports and microfiche are updated monthly and can easily be compared to last month's
reports for action taken. The December microfiche has all the information needed to store for that
year with regard to taxes and records. The records on the disc in the computer center are a backup in
the event that fire or vandals destroy the records in your office. This can be very important with
regard to accounts receivable and financial information.
The master record may change every month. Perhaps there will be a change of address or
responsible party. Information from the treatment slip or master record change is incorporated into
the new master record on microfiche each month. An entry of what happened on a particular date,
the treatment slip number, and the doctor are identified. As payment are made, they are recorded as
credits and the reduced balance is shown on the new microfiche which is delivered monthly.
Bookkeeping
The Patient History maintains financial and treatment information. Orthomatic takes the ledger
card out of the hands of the bookkeeper. It is no longer necessary for her to post credits as they
come in and do the adding and subtracting on the ledger card. Another benefit is that no one has to
remember that a charge was to be made and the amount, since the charges are built into the tables of
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Article Text 4
information on the treatment slip. Posting cash is simple. All that is required is the name of the
patient, the type of patient, the patient's number, and the amount of the payment. This becomes a
deposit slip that goes to the bank. A copy comes to the computer for posting to each individual
record. Accurate and up-to-date financial information is maintained on each patient. Accurate
statements can be generated automatically each month if desired.
For the general ledger system, the computer is sent a summary of who was paid, when they were
paid, check number, numbers of hours they worked and the rate, various tax deductions and net pay.
The employee receives a check and a stub. The bookkeeper receives a non-negotiable file copy for
her records. The ledger system utilizes a preprinted check (Fig. 4).
The same check form is used for accounts payable. The prenumbered check states the date,
supplier, and the amount. The stub on top is coded to the proper ledger account. An up-to-date
general ledger is maintained. The check and lower stub with description go to the vendor. A file
copy is retained by the bookkeeper and the data processing copy is sent to the computer. Orthomatic
has relieved the bookkeeper from the multiple steps required by the old manual system of preparing
the general ledger, balance sheet, journal, and profit and loss statement. In the manual system, there
are sixteen steps: write the check; post it to a journal; foot the journal; crossfoot the journal and
balance it; take off a balance sheet and type it up; pull off a consolidated profit and loss statement;
check that; make profit and loss statements for each department; and then reconcile the entire ledger
system. Orthomatic has reduced the sixteen steps to one. This has lessened the possibility of error
and the need to track down mistakes and correct them. It has reduced the manual bookkeeping effort
by 80%.
This does not mean that errors may never occur with the computer. We are dealing with human
input. But, there are controls to guard against error. Orthomatic prints an itemized listing of all the
entries. This is a proof list. An edit run is made on the computer which gives a summary of the cash
receipts and charges. These totals are balanced in the computer against the daily deposit totals and
charges kept on a daily list in the office. If there are any treatment slips that are not entered, they are
listed in a report which, by putting them in numerical sequence, indicates which ones are missing.
They might be voided, missing, or not entered into the computer.
Statements
In my practice, Orthomatic prepares a statement if one of two situation exists. If there is a

delinquent balance (it also appears on the delinquency report) or if there have been any new charges
(other than contract amounts, such as special charges, maintenance fees, late charges, and computer
generated charges). Parents need to be notified if charges over and above their contract are incurred.
Statements can be p re pa red each month for all patients if desired. They can be prepared and sent
automatically. The statement lists in sentence form the reason for the charge. This saves many phone
calls (Fig. 5).
In December, upon request, statements can be prepared on all patients, notifying them of what
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Article Text 5
they have paid for the year for income tax purposes. This service also saves phone calls and
improves public relations between practice and parent.
Additional Reports
From the input of the treatment slips, an Analysis of Services Rendered Report is prepared which
monitors each of the treatment codes monthly and counts the number performed. This can be
valuable for the doctor to analyze the treatment procedures. For example, if there is continual
breakage with a particular headgear, change in design or manufacturer may be considered .
The Delinquency Report shows the patient, his status and the delinquent amount. This system,
unlike most other computer systems, has an aging report by 30, 60, 90, and 120 days delinquent. The
amount of the contract, delinquent amount, and unpaid balance are indicated. It also may indicate a
financial consultation is needed. This report is easy to work with. When the bookkeeper receives it,
all the preparative work is done. She can start on collections without spending several days in
preparation.
A report is generated if a patient is no longer on active treatment, but has a balance. This is a high
priority collection list. A report is also generated if a patient is still in active treatment, but has a
zero balance.
Some of the other reports are: Problem Patient Report; Not Treated in the Last 60 Days; and
Gross Income by Office. The Patients Whose Status is Unchanged or Skipped Report is worked with
extensively. It allows the office to keep a more constant flow of patients through the eight steps of
the treatment cycle. Non-start patients have been dramatically reduced because they are followed
after their examination. A norm of months is set by the practice for each step in the treatment cycle
and that schedule should be maintained. Patients need consistent care and should progress from step
to step on schedule. Orthomatic provides a monthly report of patients who stay in a treatment status
longer than prescribed or who skip a status In most practices, the work overload is in the active
treatment stage because cases are not finished on time. A high percentage of problems result from a
small percentage of patients. If problems can be solved when they're small, the patients more closely
follow their treatment plan. The Problem Patient Report provides a list of patients who are having
difficulty following the prescribed treatment plan Consultation with the parents and patients may
resolve the problems. Projected active treatment completion and retention completion dates are part
of the treatment plan. If patients remain in these statuses longer than projected, they are listed on a
report.
Active Treatment Completed report is also maintained. It is used to maintain office order by
clearing files of patients that have changed status. It also allows communication with patients,
parents, and their dentists that active treatment is complete.
Reviewed each month are: total monthly contracts, special charges that have been added,
payments made and any adjustments, plus the total unpaid balance or deferred receivables. Each
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month the doctor has a current and accurate financial accounting of his practice.
Advantages of Computer
People, especially extroverts, don't like to do mundane and repetitive chores. They don't usually
do them well. A properly programmed computer does such tasks over and over in the same way with
uniform control systems and uniform mechanics of administration. We should not be using our
personnel in place of machines. We should let the machines do what they are designed for and allow
people to treat people. Computers handle data computation information 100,000 times or more as
fast as people.
Maintaining the longevity of personnel is a problem for orthodontists The loss of personnel
places an added burden on the staff to train new staff members. The Orthomatic System standardizes
office procedures. It establishes continuity of office administration. Computers do not get sick, take
vacations, or get pregnant. Orthomatic does not go to sleep; it works night and day the year around.
Many orthodontists base their fees on a projection of treatment time which is generally optimistic.
In most practices, there is a hangover of patients who continue treatment months past their projected
finish date. Orthomatic helps the doctor make reasonable treatment projections and keeps patients
on their treatment schedule.
Some practice locations provide an inadequate number of patients to fill a doctor's practice. It
may be necessary to have an additional office. The management of a multiple office practice is
somewhat different than one orthodontist in one office with two or three auxiliaries. The
computerized Orthomatic System is excellent for the management of this type of practice.
The Orthomatic System was designed to be responsibility oriented, to give each person in the
office the information he or she needs to know. It was designed for easy input, even by untrained
personnel. It was also designed with enough flexibility to adapt the treatment cycle to any
orthodontic office Orthomatic eliminates many manual operations and automates what can be
automated.
It is a well known fact that one half of all clerical work involves file maintenance. Several
different files were compiled into the Patient Master Record. Much time is saved in using the
microfiche for easy access to information instead of pulling and refiling charts.
Doctor's lnvolvement With Reports
I am asked how much involvement I have with the various reports that are generated, and what
consequences I expect them to produce in my practice. I am interested in all the reports, but many of
them I just look over after they have been worked by auxiliaries.
I have multiple offices and I want to know what the income is for the different offices, the totals
per office, the contract amounts, special charges to date, adjustments, payments to date, and balance
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I am interested in bookkeeping adjustments and what they are for. Inventory and scheduling
improvements can be obtained from the reports I read the emergency list. It is divided into types of
problems. This list often helps me to improve my treatment technique by avoiding procedures that
result in emergencies I changed the headgear design because of increased breakage I keep track of
the new patient starts per month and year-to-date. I want to know how many of the various treatment
procedures are done each month. This provides me with a good flow pattern of the work load. I may
change technique or methods as indicated by the reports.
I want to know how many patients I see in all categories, the number of appointments, bandings,
retention patients, archwire changes and what kinds. All of this relates to patient flow and
scheduling. Active Treatment Completed With An Unpaid Balance is a high priority collection list.
Also, bankruptcy and divorce cases fall in this category. Of course I am very interested in referrals. I
want to know who is sending patients, when, and how many. The patient referral report lists by
doctor the number of patients he has referred by month and year to date.
I review delinquency reports and accounts 30 days past due with my bookkeeper after she has
worked the list. I have to decide what to do about some of these problems; especially if there has
been no response.
I don't have to concern myself with progress reports; these are handled by the assigned staff
member. I glance at the report to see that it is being worked. Occasionally, I may have a question.
As much as I can, I let the patient coordinator do the progress report consultations. I am available,
when it is necessary. The Problem Patient report is especially important. If we can reduce our
treatment problems, we reduce our total effort. The patient coordinator handles the problem patient
area. She sets up the consultations and schedules her time for them. If necessary, she will schedule
my time for this and prepares me if I am involved.
Patients Not Seen for 60 Days is a report I want to see. Some of these may be on suspension due
to lengthy recall, transfer or completion. This helps with filing patient charts and models. We
reduced our files significantly when we went on Orthomatic.
Being aware of upcoming band removals, 30, 60, 90 days in advance, helps scheduling and I can
work on finishing touches in treatment. Delinquent accounts can be arranged to be paid by the time
of band removal. On Patients Beyond Projected Finishing Date, I want to identify the reason so a
decision can be made. If it is because of non-cooperation, I will probably have a consultation to
discuss a maintenance fee. This was covered in the payment arrangements before treatment was
started. The patient may have been on suspension, waiting for growth, which would alter the
projected finish date. In that case, I would not charge them. I make a concerted effort to get these
patients finished and off this list. I want to identify the reason for missing the projections. If it is my
miscalculation, I may not be meeting my projections. I may want to re-evaluate my diagnosis and
treatment planning.
The No Charge Patient list calls my attention to what I am giving away. Of course, this includes
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children of referring dentists.
I am concerned with Unchanged and Skipped patients. It is important not to lose track of these
patients. If I see too many in this category, it means our consistency of service needs improvement.
They have to go some place from this list. We may terminate, recall, wait for growth, or suspend.
They can't sit here. I am especially concerned about status three, the diagnosis. They are making up
their minds about starting treatment. We don't want too many people waiting there. We want a
smooth transition from examination, pretreatment records, diagnosis, instructions, to active
treatment. This is the key report for reducing non-starts.
I am also interested in the bookkeeper's reports. I look over the journals and the accounts. I'm
interested in the profit and loss statement and spend some time reviewing and considering this
information. It is used in financial planning projections, short term and long term; next month, next
year, equipment, purchases, and salary increases, etc. Orthodontists are in a cost-price squeeze. I
like to know what my expenses are, both the dollar amounts and the percentage of gross income. I
like to see the practice trends.
ORTHOMATIC REPORTS BY APPLICATION
Patient Coordination Treatment
Patients Whose Status is Unchanged or Patients Whose Status is Unchanged or
Skipped Skipped
Patient Flow Analysis Patient Flow Analysis
Treatment History ton microfilm) Patients Not Treated in Last 60 Days
Patient Progress Report Follow-Ups Patients Under Treatment Who Have Paid in
Full
Patients Recall Treatment Follow-Ups Patients Beyond Projected Treatment Time
Problem Patients Upcoming Band Removals
Patients Without Post-Treatment Evaluation Active Treatment Complete, Balance Due
Transfers Out Patients Beyond Projected Retention
Referrals Finished Retention, Balance Due
Analysis of Services Rendered Delinquency Reports
Delinquencies Analysis of Services Rendered
Master Files (on fiche) Termination Report
Master File (on microfilm)
Doctor
Patient Flow Analysis
Analysis of Services Rendered
Bookkeeping Referrals Source Analysis
Balance Over $10, Active Treatment Termination Reports
Completed
Delinquent Reports Transfers Out
Statements (prepared by computer) Beyond Projected Active Treatment Time
Third Party Payments Patients Beyond Projected Retention
Finished Retention, Balance Due Delinquency Report
Patients Under Contract, Paid in Full Balance Over $10, Active Treatment
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Completed
Treatment History (fiche) General Ledger
General Ledger Balance Sheet
Balance Sheet Profit and Loss Statement
Profit and Loss Statement Patients Who Status is Unchanged or Skipped
Termination Report Gross Income per Office
Master Files (fiche) Recall Projections
Need to Know Information
The orthodontist has the hazard of making at least two-year fee arrangements in an inflating
economy with built-in overhead increases. If he misses his treatment projections, he is frequently
not being paid for the extra time and effort. Thorough examination of the overhead expenses helps
to increase awareness of what costs really are. If the orthodontist does not have extensive practice
information, he cannot make reasonable, practical decisions. This is especially needed now with the
uncertain economy. Orthomatic gives extensive practice information monthly and year-to-date.
Salaries continue to contribute to the cost-profit squeeze. Salaries are the number one cost
consideration of overhead. We either become less profitable or help our auxiliaries to become more
efficient. Orthomatic allows our staff to reduce effort and maintain high quality service.
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The purpose of efficiency is not just profits, but better treatment of patients. The percentage of
extended treatment cases is high in many practices. The cost-income ratio becomes more and more
unbalanced. Many orthodontists have not examined this aspect of their practice realistically. The
question is how much longer they can continue to be inadequately informed and still give high
quality patient treatment and make a living. Apathy and complacency may be the biggest problems
that some orthodontists have. If the orthodontist had a system like Orthomatic, he would not have to
wonder what his alternatives were when he reached a point where his net was down, his expenses
up, his starts declining, and his living expenses up. These problems are to become even more critical
as the cost-profit squeeze accelerates.
If the practice gross income is the same and overhead is increased, there will be less net income.
Next year the doctor may find that his net is 20% less, but meantime his standard of living is at the
upper level to which he has become accustomed. He won't necessarily net this year what he did last
year. As a matter of fact, the whole economic picture is working against his doing that. If he builds
increased cost expectancy into his considerations, he can make more useful judgments. Poor
information leads to poor decisions. Good information leads to good decisions. A comparison of the
profit and loss statement would be one way of knowing cost trends. Treatment trends and case load
can be identified from the Patient Flow Analysis Report.
Many orthodontists don't know what their case load is. They don't know the numbers of cases
they are starting and finishing. They don't know how long treatment is actually taking. They borrow
money to pay their taxes. They've been successful in a can't lose situation. That may be different
now.
Many orthodontists who have recognized the need for more patient and practice information have
not been able to accumulate the data manually. The manual method is expensive and the accuracy is
questionable. They wind up without the information, or they use consultants to help them fill in the
information deficiency, which is a partial solution.
There was a time when only large practices, which had these problems, were interested in this
kind of a system. All practices, large and small, are now confronted with these problems. In fact, in
a small practice the situation is even worse. The practice is not large enough to have a bookkeeper,
to have someone in charge of the operatory and someone in charge of patient flow and reception
area. With Orthomatic the practice effectiveness is ex tended, comparable to that of a large staff.
The system gives a small practice controls that no small practice can afford to be without.
A young man recently graduated can avoid practice problems that others have experienced by
adopting Orthomatic from the start. It is inexpensive compared to the cost of auxiliaries. It is easy to
organize a new practice with the help of Orthomatic. In the average-size practice, the cost of
Orthomatic's services is approximately one-half the cost of one auxiliary.
Giving the doctor the information he needs makes him a better orthodontist and a better
businessman. He can spend more time in the operatory and less time worrying about the things that
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detract from his professional involvements. His staff can operate more efficiently as a team and they
can concentrate on the one thing that is most important, the care and treatment of the patient.
Advantages of Orthomatic
• Non-start patients have been reduced; they are followed after the examination.
• It is highly effective and low in cost.
• Useful for both single or multiple doctor practices and satellite offices.
• The total patient load is reported in the treatment cycle monthly.
• The training of new staff members is simplified.
• Increases doctor awareness of overhead costs and income.
• Significantly reduces bookkeeping effort.
• An excellent recall system.
• Communications between the office, parents, and patients are improved.
• Patient problems are identified so they can be corrected.
• Treatment time is reduced by keeping patients on their treatment plan.
• Reduces patient files into one master record .
• Identifies specific emergency problems.
• Inventory control is improved.
• It gives accurate data to make good decisions.
• Files are uncluttered.
• It provides accurate and more consistent records.
• Places doctor in control of his practice.
• Delinquencies are aged.
• A high priority collection list is provided .
• Identifies income for multiple offices.
• Practice building.
• No charge patients are listed.
• Prepares profit and loss statement.
• Aids in scheduling.
• Busy work is reduced, saves time.
• Helps assure that accounts are paid by the time of band removal.
• Cost control of laboratory procedures.
• Projections are more accurate.
• Cost accounting is possible.
• Reduces lost patient information.
• Financial records, master records, and patient history are available on microfilm.
• Disciplines the office record keeping.
Orthomatic
Practice Management Systems, Inc. 7280 North Irving

Street, Westminster, Colorado 80030 (303) 429-7356.
36
Footnotes 12
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume Jan
FIGURES
Fig. 1
Fig. 1 Treatment cycle. At any status in the treatment cycle a patient may progress in one of three directions. He may
progress to the next status, he may be placed on recall, or he may be terminated.
37
Figures 13
Fig. 2
Fig. 2 Patient Master Record microfiche and image of individual record on microfiche reader. One fiche holds over 400
patient master records.
38
Figures 14
Fig. 3
Fig. 3 Treatment slip.
39
Figures 15
Fig. 4
Fig. 4 Preprinted check.
40
Figures 16
Fig. 5
Fig. 5 Sample statement.
41
Figures 17
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Jan(43 - 43): Technique Clinic: Direct Bond Maxillary Retainer
technique clinic
A DIRECT BOND MAXILLARY RETAINER
BARRY M. RUBENSTEIN, DDS
To fabricate a direct bond maxillary retainer, an .030 or an .036 round wire is contoured to extend
to the distal interproximal embrasures of the maxillary cuspids. The wire is then bonded directly to
the buccal surfaces of the cuspids.
I have used the Caulk Nuva-Seal/Nuva-Tach System or Orthomite IIS, and have had equally good
success with both.
If minor interproximal spacing exists after debanding, a 5/8" elastic (3.5 ounce) is worn from the
distal extension of one end to the distal extension of the other across the labial surface of the upper
anterior teeth.
The spaces close shortly. The patient should be checked at seven to ten day intervals while the
anterior elastic is worn to prevent mesial slippage of the maxillary cuspids.
In the case shown, the direct bond maxillary retainer had been in place for four months.
43
Article Text 1
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Jan(44 - 60): JCO Interviews: Dr. Jack G. Dale on Serial Extraction
jco/interviews
DR. JACK G. DALE on Serial Extraction
DR. BRANDT Serial extraction has been criticized lately as a bad procedure. Can it do more
harm than good?
DR. DALE Serial extraction can be a bad procedure and it can do more harm than good if it is not
done properly (Fig. 1). In my practice, based on a thorough diagnosis and carried out on a selected
group of patients, I feel that it is an excellent and valuable procedure (Figs. 2 and 3).
The principle of early treatment, associated with the extraction of primary teeth followed by the
removal of permanent teeth, has stood the test of time. Kjellgren's catchy term "serial extraction" has
caught on. However, I feel that the term "serial extraction" is dangerous because it oversimplifies
and is, in fact, misleading. It implies that there is no more involved than the mere extraction of teeth.
I prefer Hotz's term "guidance of eruption," or possibly "guidance of occlusion." These terms are
comprehensive and encompass all the measures available for influencing tooth eruption into a
favorable occlusion. It suggests that a thorough knowledge of anatomy, growth and development,
and neuromuscular physiology is required to make a number of key decisions throughout the
developmental period (Fig. 4).
DR. BRANDT Is there any validity to waiting for growth to increase arch length as a substitute
for serial extraction?
DR. DALE This may be possible. However, scientific evidence indicates that the reverse is true.
It has been known for some time that the posterior teeth are moving forward throughout life, which
would tend to reduce arch length. Moorrees has established that arch length decreases 2-3mm from
ten to fourteen years of age, when the primary molars are being replaced by the permanent
premolars (Fig. 5).
DeKock measured a ten percent decrease in arch depth for males and a nine percent decrease for
females over a period of ten years, between the ages of twelve and twenty-six (Fig. 6).
Brodie has observed that the tongue of the newborn infant tends to fill the oral cavity and often
encroaches on the alveolar ridge area. As a consequence of the more rapid anterior growth of the
jaws in the postnatal period, the tongue lags behind and comes to occupy a relatively more posterior
position in the central portion of the mouth. This is consistent with the uprighting of the incisors that
occurs in many adolescents as noted by Enlow (Fig. 7), Bjork (Fig. 8), Tweed and others. These
findings suggest that facial growth in the anterior direction continues into adulthood, thrusting the
mandible into the facial musculature and producing a posterior force vector on the crowns of the
incisors. Thus, arch length decreases from the anterior as well as the posterior.
44
Article Text 1
DR. BRANDT Can you describe just how that occurs?
DR. DALE In patients with a spaced primary dentition and a straight terminal plane relationship
of the primary second molars, the permanent mandibular first molars emerge at approximately six
years of age, move the primary molars mesially, close the space distal to the primary cuspids,
convert the straight terminal plane to a mesial step relationship, reduce arch length in the mandibular
dentition, and allow the permanent maxillary molars to emerge into a Class I relationship. This has
been referred to as the early mesial shift (Fig. 9).
In patients with a closed primary dentition and a straight terminal plane, the permanent maxillary
and mandibular first molars emerge into a cusp-to-cusp relationship simply because there are no
spaces to close. At approximately eleven years of age, the primary mandibular second molars are
exfoliated and the permanent mandibular first molars migrate mesially into the excess leeway space
provided by the difference in the mesiodistal dimensions of the primary second molars and the
permanent second premolar teeth. This, again, reduces arch length, converts the straight terminal
plane to a mesial step, and provides for a Class I relationship of the permanent first molars. This has
been referred to as the late mesial shift (Fig. 10) and is substantiated by the investigations of
Moorrees.
DR. BRANDT How do you present serial extraction to patients and parents?
DR. DALE Three appointments are scheduled in my practice prior to the beginning of treatment.
The first appointment is an examination and consultation. During this appointment we determine
whether a malocclusion exists and, if so, we familiarize the parents with orthodontic treatment
explaining, in general terms, the tentative diagnosis, possible treatment, time involved, cost of
orthodontic care, and the need for diagnostic records and a case presentation.
During the second appointment, we take a complete set of diagnostic records including study
models, a complete series of periapical radiograms, cephalometric radiograms, black and white
facial photographs, and color slides of the dentition. These records are thoroughly studied and
analyzed in preparation for the case presentation.
The third appointment is the case presentation which includes a detailed description of all aspects
of the patient's treatment with the aid of the diagnostic records. Both the parents and the child are
present in the business office. I outline the etiology, diagnosis, treatment plan, and prognosis. I
explain how growth and development of the jaws takes place and that this growth does not provide
for an increase in arch length. I describe serial extraction as a procedure which has been in existence
for over two hundred years and which is based on the fact that arch length does not increase. I find
case presentation is one of the most valuable, most rewarding and most enjoyable appointments that
I schedule throughout treatment. It creates better understanding, reduces misconception, ensures
better cooperation and, in general, provides a smoother, more enjoyable treatment period. It is one
of the most important things that I do in my practice to promote favorable public relations.
Following the case presentation, a written report is forwarded to the parents.
45
Article Text 2
DR. BRANDT What cephalometric measurements do you use?
DR. DALE I routinely use the Steiner and the Tweed Cephalometric Analyses, and the Merrifield
Soft Tissue Analysis.
DR. BRANDT Would you describe the significant highlights of each of these?
DR. DALE In the Steiner Analysis (Fig. 11) the SNA angle indicates whether the maxilla is
prognathic, orthognathic, or retrognathic. The ANB angle indicates the relationship between the
maxilla and the mandible. The maxillary incisor to NA indicates the relationship between the
maxillary dentition and the maxilla. The mandibular incisor to NB indicates the relationship
between the mandibular dentition and the mandible. This is particularly important when extractions
are being contemplated. The mandibular plane to SN indicates a high angle or a low angle facial
configuration. The occlusal plane to SN provides a valuable reference for treatment progress. Every
effort is made to avoid tipping the occlusal plane forward by extruding mandibular molars or
intruding and "dumping" mandibular incisors forward. The Steiner Analysis, with its logical
sequence of measurements, is particularly useful in the discussion with parents during case
presentation, and for other teaching purposes.
In the Tweed Analysis (Fig. 12) the FMA angle indicates a high angle or a low angle facial
pattern. The IMPA and the FMIA indicate the position of the mandibular incisors. The measurement
of these angles in essential for me in the determination of the extraction of permanent teeth.
In the Merrifield Soft Tissue Analysis (Fig. 12) the measurement of the Z angle assist in the
assessment of the soft tissue profile.
DR. BRANDT Please describe how you use these analyses.
DR. DALE I use them to help me classify the face into fifteen categories: one standard, twelve
horizontal and two vertical.
STANDARD
The standard or ORTHOGNATHIC face ( Fig. 11) exhibits a harmonious relationship between
the facial structures and the cranium, between the maxilla and the mandible, between the maxilla
and the maxillary dentition, between the mandible and the mandibular dentition, between the
maxillary dentition and the mandibular dentition, and between the soft tissue profile and the
underlying hard tissue structures. Utilizing the Steiner Analysis, SNA approximates 82°, SNB 80°,
ANB 2°, the maxillary incisors to NA 22° and 4mm the mandibular incisors to NB 25° and 4mm,
occlusal plane to SN 14°, mandibular plane to SN 32°. The Z angle of the Merrifield Soft Tissue
Analysis approximates 80°. The teeth are in ideal occlusion.
HORIZONTAL
46
Article Text 3
The twelve categories of the horizontal section are divided into three groups— Class I, II and
III— which are related to the Angle classification.
CLASS I
1. MAXILLARY-MANDIBULAR PROGNATHISM. Both the maxilla and the mandible are
relatively forward. SNA is greater than 82° and SNB is greater than 80°, but the ANB angle
approximates 2° (Fig. 13).
2. MAXILLARY-MANDIBULAR RETROGNATHISM. Both the maxilla and the mandible are
relatively back. SNA is less than 82° and SNB is less than 80°, but the ANB approximates 2° ( Fig.
14).
3. MAXILLARY-MANDIBULAR ALVEOLAR DENTAL PROTRUSION. Both the maxillary and
mandibular dentitions are relatively forward. The maxillary incisor to NA is greater than 22° and
4mm, the mandibular incisor to NB is greater than 25° and 4mm. This facial pattern, in general,
responds well to serial extraction (Fig. 15).
4. MAXILLARY-MANDIBULAR ALVEOLAR DENTAL RETRUSION. Both the maxillary and
mandibular dentitions are relatively back. The maxillary incisor to NA is less than 22° and 4mm, the
mandibular incisor to NB is less than 25° and 4mm. I think very seriously before I conduct a
program of serial extraction in this type of facial configuration, even though it is a Class I
malocclusion (Fig. 16).
The dentition in all four categories exhibits an Angle Class I malocclusion.
CLASS II
1. MAXILLARY PROGNATHISM. The maxilla is relatively forward. The SNA angle is greater
than 82° and ANB is greater than 2° (Fig. 17).
2. MANDIBULAR RETROGNATHISM. The mandible is relatively back. The SNB angle is less
than 80° and ANB is greater than 2° (Fig. 18)
3. MAXILLARY ALVEOLAR DENTAL PROTRUSION. The maxillary dentition is relatively
forward. The maxillary incisor to NA is greater than 22° and 4mm ( Fig. 19).
4. MANDIBULAR ALVEOLAR DENTAL RETRUSION. The mandibular dentition is relatively
back. The mandibular incisor to NB is less than 25° and 4mm (Fig. 20). Again, we would think
seriously before embarking on a serial extraction program in this type of facial pattern.
The dentition in all four categories exhibits an Angle Class II malocclusion. Serious thought
should be given concerning serial extraction in Class II malocclusion. It aids in the correction of a
tooth size-jaw size discrepancy, but not in the correction of the Class II relationship. Therefore, the
clinician must be prepared to place appliances for an extended period of time, as well as extract
primary and permanent teeth. The diagnosis is particularly important, because permanent teeth other
than the four first premolars may be extracted in the treatment of Class II malocclusions.
CLASS III
1. MANDIBULAR PROGNATHISM. The mandible is relatively forward. SNB is greater than 80°
and the ANB angle is less than 2° or negative (Fig. 21). It is possible that this malocclusion would
be treated without extraction of permanent teeth. Often, surgery is indicated.
2. MAXILLARY RETROGNATHISM. The maxilla is relatively back. SNA is less than 82° and the
47
Article Text 4
ANB angle is less than 2° or negative (Fig. 22). Again, it is possible that this malocclusion would be
treated without the extraction of permanent teeth. Quite often, palatal separation and Class III
mechanics are employed.
3. MANDIBULAR ALVEOLAR DENTAL PROTRUSION. The mandibular dentition is relatively
forward. The mandibular incisor to NB is greater than 25° and 4mm (Fig. 23). It is quite possible
that only the mandibular first premolars would be extracted in the treatment of this type of Class III
malocclusion.
4. MAXILLARY ALVEOLAR DENTAL RETRUSION. The maxillary dentition is relatively back.
The maxillary incisor to SN is less than 22° and 4mm (Fig. 24). The treatment of this type of Class
III malocclusion frequently does not require the extraction of permanent teeth. Thus, you can see
that it would be particularly risky, in view of the difference in treatment procedures, to carry out
serial extraction in this type of malocclusion.
The dentition in all four categories exhibits an Angle Class III malocclusion.
VERTICAL
There are two categories in the vertical section of the facial classification— high angle and low
angle.
HIGH ANGLE (Hyperdivergent)
This facial pattern always includes a steep mandibular plane and is usually associated with a
retrognathic mandible, a maxillary-mandibular alveolar dental protrusion, an open bite relationship
of the incisor teeth, an open bite relationship of the incisor teeth, an incompetent lip relationship,
and a flattened chin exhibiting muscle tension. Cephalometrically, the mandibular plane to SN angle
is greater than 32° if you are utilizing the Steiner Analysis, or the FMA angle is greater than 25° if
you are utilizing the Tweed Analysis ( Fig. 25). This facial pattern usually responds well to the
extraction of permanent teeth and, thus, to serial extraction. However, you should proceed with
caution. There are times when this malocclusion is better treated with the extraction of permanent
molars.
LOW ANGLE (Hypodivergent)
This facial pattern always exhibits a low mandibular plane angle and is accompanied quite often
by a favorable horizontal skeletal relationship, a maxillary-mandibular alveolar dental retrusion, a
deep overbite relationship of the incisor teeth, a prominent chin, and a "dished-in" soft tissue profile
(Fig. 26). Again, serious consideration must be given concerning the extraction of permanent teeth
in this type of individual. Quite often, extractions exaggerate a maxillary-mandibular alveolar dental
retrusion and accentuate the "dished-in" soft tissue profile.
DR. BRANDT How does knowledge of high or low angle influence your judgment?
DR. DALE In a high angle pattern, the face can be ruined by poor treatment or improved by
favorable treatment. A facebow headgear on the maxillary first molars will simply extrude the
molars, rotate the mandible down and back, aggravate the retrognathism, increase the open bite, and
48
Article Text 5
accentuate the soft tissue facial disharmony. But, if you extract teeth to provide space, you will
correct the alveolar dental protrusion, move the posterior teeth forward, rotate the mandible up and
forward, reduce the retrognathism, decrease the open bite, and improve the soft tissue profile. Thus,
you will create a harmonious result which will remain stable after treatment (Figs. 27 and 28).
In a low angle facial configuration, a facebow headgear on the maxillary first molars with
cervical traction would produce a more favorable result but, because the dentition is collapsed
lingually, the extraction of permanent teeth should be carefully considered.
DR. BRANDT What significance do you attach to facial photographs of an 8-9 year old?
DR. DALE They help me classify facial patterns and I feel that these facial patterns can be
detected between eight and nine years of age. The detection of facial pattern plays an extremely
important role in early treatment, including serial extraction.
I am careful to point out to parents that I am not trying to produce an ideal face, simply because I
do not know precisely what an "ideal" face looks like. I am also not trying to produce an esthetic
face, because esthetic appreciation is a very personal thing. I am attempting to produce a face
exhibiting a harmony of structures— teeth in favorable alignment in harmony with the skeletal
pattern and the soft tissue matrix.
DR. BRANDT What information do you get from intraoral and panoramic x-rays?
DR. DALE If there is one record that must be taken before the initiation of serial extraction, it is
a complete series of periapical radiograms or a panoramic film. Can you imagine extracting four
first premolars and then discovering that second premolars are congenitally missing? For your own
protection, make sure that the dental radiograms are taken. I use them for many reasons:
1. To detect the congenital absence of teeth.
2. To detect supernumerary teeth.
3. To determine the size, shape, and relative position of unerupted permanent teeth.
4. To assess the dental health of the permanent teeth, especially the first molars.
5. To detect evidence of a true hereditary tooth size-jaw size discrepancy, such as the resorptive
pattern on the mesial of the roots of the primary cuspids (Fig. 29).
6. To evaluate the eruptive patterns of the unerupted permanent teeth.
7. To determine the dental age of the patient by assessing the length of the roots of the permanent
unerupted teeth.
DR. BRANDT Jack, how do you use models to help you in diagnosis?
DR. DALE I measure, with a pair of calipers on the study models, the space available from the
mesial of the permanent right first molar to the mesial of the permanent left first molar. I then
measure with the calipers on the periapical radiograms the mesial-distal diameter of the unerupted
permanent cuspids and premolars. I add this measurement to the mesial-distal dimensions of the
49
Article Text 6
mandibular incisors on the study models to determine the space required for the permanent dentition
from molar to molar. By subtracting the "available space" from the "required space", the dental
discrepancy is established.
Then I construct a Tweed analysis on the cephalometric radiogram. After I establish the size of
the FMA angle, I determine the desirable FMIA angle. I then measure the distance on the occlusal
plane from the original line through the mandibular incisor to the new line representing the desirable
FMIA angle. I double that distance and add it to the dental discrepancy. This gives me the total
space required to produce a stable treatment result. For example:
Space required 68mm
Space available 62mm
Dental discrepancy – 6mm
Ceph. correction: 6mm  2 – 12mm
Total Discrepancy – 18mm
The cephalometric correction, whether it be the one advocated by Tweed, Steiner or someone
else, takes the alveolar dental position on the jaw into consideration and I think that this is essential
in the assessment of a tooth size-jaw size discrepancy. To me, an alveolar dental protrusion without
spaces is a form of crowding. There is too much tooth material to be accommodated within the
limits of the jaw and you require space to correct it.
DR. BRANDT How much arch length deficiency does there have to be before you embark on a
serial extraction program?
DR. DALE There are many factors to consider and it is impossible to pull a figure out of the air
that will be suitable in all situations. Generally speaking, if I have a total discrepancy of four
millimeters, I will in all likelihood initiate a serial extraction program. I have found from bitter
experience over the years that I cannot extend arch length posteriorly, anteriorly or laterally unless
the position of the teeth is the result of environmental factors, such as premature loss of primary
teeth. Most of my problems during treatment and retention have been associated with creating space
and maintaining alignment in patients where I have not extracted teeth. If retainers are required for
prolonged periods of time. I feel that the teeth have been placed in the wrong position relative to the
skeletal pattern and the soft tissue matrix.
DALE
50
Footnotes 7
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume Jan
FIGURES
Fig. 1
Fig. 1 Class II division 2 malocclusion with badly impacted permanent maxillary right cuspid. During bad serial
extraction procedure, one mandibular incisor and the maxillary right first premolar were extracted.
51
Figures 8
Fig. 2
Fig. 2 Thirteen-year-old girl who did not have the benefit of serial extraction and early treatment.
Fig. 3
Fig. 3 Result of excellent treatment of Class I malocclusion including serial extraction.
Fig. 4
Fig. 4 Diagram indicating the key decisions that must be made during serial extraction. (From Mayne, W. R.: Serial
Extraction, Current Orthodontic Concepts and Techniques, edited by T. Graber, W. B. Saunders Company,
Philadelphia, Pa., 1969, Chapter 4.)
52
Figures 9
Fig. 5
Fig. 5 Reduction in arch length. (From Moorrees, C. F. A. and Reed, R. B.: Changes in dental arch dimensions
expressed on the basis of tooth eruption as a measure of biologic age, J. Dent. Res. 44:129,1965.)
Fig. 6
Fig. 6 Reduction in arch depth. (From DeKock, W. H.: Dental arch depth and width studies longitudinally from 12 years
of age to adulthood, Am. J. Ortho. 62:56, July 1972.)
Fig. 7
Fig. 7 Uprighting of incisors. (From Enlow, D. H.: The Human Face, Hoeber Medical Division, Harper & Row. New
York. N.Y.. 1968.)
53
Figures 10
Fig. 8
Fig. 8 Uprighting of incisors with horizontal growth. (From Bjork, A.: Variations in the growth pattern of the human
mandible, J. Dent. Res. 42:400,1963.)
Fig. 9
Fig. 9 Early mesial shift. (From Baume, L. J.: Physiological tooth migration and its significance for the development of
occlusion, J. Dent. Res. 29:331, June 1950.)
Fig. 10
Fig. 10 Late mesial shift. (From Baume, L. J.: Physiological tooth migration and its significance for the development of
occlusion, J. Dent. Res. 29:331, June 1950.)
54
Figures 11
Fig. 11
Fig. 11 Orthognathic facial pattern. Diagram illustrating the four basic units: maxilla, mandible, maxillary teeth,
mandibular teeth (left); the patient (center); the Steiner Cephalometric Analysis (right).
Fig. 12
Fig. 12 The Tweed Analysis.
55
Figures 12
Fig. 13
Fig. 13 Class I. Maxillary-mandibular prognathism.
Fig. 14
Fig. 14 Class I. Maxillary-mandibular retrognathism.
56
Figures 13
Fig. 15
Fig. 15 Class I. Maxillary-mandibular alveolar dental protrusion.
Fig. 16
Fig. 16 Class I. Maxillary-mandibular alveolar dental retrusion.
57
Figures 14
Fig. 17
Fig. 17 Class II. Maxillary prognathism.
Fig. 18
Fig. 18 Class II. Mandibular retrognathism.
58
Figures 15
Fig. 19
Fig. 19 Class II. Maxillary alveolar dental protrusion.
Fig. 20
Fig. 20 Class II. Mandibular alveolar dental retrusion.
59
Figures 16
Fig. 21
Fig. 21 Class III. Mandibular prognathism.
Fig. 22
Fig. 22 Class III. Maxillary retrognathism.
60
Figures 17
Fig. 23
Fig. 23 Class III. Mandibular alveolar dental protrusion.
Fig. 24
Fig. 24 Class III. Maxillary alveolar dental retrusion.
61
Figures 18
Fig. 25
Fig. 25 High angle facial pattern.
Fig. 26
Fig. 26 Low angle facial pattern.
62
Figures 19
Fig. 27
Fig. 27 Class II patient before (above) and after (middle) serial extraction and early treatment. Superimposed tracings
(below) indicate favorable treatment.
63
Figures 20
Fig. 28
Fig. 28 Class I patient before (above) and after (middle) serial extraction and early treatment. Superimposed tracings
(below) indicate favorable response.
64
Figures 21
Fig. 29
Fig. 29 Radiogram revealing the resorptive pattern on the mesial of the root of the primary maxillary cuspid when there
is an hereditary tooth size-jaw size discrepancy.
65
Figures 22
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Jan(62 - 64): Full-Scale Color Transparencies of Cephalometric Tracings
Full-Scale Color Transparencies of

Cephalometric Tracings
RICHARD J. ACKERMAN, JR., DDS
The purpose of this article is to describe how to prepare full-scale color transparencies of
cephalometric tracings. A cropped version of an actual film is bound with this article.
The Film
The film, Tecnifax Diazochrome®, costs 31¢ per 8½" × 11" sheet and is available in ten different
colors (from Scott Graphics, Inc., Holyoke, Mass. 01040). It can be handled for brief periods in
incandescent and fluorescent light. Sunlight must be avoided because the dye is bleached from the
film by ultraviolet radiation.
The Apparatus
Figure 1 shows the equipment used by the author. The exposure box is 3/8" plywood, 30'' high ×
12" wide × 13" deep, open at the top and across the bottom of the front. The light source is a
275-watt sunlamp. The timer was added for convenience. A photographic proof printer is used to
hold the film and tracing in tight contact during exposure. After exposure the film is developed in
the spring-top glass jar (also available from Scott Graphics). A large restaurant-size pickle jar
containing a sponge covered with a rubber drain mat would work equally well. The sponge is
saturated with 58% (26° Baume) aqueous ammonia. If the jar is kept tightly closed when not in use,
weekly replenishment of the ammonia is sufficient.
The Process
A cephalometric tracing is made in the conventional manner on acetate film, using a lead pencil.
The cephalogram is removed and the tracing taped on a view box. Using a Koh-I-Noor Acetograph
Pen (Koh-I-Noor, Inc., Bloomsbury, New Jersey 08804), all pencil lines are darkened with black
opaque drawing ink. Lettering is applied by using a typewriter or pressure sensitive drafting symbols
which can be purchased in sheets from a drafting supply store.
A sheet of unexposed diazo film is placed on the stage of the proof printer; on top of this is
placed the acetate tracing inked side down (Fig. 3). The proof printer is closed and placed in the
exposure box. The sunlamp is turned on. Exposure time varies depending on the color of the film.
With the apparatus described, 5 to 7 minutes are required to render a sharp image against a
color-free background. The image is revealed by placing the exposed film in the ammonia jar for
approximately 2 to 3 minutes.
The film remains dry throughout the process, and is available for immediate use upon removal.
Unlike a conventional acetate tracing, the lines are smudge-free and the background is clear and
62
Article Text 1
colorless, thus allowing superimposition of many films without loss of detail. The transparency can
be kept in the patient's folder or mounted in a cardboard frame for presentation at the view box or
projection to a group.
FIGURES
Fig. 1
Fig. 1 Diazo apparatus. A. Exposure box. B. Sunlamp. C. Electric timer. D. Proof printer. E. Development jar.
63
Figures 2
Fig. 2
Fig. 2 Cropped sample of actual transparency.
64
Figures 3
Fig. 3
Fig. 3 Preparing the film for exposure. A. Thin sheet of cardboard. B. Unexposed diazo film. C. Black ink cephalometric
tracing.
65
Figures 4
FEBRUARY 1976, VOL. 10 / ISSUE 2

The Straight-Wire Appliance: Origin, Controversy, Commentary 99
An Approach to Incisor Retreatment 115
JCO Interviews: Dr. Jack G. Dale on Serial Extraction- Part 2 116
Orthodontic Welding 137
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Feb(81 - 81): THE EDITOR'S CORNER
the editor's corner

The United States is one of the few places in the world which does not use the metric system of
weights and measures. Legislation has recently been enacted to encourage conversion to the use of
metric measurements. Orthodontics in this country has been using a system in which some
measurements were metric and some were not. Thus, we have customarily measured force in
ounces; arch length, arch relationships, tooth dimensions, tooth movement, cephalometric linear
measurements in millimeters; band width and thickness, wire cross-sectional measurements, bracket
slots in thousandths of an inch.
Since worldwide uniformity in measurement is desirable, we can begin the conversion of ounces
to grams and inches to millimeters and centimeters by printing the equivalent measurements
together and JCO will make an effort to do this.
Actually, the conversion is not difficult and can be made quite simple with the handy conversion
tables on pages 82 and 83 of this issue. Failing that, keep in mind that 1 gram = .035 oz. and 1
millimeter = .039 in.; 1 ounce = 28.35 gm. and 1 inch = 2.54 cm. or 25.40 mm.
The next area for international uniformity should be terminology. We may not be able to make
terminology as precise as mathematics, but scientific understanding would be advanced if we found
a means to establish a common orthodontic language. It might be a worthy project for an
international committee of representatives of the various orthodontic associations.
81
Article Text 1
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Feb(99 - 114): The Straight-Wire Appliance: Origin, Controversy, Commentary
THE STRAIGHT-WIRE APPLIANCE

Origin, Controversy, Commentary
LAWRENCE F. ANDREWS , DDS
When the Straight-Wire Appliance was introduced to the profession in 1970 it seemed advisable,
for transitional purposes, to explain the SWA with reference to its closest kin. So it was sometimes
called "a sophisticated edgewise appliance." Actually, although it employs an edgewise slot, the
SWA fits no existing appliance category because of certain innovations in concept, in
implementation, and in effects or results. The SWA design seeks to build as much treatment into the
appliance as is practical, this side of an appliance totally customized for each patient:
1. Each bracket is customized for its tooth type, reflecting several considerations including
relative size of teeth, gingival and hygienic factors, ease of clinical use, patient comfort, and
reduction of occlusal interference by bracket.
2. Pre-angulated slots accomplish mesiodistal tooth tip, permitting the bracket to be placed
"squarely" on the crown instead of being angulated This eliminates the potential for
"rocking" that is inherent in the two-point contact of an angulated bracket.
3. The bases of the brackets are inclined for each tooth type, to achieve proper tooth "torque"—
with the center of each slot at the same height as the middle of the clinical crown (an
essential for Straight-Wire technology). This innovation replaces the edgewise slot-torque
that is not compatible with true straight-wire treatment. SWA slots are not torqued, although
they may appear to be because of the design of the face of the bracket.
4. SWA bases are contoured vertically as well as horizontally, resulting in a good

bracket-to-tooth fit and a dependable, reproducible location of the bracket slot in relation to
the crown.
5. The distance from the base of the slot to the base of the bracket varies for each tooth type,
satisfying in/out requirements.
6. Built-in guidance (tip, torque and in/out) minimizes archwire manipulation, making tooth
movement more direct, saving treatment time and chairtime, and improving consistency in
end results.
7. The guidance features are preprogrammed to reflect research findings that are consistent
with the requirements of functional occlusion. Thus, better occlusal goals are promoted,
although these goals can be modified by the SWA user.
8. Bracket design facilitates accurate bracket placement at a crown site more reliable than any
reference point previously used in this process. This site is a "part of the package" of the
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Straight-Wire approach, and it is sustained by an explicit rationale. Final slot location no

longer varies because of faulty reference points or inconsistencies in banding techniques.
9. Extraction and Extraction Series brackets are available, and provide anti-tip and anti-rotation
features.
10. Each bracket carries its own identification as to tooth type— a convenience that will grow
in value as direct bonding evolves.
How It Started
As for its origin— the appliance and the "Six Keys" are interrelated, and both are more clearly
understood after reviewing the conditions that brought about the Keys investigation. And in that
matter, need, if not necessity, was the mother of research.
Some newborn orthodontists may emerge from graduate school in a happy state of supreme
understanding and competence. I didn't. My credentials were all right, but I was uneasy about my
treatment goals, which often were seat-of-the-pants estimations of what ought to be (about) right for
the patient at hand.
Another impetus for exploring the occlusion enigma lay in some understandable aspirations.
Membership in the Tweed Foundation and the Angle Society, and the revered status of a Diplomate
of the ABO, were shimmering professional objectives. Attending national and other orthodontic
meetings, I saw many different occlusal schemes and tooth positionings in the end-result models
displayed. All of the completed cases showed great improvement over the original condition, but I
found no explanation for the variations, case-to-case, in any one orthodontist's results, nor for the
evident differences in treatment from doctor to doctor. Perceiving the differences was easy enough,
but I didn't know which occlusal scheme was right nor which doctor to emulate.
So, a study of excellent normal occlusion and of the state of the orthodontic art, in this respect,
appeared to be a good thesis subject— and one that might provide clear, coherent treatment goals to
replace the perplexity in my own mind.
The findings of the research have been reported elsewhere. 1 For readers not familiar with that
report, here is a tight summary:
The project amounted to a study of the best static occlusion that occurs naturally, compared with
the best end results achieved by leading orthodontists. (Functional occlusion is discussed later in the
present article.) The first stage has been described— the early, somewhat impressionistic
examination of completed cases displayed at meetings.
The second step was based on the premise that what nature does in its best products should be
worthy of emulation. (This was not an entirely new premise. For example, Bolton included excellent
untreated dentitions in a sample reported in 1958. 3 And Dewel wrote in 1949 of useful referents and
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norms offered by "nonorthodontic normals." 4) A gathering of plaster models was begun, and the
resultant collection is believed still to be unique: 120 models of dentitions that had had no
orthodontic treatment and that needed none, in the professional judgment of the many sources of the
material (other orthodontists, general dentists, university faculty and students). The teeth were
straight and pleasing in appearance with no obvious defects, and the bite looked generally correct.
The relationships and positions of the crowns in these models were subjected to detailed study.
Six significant characteristics were found to be notably consistent in occurrence, and they were
designated "the Six Keys to Normal Occlusion." (They will be described, but first let's complete the
chronology.)
The third phase was a methodical examination of the other group of models— the treated cases
shown by skilled orthodontists. Eleven hundred and fifty such models were studied from 1965 to
1971. Findings strengthened the inferences drawn from the nonorthodontic normals. There were
indeed significant differences between Nature's best and many of Orthodontia's best. And the lack of
any one of the six signal keys was predictive of other inadequacies. (This study has been maintained
since 1971 with no appreciable change discerned in the models shown.)
The "NONs" Again
Finally, the collection of nonorthodontic normal models was turned to again and further screened.
The consistent characteristics in these examples of natural excellence were subjected to careful
measurements. A condensed general description of the findings is given in the accompanying box
and in the illustrations.
SIX KEYS TO NORMAL OCCLUSION
KEY 1— Molar relationship. (A) The distal surface of the distal marginal
ridge of the upper first permanent molar contacts and occludes with the mesial surface of the mesial
marginal ridge of the lower second molar. (B) The mesio-buccal cusp of the upper first permanent
molar falls within the groove between the mesial and middle cusps of the lower first permanent
molar. (C) The mesio-lingual cusp of the upper first molar seats in the central fossa of the lower first
molar.
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KEY II— Crown angulation, the mesiodistal

"tip". In normally occluded teeth, the gingival portion of the long axis of each crown is distal to the
occlusal portion of that axis. The degree of tip varies with each tooth type.
(Photo from Andrews, L. F.: The six keys to normal occlusion, Am. J. Orthod. 62:296, 1972.)
KEY III— Crown inclination, the labiolingual or bucco-lingual

"torque". Crown inclination is the angle between a line 90 degrees to the occlusal plane, and a line
tangent to the middle of the labial or buccal clinical crown.
(A) Anterior crowns central and lateral incisors): In upper incisors, the occlusal portion of the
crown's labial surface is labial to the gingival portion. In all other crowns, the occlusal portion of the
labial or buccal surface is lingual to the gingival portion. In the non-orthodontic normal models, the
average inter-incisal crown angle was 174 degrees.
(B) Upper posterior crowns (cuspids through

molars): Lingual crown inclination is slightly more pronounced in the molars than in cuspids and
bicuspids. (C) Lower posterior crowns (cuspids through molars): Lingual inclination progressively
increases.
KEY IV— Rotations. Teeth should be free of

undesirable rotations. If rotated, a molar or bicuspid occupies more space than normally— a
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condition unreceptive to normal occlusion. A rotated incisor can occupy less space than normal.
KEY V— Tight contacts. In the absence of such abnormalities as genuine tooth-size discrepancies,
contact points should be tight.
KEY Vl— Curve of Spee. A flat occlusal plane should be a treatment

goal. Measured from the most prominent-cusp of the lower second molar to the lower central
incisor, no curve was deeper than 1.5 mm in the nonorthodontic normals.
(A) A deep curve of Spee results in a more confined area for the upper teeth, creating spillage of
upper teeth mesially and distally.
(B) A flat curve of Spee is most receptive to normal occlusion.
(C) A reverse curve of Spee results in excessive room for the upper teeth.
The six identified characteristics were deemed to be realistic treatment objectives for more than
ninety percent of the patients accepted by North American orthodontists. Therefore, in treatment of
malocclusions of basically normal teeth, it was logical to standardize at least to the state represented
by the six characteristic goals; any subsequent fine-tuning could be discretionary with the individual
orthodontist. A commonality of objectives for most patients meant also that it should be feasible to
develop an efficient appliance, economical in time and energy requirements, for getting to these
goals.
And the Straight-Wire Appliance, although it is not a panacea nor "the ultimate appliance" (will
there ever be one?), was designed to take advantage of these findings and feasibilities.
As Wheeler perceived long ago, ". . . in anatomy, variations must be expected . . . Nevertheless,
certain tendencies may be discovered, and those tendencies must be considered in order to acquire
perspective . . . definite tendencies may . . . have important practicable application." 13
"BURNING ENERGY"
Sometimes, a student says that he has heard that the SWA "burns anchorage."
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Let's use the word "energy" instead of "anchorage" to discuss this. Anchorage is a
passive-to-negative term that implies either holding or losing space. When you set an anchor from a
boat, the only thing you want to do is stay there. In orthodontics, however, we don't just strive to
hold space; sometimes we want to lose it (close it), but— my primary point here— often we need to
create additional space. Energy is a more suitable word for contemporary orthodontics, for it implies
a force usable for losing, holding or gaining space.
Does the Straight-Wire Appliance "burn energy?" Actually, the opposite is true for several
reasons that can be grouped into two categories. The first can be called human and procedural
variables. The other category is related to physics, physiology and treatment objectives Taking the
human and procedural reasons first:
(1) With all full-banded appliances, the process of placing the bracket offers several opportunities
for error or inconsistency (discussed elsewhere in this article). Only if the brackets are properly
placed initially, will there be no treatment variables, in this area, to consume more energy or less.
(2) Any appliance that requires archwire bending presents additional opportunities for variables,
including errors that result in burning energy (anchorage) over and above the amount actually
required to solve the problem. Among these variables are misjudgment of the amount of archwire
bend required; ineffectiveness in mechanically expressing one's judgment accurately in the
archwire; misreading or forgetting the treatment card's specification of the degree of bend or bends
incorporated into the archwire during the previous visit (Exact continuity is essential if energy is to
be used efficiently throughout treatment ) And in multiple-doctor offices it can be difficult or
impossible to ascertain precisely what the preceding doctor did to the archwire, for no two doctors
bend wires in an identical manner.
These variables can result in teeth's jiggling during treatment, or tipping, or moving farther than
was intended so that round-tripping becomes necessary At the minimum, such variables are likely to
result in the moving of teeth in circuitous routes; and that is wasteful both in terms of energy
(anchorage loss) and in efficiency (treatment time).
With the Straight-Wire Appliance, wirebending is minimized; so, therefore, are the variables.
Each progressively larger archwire delivers a programmed amount of its deflected energy to each
tooth. The built-in features of the SWA guide the teeth along direct vector lines, virtually
eliminating jiggling, round-tripping and other excessive movements. In multiple-doctor offices the
attending orthodontist knows better what his predecessor has done for the patient, adding to the
efficiency and consistency of treatment. In short, the SWA gets more miles to the gallon by avoiding
detours and wrong turns en route.
The Other Reasons
Another problem lies in the dynamics of wirebending effects. For example, as you place torque in
the anterior part of the archwire you negate tip by a ratio of four-to-one. 1
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The final matter involved in the energy-anchorage issue is easily explained: energy requirements
reflect not only the extent of the original malocclusion, bracket placement variables, and efficiency
in treatment and in coping with the dynamics; the requirements also reflect the treatment objective.
The question about burning anchorage ought to be phrased: "Does it take more energy to get to a
desirable goal than is needed to travel part-way?"
The SWA is goal-programmed, and it will get there unless the user chooses to change its
instructions, or to turn off the ignition by removing the archwire before treatment needs have been
fully satisfied. Another paragraph of this article discusses adapting the archwire for different end
results; but if your objective is the Six Keys statically, and the cuspid-rise scheme of occlusion
functionally, then more horsepower is required to reach that goal than is needed to approach it or
needed to arrive at any destination that happens to be less demanding.
Historically, most orthodontists have treated toward their own personal, subjectively determined
occlusal objectives A group may agree on cephalometric goals, but that is not the same thing; a
cephalometric goal is not an adequate occlusal goal. (Cephalometric x-rays offer an accurate
measurement source for only one portion of one of the Six Keys, the interincisal crown angle.) A
group of orthodontists may agree generally about some other static occlusion goals, but only
generally, because such goals have been ill-defined except for the cusp-groove relationship of the
first permanent molars, and the interincisal tooth angle. No concurrence in specific terms exists
about anything else pertaining to that portion of the crown with which we work, or with its
relationship to the remainder of the tooth.
So while patients vary, to be sure, orthodontic end results range far more widely. Treated cases by
almost any 50 orthodontists will show 50 different sets of occlusal results. Why? Because of a lack
of concurrence about goals.
The work of an individual orthodontist may contain features that are consistent from case to case.
Indeed, certain features can be recognized as trademarks or thumbprints identifying individual
doctors. For example: distinctive archform; upright cuspids; super paralleling of roots in extraction
sites (or, more often, absence of this feature); bicuspids and/or molars rotated into extraction sites;
rotated six-year molars (due partly to not banding 12-year molars); too much or not enough torque in
upper anteriors; Six Key-like molar relationship, or arbitrary end-to-end positioning; upper central
and lateral incisors with esthetically pleasing crown tip, or very upright. And, there are many other
clues or patterns that mark an individual orthodontist's work.
Meanwhile, his equally conscientious colleague, with offices just a few miles distant, may be
working to an entirely different set of standards. The implications of this fact, concerning the state
of our art, deserve serious thought.
But, while I may inquire about facts and documentation, I respect every man's reasoned
judgment; and in this comment I am not arguing about the respective merits of alternate goals. I am
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only pointing out that different treatment "journeys" go to different places, and some require more
energy than others. Earlier in this paper I discussed how one appliance can contribute more to
efficiency than another; but even if all vehicles (appliances) were equal, the amount of energy
needed would depend largely on the destination chosen. The SWA is designed to go all the way to
the occlusal qualities found in the nonorthodontic normals— Nature's best.
I believe that users of the Straight-Wire Appliance are treating their patients to more advanced
and better objectives than ever before. To put it another way— I believe that until now, most cases
have been undertreated by 20 percent. If so, the right question is not whether the SWA uses more
energy, but whether orthodontists have been utilizing too little energy by undertreating to less
demanding goals.
FUNCTIONAL OCCLUSION
The Six Keys research dealt with static occlusion. It is entirely appropriate to ask whether the
results can be reconciled with demands for good functional occlusion.
I'm not sure everyone, even educators, have fully recognized that a new era has come of age in
our specialty. Today, we have the burden or privilege of orthodontically achieving functional
occlusion. Not enough recognition has been given to Dr. Ronald H. Roth for his role in this event I
gladly acknowledge my debt to him for demonstrating to the profession a sound functional
occlusion scheme that is orthodontically attainable even in extraction cases.
Happily, the requirements of functional occlusion are totally compatible with advanced standards
for static occlusion The concordance of findings in these two areas is significant So is their
coincidence in timing. Is it reaching too far to suggest that substantiation lies in this circum
stance?— that when occlusion is approached from different directions, the conclusions of
independent researchers coincide? I am not saying that Roth's findings and the Keys are identical;
the answers to different questions were being sought, and are still developing. But the answers are
so mutually supportive that they seem complementary.
Let me illustrate with one example of the elements shared. As every dental student knows, tooth
types are specialized, each for its own roles A tooth, like a carpenter's tool, is damaged by being
subjected to the wrong type or duration of stress. Therefore, just as a journeyman cabinetmaker
shields his saw blade from vagrant contacts, so nature provides "mutually protective occlusion" (a
functional occlusion scheme) to guard human teeth against improper abrasions and stresses.
In desirable static occlusion the teeth are harmoniously located and positioned in the jaws, and
the mandible and maxilla are in the appropriate skeletal relationship. Such dentitions, I submit,
should exhibit the Six Key static characteristics, and also allow the teeth to function according to the
mutually protective occlusal scheme endorsed by Roth; i.e., without undesirable cusp interferences,
and with no problems of the type caused in the TMJ when the mandible must always detour
excessively to prevent collisions or sideswipings by cusps which, at that point in mastication, should
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have no contact. In a smoothly functioning society of teeth, the individuals mate intimately when
they should; and when they shouldn't, they avoid contact without help from compensatory
mandibular movement that abuses the TMJ. It is an intricate but automatic scheme of behavior:
when teeth are not productively collaborating they ostracize each other, thanks to the native or
treated design of the total dental apparatus and the positioning of all its components.
Now we can tie static and functional goals together.
Centric occlusion and centric relation should coincide. This is a major consideration. In my
writing and lecturing I have assumed it as axiomatic. Roth wants it stated, not assumed. Given that
condition, he has declared, the Six Keys are "consistent with desirable functional-occlusion goals.'' 11
He has said more to the point,12 but those few words tell the story.
We orthodontists have much left to learn and much yet to refine. But, evidence to date sustains
confidence that advanced static and functional occlusion goals not only are compatible but
seemingly validate each other.
As Ramfjord and Ash foresaw in 1966: ". . . good anatomic relationships provide the best
background for functional harmony." 10
TREATMENT APPROACH
An experienced clinician, examining a meaningful innovation, may reasonably ponder whether a

deep-reaching change in treatment philosophy would be involved.
We ought to decide first what the question means— whether the term "philosophy" embraces
mechanics, cephalometric goals and other concepts and specifics, or just refers to how the teeth fit
together when active treatment is completed. But, the shortest answer is that the SWA requires no
philosophy change for anyone using an edgewise approach, even though new principles are
incorporated and are implemented by design innovations.
The SWA is not a philosophy of treatment; it is an appliance. Its design helps achieve the Six
Keys, but the Keys are not a philosophy— they are a treatment goal involving an occlusal scheme.
An Andrews philosophy of treatment exists, but it is in no way a prerequisite for successful use of
the SWA.
Any edgewise approach is different from that used with the Begg appliance; but any edgewise
approach or philosophy is applicable to use of the SWA. Orthodontists who have adopted the Six
Keys believe these treatment goals are best. Others, who prefer the Tweed concept that posterior
teeth need not be in total occlusion at the completion of active treatment, can treat to five of the
Keys and incorporate the molar-relationship Key as the ultimate, post-retention condition.
Meanwhile, Tweed men need only adapt the SWA by installing compensating curves in the
archwires and tip-back bends where required, much as they are doing now but without all of the
other routine wirebending necessary with the edgewise appliance.
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This is one example of the functional adaptability of this appliance. The SWA is programmed by
its design to do more of the orthodontist's traditional chores than any other appliance, and to take a
case to Six Keys occlusion. But, a user is free to make various modifications during the course of
treatment, and free to fine-tune to arrive at his own goals instead, if he does not fully concur with
the Keys for any or all of his patients. For example, he can extract only the upper bicuspids, leaving
the molars in Class II relationship. At the same time, he can allow the SWA to reduce the tedious
wirebending that historically has been the exclusive privilege (or burden) of the doctor himself. In
other words, he can replace most manual manipulation, and its inherent variability in precision and
consistency, with the dependable exactness built into a programmed appliance.
The SWA design does reflect a treatment goal; but it is not uncontrollably dictatorial about the
matter.
THE SNOWFLAKE PROBLEM
Later installments in this series will offer intraoral photographs of cases in treatment and of end
results. This introductory article should conclude with a discussion of the most common
misconception concerning the Keys and the SWA. Does the SWA assume that teeth are
morphologically alike from individual to individual and should always be positioned similarly? With
what proportion of cases is the SWA effective?
Recently, these questions were inherent in what seemed to be an outright dissent. In the exhibit
area at the 1975 national meeting of the AAO, one orthodontist displayed photos and models of a
large number of untreated dentitions whose teeth varied widely in size and malocclusion. The
exhibit title was "One Thousand (1000) Cases to Assess the Validity of the Straight Wire Appliance
Concept."
The doctor who prepared that exhibit assured me later that he had not intended to imply, through
the exhibit title or otherwise, that the cases shown represented SWA results. Indeed, none of the
cases shown had been treated with the SWA. He said he warmly approved the Six Keys as
objectives, but that he believed the shapes of crowns, and the angular relationships between crown
and root, vary so often and so greatly that is it not feasible to treat each patient with the same pre
programmed appliance. Let's deal adequately with the question.
Abnormalities or extremes: It's true that the SWA is designed to reach the Six Keys efficiently as
an end-result, if that's what the orthodontist using it wants. For certain cases that objective is not
attainable, and no one has ever suggested that the Keys are realistic for treatment of the extreme or
abnormal variations that every dentist sees occasionally.
The original report of the Keys research 1 noted that some conditions require help from other
specialists such as the oral surgeon, or from the general dentist. My course syllabus 2 lists some of
the problems that place a patient outside the basically normal group. It states in italics: "To
[orthodontically] achieve these goals with all patients is not feasible . . ." (Then it adds: "but to stop
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short of them when they are attainable may be unacceptable.")
This first part of the answer to the quoted question just acknowledges, once more, the exceptional
cases. The only thing we might differ about is how often one sees them. I don't think they account
for more than five per cent of our patients. We are talking, you see, about normal distribution— the
familiar bell shape on a statistical graph. The great hump in that bell encompasses .most cases.
When we say the basically normal dentitions can be treated to the Six Keys, "normal" has far more
scope than "average" or "median."
As Graber expressed it: "A cardinal axiom to begin with is that the normal in physiology is
always a range, never a point."5
Norms for normals: Can we apply norms and preprogrammed treatment even to most of the cases
within the "normal range"? I agree that all teeth are different, and that each patient must be
examined and diagnosed as an individual. It is also true that the SWA is not capable of treating
every basically normal dentition "ideally" without some fine-tuning of the archwire during the later
visits. In cases where that final 'detailing is going to prove necessary, the SWA will "only" get you
very close. But, if you're heading for a specific street address a thousand miles distant, won't you fly
to the right city or proximity, instead of taking a taxi all the way?
Central Tendency
The SWA is designed to take advantage of some basic facts about dental anatomy (the
"tendencies" Wheeler referred to) and the known characteristics of excellent occlusion. That's what
makes it a practical orthodontic tool.
Nature's grouping of individuals— Nature's practice of making most of any one species more
alike than unlike— called by some "the central tendency"— is of immense value to physicians and
dentists. For decades, orthodontists have properly exploited it in some ways. The shape of bands for
a given tooth type is the same regardless of size. And we don't have to stock an infinite variety of
sizes. Nor do we use all sizes with the same frequency. Band trays are supplied with some sizes in
greater quantities than other sizes, and this is just a familiar application of the fact that we do know
about normal distributions, and do use the knowledge to predict needs.
Size differences: Furthermore, some differences, such as size, have no real significance. Tooth
size has no effect on angulation or inclination, which are important. When an individual has small
teeth, his teeth are generally (with some qualifications) found to be proportionally small. The same
consistency exists in dentitions with large teeth. (And root-length is best studied in terms of its ratio
to tooth-length in the same individual. 9) As for in/out— alignment is not a matter of whether a
patient's teeth are large or small. True tooth-size discrepancies of clinically significant degree are far
from commonplace.
Shape: No two tooth types are identical, but teeth of any one type are very much alike. No dentist
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would have any difficulty describing, drawing or carving any specific tooth type. Scramble 100
extracted teeth, toss them on a table, and which of us could not easily identify each tooth?
Contact points and angulations: One of the important similarities within a given tooth type is the
location of the contact points. The commonality of this feature is described precisely by Wheeler. 13
This being true, the angulations of teeth of any one type must have much in common — be the teeth
large, small, wide or narrow.
All in all, then, most individuals' teeth vary within so limited a range that they can be treated to
optimum goals. The SWA is programmed to deliver such treatment, and has done so for about 90
percent of my patients, with few if any archwire bends needed because of tooth morphology. The
Standard SWA has been adequate for some 50 percent. SWA Extraction Series brackets will treat
another 40 percent (approximately) with few if any archwire bends. Customizing the selection of
individual Extraction Brackets will encompass still others satisfactorily. I will add that I believe that
more of the extreme cases than one would first think can be brought to or substantially toward those
same goals.
Clinical Common Sense
Changing Times defines statistics as "a group of numbers looking for an argument." I feel most
comfortable when I can relate to a statement "clinically," without the statistics, although of course I
like to have statistical analyses to substantiate my observations and common-sense conclusions.
The nonorthodontic normal models from which the Six Keys conclusions were drawn were
measured as to specific crown angulations, inclinations, and in/out. Those data were made available
years ago. But let's forget about the statistics for now, and think in terms of common sense and
personal experience, with the six year molar as an example.
Prior to the SWA, I used edgewise. With that appliance I constructed thousands of lower
rectangular archwires with progressive posterior lingual crown torque— usually about the same
amount of torque from one case to another. The torque provided for the lower six-year molar was
always in the neighborhood of 30 degrees. Since that was the fact, it would seem illogical not to
have the 30 degrees built into the bracket, along with the appropriate torque for other teeth. When
that is done, the orthodontist has only the fine-tuning "number" to contend with, rather than the
chore of repeatedly manipulating the archwire just to get to the target proximity before beginning
the fine-tuning. Remember Wheeler's advice: ". . . tendencies may have important practicable
application."
Again— you may want to walk the last few blocks, to an individual address. But why walk the
first thousand miles just to get to the neighborhood?
Neither the findings of the Six Keys study nor, so far as I am aware, other published research
sustains the "1,000 Cases" exhibitor's views about the disabling impact, on technology and the
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orthodontist, of variations in tooth morphology. And crown-root relationships are not visible in
plaster models.
"It is important that the orthodontist cultivates an anthropologist's eye for tooth variations." 8 But,
commonplace variations in morphology seem rather far down the urgency list for orthodontic
analysis now. In the present state of our art, higher priority rankings should go to agreement on
goals; to agreement about exactly where the bracket goes on the crown; to use of anatomical bracket
bases to permit consistent slot location; to inclination of bracket bases so that slots will be at the
same height on the teeth as the middle of the bracket bases; and to elimination of wirebending
variables. It is my considered opinion that attention to these higher priority factors will contribute
far more to the improvement of end results than will preoccupation with tooth morphology.
In any event, "the validity of the Straight-Wire Appliance concept" can be evaluated
pragmatically. I do not claim exemplary clinical achievements; the quality of my end results may
approach, but does not equal, Nature's in her nonorthodontic normals, and the reader may be a more
skillful technician than I. But using the SWA, I have completed hundreds of cases, and hundreds
more have been completed by other orthodontists, with a gratifying rate of success. The Straight
Wire principles are already being evaluated or taught in many respected orthodontic departments
throughout this country, and acceptance by clinical orthodontists is growing at a remarkable rate.
Each clinician must bring to bear, during diagnosis, all of his specialized training, experience and
judgment, along with his philosophy and the procedures he has selected for finding significant
aberrations. One does not assume that any new patient is within the basically normal group. But, he
will find that most are. And he can choose to treat this large group efficiently, to precise goals based
on research and clinically proven to be feasible.
LAWRENCE F. ANDREWS
This is the first in a series of articles in which Dr. Andrews

will present the concept, the appliance, and the techniques of
straight-wire treatment. As far as is known, Dr. Andrews is
the originator of the Straight-Wire Appliance and we are
fortunate to have him present this series on what has
become one of the most significant recent developments in
orthodontics. ED.
axiom
That axiom could be interpreted wrongly, as well as rightly.

The wrong way would be: that whatever conditions a patient
presents exist for him, hence are "natural" for him— and, by
extension, "normal" for him. That glib interpretation would
allow or compel all physicians as well as orthodontists and
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume Feb
general dentists (and educators and many others) to change

careers or to retire immediately, for it says: "The way one is
should not be tampered with." Instead, we must first agree
that we are talking about patients— i.e., people who need
helpful treatment of a defect. Malocclusion may be the
untreated "natural" condition of our patients, but it cannot
reasonably be ignored with that excuse. A semantics
problem does exist, since the word "normal" is used in
various ways. In "the Six Keys to Normal Occlusion" it refers
to characteristics consistently found in Nature's most
successful occlusal scheme. (The word "ideal" is frowned
upon in orthodontics.) The valid application of the quoted
axiom is that basically normal members of a population
exhibit differences that have no major significance. Such
cases, though no two are identical, are eligible for similar
treatment of their actual problems. En route, minor
deficiencies can be corrected, and these "basically normal
cases" can be brought to the target occlusal scheme.
References
1. Andrews, L. F.: Six Keys to Normal Occlusion. Amer. J. Orthodontics, 62:296-309, 1972.
2. ...............: The Straight Wire Appliance: Syllabus of Philosophy and Techniques, rev. ed., San Diego, 1975,
Lawrence F. Andrews, 28.
3. Bolton, W. A.: Disharmony in Tooth Size and Its Relation to the Analysis and Treatment of Malocclusion. Angle
Orthodontist, 28:113-130, 1958.
4. Dewel, B. F.: Clinical Observations on the Axial Inclination of Teeth. Amer. J. Orthodontics, 35:98-115, 1949.
5. Graber, T. M: Orthodontics Principles and Practice, ed. 3, Philadelphia, 1972, W. B. Saunders Company, 180.
6. Grewe, J. M., Coccaro, P. J. Jr., and Stein, A.: Orthodontic Appliance Therapy: A Changing Perspective. In 1975
Advances in Orthodontics, p. x. Chief ed., H. C. Butts. N.p., 1968, American Dental Association.
7. Norton, L. A. and Williams, C. A.: Prediction of Orthodontic Band Sizes from Selected Teeth. Amer. J. Orthodontics,
64:480-490, 1973.
8. Peck, S. and Peck, H.: Orthodontic Aspects of Dental Anthropology. Angle Orthodontist, 45:102.
9. Plets J. H., et al: Maxillary Central Incisor Root Length in Orthodontically Treated and Unteated Patients. Angle
Orthodontist, 44:47, 1974.
112
References 14
10. Ramfjord, S. P. and Ash, M. M. Jr.: Occlusion, Philadelphia, 1966, W. B. Saunders Company, 90.
11. Roth. R. H.: personal communication, 1975.
12. .....................: Five-Year Clinical Evaluation of the Andrews Straight-Wire Appliance Scheduled for 1976
publication, Associated Orthodontic Journals of Europe.
13. Wheeler, R. C.: A Textbook of Dental Anatomy and Physiology, ed. 4, Philadelphia, 1965, W. B. Saunders
Company, 381.
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References 15
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Feb(115 - 115): An Approach to Incisor Retreatment
An Approach to Incisor Retreatment

MARION F. DICK , DDS
One of the most disconcerting events in the practice of orthodontics is the return of a beautifully
treated patient of yesteryear, with severely crowded mandibular incisors.
It is exceedingly nice to present an understanding heart to the patient and to immediately place, at
that visit, a treatment arch which will quickly realign the incisors. We agree to realign the incisors if
the patient will pay for another retainer and will agree to wear it indefinitely.
The "Little Dicktator" is an anterior sectional arch with "s" bends over the center of each anterior
tooth. It is used for retreating and overcorrecting incisor crowding, and does so efficiently and well.
Each tooth is tied with .012 ligature, but .008 may be used in close places.
Incisor relapse overcorrected

with the "Little Dicktator" in 30 days and placed on indefinite retention. Note adjustment on central
loop to relieve irritation.
Response is usually very rapid. Patients are appointed to return in three weeks, at which time
most cases are already aligned, but, if not, the arch is removed, adjusted, and replaced for an
additional three-week period. Spaces usually develop between incisors, thus facilitating stripping, if
needed, prior to the placing of permanent retention.
"Little Dicktators" should be made up in advance in three sizes so as to be available when

needed, otherwise, the time needed to prepare one may preclude its use. We color code ours by the
use of a dab of hobby enamel; red for small, yellow for medium, and blue for large. The device is
available from Mardick Labs, 2205 Chestnut Rd., Birmingham, Ala. 35216.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Feb(116 - 136): JCO Interviews: Dr. Jack G. Dale on Serial Extraction- Part 2
jco/interviews
Part 2
DR. BRANDT Under what circumstances would you suggest stripping teeth instead of removing
them?
DR. DALE From time to time, I will reduce the mesial surfaces of the primary cuspids in patients
where I do not intend to extract permanent teeth (Fig. 30).
I will do this to relieve a minor irregularity of the permanent incisors and where I do not want a
lingual collapse of the mandibular incisors. We know from research conducted by Moorrees and
Chadha that there is an increase in the crowding of both the maxillary and mandibular incisors when
they are emerging into the oral cavity. We also know that two millimeters of crowding in the incisor
segment in the mandible of males will recover to zero crowding by eight years of age on the
average. Females recover to approximately one millimeter of crowding. In the maxillary dentition of
both males and females there is not the same tendency for crowding. However, during the eruption
of the incisors, two to three millimeters of spacing is reduced to zero (Fig. 31). This is a significant
study, because it tells the clinician not to be alarmed with a slight amount of crowding in the early
stages of the emergence of the permanent incisors, and that the extraction or reduction in size of the
primary cuspids should be deferred. In fact, it may not be an extraction case at all.
We know from Moorrees' research that there is an increase in intercanine distance with the
emergence of the permanent incisor teeth (Fig. 32). The mandibular incisors emerge and the primary
mandibular cuspids are moved laterally. When these teeth come into occlusion with the primary
maxillary cuspids, they in turn are moved laterally and the space created enables the permanent
maxillary lateral incisors to emerge into a favorable alignment. This is referred to as "secondary
spacing" (Fig. 33).
If the primary cuspids are extracted or reduced in size when this natural phenomenon is
occurring, "secondary spacing" and an increase in intercanine distance may not occur. Thus, a
nonextraction malocclusion may be converted into one that requires extraction of permanent teeth.
A hereditary tooth size-jaw size discrepancy is characterized by an ectopic eruption of the
permanent mandibular lateral incisors and a premature exfoliation of the primary cuspids (Fig. 34).
Occasionally in nonextraction malocclusions, the primary second molars will be retained for an
unusually long period of time. Since these teeth are wider mesial-distally than the underlying
permanent second premolars, they force the first permanent premolars into a forward position in the
dental arch and thus impact the permanent cuspids. When this occurs, I will reduce the mesial
surface of the primary second molar the amount of the leeway space (Fig. 35).
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This usually provides sufficient space for the emergence of the cuspid. At times, I will reduce the
primary second molar to allow the first premolar to emerge. I will reduce the distal surface of the
primary second molar to ensure the conversion of a straight terminal plane into a mesial step in
preparation for a Class I relationship of the permanent first molars. I do this when the primary
maxillary second molars are exfoliated prior to those in the mandible and I can afford to allow the
molars to move mesially. Ideally, we prefer to see the mandibular molars lost first. For a more
detailed discussion of interproximal reduction of primary teeth, I refer the reader to an excellent
article by Dr. Rudolph Hotz in the American Journal of Orthodontics, July 1970.
DR. BRANDT What do you consider to be signs of a true hereditary tooth size-jaw size
discrepancy?
DR. DALE This may be revealed by:
1. Premature exfoliation of one or more primary cuspids (Fig. 36).
2. A midline displacement of the mandibular incisors, with one permanent lateral incisor blocked
out (Fig. 37).
3. Gingival recession on a prominent mandibular incisor (Fig. 38).
4. Prominent cuspid bulging in the maxilla or in the mandible due to crowding of the cuspids in the
unerupted position (Fig. 39).
5. A splaying out of incisor teeth in the maxilla or mandible due to the crowded position of the
erupted cuspids (Fig. 40).
6. Ectopic eruption of the permanent maxillary first molars resulting in the premature exfoliation of
the primary second molars (Fig. 41).
7. A vertical palisading of the maxillary permanent first, second and third molars in the tuberosity
area, indicating a lack of jaw development.
8. Impaction of the permanent mandibular second molars.
9. A crescent form of resorption on the mesial aspect of the roots of the primary cuspids, caused by
the crowded permanent lateral incisors, and
10. Maxillary-mandibular alveolar dental protrusion without interproximal spaces.
With further thought, this list could be extended.
DR. BRANDT Of course, there are other causes of crowding than heredity.
DR. DALE In addition to heredity, other causes of crowding are:
1. Premature loss of primary teeth resulting in the reduction of arch length due to the drifting of
permanent teeth (Fig. 42).
2. A reduction of arch length as a result of interproximal caries in the primary teeth ( Fig. 43).
3. Uneven resorption of the primary teeth (Fig. 44).
4. An aberration in the eruptive pattern of the permanent teeth.
5. Contracted dental arches as a result of mouthbreathing, thumbsucking, occlusal interference or
muscle imbalance (Fig. 45).
6. A discrepancy in the size of individual teeth.
7. Oversized restorations and crowns (Fig. 46).
8. A discrepancy in the size of teeth in the mandibular dentition when related to those in the maxilla,
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assessed by the Bolton analysis.

9. Emergence sequence (Fig. 47), and
10. Prolonged retention of primary teeth.
Again, this list could be longer with further deliberation.
DR. BRANDT Which cases are the best candidates for serial extraction?
DR. DALE The most ideal conditions for serial extraction are:
1. Relatively severe hereditary tooth size-jaw size discrepancy.
2. A mesial step mixed dentition malocclusion, developing into a Class I permanent molar
relationship.
3. Minimal overjet and overbite relationship of the incisor teeth.
4. Orthognathic facial pattern or a slight maxillary-mandibular alveolar dental protrusion.
5. Class I malocclusions are more ideal for serial extraction because the dentition is basically in a
favorable relationship and successful treatment is possible with minimal mechanotherapy.
DR. BRANDT You do treat some Class II cases with serial extraction?
DR. DALE Yes, but if you do not exercize extreme caution, you can aggravate a Class II
malocclusion by the lingual collapse of the mandibular incisors which increases the overbite and
overjet relationships of the anterior teeth, and by utilizing space that will be required later when
multi-banded appliances are placed. In Class II cases, I always inform the parents that bands will be
required to treat the malocclusion when all the permanent teeth have erupted.
DR. BRANDT What is the typical serial extraction treatment that you use in Class II division 1
cases?
DR. DALE A common treatment plan in my office for Class II division 1 malocclusions is:
A. INITIAL PERIOD OF INTERCEPTIVE TREATMENT. During this period, which may extend
approximately one to one and a half years, I extract the primary maxillary first molars and the
permanent maxillary first premolars as early as possible. This provides space for the retraction of the
permanent maxillary anterior teeth. I place bands on the permanent maxillary incisors and first
molars and on the primary second molars. I progress to a maxillary edgewise arch and a high pull
headgear. I retract the maxillary incisors, intrude them and torque the roots distally. This reduces the
overjet and overbite relationship of the incisors.
In the mandible, I extract the primary cuspids to relieve the permanent incisor crowding. Later, I
extract the primary first molars and, finally, the permanent first premolars. To prevent the collapse
of the mandibular incisors and the accentuation of the curve of occlusion, I place bands on the
permanent incisors and first molars and on the primary second molars. I progress from levelling
arches to an ideal arch.
The type of treatment utilized in the correction of Class II malocclusions in the interceptive phase
is determined by the type of Class II malocclusion and by the growth pattern.
B. PERIOD OF OBSERVATION. During this period, retention appliances are worn and serial
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extraction is continued. The parents are informed that appointments will be required every three
months for assessment of growth and development with the aid of diagnostic records and that teeth
will be extracted as indicated.
C. SECOND PERIOD OF MULTIBANDED TREATMENT. When all the permanent teeth have
erupted, a multibanded appliance is placed and the Class II is corrected, adhering in my office, to the
Tweed principles of edgewise treatment.
DR. BRANDT Would you consider serial extraction in Class II division 2 mixed dentition cases?
DR. DALE First a word of caution. Class II division 2 malocclusions are characterized by a
macrogenia or a prominent pogonion. Every effort should be made to maintain the mandibular
incisors as far mesially as stability will permit for fear of overflattening or "dishing-in" the face,
because the mandibular incisors tend to tip in a lingual direction during this procedure. However, if
the chin is very pronounced, the patient unavoidably will have undesirable facial esthetics whether
treated nonextraction, extraction, or left untreated.
If the patient has a true hereditary tooth size-jaw size discrepancy plus a Class II division 2
malocclusion, I will treat it by extracting permanent teeth. If not, I will treat it nonextraction. If I
treat a division 2 case by serial extraction, I always inform the parents that bands will be required
when all the teeth have erupted.
DR. BRANDT What is your typical serial extraction treatment plan for a Class II division 2 case?
DR. DALE A typical treatment plan for Class II division 2 in my office is:
A. INITIAL PERIOD OF INTERCEPTIVE TREATMENT. Quite often in Class II division 2 I will

begin treatment with a cervical facebow headgear on the permanent maxillary first molars. I do this
to initiate the correction of the Class II molar relationship and to extrude the molars, which causes
the mandible to rotate down and back. This reduces the prominence of the chin and tends to correct
the deep overbite relationship of the anterior teeth. A maxillary Hawley bite pad is worn in
conjunction with the headgear simply to facilitate distal movement by disengaging the cusps of the
posterior teeth.
When the Class II molar relationship has been corrected, I band the permanent maxillary incisors
and the primary maxillary second molars. I progress through a series of levelling arches to an
edgewise arch, attach a high pull headgear to anterior hooks, and torque the maxillary incisors up
and back into a more favorable relationship. The facebow headgear and the maxillary Hawley
appliance are not worn during this stage of treatment.
In the mandible, I place bands on the permanent first molars and incisors and on the primary
second molars, and progress through a series of levelling arches to an ideal edgewise archwire. I do
this in an effort to upright the permanent mandibular incisors, to maintain arch length, to create ideal
arch form, and to establish a favorable curve of occlusion.
Frequently in Class II division 2, if dental development permits, I will extract the primary first
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molars first and the primary cuspids second. However, if the mandibular incisors are severely
crowded, I will extract the primary cuspids first and the primary second molars second. If so, I
prevent the lingual collapse of the incisors with the banded appliance.
B. PERIOD OF OBSERVATION. Again, during the period of observation, retention appliances are
worn and serial extraction continued. The maxillary Hawley includes an anterior bite pad, and a
lingual arch is worn in the mandible to prevent collapse of the anterior teeth.
C. SECOND PERIOD OF MULTIBANDED TREATMENT. Again, a multibanded appliance is
placed when all the permanent teeth have erupted, including the permanent second molars, and the
malocclusion is corrected with edgewise treatment. Under no circumstances would I carry out serial
extraction in a Class II division 2 without appliance therapy.
DR. BRANDT Do you recommend serial extraction in crowded open bite mixed dentition cases?
DR. DALE To preface my remarks on the treatment of this type of malocclusion, I would like to list
the characteristic features of a true hereditary open bite malocclusion as outlined by Subtelny: 1. An
excessively steep mandibular plane angle or a high angle facial configuration. 2. A retrognathic
mandible relative to cranial base. 3. A significantly greater anterior vertical dimension to the skeletal
face, especially in the lower. 4. A maxillary-mandibular alveolar dental protrusion. 5. A relatively
short ramus height. 6. A relatively large gonial angle. 7. A significantly greater eruption of the
maxillary molars and incisor teeth. This is an extremely important observation and must be
considered when planning treatment. 8. A significantly shorter posterior cranial base. 9. A relatively
acute angle between the posterior cranial base and the anterior cranial base. 10. A relatively distal
maxillary alveolar process in relation to the anterior cranial base.
A word of caution relative to Subtelny's remarks regarding the overeruption of the maxillary
molars, which contributes to the open bite relationship. It is quite possible that the extraction of
permanent molars would be preferable to the extraction of premolars in the attempt to correct this
malocclusion. Molar extraction has the same effect as intruding molars. By encouraging the
mandible to rotate up and forward, it reduces the steep mandibular plane, the long lower anterior
face height, the retrognathism of the mandible, and the anterior open bite. I have followed this
treatment plan many times with dramatic results.
With this in mind, let's look at how I use serial extraction in the various types of open bite
malocclusion.
CLASS I, HIGH ANGLE, OPEN BITE MALOCCLUSION. If the open bite is moderate, I will
proceed with serial extraction, extracting primary cuspids or primary first molars, depending on the
dental development, and ultimately the first premolar teeth. This provides space for the mesial
migration of the posterior teeth and the distal migration of the anterior teeth. The mesial migration
of the posterior teeth will tend to have the same effect as the extraction of permanent molars. The
distal migration and lingual tipping of the anterior teeth will initiate the correction of the alveolar
dental protrusion. I avoid the use of a lingual arch during the observation period with this type of
problem, because it interferes with the correction of the alveolar dental protrusion.
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CLASS II, HIGH ANGLE, OPEN BITE MALOCCLUSION. Under no circumstances do I use a
facebow headgear to correct the Class II molar relationship with this type of facial configuration.
Extrusion of maxillary molars aggravates the problem by rotating the mandible down and back, thus
increasing the retrognathism of the mandible, the anterior face height, and the anterior open bite. I
proceed with the serial extraction program in the same manner as I did with the Class I
malocclusion. However, in this instance, I often place a high pull facebow headgear to the maxillary
first molars to prevent these teeth from extruding while the mandibular posterior teeth drift forward
producing the favorable treatment response.
Relevant to the remarks by Subtelny that the maxillary incisors are usually overerupted, I hestitate
to use vertical elastics in the incisor segment during the multibanded phase of treatment. This
attempts to close an open bite by the overeruption of teeth that are already overerupted.
CLASS I, LOW ANGLE, OPEN BITE MALOCCLUSION. Since the list of characteristics
describing a typical hereditary open bite malocclusion does not include a low mandibular plane
angle, I suspect that the open bite relationship in this case is caused by an environmental factor.
Therefore, I attempt to determine the cause of the open bite and, if possible, eliminate it. Then I
direct my attention to the correction of the malocclusion. Treatment may proceed in several different
directions, depending on the type of Class I dental and facial relationship.
If a true hereditary tooth size-jaw size discrepancy exists, I proceed with serial extraction taking
necessary precautions and utilizing appliance therapy where necessary.
CLASS II, LOW ANGLE, OPEN BITE MALOCCLUSION. The remarks about Class I low angle
are relevant to the correction of this problem. Low angle faces are quite often associated with an
excessive interocclusal space due to the undereruption of posterior teeth. When this is the case, I am
not so concerned about extruding molars and I proceed with a facebow headgear to initiate the
correction of the Class II molar relationship. I do this, knowing that the anterior open bite is not due
to an overeruption of molars, but to an undereruption of incisors caused by an environmental
influence such as thumbsucking. In this instance, I quite often use vertical elastics in the anterior
area to correct the anterior open bite. I proceed with caution, however, since I know that a low
skeletal pattern is also related to a deep overbite relationship of the incisor teeth.
CLASS III, OPEN BITE MALOCCLUSION. If I diagnose a pseudo Class III, I correct the anterior
crossbite and proceed with serial extraction. If my diagnosis reveals a true hereditary Class III
malocclusion, I am reluctant to initiate serial extraction.
Earlier, I classified Class III malocclusion into four categories: a prognathic mandible, a
retrognathic maxilla, a mandibular alveolar dental protrusion, a maxillary alveolar dental retrusion.
With mandibular prognathism, the treatment of choice is quite often surgery. To treat a
retrognathic maxilla, palatal separation and Class III mechanics may be indicated. A mandibular
alveolar dental protrusion is often treated by the extraction of mandibular premolars only. A
maxillary alveolar dental retrusion is quite frequently treated without the extraction of teeth at all.
None of these treatment plans include the extraction of four first premolar teeth. Therefore, it would
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be unwise to proceed with serial extraction in such cases.
On occasion, I have treated Class III malocclusion by extracting four first premolars, when there
was a maxillary alveolar dental retrusion with severe crowding and a mandibular alveolar dental
protrusion. The removal of the maxillary teeth provides space for the alignment of the maxillary
dentition. The removal of the mandibular teeth provided space for the retraction of the mandibular
anteriors.
I would like to stress that serial extraction facilitates the correction of a true hereditary tooth
size-jaw size discrepancy and is not intended to correct a Class III malocclusion. Mixed dentition
Class III treatment, with or without serial extraction, is a complicated undertaking. Treatment is
often extensive, prolonged and may have to be repeated. Concerning this type of malocclusion Dr.
Tweed said: "The size of the orthodontist's heart and his inherent decency has much to do with the
success or failure of such treatment."
DR. BRANDT Which headgears do you use?
DR. DALE I sometimes use the posterior pull facebow headgear attached to maxillary first molars.
I classify it into nine categories, which are divided into three groups:
1. High pull headgear with long, medium, and short outer bow.
2. Straight pull headgear with long, medium, and short outer bow.
3. Low pull headgear with long, medium, and short outer bow.
The high pull headgear has a distal and intruding influence on the maxillary molars; the straight
pull has primarily a distal influence; and the low pull has a distal and extruding influence.
Therefore, the high pull headgear is suitable for high angle patients; the low pull for low angle
patients; and the straight pull is suitable for those in between. If we move teeth posteriorly with a
headgear, we must be prepared to remove the third molars at a later date.
I most often use the anterior pull J hook headgear attached to the maxillary arch in the anterior
area and I classify it into three categories: High pull, Straight pull, and Low pull. The J hooks may
be attached to hooks on the edgewise arch are they may slide freely on the arch in contact with the
mesial of the cuspid brackets. The high pull mode is particularly suitable for torquing maxillary
incisors in the treatment of deep overbite malocclusions; the straight pull is helpful in retracting
protruding incisors; and the low pull is used primarily in the treatment of anterior open bites caused
by environmental factors.
Headgears can be used to move teeth or to hold them, depending on the malocclusion. Their basic
use is to move teeth distally without risk of moving posterior teeth forward. Class II intermaxillary
elastics will move anterior teeth distally but, if anchorage preparation has not been suitable, that
movement will be accompanied by an unfavorable extrusion and mesial migration of mandibular
first molars. Quite often, the maxillary incisors are tipped lingually and extruded unfavorably with
Class II elastics, unless a high pull headgear is used in conjunction with them. Similarly,
intramaxillary elastics, Alastiks, coil springs, or loops can move incisors distally, but the posterior
teeth will move forward unless they are held by headgear therapy.
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DR. BRANDT How long each day do you have your patients wear their headgear?
DR. DALE I have them wear headgear preferably from four o'clock in the afternoon to seven
o'clock in the morning— a period of fourteen hours, excluding the dinner hour. I am reluctant to ask
patients to wear their headgears while out-of-doors or at school.
DR. BRANDT Do you expect serial extraction to make treatment easier and shorter?
DR. DALE My objective in using serial extraction is to make treatment easier and to make
mechanotherapy less complicated, less extensive and shorter, especially during the teen years. In my
practice, treatment is divided into four categories:
1. ONE PERIOD OF INTERCEPTIVE GUIDANCE extending approximately five years, from
seven and one-half to twelve and one-half. This treatment plan consists entirely of the guidance of
occlusion including serial extraction and is, in my opinion, the most ideal service that I can provide.
Unfortunately, I am able to produce excellent occlusion in only very few patients treating in this
manner but, when I do, it is the most rewarding and most satisfying because the results are achieved
without multibanded mechanotherapy.
2. AN INITIAL PHASE OF INTERCEPTIVE GUIDANCE extending approximately four years,
from seven and one-half to eleven and one-half, plus A SECOND PERIOD OF MULTIBANDED
TREATMENT extending, on the average, for one year, from eleven and one-half to twelve and
one-half. Class I treatment falls primarily into this category.
3. AN INITIAL PERIOD OF INTERCEPTIVE TREATMENT extending approximately one year,
from eight and one-half to nine and one-half; A PERIOD OF INTERCEPTIVE GUIDANCE
extending approximately two years, from nine and one-half to eleven and one-half; and A SECOND
PERIOD OF MULTIBANDED TREATMENT extending, on the average, one and one-half years,
from eleven and one-half to thirteen. Class II and Class III malocclusions fall primarily into this
category.
4. ONE PERIOD OF MULTIBANDED THERAPY extending, on the average, for one and one-half
to three years, from eleven and one-half to fourteen and one-half. Serial extraction is not involved in
this treatment plan. To me, this is the least desirable. Wherever possible, I try to avoid extensive
treatment in the teenage period.
Naturally, this is a general classification which may vary considerably depending on the
individual patient, the malocclusion and the dental age.
DR. BRANDT Jack— this is most essential— how stable are the treated results?
DR. DALE I like to think that my results are stable whether they are treated early or late. I was
taught that the most ideal conditions for stability are achieved when the teeth are placed in a
harmonious relationship early. I was also taught that if prolonged retention is required, either the
occlusion is not satisfactory or the dentition is not in harmony with the skeletal pattern and soft
tissue matrix. There are exceptions. For instance. I keep mandibular cuspid-to-cuspid retainers in
patients for prolonged periods to maintain incisor alignment where there is horizontal growth of the
mandible. I do this between the ages of thirteen and seventeen, when the maxilla has stopped
growing and the mandible is still growing.
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Serial extraction allows teeth to become aligned when they emerge into the oral cavity, rather
than stay in crowded, unfavorable conditions for several years. In the case of alveolar dental
protrusion, the procedure allows the mandibular incisors to upright lingually to a position of
balance, and then you treat the dentition to that position. This alone will reduce multibanded
mechanotherapy by six months and will contribute to the stability of the dentition. I have found that
in many cases the need for retention is minimal. However, you must remembers that under ideal
serial extraction conditions, you are not dealing with severe skeletal discrepancies, or severe
overbite or overjet problems. Therefore, the need for retention should be less.
DR. BRANDT Do you feel that if the roots of the permanent incisors complete their formation in a
more favorable position, their stability is enhanced?
DR. DALE Quite honestly, I do not know. It seems logical to me that if a tooth completes its
formation in the site where it will remain when treatment is completed, it will be more stable.
Conversely, if you leave a tooth in a crowded, tipped and rotated position for several years and then
move it to a new position relatively rapidly, I feel it will be less stable for a period of time and
require retention.
DR. BRANDT Does the initiation of serial extraction with the removal of deciduous teeth always
mean that permanent teeth will be removed?
DR. DALE Once you initiate serial extraction, more often than not you end up by extracting the
four premolar teeth simply because arch length, which is deficient to begin with, is reduced even
more. In spite of a thorough diagnosis and even though I am confident that I am dealing with a true
hereditary tooth size-jaw size discrepancy, I occasionally change my plan to non extraction. I am
always prepared to treat nonextraction if I think I can do it successfully with stability and without
asking the patient to wear retainers for a prolonged period of time.
DR. BRANDT Is that the way you present it to parents?

DR. DALE In most instances, at the beginning of treatment I inform the parents that extractions
may be necessary to produce a successful and stable treatment result. Later, if extractions are not
necessary, they are relieved and happy. I find it best to prepare the parents during the case
presentation when I have them before me as a captive audience, while I am describing all phases of
treatment for their child.
DR. BRANDT Many times, practitioners prescribe the removal of deciduous canines without any
diagnostic records. What do you think of such a procedure?
DR. DALE Inexcusable! Serial extraction should not be initiated without a thorough diagnosis with
complete records. One of the most crucial decisions that we make as clinicians is whether to extract
teeth in the correction of a malocclusion. To do this, we need all of the intelligence, training and
experience that we can muster. To add the dimension of time, to complicate it by growth and
development, and to carry it out by serial extraction procedures is even more demanding. Therefore,
just to "pluck out" teeth without study, planning and discussion is, as I said, inexcusable.
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DR. BRANDT Do you have a definite timetable for taking certain records before, during and after
treatment?
DR. DALE Definitely. Let me give you that for the categories of treatment I just outlined.
1. ONE PERIOD OF INTERCEPTIVE GUIDANCE. Here, a complete set of records is taken: a. at
the beginning, b. periodically during the guidance period, c. when the dentition is complete, and d.
at two, five and ten years later.
The first set of records aid in the diagnosis. The records taken during the guidance period are
used to monitor progress, to assess the timing of the extractions, and to evaluate growth and
development. The records taken at the end of the guidance period aid in the assessment of the final
result. Subsequent records are taken to evaluate stability and the remaining growth and development.
2. AN INITIAL PERIOD OF INTERCEPTIVE GUIDANCE and A SECOND PERIOD OF
MULTIBANDED TREATMENT. A complete set of records is taken: a. at the beginning, b.
periodically during the guidance period, c. at the beginning of the multibanded period of treatment,
d. at the end of treatment, and e. at two, five, and ten years later.
The most crucial records, here, are taken prior to and during the interceptive guidance period to
diagnose the malocclusion, to assess the progress of serial extraction, to monitor the position of the
mandibular incisors, to observe the root length and relative positions of the unerupted cuspids,
premolars, and second molars in an effort to predict extractions, emergence, and the initiation of
multibanded treatment. The records are also useful in determining the changes in the soft tissue
profile, mandibular position and the occlusal plane.
3. AN INITIAL PERIOD OF INTERCEPTIVE TREATMENT, A PERIOD OF INTERCEPTIVE
GUIDANCE, and A SECOND PERIOD OF MULTIBANDED TREATMENT. With this treatment
plan, records are taken: a. at the beginning and at the end of the first period of treatment, b.
periodically during the guidance period, c. at the beginning and at the end of the second period of
active treatment, and d. at two, five and ten years later.
4. ONE PERIOD OF MULTIBANDED TREATMENT. In this instance, I take records; a. prior to
the beginning of treatment, b. approximately two months after treatment is completed, and c. two
years after treatment and, in some instances, five and ten years after treatment.
DR. BRANDT Do you use these records to validate your original treatment plan?
DR. DALE I am constantly comparing my original records with progress and final records to learn
if I was correct and, if not, where I could have improved. I group malocclusions and relate them to
each other as to objective, treatment plan, treatment method, and results. I try to compare them,
classify them, and standardize them in an effort to improve my methods and to achieve the best
possible results.
DR. BRANDT Have you very often discarded the concept of extracting permanent teeth when later
records were studied?
DR. DALE I rarely change my treatment plan from extraction to nonextraction except for the
occasional borderline tooth size-jaw size discrepancy. If sufficient energy is spent establishing a
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Article Text 10
sound diagnosis with complete records, the treatment usually proceeds without alteration.
DR. BRANDT Is there a precise point in your extraction program when you insert appliances?
DR. DALE In most cases, I insert a multibanded appliance when the maxillary permanent cuspids
and the mandibular second premolars have erupted sufficiently. Quite often, especially in deep
overbite cases, I will delay band placement until the permanent second molars have emerged.
Prior to the case presentation, when I am studying the diagnostic records, I assess the dental age
of the patient according to the method outlined by Dr. Elizabeth A. Fanning ( Fig. 48), which enables
me to predict precisely when the cuspids, premolars, and second molars will emerge. As a result, I
am able to outline the treatment plan more specifically and with more confidence during the case
presentation (Fig. 49).
The longitudinal growth and development studies of Moorrees and his associates, Fanning, Gron,
Chadha, Reed, Hunt, and Hurme; and of Meredith and many others have provided a scientific basis
for prediction of the development of the dentition, for guidance of occlusion including serial
extraction, and for timing of treatment.
The dentition counts as a separate tissue system in the growth process and the timing of its
growth changes is dependent on the formation of the teeth. An absolute prerequisite, therefore, for
the prediction of events in the development of the dentition is the establishment of the dental age of
the patient.
Tooth emergence is a convenient method for dental age assessment ( Fig. 50), but its value is
limited. Emergence is a single, fleeting occurrence in the continuous process of tooth eruption, and
the chance that your observation will be at that precise moment is small. Moreover, emergence may
be influenced considerably by exogenous factors such as infection, injury, obstruction, crowding and
extraction of teeth. The rate of eruption may be decreased by Vitamin A or D deficiency,
hypothyroidism, and sickness; the rate may be increased by prolonged intrauterine development,
semi-starvation, hyperthyroidism, cortisone administration, prolonged sleep and just increased
activity, to mention only a few. Tooth formation ( Fig. 48) is preferable to tooth emergence for
assessing dental age. It is not influenced as markedly by exogenous factors and a rating is possible at
all times from birth until the completion of the third molars.
Root resorption of the primary dentition is also utilized by Dr. Fanning for the determination of
dental age from four to twelve years. However, it is subject to considerable variation. Combined
with formation and emergence it completes the developmental history of the dentition.
DR. BRANDT Do you feel that growth prediction could be a deciding factor regarding planned
extractions?
DR. DALE Prediction is based on a statistical analysis of data derived from measurements of a
great number of people on a longitudinal basis and cannot be applied with absolute accuracy to an
individual whose growth and development are subject to innumerable unforeseeable influences of
heredity and environment. However, as Ricketts says, "The ability to forecast natural growth lies at
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Article Text 11
the very heart of contemporary clinical orthodontics. Without this ability on a reasonable basis, the
orthodontist will have difficulty in evaluation of his treatment techniques." Therefore, we must
establish treatment objectives and attempt to assess natural growth and development, tooth
movement, and soft tissue behavior.
In orthodontics, we are interested in predicting the ultimate size and rate of maturation of the
jaws; the ultimate size, rate of maturation, and emergence of the teeth into the oral cavity; and the
ultimate treatment result. We are also interested in the adolescent growth spurt of the body and its
relationship to accelerated growth in the craniofacial complex, and we must be interested in the
relationship between chronological age, skeletal age, and dental age.
Utilizing information from longitudinal studies, the clinician can predict events in the
development of the dentition more accurately. For instance, we know that the unerupted permanent
tooth is literally standing still until one-half of its root is formed; that teeth emerge into the oral
cavity when three-quarters of their roots are formed (Fig. 51A); that it requires two and one-quarter
years for the cuspid root to go from one-quarter to one-half root length and one and one-half years to
go from one-half to three-quarters root length (Fig. 51B); that it requires one and three-quarters
years for the first premolar root to go from one-quarter to one-half root length and one and one-half
years to go from one-half to three-quarters root length (Fig. 51B). Armed with this information, the
clinician can predict the emergence of these teeth and time his extractions more precisely by
studying periapical radiograms. Similar information associated with the maxillary incisors, the
second premolars, and the second molars will guide him in the timing of interceptive and
multibanded treatment.
DR. BRANDT Do you feel that planned removal of deciduous teeth exercizes some control over the
eruptive sequence of the permanent teeth?
DR. DALE Yes! In the January 1962 issue of Angle Orthodontist, Fanning described the effects of
the extraction of primary teeth on the rate of root formation and eruption of the underlying
permanent teeth. No change in the rate of root formation of the premolar was observed after the
extraction of the primary molar. However, an immediate spurt occurred in the eruption of the
premolar regardless of its stage of development and the age at which the primary molar was
extracted. Early clinical emergence occurred if the extraction of the primary molar coincided with
the later period of development of the premolar.
Three factors that may be applied by the clinician to decide the optimum time for the removal of
teeth in the guidance of occlusion are: the effect of extraction of a primary tooth upon the eruption
of its permanent successor, the amount of root formation at the time of emergence, and the length of
time for attainment of various stages of root development.
DR. BRANDT Do you ever have the oral surgeon scrape away some of the bone overlying the
unerupted bicuspid in an effort to hasten eruption?
DR. DALE I have not found this procedure necessary during serial extraction. However, I have at
times requested the removal of bone overlying a permanent mandibular second premolar when the
primary second molar has been lost prematurely. This certainly hastens the emergence of the second
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Article Text 12
premolar.
DR. BRANDT Can serial extraction started too early in the deciduous dentition delay eruption of
the permanent successors?
DR. DALE Fanning reported, in the case of early extraction of the primary molar, for instance at
four years of age, an initial spurt in the eruption of the premolar, but this spurt leveled off and the
tooth then remained stationary, erupting later than its anti-mere with a normally shedding primary
precursor. The studies of Moorrees, Fanning and Gron show that the permanent premolar is literally
standing still until one-half of its root is formed; that if the overlying primary molar is extracted
before the permanent premolar has reached one-half root length, the emergence of the premolar will
be delayed; that if the primary molar is extracted after one-half of the premolar root is formed,
emergence will be accelerated. If serial extraction starts with the extraction of the primary cuspids,
the length of the roots of the premolars is not an important consideration regarding the initiation of
the serial extraction. If, however, I am contemplating initiating serial extraction by the removal of
the primary first molars rather than the primary cuspids, then the length of the roots of the premolars
is an important consideration and guide for the commencement of the procedure.
FIGURES
Fig. 30
Fig. 30 Interproximal reduction of primary cuspid.
128
Figures 13
Fig. 31
Fig. 31 Available space in the incisor segment. (From Moorrees, C. F. A. and Chadha, J. M.: Available space for the
incisors during dental development, Angle 0. 35:12, Jan. 1965.)
Fig. 32
Fig. 32 Intercanine distance. (From Moorrees, C. F. A. and Reed, R. B.: Changes in dental arch dimensions expressed
on the basis of tooth eruption as a measure of biologic age, J. Dent. Res. 44:129,1965.)
Fig. 33
Fig. 33 Secondary spacing.
129
Figures 14
Fig. 34
Fig. 34 Ectopic eruption of the permanent mandibular lateral incisors.
Fig. 35
Fig. 35 Interproximal reduction of primary second molar.
Fig. 36
Fig. 36 Premature exfoliation of one primary mandibular cuspid with resulting midline discrepancy.
130
Figures 15
Fig. 37
Fig. 37 One permanent mandibular lateral incisor blocked out with midline discrepancy.
Fig. 38
Fig. 38 Gingival recession.
131
Figures 16
Fig. 39
Fig. 39 Cuspid bulging.
Fig. 40
Fig. 40 Splaying out of maxillary and mandibular incisors.
132
Figures 17
Fig. 41
Fig. 41 Ectopic eruption of maxillary first molars.
Fig. 42
Fig. 42 Premature loss of primary second molar.
133
Figures 18
Fig. 43
Fig. 43 Carious primary teeth.
Fig. 44
Fig. 44 Uneven resorption and prolonged retention of primary teeth with resulting change in eruptive path of permanent
teeth.
134
Figures 19
Fig. 45
Fig. 45 Contraction of maxillary dentition with mouthbreathing.
Fig. 46
Fig. 46 Oversized crown restoration.
135
Figures 20
Fig. 47
Fig. 47 Emergence sequence: Permanent second molars emerging relativelyearly, blocking out the maxillary cuspids
and mandibular second premolars.
Fig. 48
Fig. 48 The assessment of dental age by tooth formation. (From Moorrees, C. F. A., Fanning, E. A., Gron, A. M. and
Lebret, J.: Timing of orthodontic treatment in relation to tooth formation, Europ. Ortho. Soc. Trans., 38:87, 1962.)
136
Figures 21
Fig. 49
Fig. 49 Example of determination of dental age from periapical radiograms and Fanning's chart (Fig. 48).
A. Radiogram of a girl chronologically eight years of age. The second premolar has one-half of its root formed.
B. Radiogram of a girl chronologically eight years of age. The second premolar is just initiating its root formation.
C. Detail of Fanning's chart (Fig. 48) in the second premolar area. The mean for root initiation is seven years and the
mean for "root one-half" is nine years. Therefore, the girl in A has a dental age of nine and the girl in B has a dental age
of seven.The mean for "root three-quarters" is ten years.
The second premolar emerges at "root three-quarters" and multibanded treatment begins when the second premolar
emerges. Therefore, treatment will begin for the girl in A at nine years chronologically, and for the girl in B at eleven
years chronologically.
137
Figures 22
Fig. 50
Fig. 50 The assessment of dental age by emergence. (From Hurme, V.O.: Ranges in normalcy in eruption of
permanent teeth, J. Dent. Children, 16:11, 1949.)
Fig. 51a
Fig. 51A The extent of root formation at emergence.
Fig. 51b
Fig. 51B The average time for the development of quarter stages of root length.
138
Figures 23
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Feb(137 -): 139 Orthodontic Welding
ORTHODONTIC WELDING
ROBERT E. BINDER. DMD
Although welding is one of the technical procedures most commonly used by orthodontists, the
process is usually poorly understood and not employed efficiently. The purpose of this discussion is
to enable the orthodontist to employ electric-arc welding more effectively.
Definitions
Welding is the process by which the surfaces of metals are joined by mixing, with or without the
use of heat.
Cold welding is done by hammering or pressure. An example of cold welding is the gold foil
filling.
Hot welding uses heat of sufficient intensity to melt the metals being joined. The heat source is
usually an oxyacetylene flame or high amperage electricity. Orthodontic spot welders employ the
electrode technique and are used instead of soldering in cases where the heating cycle must be very
short, in order to prevent changes in the physical properties of the components being joined.
Theory
Orthodontic welding is achieved by passing a large amount of current for a very short duration
through an area of high resistance. Heat is generated of a magnitude great enough to cause melting
at the interface.
The copper electrodes in orthodontic spot welders have low resistance. The stainless steels used
in most orthodontic materials have 50 times the resistance of copper. Although somewhat variable,
the resistances at the electrode-stainless steel (electrode-weldmate) interface and at the stainless
steel-stainless steel (weldmate-weldmate) interface are respectively two and four times that of the
stainless steel alone.
Thus, in orthodontic welding, the resistance at the junction between the two pieces of stainless
steel being joined is much greater than that of either the electrode or the stainless steel masses.
Because of this differential resistance, essentially all of the heat generated by the current flow is
contained within the weld area. As sufficient heat is generated at the weldmate-weldmate interface,
the stainless steel components soften, flow and fuse together under the influence of mechanical
pressure, forming a weld nugget (Fig. 1).
Variables and Their Misapplication
Welding of stainless steel depends on the proper use of each of the following three variables:
1. The current flowing through the circuit.
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Article Text 1
2. The time during which the current is allowed to flow.

3. The mechanical pressure applied at the welding head.
The improper application of these variables can result in either over- or underwelding of the
weldmate. An underwelded assembly (Fig. 2) may have had insufficient current; or the current may
have been passed for an insufficient amount of time to achieve a high enough temperature for
melting; or pressure applied to the weldmate may have been inadequate to bring them into
maximum approximation.
Overwelding (Fig. 3), by overheating the metals, may yield as weak a joint as underwelding. The
appearance of sparks during the welding procedure is indicative of localized overwelding and
should be avoided. Another undesirable consequence of an overweld and an oversized joint is
progressive corrosion. This occurs when chromium is precipitated at the grain boundaries of each
crystal. This process is known as weld decay. Better grades of stainless steel usually contain trace
rare metals which help to inhibit this process.
A satisfactory welded joint is one which is strong, has not undergone oxidation (blackening), and
has not been overcompressed during fusion.
Clinical Application
The use of the spot welder in orthodontics is so common that it is almost a reflex. Herein lies the
problem. Application without understanding may result in a poor product. In order to minimize
errors, the following technique should be used:
1. The weldmates should be clean of all extraneous materials and oxides.
2. The surface of each electrode must be smooth, flat, and perpendicular to its long axis. When the
electrodes are together, they should be in total contact. If not, they should be filed until total contact
is achieved. Sparking and localized overwelding will result if interface contact is not uniform.
3. Adjust the welder to settings recommended by the manufacturer.
4. Select the proper electrode for the thickness or shape of the material to be welded. A broad
electrode should be used for thin material and a narrow one for thick material. This will allow
sufficient heat to reach the weld area, but not overweld or oxidize the weldmates.
If too narrow an electrode is used in welding a bracket (thick) to a band (thin), localized
overwelding will occur in the thin material and underwelding in the thick material (Fig. 4).
Proper electrode selection— a broad electrode for thin material in conjunction with a narrow
electrode for the thicker material— will result in an even distribution of the weld nugget (Fig. 5).
5. Insert the weldmates between the electrodes, close them together, and depress the weld button.
If sparking is observed, localized overwelding has occurred. The electrodes should be checked
for size and/or contact. If black areas are seen at the points where the electrodes contacted the
weldmates, overwelding has occurred.
ROBERT E. BINDER 138
Footnotes 2
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume Feb
Professor and Chairman Department of Orthodontics, New

Jersey Dental School
FIGURES
Fig. 1
Fig. 1 Welding components (left). Resistance/temperature cross-section (right).
Fig. 2
Fig. 2 Underwelding (insufficient current and/or time).
139
Figures 3
Fig. 3
Fig. 3 Overwelding (excess current and/or time).
Fig. 4
Fig. 4 Improper electrode selection for welding materials of different thickness. Bottom electrode too small for thin
material.
140
Figures 4
Fig. 5
Fig. 5 Proper electrode selection for welding materials of different thickness. Broader electrode under thin material.
141
Figures 5
MARCH 1976, VOL. 10 / ISSUE 3

The Straight-Wire Appliance: Explained and Compared 174
JCO Interviews: Dr. Jack G. Dale on Serial Extraction- Part 3 196
Isolation of Teeth for Bonding 218
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Mar(157 -): 158 THE EDITOR'S CORNER
the editor's corner

Conservation of human effort and elimination of human error is a hallmark of current orthodontic
thought in practice administration and in treatment technique.
In this issue of JCO, Dr. Larry Andrews in an installment of his series on the Straight-Wire
Appliance pictures the wire-benders of years past laboriously forming ideal edgewise archwires with
remarkably similar first, second and third order bends. This repetitive and difficult task was
enormously wasteful of human effort, but perhaps was necessary in the evolution of orthodontic
treatment objectives and appliance mechanics.
Dr. Andrews is certainly making a land mark contribution to both with his synthesis of the Six
Keys of Occlusion in his standardization of treatment objectives, and in his development of the
Straight-Wire Appliance as a vehicle to achieve those objectives in an efficient manner, sparing of
human effort and human error.
Dr. Sam Callender has applied the same yardstick to practice administration (JCO, January 1976).
He has computerized orthodontic practice administration to extract high performance from machines
in areas where machines excel and to free people to perform "people tasks". This has not only
resulted in conservation of human energy and reduction of human error, but it has permitted a
downgrading of repetitive, mechanical tasks in the hierarchy of costs.
The principle of downgrading task assignments in orthodontic practice is not new, nor is the
principle of further downgrading from auxiliaries to machines. We have had the MagCard
typewriter, which Jim Reynolds introduced in orthodontics, which permitted orthodontists to
achieve a new level of communication in a variety and volume that would have required an
additional employee to achieve. We have also seen how the Acme Electrofile with random filing
and instant retrieval may replace a repetitive chore which previously required a great deal of an
employee's time.
We are now in the age of the computer and we are indebted to Dr. Callender for harnessing the
special talents of the computer to the administrative organization of all facets of an orthodontic
practice. In actual practice, this has resulted in elimination of up to 80% of a bookkeeper's job, with
far less possibility of human error; the amalgamation of numerous office forms and records into two
records and the conversion of these to microfilm for convenient storage and retrieval of all patient
treatment and financial information, using microfiche viewers; the phasing out of a percentage of
auxiliary personnel with no loss of efficiency; and, best of all, freeing people— the doctor and his
staff— to care for people — the patient, his parents and his dentist .
Bob Schulhof at Rocky Mountain Data Systems (JCO, December 1975) has applied the computer
to a broad spectrum of orthodontic research for a significan contribution to our knowledge; and to
the development of a system of orthodontic diagnosis, treatment objectives and treatment evaluation
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Article Text 1
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Mar(157 -): 158 THE EDITOR'S CORNER
through a consideration of more factors and relationships that a human would be able to do or be
likely to do with paper and pencil.
It is not intended to imply that only these few people are in the forefront of progress in
conserving human effort and eliminating human error in orthodontics. This certainly seems to be the
direction that many people in orthodontics are taking. Paradoxically computerization and
mechanization should have a humanizing effect on our specialty. Personnel will be, as they should
be, more concerned with personal relationships. The emphasis will shift from the mechanics of
treatment and office administration to public relations, patient motivation, education, prevention,
and practice research. For the doctor, it will mean more time to devote to a study of his patients both
in terms of their behavior and in terms; of their morphological problems.
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Article Text 2
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Mar(174 - 195): The Straight-Wire Appliance: Explained and Compared
THE STRAIGHT-WIRE APPLIANCE Explained

and Compared
(This is the second article in a series in which Dr. Andrews is presenting the concept, the appliance
and the techniques of straight-wire treatment. The first article appeared in the February issue of
JCO.)
As reviewed in last month's installment, a study of 120 non-orthodontic normal models identified
six significant occlusal characteristics as structural elements in Nature's way of producing excellent
dentitions. These "Six Keys," which pertain to static occlusion, appear to be fully compatible with
the requirements of exemplary functional occlusion.
It seems evident that orthodontics, orthodontists and patients all would benefit if treatment goals
could be objectified. The Six Keys were offered for consideration as one step in that direction.
Described in 1972 in the American Journal of Orthodontics, 1 the Keys are being evaluated or taught
at leading schools of orthodontics, and have been applied by hundreds of doctors. I believe that
several years of clinical results now credibly sustain the proposition that the Keys are suitable
treatment objectives for at least 90 percent of North America's orthodontic patients— the large
majority who, sharing the preponderant alikeness of any species, have basically normal dentitions.
(Truly abnormal cases are excluded from this discussion, but they are relatively infrequent.)
Last month we referred to the finding that most of the orthodontic models displayed at national
and other meetings fell short of the six identified objectives. Moreover, the doctors whose work was
studied evidently differed among themselves as to desirable treatment goals. There was far greater
variation in what they were doing than was found in Nature's best work, and the latter source offered
the only consistent pattern for emulation.
Emerging Need for a New Appliance
The occlusion research (study of the non-orthodontic normals) had been launched to get a better
understanding of occlusion and how it was related to the buccolabial surfaces of the crowns. There
was no intention originally to produce a new appliance, but the need for one became evident. Since
orthodontists are a dedicated company of specialists who work hard, some of the explanation for
widely ranging end results seemed to lie in the nature of traditional appliances.
Building treatment into the appliance, to improve consistency of results or to ease the doctor's
workload, was not a new concept. It had been made when Holdaway and others began angulating
brackets on bands; when Lee introduced the torque bracket; and when Jarabak recommended torque
and bracket angulation.
But by the 1960's, although we had bands for each tooth type we were, for the most part, still
using untorqued edgewise brackets. Torqued brackets were available, but in no less than 5-degree
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Article Text 1
increments. Many doctors were ordering brackets angulated on bands, but there was no consensus
about the right number of degrees, and little if any advice being offered by manufacturers. No
bracket had angulated slots. We did not have brackets of varying thickness to satisfy in/out
requirements. And, of course, no brackets then had vertical curvature in the base and none had
torque built into the base.
So there was much to be done in improving precision and consistency of results, and in
transferring standardized, routine work from the chores of the doctor to the role of the appliance.
Like many orthodontists I had been laboriously doing "ballpark" wire-bending for certain teeth
for virtually all of my patients— for example, to get torque and tip in the upper anteriors, and in/out
alignment, and progressive torque for the lower posterior teeth. It was obvious that for any one of
those purposes, the amount of bend was similar for most patients — a fact confirmed when
measurements of the non-orthodontic normal models provided, for each tooth type, the needed
standards and goals. These data seemed totally compatible with the existing body of knowledge
about contact point locations and other relevant factors including aesthetic goals and occlusion.
Why, then, plod through the same processes for every patient and every tooth, to achieve effects that
an advanced appliance could deliver?
A doctor's wisdom and experience can never be made obsolete by technology, but such resources
deserve to be focused where they can justify their cost— focused especially on diagnosis, planning,
and total treatment management. An orthodontist may be proud of his skill as a mechanic, but he has
more important responsibilities that cannot be delegated.
After all, there are only a few tooth types. Appliance design could take advantage of known
commonalities and uniformities, conducting teeth at least to the "ballparks" of angulation,
inclination and in/out objectives. Ultimate detailing, if indicated in some cases, would be a suitable
application of the doctor's expertise; but the Six Keys could be preprogrammed. (If you're heading
for a specific but distant address, why walk the first thousand miles?)
However, it is one thing to decide the positions teeth should be in, and something else to deal
with the dynamics of getting them there. Here we encounter equal and opposite effects,
interrelationships of three-dimensional forces and movements— a fabric of complexities. One
example is in the effect that anterior archwire torque has on the tip of upper anterior teeth. Failure to
understand this can result in improper posterior occlusion or undesirable spaces. This phenomenon
is shown in the "Wagon Wheel" illustration ( Fig. 1).
"There is no such thing as an isolated orthodontic act . . . Much more effort is required to prevent
or control unwanted movements than to apply the primary forces." 5 A proper appliance might
reconcile the interwoven forces and responses.
Problems of "Doing"
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Article Text 2
How to cope with the dynamics and other problems? Since, within any one dentition, tooth types
always are significantly different each from the other, each would require its own bracket— a
bracket type for each tooth type. This had never been done.
Moreover (and this is important), more certainty would have to be achieved somehow— more
specificity— about where the bracket should be located on the tooth. Why? Because where the
brackets are placed profoundly affects everything that is built into any appliance. Regardless of the
sophistication of bracket or appliance, if it is not located properly all that has been programmed into
it is proportionately altered. The torque required in the gingival one-third of a crown can be from 5
to 40 degrees different from that required by the occlusal half.
Measurements of the non-orthodontic normal models had provided data about the angular
positions of crowns in excellent occlusion, but the numbers alone would mean nothing. Such data
are useless unless known to be measurements taken from specified, unchanged crown sites, and
subsequent treatment must have the same consistent certainty of being launched from a known site.
Traditional bracket placement technique often involves measurement from an undependable

reference point or line, such as an incisal edge. Central incisor edges often have been altered by
fracture, chipping or wear. Certainly the height of central incisor crowns varies from patient to
patient, so any chosen, constant distance in millimeters from the edge will involve different
inclination requirements from patient to patient.
Another trouble source exists in the simple fact that different clinicians use different reference
points in the banding procedure. (Even using the same poor one could be a gain.) Some measure or
"eyeball" incisors, but with posterior teeth simply band to the marginal ridges. Some arbitrarily band
occlusally, some gingivally, thus facing different torque requirements for guiding a tooth to a given
position. Is it any wonder that we orthodontists have so much trouble communicating with each
other; that often, when trying to discuss a certain case or treatment in general, we have to diverge to
specify our individual procedures in banding or bracketing? "Two millimeters"— from what?
"Three degrees"— very well, but you mean the angle between which two lines?
Such a range in practice is one of the reasons why end results vary from orthodontist to
orthodontist, community to community, interstate and regionally. Another reason is that historically,
clinicians have related bracket to band, then band to tooth. A two-step procedure offers twice the
opportunity for error.
If the above discussion is valid, it requires these conclusions: The creation of an appliance with
built-in treatment destinations must be founded on prior selection of the crown site where the
essential measurements originate. Successful use of any appliance (but especially one with built-in
treatment) is equally dependent on knowledge and utilization of such a point. The chosen site may
have additional advantages if it is the point of contact for forces applied. But in any event, for such a
site to have scientific reliability, it must be precisely, dependably locatable and refindable.
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Article Text 3
So, I ask you now to consider a proposal that can deal with some of the problems all
orthodontists share. This is not a detour from explanation of the Straight-Wire Appliance, because
accurate bracket-siting is a "part of the package" of the Straight-Wire approach; and with the SWA,
the method I'm going to describe yields extra benefits not yet mentioned. However, this clinical
procedure can hold rewards for every orthodontist, regardless of what appliance he now uses or will
use next year.
Changes Needed
I am proposing, first, some changes in our thinking and our terminology. Whether we use bands
or direct bonding, we should think in terms of bracket placement, and never speak of banding, but
call the process "bracketing."
Another flaw in our attitudinal "set" is that all of us were trained to think in terms of the long axis
of the tooth, meaning crown-plus-root. But, our work is almost always keyed to the buccal or labial
surface of the crown. Thus, as crowns are our usual clinical base, they should also be our
communication base or referent. (Specifically, the clinical rather than the anatomical crown; that is
always my meaning.)
But primarily, we require a procedure that yields uniform, constant bracket-siting— keyed from
dependable features of the clinical crown. Of course, from one tooth type to another, buccolabial
crown surfaces differ in contours. Can we hope for a "common denominator," an easily identified
location common to all crowns?
The LACC
All of us have studied the development of teeth. We know that they form from embryonic lobes
that fuse together, creating the total crown. The resulting morphology includes consistent
developmental landmarks. Among these are the ridges and grooves on the crown's labial or buccal
surfaces. These ridges and grooves can be easily recognized, and are not significantly subject to
environmental alterations such as chipping, wear and fracture.
For several years now, users of the Straight-Wire Appliance have made good use of these
landmarks by successfully and consistently placing brackets at the mid-point of the long axis of the
clinical crown. I recommend that every orthodontist consider the advantages of this procedure.
Where is the long axis of the clinical crown (LACC)? Best viewed from the labial or buccal
perspective, the long axis of the clinical crown (LACC), for all teeth except molars, is located at the
mid-developmental ridge that runs vertically and is the most prominent portion in the central area of
the labial or buccal surface.
The long axis of molar crowns is identified by the dominant vertical groove on the buccal surface.
Viewed from mesial or distal perspective, the LACC is represented by a line that is parallel to the
mid-developmental ridge (or with molars, the dominant groove), and tangent to the middle of the
clinical crown on the labial or buccal surface (Fig. 2).
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The LA-Point
That vertical line, the LACC, is easy to find. But how far "up" on it should the bracket be placed?
At its mid-point (Figs. 2 and 4). The crown has no obvious horizontal axis or equator, so you
judge the point, just as you would easily select the mid-point on a quarter-inch line. You will be glad
to know that this works; the accuracy of this procedure has been measured and found satisfactory. It
is as accurate as judging the middle of sella turcica on a lateral headfilm— a common diagnostic
procedure that has been experimentally proven reliable.
The depth of the sulcus probably averages 1 mm in a healthy gingiva. If in doubt, you can
measure from the cementoenamel junction when establishing the mid-point of the clinical crown.
Nature, then, has made it simple for us. All we lack is a brief word or term for this chosen site.
We want to refer to a point on the Long Axis so why not call it the LA-point? True, that site-name
doesn't contain a reminder that we mean the clinical crown's long axis mid-point; but nobody ever
speaks of an "LA-point" in reference to any other axis; so the proposed abbreviation, having only
one usage, should suffice.
The adoption of a "new" reference point is not being recommended for the purpose of serving a
philosophy or a treatment fad. It is proposed because this landmark is refindable and is more reliable
than any other in use; more consistent, less exposed and less vulnerable to environmental hazards.
Fusion and ridge lines are unlikely to be changed in a human lifetime. We can gratefully accept
them as more of Nature's guidelines.
When we do so, we acknowledge the utility of the tooth portion made readily available to us—
the clinical crown. Its long axis is not parallel to that of our old standby, the long axis of the tooth.
The LACC is far more practical for measuring and for other uses. No x-rays needed, no guessing;
this axis can be directly seen, touched, even marked with a pencil and shown in a mirror to the
patient. Its tip and torque can be promptly and precisely established, and then watched during the
progress of treatment.
Moreover, keying to the long axis of the crown makes accurate bracket placement much easier.
One simply places the tie-wings of the bracket parallel to the LACC, and the base point of the
bracket (see Terminology) at the LA-point.
TERMINOLOGY
The long axis of the crown (LACC) and the LA-point have been discussed. Needed are brief
explanations of a few other word usages in this series. Some elements here are applicable only in
connection with use of the Straight-Wire Appliance.
Bracket Base The most lingual portion of the bracket stem (Fig. 3).
Bracket Stem The portion of a bracket between the bracket base and the most lingual portion of the
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slot (the slot base) excluding tie-wings (Fig. 3).

Slot Base The lingual wall of the slot (Fig. 3).
Base Point On the bracket base, the point that would fall on a lingual extension of the slot axis (Fig.
3).
Slot Axis The buccolingual (or labiolingual) centerline of the slot. It is equidistant from the gingival
and occlusal slot walls and is centered mesiodistally. Extended lingually, the slot axis would include
the base point and the LA-point; and it would be included by a labial or buccal extension of the
Andrews plane (defined below).
Slot Point The center point of the (buccolingual) slot axis (Fig. 3).
The Andrews Plane An imaginary surface that would intersect the crowns of normally occluded
teeth at their LA-points; or, in the case of an individual tooth, the plane that would separate the
occlusal and gingival portions of the crown at the LA-point (Fig. 4).
In full Straight-Wire technology, the extended plane also includes the base point and the slot axis.
Crown Angulation Crown "tip." It will be described in terms of degrees, plus or minus (Fig. 5). The
degree of crown tip is the angle formed by the long axis of the clinical crown (as viewed from labial
or buccal perspective) and a line perpendicular to the occlusal plane. A "plus reading" is awarded
when the gingival portion of the LACC is distal to the incisal portion. A "minus reading" is given
when the gingival portion of the LACC is mesial to the incisal portion.
Crown Inclination Crown "torque." It will be expressed in degrees, "plus" or "minus," representing
the angle formed by: (a) a line perpendicular to the occlusal plane; and (b) a line tangent to the
middle of the labial or buccal LACC, as viewed from mesial or distal perspective (Fig. 6). A plus
reading is given if the gingival portion of the crown is lingual to the incisal portion. A minus
reading is earned when the gingival portion is labial or buccal to the incisal portion.
"STRAIGHT-WIRE" DESIGN AND COMPARISONS
We have examined the reasons for one of the first design purposes established for the SWA:
pre-programming suitable treatment into the appliance. We have explored why bracket placement is
vital, and have proposed a new siting (and convenient terminology). Now let's scrutinize another
concept adopted early in the design process: that at the conclusion of active treatment, the bracket
slots should form so straight a line that a flat and unbent rectangular archwire could be placed in
them without bends or torsion, or one already there would be under no stress (Figs. 7C, 8C and 9g).
The SWA, if used as designed, utilizes a "straight" wire throughout treatment. Worth noting is a
fact that is significant to the entire SWA concept: at the beginning of treatment when SWA bracket
slots are as "maloccluded" as are the teeth, the slots actually are nearly enough aligned so they will
accept an archwire that is merely deflected, not kinked .
Now link that beginning-of-treatment fact with an image of the same slots at the conclusion of
active treatment. The progress of all slots toward the end-result has been coordinated, traveling
straight vector lines, the positional relationships always clear.
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Occasionally at the beginning of treatment there is a need for multiple loops. This is not truly a
departure from Straight-Wire treatment, for the working area of the wire (between the loops) is only
deflected. (With extraction cases, in the intermediate and later stages of treatment it usually is
necessary to install second order bends unless SWA Extraction Brackets are used.)
We can best understand how the Straight-Wire Appliance works by considering its design
features and how they differ from those of other contemporary appliances.
Straight-Wire technology is dependent, first, on the use of a specific, reliably locatable

bracket-siting point. It is also dependent on certain appliance design features. The SWA contains
some proprietary features not found collectively in conventional edgewise or pretorqued appliances.
Among SWA innovations are torque built into the base of all brackets, a base contoured vertically as
well as horizontally, tip built into the bracket, and in/out and molar offset built into the appliance.
Torque in Bracket Base
Here we deal with one of the crucial elements in SWA design.
"Torque" as orthodontists use the word is jargon. A mechanical engineer would object to our
misuse of the term, but we know what we mean: buccolingual or labiolingual inclination.
Exactly how is torquing accomplished by the SWA? The bracket base is inclined in relation to the
stem, allowing the stem to be parallel to the Andrews plane, and the LA-point, base point and slot
point to be included in the Andrews plane (Figs. 7C, 8C and 9g). Making the torquing function a
product of the base design allows all slots (at the completion of active treatment) to be aligned with
each other and thus receptive to a flat, unbent rectangular archwire. A separate bracket for each
tooth type is necessary, with torque built into the bracket base. Nothing in SWA design, except
compound base curvature, is so vital to effectiveness of the appliance.
The traditional non-torqued edgewise brackets are not suitable for Straight-Wire technology,
because manual manipulation of the archwire is required for torque and height (as well as for in/out
and molar offset). See Figs. 8A and 9a.
Pretorqued edgewise brackets also are unsuitable for Straight-Wire technology. They do
eliminate the need for manual torquing of the archwire, but second order bends are required because
the slots' relationships to the Andrews plane vary, proportionately to the tooth torque for each tooth
type, requiring an adjustment to be made in the archwire. Fig. 8B shows pretorqued edgewise
brackets in place on an upper central incisor and a bicuspid. One crown has positive inclination and
one has negative inclination. The pretorqued slot method cannot produce alignment of the slots at
the conclusion of active treatment, for the slot centers are not at the same height as the LA-points.
This is because each bracket's stem is at a right angle to the base of its pretorqued bracket.
The third drawing in Fig. 8B shows positive 7-degree and negative 7-degree pretorqued edgewise
brackets superimposed. When their bases are parallel, the slot centers line up; but that would occur
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clinically only if the crowns' surfaces were parallel. In fact, the crown surfaces of the upper central
incisor and upper bicuspid are not parallel, so the slots do not line up when the teeth are properly
positioned.
Fig. 9f shows pretorqued edgewise brackets located at the LA-points. Note that the slots do not
fall on the Andrews plane, so they require progressive archwire height adjustment (second order
bends) if they are to receive a full-size archwire passively. This dilemma might appear to be
resolvable by machining the slots progressively more gingivally, to allow them to line up. But Fig.
9d shows what would happen if this were attempted; the slots would run out of bracket material.
Compound-Contoured Bases
This is the second of "the crucial elements in SWA design."
Most conventional appliances have simple horizontal curvature in the bracket base. The
Straight-Wire Appliance added vertical curvature. It is the combination of the two that we refer to as
"compound contour" or "compound curvature."
Installing a bracket with a vertically flat base against the vertically curved surface of a tooth
allows a variety of slot-to-tooth positions. Figures 7 (A and B), 9 (c and e) and 10 (A, B and C)
show the problems. Not only is torque affected by any rolling motion during bracket placement. So
is the height of the slot in relation to the occlusal plane or Andrews plane, destroying proper
relationships between the LA-point and the slot axis. And third, the various positions involve the
distance of the slot from the tooth's surface, affecting in/out requirements.
The variation in torque requirement is illustrated in Fig. 10 (A, B and C), showing a bracket
rolled through a range of 7 degrees, a mere 50 percent of its potential range with this tooth. And the
tooth shown, a lower first bicuspid, does not contain the greatest crown curvature. To appreciate the
full significance of this factor, visualize the continuing up-and-down flow that could exist within one
arch, if flat-base brackets were rolled (each successive bracket in an opposite direction) to their
maximum points of variation (Fig. 7A, 7B and 9c).
Bracket bases that are not curved vertically are easy for the manufacturer to make but place the
burden on the orthodontist, for he must compensate for inherent slot location variables throughout
treatment.
Angulated Slots
Correct mesiodistal angulation is delivered by a process that is direct and cleanly efficient. A
gently flexed archwire is inserted into slots that are exactly as maloccluded as are the untreated
teeth. The slots are angulated for tip, but each bracket is squarely aligned with the LACC (Fig. 2).
As the archwire straightens itself, it carries along the teeth to their desired positions. Most or all,
manual wire-bending is eliminated. Most routine chores are reduced to inserting a series of
progressively larger, stiffer archwires, decreasingly flexed as the tooth positions improve and the
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bracket slots approach the formation of a single row. The ultimate Fining-up of the slots occurs
simultaneously with the achievement of the pre-programmed tip. Meanwhile there has been no
zig-zagging, no trial-and-error. no need for re-estimations of multiple directions, no guessing about
interacting compound forces, no compensatory manipulations to offset misjudgment of inaccurate
manual wire-bending. And because the bracket was not angulated, there was no opportunity for
rocking on a two point contact.
If any existing bracket with a horizontally curved base is angulated on the tooth to achieve tip,
this creates a two-point contact between tooth and two diagonally-opposite corners of the bracket
base, resulting in a potential for rocking (Fig. 11). The bracket-rolling range of 7 degrees shown in
Fig. 10 for an unangulated bracket would be replaced by a rocking potential of more than 7 degrees,
if the bracket were angulated on the tooth .
Even a sophisticated bracket with curvature and torque built into the base, if angulated on the
tooth would lose the advantages of built-in curvature and torque, for such a bracket also could rock.
To obtain the full effects of the Straight-Wire approach, tip must be built into the slot of the
bracket, torque must be in the base, and the base of each bracket must be contoured to fit firmly and
unchangingly when the bracket is installed "squarely" (not angulated) at the chosen site.
In/Out and Molar Offset
No one who has manipulated in/out and molar offset bends into wires for thousands of patients
will be surprised that measurement of the non-orthodontic normal models proved these features
suitable for building into the appliance. Figure 12 shows how this is done in the SWA.
Tooth types differ in buccolingual thickness, but there is a constant pattern in upper teeth, and a
different but constant pattern in lower teeth. (For example, molars are thickest, incisors thinnest in
both arches; but in uppers the lateral incisors are thinner than the central incisors.) The fact that the
relative thicknesses are constant and known allows the designer to vary the thickness of the brackets
accordingly— inversely, of course. Elimination of first order archwire bends has several advantages,
including time-saving and the enabling of en masse space closures without interference from
wirebends.
A 10-degree offset for the distal cusps of the upper molars is incorporated in the SWA brackets
for those teeth.
Other Aspects
Designing an individual bracket for each tooth type also permits innovations not involving the
slot or the base. SWA tie-wings, instead of being bilaterally symmetrical, step-out farther on the
gingival sides of posterior brackets, resulting in easier ligation and less frequent gingival
impingement (Fig. 13).
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The vertical tie-wings also are the convenient guides regularly used in siting the bracket in
relation to the crown. They straddle and parallel the LACC.
Identification
One further special design element in the Straight-Wire Appliance is that every bracket can be
identified as to its tooth type. Drop a tray, and your assistant can readily re-sort the brackets.
Extraction Brackets and Series
Bodily tooth movement usually is necessary in extraction cases, presenting a requirement for
anti-tip and anti-rotation forces (in addition to torque, tip and in/out). The amount required is
proportionate to the distance a tooth must be moved, and a formula has been worked out. 2 The use
of Extraction Brackets providing these additional features is desirable for all posterior teeth
requiring bodily movement.
The Standard SWA does not have anti-rotation and anti-tip built into the bracket. The SWA
program calls for production of three Extraction Brackets for each tooth type, but not all are
available as yet.
The Straight-Wire Again
Let's return for a moment to an earlier matter. Not counting the advantages during treatment,
what other values exist in having the archwire straight when the teeth are properly positioned?
1. This portion of the treatment plan terminates itself, automatically. A flexed archwire provides
force only until it returns to its original passive form. When it stops working, its passivity is a
signal that the goals are reached. You know that "you are there."
2. Even if a patient misses an appointment, no unplanned over-treatment occurs, because the

appliance is self-limiting.
3. The archwire is straight because the slots are lined-up, and their single-file ranking reflects the
same condition in the crowns' LA-points. An arrow would follow the slot axis and then pierce
the base point and the LA-point; all are on the Andrews plane. Thus you have an integrated,
relatively simple and easily understood set of relationships. The angulations, the inclinations,
the bracket sitings, the built-in treatment process itself— all are referenced to the same known
point on every tooth, a landmark that you can return to, or that another orthodontist can find if
he must repeat or extend your procedure because of injury or patient transfer. And finally, this
system of referencing and treating allows us to communicate precisely.
Further Comparisons
In commissioning this series of articles, the editor of JCO specifically asked that comparisons be
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drawn between the Straight-Wire Appliance and any others that resemble it. Several appliances that
were introduced after the SWA appear to contain one or more of the features that until then had
been found only in the Straight-Wire Appliance. However, drawing the explicit comparisons that
could, indeed, be helpful to orthodontists might raise questions of ethics. (The writer of this article,
although he designed the appliance, does not own, control or receive royalties from the company
manufacturing the SWA, but is among the stockholders.)
Actually, an explanation of the SWA design goals, the reasons for them, and the technology by
which they are achieved, has in this article provided enough explicit information so that readers can
make their own comparisons. Anyone who knows the essential components of the SWA, and the
reasons they were adopted, can prepare a checklist, and also can evaluate alternative components
and approaches offered by other appliances. I do not for a moment dispute the fact that I favor the
SWA combination of features, and cannot see how their integrated functioning can be productively
revised— although additions consistent with the total SWA concept (including more Extraction
Brackets) are approaching completion. The SWA is a part of the evolution of orthodontic
technology, evolution may be confidently expected to continue, and I have many times flatly
rejected any suggestion that this is "the ultimate appliance."
Two recently introduced appliances, manufactured by Unitek, offer torque in the faces of their
brackets, in amounts essentially identical to those established by the Six Keys research and built into
the bases in the SWA. Whether this reflects independent verification of the Key measurements is not
known to this writer. Both of the newer appliances referred to use vertically flat instead of
compound-contoured bracket bases. Tip is not built into the brackets.
An Ormco appliance introduced in 1975 at present provides torque built into the base for the 2nd
permanent molars; for all other teeth, torque is in the face of the brackets. Tip is achieved by
angulating the bracket on the tooth. Again, the familiar Six Key measurements are used.
No claim is made here for perpetual exclusivity or miraculous superiority of the SWA in any
particular. But as a simple statement of fact I suppose it can properly be stated that to the best of my
knowledge, the Straight-Wire Appliance is the only appliance now available that can reliably
position the LA-point, the base point and the slot axis on the Andrews plane. This is related to the
fact that no other provides individual bracket design with pretip in the bracket, pretorque in all
bracket bases, completely built-in in/out alignment, a compound-contoured base for precise fit to
each tooth type, direct bracket-to-crown reference during bracket placement, individual bracket
identification, and Extraction Brackets.
Of all these features, contoured bases and torque built into each base are the two most important
things to remember in understanding how the Straight-Wire Appliance fulfills its design purposes.
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FIGURES
Fig. 1
Fig. 1 The wagon wheel. Anterior archwire torque negates archwire tip in a ratio of 4:1. Clinical result is that the gingival
portions of the crowns converge 1° for each 4° of lingual torque placed in the wire.
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Figures 12
Fig. 2
Fig. 2 The long axis of the clinical crown, and the LA-point
Fig. 3
Fig. 3 Bracket components.
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Figures 13
Fig. 4
Fig. 4 Andrews Plane.
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Figures 14
Fig. 5
Fig. 5 Crown tip.
Fig. 6
Fig. 6 Crown inclination.
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Figures 15
Fig. 7
Fig. 7 (A) Rolling potential of a flat-base bracket on curved surface of a crown, indicating effects on torque, on height of
slot, and on horizontal distance of slot from intended bracket site- which affects in/out requirements. (B) Three of the
possible bracket positions inherent in the rolling potential described above. (C) Bracket with vertically curved base
eliminates the rolling potential, assuring consistent location of slot in relation to bracket site.
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Figures 16
Fig. 8
Fig. 8 (A) Untorqued edgewise brackets located at LA-point. (B) Pretorqued edgewise brackets located at LA-point;
and (far right) two such brackets superimposed. (C) Straight-Wire brackets on the LA-point.
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Figures 17
Fig. 9
Fig. 9 Potential variations in locations of slots at conclusion of active treatment (posterior teeth). Rows a, b and c:
untorqued edgewise brackets. Rows d, e and f: pre-torqued edgewise brackets. Row g: Straight-Wire Appliance
brackets.
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Figures 18
Fig. 10
Fig. 10 Effect on torque of flat-base bracket's rolling potential.
Fig. 11
Fig. 11 (A) When tip is built into the slot, the bracket can mate solidly with the tooth. (B) When bracket is angulated on
tooth to accomplish tip, a rocking potential is created.
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Figures 19
Fig. 12
Fig. 12 In/out and molar offsets in the SWA.
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Figures 20
Fig. 13
Fig. 13 Gingival wings of posterior brackets, in SWA, are stepped out. Results: easier ligation and less frequent gingival
impingement.
References
1. Andrews, L. F.: The Six Keys to Normal Occlusion, Amer. J. Orthodontics, 62:296309, 1972.
2. Andrews, L. F.: The Straight-Wire Appliance: Syllabus of Philosophy and Techniques, rev. ed., San Diego, 1975,
Lawrence F. Andrews, 59.
3. Jarabak, J. R. and Fizzell, J. A.: Technique and Treatment with the Light-Wire Appliance, St. Louis, 1963, The C. V.
Mosby Company.
4. Sorrin, S.: The Practice of Periodontia, New York, 1960, McGraw-Hill Book Company.
5. Thurow, R. C.: Atlas of Orthodontic Principles, St. Louis, 1970, The V. C. Mosby Company, p. 111.
6. Wheeler, R. C.: A Textbook of Dental Anatomy and Physiology, ed. 4, Philadelphia 1965, W. B. Saunders Company.
194
References 21
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Mar(196 - 217): JCO Interviews: Dr. Jack G. Dale on Serial Extraction- Part 3
jco/interviews
Part 3
This is the final installment in this series. The first two appeared in the January and February issues.
DR. BRANDT How do you apply growth prediction to serial extraction decisions?
DR. DALE Dr. Tweed, a pioneer in prediction, impressed upon me the importance of evaluation of
the facial pattern and its relationship to future growth and development. Dr. Tweed classified facial
development into three categories: Type A— downward and forward, Type B— primarily
downward, and Type C— primarily forward ( Fig. 52).
Growth prediction has become much more complicated and sophisticated since Dr. Tweed first
described his growth trend classification. Nevertheless, there is one basic principle at the very heart
of prediction and that is: You should never initiate orthodontic treatment without first establishing
your objectives.
DR. BRANDT How often does growth occur differently from what you anticipate?
DR DALE It usually corresponds to my prediction, which I attribute to a thorough diagnosis and
treatment plan. However, I have had a few patients whose growth and development behaved
differently from what I anticipated. For instance, I initiated a relatively simple treatment plan on
what I considered a Class I, Type A growth trend malocclusion. Before growth was finished, I was
forced to realize that I was dealing with an exaggerated Type C growth trend and a developing Class
III malocclusion.
DR. BRANDT Do the relative eruptive rates of the cuspids and first bicuspids influence the
decision which deciduous teeth to remove?
DR. DALE Yes. For instance, if upon examination of the periapical radiograms I observe the
permanent mandibular first premolar crown ahead of the permanent cuspid crown, the premolar with
less than one-half of its root formed, and the mandibular incisors crowded, I will extract the primary
cuspid to relieve the crowding and leave the primary first molar.
If the crown of the permanent mandibular first premolar is level with the permanent cuspid
crown, the root of the premolar developed beyond one-half of its root length, and the cuspid
developed even further beyond one-half of its root length, I will extract the primary first molar in an
effort to accelerate the emergence of the first premolar. I do this because I know that the cuspid is
emerging at a faster rate and I know that the permanent mandibular cuspid emerges into the oral
cavity ahead of the first premolar far more often than the reverse (Fig. 53).
The object of serial extraction is to encourage the emergence of the first premolar ahead of the
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cuspid, so that the premolar can be extracted early to allow space for the cuspid to erupt more
favorably.
DR. BRANDT Do you ever prescribe enucleation of unerupted tooth buds?
DR. DALE I rarely prescribe the enucleation of unerupted tooth buds. If there is absolutely no
chance of placing bands at the completion of serial extraction, then the sooner the premolars are
extracted, the more favorably the cuspids emerge into the oral cavity. The result may be more
acceptable, but the procedure is more traumatic and you run the risk of removing too much bone.
In my practice, where I insist on bands to complete treatment, I avoid enucleation. This may
produce a somewhat less favorable serial extraction result, but the multibanded appliance easily
compensates and corrects the additional irregularity.
If, upon examination of the periapical radiograms, I observe that the permanent mandibular
cuspid crown is ahead of the first premolar crown, I will simply extract the primary first molar, but I
will not enucleate the premolar. Approximately six months later, I usually observe the first premolar
attempting to erupt, but being obstructed by the mesial contour of the primary second molar. I then
extract the primary second molar and extract the permanent first premolar later when it emerges. By
this time, the permanent cuspid is erupting into a relatively forward position and I am left with an
excess of space to close. With the multibanded appliance, it is not difficult to close this excess space
and it does not prolong treatment significantly.
DR. BRANDT Have you ever seen a second deciduous molar assume a mesial axial inclination
following the premature loss of the first deciduous molar?
DR DALE I do not know if the primary second molars resist mesial migration. Clinically, it appears
that they do to some extent. I cannot think of a patient where I have noticed the primary mandibular
second molars have tipped mesially noticeably following the premature loss of the primary first
molars. On the other hand, many times I have observed an exaggerated mesial axial inclination of
the permanent mandibular first molars following the premature loss of the primary second molars. I
think that the developing premolar teeth may have something to do with this. When the primary
second molar is lost prematurely, the permanent second premolar is quite often deep in the alveolar
bone. This would encourage the permanent first molar to tip forward. However, when the primary
first molar is lost prematurely, the permanent first premolar, which is scheduled to emerge before
the second premolar, is not so deeply embedded in bone. Therefore, the tendency for tipping of the
primary second molar is not as great, with the first premolar supporting the primary second molar.
Time and time again, I have observed that the primary first molar space has reduced following its
premature loss or extraction. I have also observed, especially in the mandible, the formation of a
"knife edge" ridge of alveolar bone which obstructs and retards the emergence of the underlying
first premolar.
DR. BRANDT For the loss of which deciduous teeth would you suggest a space maintainer?
DR. DALE It depends on the dentition, the diagnosis, and the treatment plan. If the patient has a
normal dentition and you are planning nonextraction treatment, you may place space maintainers
under the following circumstances:
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1. If the primary first molar is lost before the permanent lateral incisor and permanent first molar
have emerged, a space maintainer should be inserted. The space is likely to close from both the
posterior and the anterior directions.
2. If the primary first molar is lost after the permanent first molar is in position, but the permanent
lateral incisor is still unerupted, a space maintainer is still inserted. The space is most likely to close
from the anterior direction.
3. If the primary second molar is lost, a space maintainer should be placed to the age of eleven. If
the tooth is lost after this time and the radiograms reveal that the permanent second molar is liable to
emerge before the second premolar, a space maintainer should be inserted to prevent the second
molar from pushing the first molar forward.
4. When the maxillary primary anterior teeth are lost prematurely, most authorities believe that it is
not necessary to use a space maintainer.
5. When the mandibular primary anterior teeth are lost prematurely, the space is liable to close and a
space maintainer is advisable.
If the patient has a true hereditary tooth size-jaw size discrepancy with an alveolar dental
protrusion and you expect to extract the permanent first premolars, you may decide that space
maintainers are not necessary when primary teeth are lost prematurely. For instance, if the primary
mandibular right cuspid is lost early, you may simply want to extract the primary left cuspid in an
effort to maintain the midline relationship and avoid a lingual tipping of the mandibular incisors. If
the primary mandibular right first molar is lost too early, even though you are conducting a serial
extraction program, you may wish to place a space maintainer temporarily until you are prepared to
extract the opposite primary molar. This would maintain the symmetry of the denttion. However, if
this tooth is lost later, you may simply decide to extract the primary molar on the opposite side and
avoid the use of a space maintainer.
Quite often, when the primary maxillary second molar is lost prematurely, I will place a space
maintainer to avoid the development of a Class II molar relationship. There is hardly a day that goes
by in my practice on which I am not taking some measure to control the spaces in the developing
dentitions of my patients.
DR. BRANDT In a deep anterior overbite malocclusion, would the removal of mandibular
deciduous cuspids tend to deepen the bite?
DR. DALE Yes.
DR. BRANDT Would the removal of the deciduous first molars prevent the bite from deepening as
much and still allow for some unraveling of the crowded incisors?
DR. DALE I would say it depends on when the primary first molars are extracted. I extract the
primary first molars when the underlying first premolars have reached half their root length. If you
wait for this to happen, there is a minimum risk of collapse. If you extract the primary molars too
early, you run the risk of reducing the width of the alveolar bone, retarding the eruption of the
underlying first premolars, reducing the space in the extraction site, and increasing the overbite
significantly.
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If the mandibular incisors are crowded, I usually extract the primary cuspids first, in preference to
the primary first molars. I have rarely been satisfied with the improvement of the alignment of the
incisors when I have extracted the primary molars first. I would rather extract the primary cuspids
and place a lingual arch in preference to extracting the primary molars. Again, my decision is based
upon the relative positions and length of roots of the permanent first premolars and cuspids.
DR. BRANDT There are many who follow a specific sequence of eliminating first the deciduous
canines, then the deciduous first molars, then the permanent first bicuspids. Do you think this is the
best sequence?
DR. DALE It is true that the sequence that you have just outlined has been the most popular and
most widely used since Bunon first described it over 200 years ago. However, with scientific
investigation and clinical experience, the procedure has become much more sophisticated and
precise. Your results will be more rewarding if you do not cling to one sequence, but vary it
according to the malocclusion. I select the sequence that I feel is indicated for each individual
patient.
DR. BRANDT Could you give us some specific examples?

DR. DALE I will outline some of the alternatives as briefly as I can:
GROUP A, STEP 1, EXTRACTION OF PRIMARY CUSPIDS ( Fig. 54).
Here you see a typical serial extraction problem— a severe crowding, a developing Class I
malocclusion, a favorable overjet-overbite relationship of the incisor teeth, and an ideal orthognathic
facial pattern. Upon examination of the radiograms, you will often note a crescent pattern of
resorption on the mesial aspect of the roots of the primary cuspids. This is an indication of a true
hereditary tooth size-jaw size discrepancy. In this instance, you will also note that the first premolars
are emerging favorably, ahead of the permanent cuspids. You will also observe that none of the
unerupted permanent teeth have reached one-half root formation. Because of this, I would not
extract the primary first molars. Instead, I would extract the primary cuspids to relieve the incisor
crowding.
GROUP A, STEP 2, EXTRACTING OF PRIMARY FIRST MOLARS ( Fig. 55).
The incisor crowding has improved; the overbite has increased; and the extraction site has
reduced in size. The radiograms reveal that the permanent first premolars have reached one-half root
length. Therefore, it is now time to extract the primary first molars to encourage the eruption of the
first premolar teeth.
GROUP A, STEP 3, EXTRACTION OF PERMANENT Fl RST PREMOLARS ( Fig. 56).
Observe the emergence of the first premolars into the oral cavity. Since the permanent cuspids
have developed beyond one-half root length, indicating that they are prepared to accelerate their
eruption, you now extract the premolars.
GROUPA, STEP 4, MULTIBANDED TREATMENT ( Fig. 57).
The typical result of serial extraction— a relatively deep overbite, a distal axial inclination of the
cuspids, a mesial axial inclination of the second premolars, a Class I molar relationship, improved
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alignment of the incisors, and residual spaces in the, extraction sites.

GROUP A, STEP 5, RETENTION (Fig. 58).
At the completion of multibanded therapy you should observe— an ideal occlusion, a minimal
overjet-overbite relationship of the anterior teeth, parallel cuspid and premolar roots, and no spaces.
In addition, the dentition should be aligned in harmony with the craniofacial skeleton and the soft
tissue matrix.
GROUP B, STEP 1, PREMATURE EXFOLIATION OF PRIMARY CUSPIDS, EXTRACTION
OF PRIMARY FIRST MOLARS ( Fig. 59).
Here, the tooth size-jaw size discrepancy is more severe, causing premature exfoliation of the
primary cuspids. Note the splaying of the incisors as a result of the lack of space in the apical area.
Quite often, parents will interpret this spacing as evidence for nonextraction treatment. You must
explain that this is a sign of severe crowding. Once again, the radiograms reveal that the first
premolars are ahead of the cuspids in eruption and that they have attained one-half root length.
Here, you begin with the extraction of the primary first molars.
GROUP B, STEP 2, EXTRACTION OF THE PERMANENT FIRST PREMOLARS ( Fig. 60).
For reasons explained in Group A, Step 3, the permanent first premolars are now due for
extraction.
GROUP B, STEP 3, MULTIBANDED TREATMENT ( Fig. 61).
Again, the typical result of serial extraction .
GROUP B, STEP 4, RETENTION (Fig. 62).
Again, the desired result of multibanded treatment. In a severe tooth size-jaw size discrepancy,
you quite often observe splaying out of the incisor teeth due to cuspid crowding in the apical area of
the incisors. In this situation, it does very little good to extract the primary cuspids first. You are
better advised to extract the primary first molars first to encourage the permanent first premolars to
emerge as early as possible. The cuspids will then have space to migrate away from the apices of the
incisors and to begin their eruption into the oral cavity. In this instance, I am more concerned about
correcting cuspid crowding than incisor irregularity. I am very careful to avoid the correction of the
incisors with a multibanded appliance when the cuspids are in this position for fear of resorbing
incisor roots.
GROUP C, STEP 1, EXTRACTION OF PRIMARY FIRST MOLARS ( Fig. 63).
You will note a mild irregularity of the incisor teeth. Instead of crowding, this patient has an
alveolar dental protrusion. Upon examination of the radiograms, you note that the crowns of the first
premolars and cuspids are at the same level. However, the cuspid is beyond one-half root length and
is erupting faster than the premolar. Since the first premolar has one-half of its root length
developed, you extract the primary first molar to accelerate the eruption of the first premolar. This
will ensure that this tooth will emerge into the oral cavity prior to the cuspid.
GROUP C, STEP 2, EXTRACTION OF PRIMARY CUSPIDS AND PERMANENT FIRST
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PREMOLARS (Fig. 64).

When the first premolars emerge sufficiently, they are extracted along with whatever primary
cuspids remain. No effort is made to prevent the lingual tipping of the incisor teeth, since it is our
objective to reduce the alveolar dental protrusion.
GROUP C, STEP 3, MULTIBANDED TREATMENT ( Fig. 65).
GROUP C, STEP 4, RETENTION (Fig. 66).
GROUP D, STEP 1, EXTRACTION OF PRIMARY FIRST MOLARS, ENUCLEATION OF
PERMANENT MANDIBULAR FIRST PREMOLARS (Fig. 67).
If it is evident that the cuspid will emerge into the oral cavity ahead of the first premolar, you can
if necessary extract the primary first molar and enucleate the first premolar. This will encourage the
distal migration of the cuspid as it erupts.
GROUP D, STEP 2, EXTRACTION OF PRIMARY MAXILLARY CUSPIDS AND
PERMANENT MAXILLARY FIRST PREMOLARS ( Fig. 68).
Usually, in the maxilla, the first premolars emerge before the cuspids. Therefore, enucleation is
less likely to be indicated in the maxilla. At this point you observe the mandibular cuspids emerging
favorably into the oral cavity.
GROUP D, STEP 3, MULTIBANDED TREATMENT ( Fig. 69).
GROUP D, STEP 4, RETENTION (Fig. 70).
GROUP E, STEP 1, EXTRACTION OF PRIMARY CUSPIDS, PRIMARY FIRST MOLARS AND
ENUCLEATION OF PERMANENT FIRST MOLARS ( Fig. 71).
On occasion, the cuspids in both the maxilla and the mandible tend to erupt prior to the first
premolars. If this is the case, you might elect to extract the primary cuspids and first molars and
enucleate the permanent first premolars. This may be more acceptable, if there is absolutely no
opportunity to place multibanded appliances at the completion of serial extraction.
GROUP E, STEP 2, MULTIBANDED TREATMENT ( Fig. 72).
GROUP E, STEP 3, RETENTION (Fig. 73).
GROUP F, STEP 1, EXTRACTION OF PRIMARY FIRST MOLARS ( Fig. 74).
When the permanent cuspids are erupting ahead of the first premolars and because there is an
opportunity to place multibanded appliances at the completion of serial extraction, I will usually
avoid enucleation of premolars. When the first premolar has attained one-half its root length, I will
extract the primary first molars.
GROUP F, STEP 2, EXTRACTION OF THE PRIMARY MAXILLARY CUSPIDS,
PERMANENT MAXILLARY FIRST PREMOLARS, and PRIMARY MANDIBULAR SECOND
MOLARS (Fig. 75).
Approximately six to nine months later, when I observe that the mandibular first premolar is
attempting to emerge, but is being obstructed by the mesial contour of the primary second molar, I
will extract the offending tooth— the primary second molar. This sequence is usually not necessary
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in the maxillary dentition.

GROUP F, STEP 3, EXTRACTION OF THE PERMANENT MANDIBULAR FIRST
PREMOLARS (Fig. 76).
When the permanent mandibular first premolars emerge sufficently, they are extracted.
GROUP F, STEP 4, MULTIBANDED TREATMENT ( Fig. 77).
With this particular sequence, you achieve the least desirable serial extraction result. However, it
does not prolong the multibanded treatment significantly.
GROUP F, STEP 5, RETENTION ( Fig. 78).
These have been a few examples of how you can carry out serial extraction successfully by
selecting a specific sequence for a specific patient.
DR. BRANDT If a patient reports with a premature loss of one mandibular deciduous canine, with
subsequent space closure, a significant midline disharmony, and a deep anterior overbite, what is
your recommendation?
DR. DALE Assuming that the patient has a Class I malocclusion with a tooth size-jaw size
discrepancy, I would probably select one of three approaches depending on the alveolar dental
protrusion.
If the mandibular incisors have tipped excessively in a lingual direction, I would extract the
opposite cuspid, place bands on the mandibular incisors and first molars and on the primary
mandibular second molars. I would progress through a series of levelling arches to an egdewise arch
to upright the mandibular incisors and to correct the midline by moving the incisors into the recent
extraction site. To facilitate the mandibular tooth movement and to reduce trauma, I would insert a
maxillary Hawley bite pad. When the correction was completed, I would remove the bands and
place a lingual arch to maintain the mandibular incisors in the desired position until the multibanded
treatment is initiated.
If the mandibular incisors have tipped lingually into a favorable position relative to the mandible,
reducing an alveolar dental protrusion and producing an excessive overbite, I might decide on a
period of interceptive treatment to correct the excessive overbite, or I might defer mechanotherapy
until all the permanent teeth have erupted. If I decided to start treatment, I would probably extract
the remaining primary cuspids. I would then band the permanent incisors and first molars and the
primary second molars. I would progress through a series of levelling arches to edgewise arches and
place a high pull headgear attached to anterior hooks. I would then reduce the overbite by intruding
and torquing the maxillary incisors up and back and by levelling the mandibular arch. At the same
time, I would correct the midline discrepancy.
If the mandibular incisors have tipped lingually into a favorable position relative to the mandible
and an alveolar dental protrusion has been reduced without producing an excessive overbite, I would
simply extract the opposite cuspid. This is usually followed by the extraction of the maxillary
deciduous cuspids six to nine months later.
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DR. BRANDT Supposing that one deciduous molar was prematurely lost instead of one deciduous
cuspid. Would you handle this differently?
DR. DALE If the mandibular incisors have tipped excessively in a lingual direction, I would treat it
essentially in the same way, but I probably would not extract the opposite first molar.
reducing an alveolar dental protrusion and producing an excessive overbite, I would probably
extract the remaining three primary first molars and proceed in the same manner as I did when the
primary cuspid was lost. However, I would defer extraction of the primary molars until the
permanent first premolars had developed to one-half root length.
reducing an alveolar dental protrusion without producing an excessive overbite, and the roots of the
first premolar teeth had reached one-half root length, I would simply extract the remaining primary
first molars.
A word of caution regarding the uprighting of the permanent mandibular incisors and the
permanent mandibular first molars by the use of a multibanded appliance, a lingual arch, or a lip
bumper. This could impact the permanent mandibular second molars ( Fig. 79).
DR. BRANDT Have you ever seen a maxillary cuspid become impacted following the serial
extraction of the deciduous cuspid?
DR. DALE I have never seen a permanent maxillary cuspid impacted for that reason. When you
extract the primary maxillary cuspid, the space between the permanent lateral and the primary first
molar becomes reduced, but the primary first molar is then extracted, accelerating the euption of the
permanent first premolar which in turn is extracted. This usually provides sufficient space for the
permanent cuspid, without risk of impaction.
DR. BRANDT Suppose a patient who is otherwise a good candidate for serial extraction has one
mandibular second bicuspid congenitally missing How would this alter your prescription for
extractions?
DR. DALE Usually, I proceed with serial extractions as I normally do, extracting all four primary
cuspids or primary first molars depending on the development. When the four first premolars have
emerged, I extract three of them and in the quadrant where the second premolar is missing, I extract
the primary second molar. I then move the first premolar into the second premolar site which allows
space for the cuspid to emerge. Occasionally, I extract the primary second molar earlier to allow the
first premolar to emerge into a more distal position.
Garn has shown that when there is congenital absence, more often than not the treatment does not
require extraction. Thus, serial extraction is not indicated.
DR. BRANDT How do you alter your treatment plan if a maxillary lateral incisor is congenitally
missing?
DR. DALE If one maxillary lateral incisor is congenitally absent, I usually allow the dentition to
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emerge completely before initiating multibanded treatment. I prefer to see the crown of the cuspid
erupted before I decide whether to place it in the lateral incisor position or in its usual position. I do
not rely on periapical radiograms to evaluate the shape of the unerupted cuspid teeth. I am more and
more electing to place fixed restorations, rather than utilizing cuspids as laterals. (Fig. 80). When I
use them as laterals, I seem to be constantly fighting interproximal spaces during the retention
period, and in most instances it is just not esthetic (Fig. 81). However, occasionally the cuspids do
replace the laterals satisfactorily (Fig. 82).
DR. BRANDT How do you alter your prescription for extractions when a mandibular incisor is
missing?
DR. DALE If one of the mandibular incisors is missing, I will avoid extracting the premolar in that
quadrant and utilize the cuspid as an incisor. If it is an extraction case, the molars on the affected
side will be in a Class I relationship; if it is not, the molars will be in a Class III relationship.
DR. BRANDT Suppose you decide that you are going to extract maxillary premolars only in a Class
II malocclusion, or mandibular premolars only in a Class III malocclusion. Will you carry out serial
extraction in one arch?
DR. DALE Yes ( Fig. 83).
DR. BRANDT If you decide to extract second premolars, how does that affect your serial extraction
decisions?
DR. DALE Usually, second premolar extractions are prescribed for a borderline tooth size-jaw size
discrepancy, with the incisors upright over basal bone. By extracting second premolars, we correct
the minimal crowding in the anterior area by utilizing a fraction of the extraction space and without
producing an alvelolar dental retrusion. The space that remains will be closed by moving the
posterior teeth forward.
I extract primary cuspids to relieve severe incisor crowding and to reduce an alveolar dental
protrusion. Since neither condition exists in this case, the extraction of primary cuspids is not
indicated. I extract primary first molars to encourage the eruption of the first premolars. Since I am
not going to extract first premolars in this case, the extraction of the primary first molars is not
indicated.
It is difficult to encourage the eruption of the second premolars ahead of the first premolars by
extracting the primary second molars early, since the second premolars are notoriously slow in their
eruption. Also, if I extract the primary second molars, I run the risk of the permanent first molars
moving mesially too rapidly.
I do not extract second premolars very often but if I do, I wait until they have partially emerged
into the oral cavity.
DR. BRANDT If first bicuspids were always the permanent teeth removed in serial extraction
procedure, would you be concerned about creating "dished-in" faces in some cases?
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DR. DALE I am always concerned about creating "dished-in" faces. Because of this, I am
constantly monitoring the position of the mandibular incisors. I allow the incisors to tip lingually to
the desired position and then I hold them.
There are patients who will have a "dished-in" profile whether treated extraction, nonextraction,
or left untreated. These patients exhibit a maxillary-mandibular alveolar dental retrusion, a low
mandibular plane angle, a deep overbite of the incisor teeth, a relatively short anterior vertical face
height, a prominent chin, a relatively large nose, and a tense perioral musculature. If a severe tooth
size-jaw size discrepancy is superimposed, you may have to extract to produce a stable result. It is
often more advisable to defer extractions until all the permanent teeth have emerged, rather than
carry out serial extraction. If serial extraction is carried out, it must be done with extreme caution
and in conjunction with holding appliances.
You achieve the most rewarding results with serial extraction in Class I cases with a severe tooth
size-jaw size discrepancy and an orthognathic facial type, or with a moderate tooth size-jaw size
discrepancy and a maxillary-mandibular alveolar dental protrusion (Fig. 84).
DR. BRANDT Are you recommending more serial extraction now than you did five or ten years
ago?
DR. DALE Serial extraction has been a part of my practice since I began fifteen years ago. For this
I give credit to the man who was responsible for my orthodontic training, Dr. Coenraad Moorrees.
Dr. Moorrees and his associates have made significant contributions to the guidance of occlusion
and have placed serial extraction on a more scientific basis. I am doing more now than I did in the
early years of my practice for several reasons. In addition to having an excellent training in growth
and development, I have gained knowledge and experience from research, teaching and clinical
practice over the years. General practitioners are sending more patients to me at eight years of age,
because they know I prefer to treat early, and over the years I have encouraged parents to bring their
children in early. Interceptive treatment is usually less costly, which is always attractive to parents.
Prevention and interception are being emphasized more than ever in orthodontics and serial
extraction can be an important part of both.
DR. BRANDT Jack, on behalf of our readers, let me thank you for a truly outstanding interview on
this controversial subject of serial extraction. I am sure that you have made it much clearer and,
perhaps, less controversial
FIGURES
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Article Text 10
Fig. 52
Fig. 52 Tweed Growth Trend Analysis classification.

A. Type A— Class I, both jaws developing downward and forward equally, with ANB angle of less than 4½ º
As. Type A Subdivision— Class II, both jaws developing downward and for ward equally, with ANB angle greater than
4½º .
B. Type B— Both jaws developing downward and forward, with maxilla developing at a greater rate than mandible, with
the ANB angle increasing.
Bs. Type B Subdivision— Mandible developing downward while maxilla is developing forward, with the ANB angle
increasing.
C. Type C— Mandible developing downward and forward at a greater rate than maxilla, with the ANB angle decreasing.
Cs. Type C Subdivision— Mandible developing forward at a greater rate than maxilla, with the ANB angle decreasing.
206
Figures 11
Fig. 53
Fig. 53 Eruption sequences. (From Lo, R. T. and Moyers, R. E.: Studies in the etiology and prevention of malocclusion,
I The sequence of eruption of the permanent dentition, Am. J. Ortho., 39:460, 1953.)
Fig. 54
Fig. 54 Serial extraction. Group A, Step 1.
Fig. 55
207
Figures 12
Fig. 56
Fig. 57
Fig. 58
208
Figures 13
Fig. 59
Fig. 59 Serial extraction. Group B, Step 1.
Fig. 60
Fig. 61
209
Figures 14
Fig. 62
Fig. 63
Fig. 63 Serial extraction. Group C, Step 1.
Fig. 64
210
Figures 15
Fig. 65
Fig. 66
Fig. 67
Fig. 67 Serial extraction. Group D, Step 1.
211
Figures 16
Fig. 68
Fig. 69
Fig. 70
212
Figures 17
Fig. 71
Fig. 71 Serial extraction. Group E, Step 1.
Fig. 72
Fig. 73
213
Figures 18
Fig. 74
Fig. 74 Serial extraction. Group F, Step 1.
Fig. 75
Fig. 76
214
Figures 19
Fig. 77
Fig. 78
Fig. 79
Fig. 79 Impaction of permanent second molar during attempt to extend arch length with a lingual arch.
215
Figures 20
Fig. 80
Fig. 80 Congenitally missing permanent maxillary lateral incisors replaced with artifical teeth on a Hawley retainer after
moving cuspids to their normal position.
Fig. 81
Fig. 81 Congenitally missing permanent maxillary lateral incisors, space closed by moving cuspids into lateral positions.
216
Figures 21
Fig. 82
Fig. 82 Congenitally missing permanent maxillary lateral incisors, space closed by moving cuspids into lateral positions.
Mandibular first premolars extracted following serial extraction.
Fig. 83
Fig. 83 Serial extraction in one arch. In Class II case (above) maxillary first premolars extracted. In Class III case
(below) mandibular first premolars extracted.
217
Figures 22
Fig. 84
Fig. 84 Class I serial extraction cases. A. Serial extraction and early treatment. B. Serial extraction and early treatment.
C. Serial extraction only. D. Serial extraction only
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41.Moorrees, C. F. A.,Fanning, E.A., and Hunt, E. E. Jr.: Age variation of formation stages for ten permanent teeth, J. D.
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42.Moorrees, C. F. A., and Reed, R. B.: Biometrics of crowding and spacing of the teeth in the mandible, Am. J. Phys.
Anthrop., 12:77, March 1954.
43.Moorrees, C. F. A., and Reed, R. B.: Correlations among crown diameters of human teeth, Arch. Oral Biol., 9: 685,
Nov. Dec. 1964.
44.Moorrees, C. F. A., and Reed, R. B.: Changes in dental arch dimensions expressed on the basis of tooth eruption as a
measure of biologic age, J. Dent. Res., 44:129, Jan. Feb. 1965.
45.Moorrees, C. F. A., Reed, R. B., and Chadha, J. M.: Growth changes of the dentition defined in terms of chronologic
and biologic age, Am. J. Ortho., 50:789, Oct. 1964.
46.Ricketts, R. M., Bench, R. W., Hilgers, J. J., and Schulhof, R.: An overview of computerized cephalometrics, Am. J.
Ortho., 61:5, Jan. 1972.
47.Ringenberg, Q.: Serial extraction, stop, look and be certain, Am. J. Ortho., 50:327, 1964. Schudy, F. F.: The rotation
of the mandible resulting from growth, its implications in orthodontic treatment, Angle O., 35:36, Jan. 1965.
48.Steiner, C.: Cephalometrics for you and me, Am. J. Ortho., 39:729, 1953.
49.Steiner, C.: Cephalometrics in clinical practice, Angle O., 29:8, 1959.
50.Subtelny, J. D., and Sakuda, M.: Open bite, diagnosis and treatment, Am. J. Ortho., 50: 337 May 1964.
51.Tanner, J. M.: Growth at Adolescence, Oxford, Blackwell, 2nd. ed., Jan. 1962.
52.Tweed, C. H.: The frankfort-mandibular plane angle in orthodontic diagnosis, classification, treatment planning and
prognosis, Am. J. Ortho. and Oral Surg., 32:175, 1946.
53.Tweed, C. H.: The frankfort-mandibular incisor angle in orthodontic diagnosis, treatment planning and prognosis,
AngleO., 24:121, 1954.
54.Tweed, C. H.: Pre-orthodontic guidance procedure, classification of facial growth trends, treatment timing, Vistas in
Orthodontics, Philadelphia, Penn., Lea and Febiger, 1962, Chapter Vl ll .
55.Tweed, C. H.: Treatment planning and therapy in the mixed dentition, Am. J. Ortho. 49: 900, December 1963.
56.Tweed, C. H.: Clinical Orthodontics, St. Louis, Mo., Mosby, 1966.
221
References 26
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Mar(218 - 221): Isolation of Teeth for Bonding
Isolation of Teeth for Bonding

DR. SWADESH KUMAR
Saliva is detrimental to adhesive bonding. A dry surface following tooth conditioning (etching) is
of paramount importance to accomplish a lasting adhesion . Therefore, proper access and isolation
of teeth is essential for bonding. These cannot usually be obtained with cotton rolls and the ordinary
saliva ejector. The rubber dam is one of the best adjuncts, but time and complexity limit its clinical
use. There are a number of simple auxiliaries to accomplish access and isolation .
Hygoformic Saliva Ejector
The Hygoformic Saliva Ejector (Fig. 1) is more versatile than any other type. A soft wire
incorporated into its structure permits molding it into different shapes and clamping it in a stable
position.
While bonding lower anteriors, it should be positioned at 90° to the sagittal plane to keep the
tongue away from the lower anterior teeth. While bonding lower posteriors, it should be clamped in
a sagittal plane, restricting tongue movement and giving better access for bonding lingual cleats and
buttons.
The Hygoformic is available from North Pacific Dental, Inc., P.0. Box 22, Kirkland, Wash.
98033.
A useful supplement is a T-tube which permits the use of two ejectors simultaneously, enhancing
the ejection capacity and the extent of the dry field (Fig. 2).
Automaton
The Automaton (Fig. 3) is one of the best devices for use in the lower anterior segment. It has an
anterior and a right and left attachment. It is secured in position with a thumbscrew and a spiral
spring.
The Automaton is available from the Union Broach Co., 36-40 Thirty-Seventh St., Long Island
City, N.Y.
The Svedopter
The Svedopter (Fig. 4) is used for lower posterior segments.
It is composed of a reflector shield, saliva ejector, and locking device. The reflector shield
restricts the tongue from the lingual surfaces of the posterior teeth and, at the same time, serves as a
mirror which aids in examination of the lingual tooth surfaces for proper dryness prior to bonding.
218
Article Text 1
Svedopter Mark II has all the features of the original model but can be used with high velocity
suction de vices. The most recent version of Svedopter has a disposable saliva ejector.
The Svedopter devices are available from Callne Dental Co., 17905 'M' Sky Park Blvd., Irvine,
Calif.
J.C. Tongue Holder
The J.C. Tongue Holder with Saliva Ejector ( Fig. 5) is similar to the Svedopter. In it, the saliva
ejector is a soft rubber tubing which may be kinder to the soft tissues.
This device is available from the Union Broach Co.
Dri-Angle
The Theta Dri-Angle (Fig. 6) consists of a triangular piece of cardboard with a lining of silver
foil on one side and is an excellent device for the upper and lower posterior segments.
Dri-Angle is placed on the internal surface of the cheek with the apex as far posterior as possible.
It covers the parotid duct and effectively restricts the flow of saliva. In case of a heavy salivator, a
lap-over technique is recommended using two Dri-Angles.
Dri-Angle is available from Dental Health Products, Inc., P.O. Box 884, Niagara Falls, N.Y.
14302.
Lip Expander
The Expandex Lip Retractor Frame (Fig. 7) is a plastic ring-shaped de vice which fits any mouth
and is held in place by its spring like expansion action. It retracts the upper and lower lips, giving
better access to and isolating the labial surfaces of the anterior teeth.
The Expandex is available from Parkell Products, Inc., 155 Schmitt Blvd., Farmingdale, N.Y.
11735, in child and adult sizes.
A lip expander is also available from OIS, P.O. Box 2074, Wilmington, Del. 19899.
Dry Field Mouth Prop
The Dry Field Mouth Prop (Fig. 8) is a clear plastic device in two designs for anterior and
posterior teeth. It is an ingenious device for shielding the tongue, holding the jaws apart and
deflecting the upper and lower lips away from the operating field.
The Dry Field Mouth Prop is available from Parkell Products, Inc.
McSpreader
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Article Text 2
The McSpreader (Fig. 9) is an ingenious device for spreading the lips apart. It uses a wire to
spring two plastic lip and cheek retractors apart. It holds itself securely in place.
The McSpreader is available from Indirecto Corp., Box 2201, Ventnor, N.J. 08406.
A similar device designed by Dr. Philip Borges of Vallejo, California consists of cheek retractors
held apart by an adjustable bar at the back of the neck. It is expected to be available shortly.
For proper access and isolation in the various segments of the mouth, a combination of auxiliaries
will be effective, depending on the operator's preference.
FIGURES
Fig. 1
Fig. 1 The Hygoformic Saliva Ejector.
220
Figures 3
Fig. 2
Fig. 2 T-tube.
Fig. 3
Fig. 3 The Automaton
221
Figures 4
Fig. 4
Fig. 4 The Svedopter.
222
Figures 5
Fig. 5
Fig. 5 The J.C. Tongue Holder
Fig. 6
Fig. 6 TheTheta Dri-Angle.
223
Figures 6
Fig. 7
Fig. 7 The Lip Retractor.
Fig. 8
Fig. 8 The Dry Field Mouth Prop.
Fig. 9
Fig. 9 The McSpreader.
224
Figures 7
225
Figures 8
APRIL 1976, VOL. 10 / ISSUE 4

Orthodontic Economic Indicators 256
Don't Keep the Faith ... Spread It 267
Third Molars and Orthodontic Diagnosis 272
The Straight-Wire Appliance . Case Histories: Non-Extraction 282
Technique Clinic: Rotating Springs for Mandibular Incisors 304
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Apr(237 -): 240 THE EDITOR'S CORNER
the editor's corner
Orthodontists are faced with a great economic challenge (see page 256 of this issue). It will
require new efforts to extend orthodontic care to all segments of the population, especially adults; it
will result in increased competition within the specialty, and between the specialist and others now
doing orthodontic treatment; it will increase the importance of third party programs because a larger
percentage of patients may be expected to have third party benefits.
It does not test one's sensitivity to observe a growing discontent on the part of the public with all
the professions. It is on a basis of costs to be sure, but they also say that we have so tipped the
balance of our occupations away from the image of learned professionals dedicated to public service
and toward the image of entrepreneurs in search of a good livelihood, that we have virtually reduced
a profession to a skilled craft, and that they will deal with us in those terms. The implications of this
attitude are already visible in the inattention of government to the professions on professional
matters and the growing inroads of third party programs on our professional prerogatives with
mechanisms such as closed panels, prior authorization, fee schedules, lay review, professional
coinsurance, service benefits, fee profiles, indexes of malocclusion and direct payment.
Economic pressures on orthodontists could easily accelerate a third party takeover of orthodontics
and on the basis of all of those restrictive mechanisms which are not in the best interest of the public
or the profession because they relate mainly to the feasibility of insurance and have little to do with
health care.
So, in addition to the economic problems, we are faced with an image problem and a threat to our
standing as a profession. Consumers and consumer advocates are questioning the old arrangements
between producer and consumer, including their relationship to producers of professional services.
Since consumerism is going to affect our lives and our mode of practice, we ought to be concerned
about it, to understand it, and to work with it in constructive ways. If we do not, we will encourage
antagonisms and voids that will work to our disadvantage.
Lack of communication breeds suspicion and suspicion may result in change for no substantial
reason. Change alone is not always improvement. Therefore, it is in our mutual interest to establish
a dialogue with consumers and consumer advocates which recognizes their legitimate right to
question the old arrangements and our opportunity to work with them to try to see to it that mutual
understanding will result in changes that will be improvements. There are signs that we are not
aiming in the right direction.
One sign is that we have not yet found a means to establish such a dialogue. Instead, we see
erosion of the relationship such as more and more civilian representation and control of third party
health care arrangements. It is a sign of consumer distrust.
237
Article Text 1
Another sign is that we are going along with the idea that any dentist is permitted to do
orthodontics. The specialty should hold the position that no one who has not had full training in
orthodontics should be permitted to perform orthodontic treatment on the public. He could be a
pedodontist or a periodontist or a GP, but he must have full training. What is full training? At
present it would be defined as a two-year university graduate course in orthodontics. That should be
our opening dialogue with the consumer.
Others may try to say that it is self-serving, or that it is not true that education counts, or that in
some remote areas there are no orthodontists. There are so many orthodontists so widely distributed
and transportation has improved to such an extent, that lack of availability is no longer an excuse for
acting against the public interest. Furthermore, I would rather be asked to make a special
dispensation in hardship areas than to be in a position of accepting an idea in which I did not
believe— namely, that a dentist untrained in orthodontics, or less than fully trained in orthodontics,
can perform satisfactory orthodontic treatment.
Another sign is significant opposition among us to compulsory continuing education and

reexamination. Most orthodontists I know are taking courses and attending meetings and continuing
their education. The idea of reexamination is not to place the conscientious practitioner in some kind
of jeopardy. It is to place the public interest first, which is the hallmark of a profession. You may
say that we have been getting along just fine without either compulsory continuing education or
reexamination, but the consumer is saying that dentists have been using this and our codes of ethics
to protect incompetency. Here we are, a superior group of professionals, a large number of whom
have submitted themselves for reexamination by the American Board, who have nothing to fear
from similar reexamination, and yet are willing to be open to a charge of coverup of incompetence. I
think the American Board examination is uplifting to the individual who is examined and to the
level of competence of the specialty. We ought to make sure that reexamination is conducted on that
same plane and with those same objectives in mind. The more that reexamination has to be forced
upon us by laymen, the less likely it is to be to our mutual benefit.
Similarly with performance and quality control. Each professional has been his own judge of the
service he produced and each consumer has been the judge of the service he received. The consumer
wants to relinquish his judgeship and have some kind of review mechanism. The best kind of review
for both the public and the profession would be what is called peer review, which is the profession
policing itself. The more we delay in offering peer review, the less likely it is that the consumer will
want to depend on us to review ourselves and the more likely it is that he will impose hired review
with an ample amount of lay review. Peer review has an additional advantage that we ought to
consider. Peer review in orthodontics should take the form of orthodontists reviewing orthodontics.
That is in the public interest— to have the most knowledgeable professionals review the field in
which they are expert for performance and quality of performance.
So, I think that there are various avenues of dialogue with consumers on the basis that it is in our
mutual interest and that it will make sense to the American public if we come forth in their interest.
238
Article Text 2
It makes sense that a well-trained person will perform better than an untrained or inadequately
trained person 99 times out of 100. It makes sense that a trained person of good-will will be able to
make a better review of his field of expertise for performance of a service and for the quality of that
performance. It makes sense that, in a world in which the professions, including orthodontics, are
changing very rapidly, that continuing education in various forms is necessary to keep up with the
changes and the advancements, and that is in the public interest. To make it compulsory is to take it
out of the realm of desire, just as did the graduate university program in the first place. It makes
sense that the public is entitled to some evidence that the professional not only attended the
continuing education courses and meetings and read the journals and texts, but that he learned what
he needed to learn in order to keep up. Periodic reexamination of some kind is in line with that
thinking.
There are those who will ask— Why in this year of the celebration of our country's freedom
should we think of electively surrendering some of our freedom?
I think we ought to consider these moves because they are right, but also I believe that the future
of orthodontics may well depend on how we face up to two issues. One is how much we are willing
to put on the scale to tip our image back in the direction. of trusted professionals and away from
being lumped with business, and how well we communicate that image to the public; and the other
is whether we reverse the precedent in dentistry that any dentist can perform orthodontic treatment
regardless of his training.
239
Article Text 3
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Apr(256 - 266): Orthodontic Economic Indicators
ORTHODONTIC ECONOMIC INDICATORS

EUGENE L. GOTTLIEB, DDS
On the basis of what we know and what we may infer from certain economic indicators, we can
be reasonably sure that the average orthodontic practice, which is presently devoted 90% to children
under 18 years of age, must adjust in some positive ways to changing economic conditions or be
faced with an economic crisis some time within the next ten years.
The chief ingredients of the crisis are well-known. They are the declining U.S. population under
age 18, the increasing number of orthodontists and others doing orthodontics, and the inflating
economy. It is necessary to meld all three of these factors together in order to describe the
dimensions of the problem in the next ten years.
Decline in Population Under Age 18
There has been a significant decline in the birth rate in the United States since 1959.
The American Association of Orthodontists published population projections for the 12-year-old
age group which show a significant decline in this group through 1982 (Table 1).
90% of orthodontic patients are from the under-18 age group. The 12-year-old group was chosen
as representative of the child population because orthodontists treat a patient only once and since
orthodontic patients are started at various ages, the number available for treatment in any one year
can reasonably be represented by one age group. The 12-year-olds are near the middle of the
orthodontic population.
To carry the projection to 1986, the information is available in a table of population by age
groups, which is published once a year in November by the U.S. Bureau of the Census (Table 2).
If we focus on the 12-year-old group on this table and look back at the figures for the younger
groups year by year to age 1, we have an accurate estimate of the size of the 12-year-old population
through the year 1986. The 12-year-olds of 1986 are already born. They are the one-year-olds of the
July 1, 1975 chart. Their number will only be changed by death, which is a negligible factor, but a
reducing one.
The chart shows that, except for a slight rise in 1981-1983, there will be a steady decline in the
population of 12-year-olds in the next ten years of about 25% and that in 1986 there will be fewer
than 3 million 12-year-olds.
Increase in the Number of Orthodontists
There has been a rapid increase in the number of orthodontic specialists and the American
Association of Orthodontists projects a further increase from 1975 to 1982 of another 25% (Table 3).
256
Article Text 1
These figures are based on the supposition that the number of orthodontic graduate students will
continue at the present rate (350 per year) and that the number of practicing orthodontists who retire
and die each year will also continue at the present rate (.546% per year).
Orthodontists are a relatively young age group with less than 10% over 55 years of age and less
than 5% over 60. Projecting to 1986, it seems likely that the attrition from death and retirement will
continue at the present rate. In fact, as we shall see, there are factors working against the likelihood
of retirement.
It seems unlikely, however, that the number of orthodontic graduate students will continue at the
present level for the next ten years. The number of applicants to orthodontic graduate departments is
reported to be declining. If the AAO projection were carried to 1986, there would be 9600
orthodontists at that time, an increase of 50% from 1976. 9000 might be a more reasonable
expectation.
Population Per Orthodontist
When the population figures for the 12-year-old age group. as representative of the population
under 18 available to orthodontists in any one year, are combined with the figures for the number of
orthodontic specialists, we arrive at how many under -18 will be available, on the average, for each
orthodontist to draw his patients from in any one year.
The American Association of Orthodontists published a chart which represents this ratio (Table 4)
This chart shows that the 12-year-old population per orthodontist which is now about 600, is
projected to be 404 by 1982. Projecting further, to 1986, if there are going to be fewer than 3 million
12-year-olds and 9000 to 9600 orthodontists, there will be 313 to 333 children for each orthodontist
to draw his child patients from annually. If there are only 8000 orthodontists in 1986, that figure
would be 375 per orthodontist.
Orthodontic Treatment by Others
Pedodontists and GPs are doing orthodontic treatment and competing for the orthodontic patient
is that same diminishing child population. Pedodontists seem to be interested in becoming a more
significant factor in the orthodontic treatment of children. Pedodontists in some areas are now
reported to be doing up to 80% orthodontics.
Since there are now about 1000 pedodontic specialists and we know that they are doing a certain
amount of orthodontic treatment, we know that there are less than the estimated 600 children
available per orthodontist this year. Assuming only 50 new pedodontists a year and assuming that
pedodontic practices will only develop 50% orthodontics, then the 1986 projections have to be
reduced. On the basis of 9600 orthodontists in 1986, the 313 becomes 289; on the basis of 9000
orthodontists in 1986, the figure 333 becomes 308; and if there were 8000 orthodontists in 1986, the
figure 375 would become 343. That is just the pedodontist dilution and does not take into account
257
Article Text 2
orthodontic treatment by GPs. If each GP treated 1 case, children per orthodontist is reduced by a
factor of 10.
New Patient Starts— 1986
To make these figures more meaningful, considering only the two variables of decline of the
population under 18 and the increase in the number of orthodontists, how will that affect new
patient starts by 1986?
Since we know the number of practicing orthodontists and the number of students now enrolled
in graduate orthodontic departments and we know the population figures, we can be reasonably
accurate in saying that there will be a decline of 8% a year for the next two years in average patient
starts per orthodontist. There would actually be a slight delay in the realization of the 1977 and 1978
figures because new graduates cannot be expected to dilute orthodontic practice by a full unit a
piece. The 1981 and 1986 figures may be more realistic.
Projecting to 1986 we can make estimates of new patient starts based on the expected child
population available to 8000, 9000 or 9600 orthodontists, however the final total turns out. So, in
the accompanying chart (Table 5) is shown the effect on new patient starts of the decline in the child
population and a concurrent increase in the number of orthodontists to 8000, 9000, or 9600.
A practice with 100 starts in 1976 could expect to decline to 92 in 1977 and 84 in 1978 regardless
of the ultimate number of orthodontists, because the number of practicing orthodontists plus the
number of presently enrolled orthodontic graduate students is known. By 1986, the combined effect
of decreased child population and increased number of orthodontists on the practice with 100 starts
in 1976 would result in a decrease on the average to 62 starts if there are 8000 orthodontists in 1986;
or 55 if there are 9000 orthodontists; or 52 if there are 9600 orthodontists.
If you include the possible pedodontic dilution increase to 1986, then the 62 could become 57, the
55 could become 51, and the 52 could become 48.
Inflation and the Orthodontist
Like everyone else, in an inflating economy, the orthodontist is caught between the erosion of the
purchasing power of the dollar and the increased costs of the goods and services he buys to conduct
his practice. The orthodontist is more susceptible to the effect of this squeeze than many other
professionals and businesses, because the orthodontist does three things that they do not usually do:
1. He makes contracts 2, 3, and even 5 years in advance (in cases of two-phase treatment and for
retention).
2. He permits delinquency to extend the payment period even further.
3. He often neglects to raise his fees for periods of years.
258
Article Text 3
As we shall see, this combination has a devastating effect on the economics of orthodontic
practice.
Banks use Present Value Charts to show the effect of inflation on money that is received over
periods of time at various inflation percents. The accompanying chart (Table 6) is derived from
Present Value Charts and shows the effect on $1000 received in equal installments over periods of
1, 2, 3, and 5 years at varying rates of inflation.
According to the Bureau of Labor Statistics (Table 7), the inflation rate from December 1974 to
December 1975 was 7% and from December 1973 to December 1975 was 20%. To derive the
inflation rate for any period, divide the difference by the consumer price index at the beginning of
the period.
Looking at the 6%, 8%, 10% range of Present Values, it becomes clear what one is giving away
in lost purchasing power by making long term contracts and the increasing effect of longer time and
higher inflation rate.
If an orthodontist's fees remain the same over a period of time, the effect is the same as if he
retroactively made his contract at the beginning of that time and the money he receives has been
eroded by the inflation since his last increase.
Table 8 shows the effect of the erosion of the purchasing power of the dollar by a 10% inflation
rate plus the effect of an increase in the orthodontist's costs. It takes an orthodontic fee of $1800
divided into $600 initially and the rest in equal installments over 1, 2, 3, and 5 years. This is fairly
realistic since we have been working in the 10% inflation range and the increases in cost on the
chart are, if anything, low at 10% and less.
The chart points to the advisability of receiving a substantial initial payment, but still shows the
inadvisability of payments beyond one year. To the Present Value Chart erosion is added the
additional erosion of increased costs.
Inflation Effect Applied to a Hypothetical Practice
Now, let's apply these effects of inflation to a hypothetical orthodontic practice ( Table 9). Let us
assume a solo practice with an annual gross income of $100,000 from 67 starts at $1500 each. That
is not a model assumption for orthodontic practice, but let us accept it for this hypothetical practice
in order to help us develop some logical conclusions which may apply to your practice.
Recognizing that there are variations in cost factors among orthodontic practices, percentages of
cost were assigned which seemed reasonable for this hypothetical practice. Costs were assigned in
four categories. You may want to break this down to 10 or 12 or 15 categories when you construct a
similar model of your practice.
Table 9 was constructed to show first what the effect would be of increases in cost for the various
259
Article Text 4
categories. To do this, annual percentages of increase were selected which seemed modest and
reasonable in light of current experience. Then it was a matter of adding on cost increases for two
years, which is an average orthodontic contract period, and then for five years and ten years. In this
example, the cost/profit ratio changed from 55/45 at the start to 70/30 after two years, and after less
than five years the costs exceeded the gross income, provided the gross income remained the same.
Next, the profit was reduced by an amount of Federal income taxes at current rates and a figure
was arrived at for Profit After Taxes. When this figure was subjected to the effect of 10% inflation,
it can be seen that after only two years, the combined effect of increased costs and of 10% inflation
reduced the purchasing power of the orthodontist's "take-home pay" from $30,440 to $18,232.
In order to only recover the original purchasing power of the same gross income, instead of
$100,000 he would have to gross $167,000 after two years.
If the number of patient starts did not increase, the fee per case would have to increase from
$1500 initially to $2493 after two years.
If the fee were to remain at $1500, the number of patient starts would have to increase from 67
initially to 111 after two years. However, since we have already projected that the average number
of starts can be expected to go down about 25% in five years and almost 50% in ten years (if we
maintain practices that are 90% under 18 and 10% adult), the direction in which orthodontics will be
moving may not permit an increase in starts.
Returning our attention to the chart, this picture could be made worse by higher inflation —
higher than the 10% on the chart— with a deeper erosion of purchasing power, higher costs, higher
taxes, and fewer starts. On the other hand, the picture could be improved by an increase in starts,
higher fees, lowered inflation rate, lower costs, and lower taxes.
The orthodontist's standard of living depends on the interplay of these factors. In the hypothetical
practice of Table 9, if his gross income remains the same, he feels the pinch in two years and costs
exceed gross in a little less than five years.
Lest you may think that this does not apply to you because you have a better cost/profit ratio than
the hypothetical practice or because your costs are less than those in the chart, I have constructed
another hypothetical practice based on a beginning cost/profit ratio of 47½/52½ and cost increases
that are considerably less (Table 10).
As you can see, the figures are inexorable. In this case which starts with a better cost/profit ratio
and with a lesser annual increase in costs it just takes longer to get to the same financial end, again
provided that the gross income remains the same.
Some Inferences From The Orthodontic Economic Indicators
It is clear that gross income can increase by finding more new patients and by increasing fees,
260
Article Text 5
and that net income can be improved by cutting costs.
The likelihood of new patient increases in orthodontic practices is declining as the child
population per orthodontist declines. In fact, new patients referrals are declining in most practices.
This could be changed to some extent by increased numbers of people with third party orthodontic
benefits and by an increase in adult orthodontic treatment, which is now 10% of the average
practice. You must keep in mind, however, that 25 million Americans now have dental insurance
and, while the number is expected to increase greatly, it is open to question how much effect this
will have in light of the fact that, with the 25 million covered, the average orthodontic practice is
declining and patients with third party insurance benefits comprise around 10% of orthodontic
practices.
In addition, orthodontics has not been included in the most liberal of the proposed national health
plans. It may take some time for a national health plan to be enacted and additional time for
orthodontics to be included. Orthodontic treatment for adults has not been included in any third
party program. How soon the percentage of adults receiving orthodontic treatment on a private basis
will increase significantly is open to question. Since the economic projections revealed in the two
charts of hypothetical practices have a time-frame urgency of two to ten years, it may be an error to
stake one's future on the likelihood that increased third party coverage and increased orthodontic
treatment for adults will become so additionally significant in that period of time.
The adjustment of fees and costs may help the situation, but one needs to know how to increase
fees and how much, and what fee increases and cost decreases will satisfy the economic needs of the
practice.
Survival under the conditions forecast by the orthodontic economic indicators will depend to a
large extent on what each of us does to learn the economics of his own practice, to control what he
can control, and to manage the interplay of the economic factors represented in the hypothetical
practice models.
Next month I will discuss what you need to know about your own practice and how to use that
information as a blueprint for economic survival in orthodontics.
TABLES
261
Article Text 6
Table I
Table II
262
Tables 7
Table III
Table IV
Table V
263
Tables 8
Table VI
264
Tables 9
Table VII
265
Tables 10
Table VIII
Table IX
266
Tables 11
Table X
267
Tables 12
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Apr(267 - 269): Don't Keep the Faith ... Spread It
Don't keep the faith....
Doctor Conlin and staff members.
.... spread it
RICHARD T. CONLIN , DDS
In a sense, all orthodontists are created equal. The free flow of knowledge and scientific
information has assured that there is no academic advantage. The universal availability of scientific
instruments and materials precludes any mechanical advantage. It would seem, then, that in his
pursuit of excellence the orthodontist would be limited only by his own diligence and desire to
succeed. However, it is a fact of life that success in treatment, as well as in business practice,
depends to a significant extent on patient cooperation and, whatever his virtues and abilities, the
orthodontist does well to establish a good rapport in his own community of patients.
Two projects that started in our office as a positive statement of values, eventually involved our
community in a very rewarding way for all of us.
The Poster Program
Last Summer I received a letter from Dr. Larry Funt of Bethesda, Maryland in which he had
enclosed a small white card with the following message: TALK WITH CHILDREN AND SEE
THAT EACH DAY EACH CHILD ENJOYS SOME SMALL SUCCESSES AND SOME
RECOGNITION AS A PERSON.
Larry had seen this thought posted in the office of Dr. Jay Barnett of Amarillo, Texas and liked it
so well that he had these cards printed for distribution to patients and others.
I liked the message so well that I had it made into a large colored poster which we hung in our
reception room. I felt that it stated a philosophy which is essential in treating children and which I
wished to share with those who came to our office. The poster evoked a great deal of comment.
Parents copied the legend, tried to copy the artwork and even took Polaroid photographs of it.
We had so many requests to copy it, that we had it professionally printed into a small poster, 8" 
11". We then hand-colored each one and distributed them to all who inquired, plus many doctors,
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school-teachers and others not connected with our practice. There are now hundreds of our posters
throughout our community and they are still in demand. (See front cover of this issue.)
This poster has become almost a trademark with us. Every parent who sits in our waiting room
knows about our attitude and recognition of the child, and an excellent spirit of cooperation has
been the result.
Tee-Shirts ... The Community Uniform
The standard uniform in our office had always been white pants with casual colored tops. When
our staff grew to nine, the different tops became confusing and added little of esthetic value to the
office. We began considering alternatives and this culminated in our selection of the simple, but
now tremendously popular fashion item, the tee-shirt.
We liked the idea that it was simple and comfortable, inexpensive and easy to wash. It was
available in all sizes and colors and occupied a special place in contemporary dress, primarily as a
walking billboard. The idea evolved that we could provide our own message and add some punch to
the whole idea. The project was turned over to a local studio and they devised a pop art illustration
with the message, "Braces Are Beautiful".
We liked it immediately and ordered enough for our entire staff to have one in each of four
colors, which we wear as we please. We expected the idea to please us and it did. Moreover, we
were convinced that we were projecting a positive attitude and a good message. What we did not
expect was the patient reaction. The very first patient who came in wanted one immediately and the
demand has continued each day since. We gave away the few extras that we had and then we had to
order large supplies to keep up with the demand. The first youngsters promptly wore theirs to the
pool or playgrounds or shopping malls and this set off a wave of orders, many from people we have
never seen and from as far away as Chicago, Illinois.
Although everyone offered to pay, we felt that it was inappropriate to sell a patient a shirt, so we
made no charge to patients and established this policy: All new patients are given a tee-shirt as part
of their beginning treatment package which includes a toothbrush, travel brush, mouthwash, etc.
The results have been positive and rewarding. Patients who have been shy or hesitant about
wearing appliances have reinforced their self-image by projecting a positive attitude. Adult patients
especially enjoy having a shirt for parties, picnics, or informal gatherings.
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Doctor, assistant and patient attired in tee-shirts.

Perhaps the greatest value in the whole idea is that it has become a remarkable practice builder.
After the first hundred tee-shirts hit the streets, the community was now aware of the message that
braces are beautiful, and both parents and patients who procrastinated about orthodontic treatment
received a new stimulus. The response has been tremendous. The project has been a huge success.
At a few dollars each, the tee-shirts are a minimum investment and certainly a negligible part of the
patient's fee. What they have produced in good will, new patients and improved attitude has made
them a bargain.
Project Success
The success of these two projects is reaffirmed daily by our present patients and a large influx of
new ones. The interesting part is that both projects started with our dental assistant, Suzy Duffy,
putting into an art form a simple positive statement of our own convictions. Approval is reflected in
the positive response of the community.
In other years, we have sponsored poster contests and other activities that invite patient
participation and they have been equally rewarding. There is no doubt in our minds. When we
believe in something, we share the idea. We don't keep the faith ... we spread it.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Apr(272 - 281): Third Molars and Orthodontic Diagnosis
Third Molars and Orthodontic Diagnosis

ROBERT J. SCHULHOF
The mandibular third molar is different things to different people. To the patient it constitutes a
fear of a painful operation in the late teens. According to Bjork, approximately 45% of the
population will have impacted lower third molars. 1 For this 45%, the extraction of the lower third
molars can be painful and, occasionally, result in a fractured jaw or damage to the lower second
molars. Therefore, a less traumatic method for extraction of the lower third molar should be
welcome.
To the general dentist the lower third molars have both positive and negative aspects. On the
positive side, they may be used to replace a lost first or second molar, provide critical vertical
support for the temporomandibular joint, or may be used as a bridge abutment. On the negative side,
they may trap food, be difficult to clean, contribute to periodontal disease, cause the patient pain
and, at worst, epithelial remnant differentiation to squamous cell carcinoma has been reported due to
impacted third molars. The negatives easily outweigh the positives, resulting in the extraction of the
lower third molars in approximately 75% of the population receiving regular dental care.
To the orthodontist the lower third molar has many ramifications. Patients report first observing
mandibular crowding coincident with the eruption of lower third molars and see the orthodontist for
this reason. The eruption of third molars is blamed for relapse in many cases. Some techniques tend
to cause entrapment of the second molar between the first and third molars in nonextraction cases.
Extraction of bicuspids has been justified as creation of space for the erupting third molars.
Temporomandibular joint problems have been reported to occur both from malposition of third
molars and from their absence.
Recent findings regarding growth prediction, the effect of space available on impaction, and third
molar enucleation have shed new light on the third molar and give new hope that problems
associated with third molars will be lessened in the future. The author has helped statistically with
much of the research in this area and offers here an up-to-date summary of developments.
Can Erupting Third Molars Cause Crowding?
This has been a subject of considerable controversy in orthodontics. Some investigators say yes,
others say no. As with all biologic research, the design of the experiment and the interpretation of
data can give apparently conflicting answers to the same questions. While I have not had an
opportunity to review every paper on the subject, the work of Dr. Leroy Vego 2 provides a most
definitive answer. Using serial untreated case records from the Bolton Foundation, Vego determined
that arch perimeter loss was, on average, .8mm greater in cases with third molars than in cases with
congenitally missing third molars, and this was shown to be statistically significant. While arch
perimeter loss is a normal phenomenon, occurring in almost every case between the eruption of the
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Article Text 1
second molar and age 17, Vego's work ( Table 1) showed that the probability of a loss of more than
3mm was approximately 8% in cases without third molars, but 33% (more than four times as likely)
in cases with erupting third molars. Hence, from this work it can be concluded that, whereas the
third molars are not always the reason for teenage mandibular crowding, they are a significant
contributor in a great number of cases.
Other researchers have reported "no significant differences" between cases with and without third
molars. Kaplan3 concluded: "These data indicate that the presence of third molars does not appear to
produce a greater degree of lower anterior crowding and rotational relapse after the cessation of
retention than that which occurs in cases with third molar agenesis. The theory that third molars
exert pressure on the teeth mesial to them could not be substantiated in this study."
A closer look at the details of Kaplan's work shows, however, that the group with erupting third
molars had an average of 1mm more crowding than the group with third molar agenesis, almost
precisely the same result as Vego obtained. However, since the statistical test employed (the F test)
included an evaluation of extraneous factors (particularly the effect of impacted third molars which
fell between the two groups discussed) and the sample size was slightly smaller than Vego's, the
difference in the conclusion was more a function of the number of samples used than of the actual
results. Had Kaplan gotten the identical result on a larger sample, he would have been forced to
agree with Vego. That's part of the problem with statistics. I am belaboring this point because
apparently conflicting results are a constant cause of frustration to the clinician who needs a yes or
no answer and who is applying the results daily on real patients. On the evidence presented, I have
to conclude that erupting third molars are a factor in crowding.
Will Extraction Make Enough Space for the Third Molars to Erupt?
Here we need to refer to studies concerning the probability of impaction as a function of space
available. Space available has been measured in many different ways. In 1956, Bjork 1 showed that,
if space available is measured on a cephalometric x-ray as the distance between the anterior border
of the ramus and the second molar, the likelihood of impaction decreases as more space is available.
Ricketts, using approximately 100 mature Indian skulls, drew the same conclusion, noting as a
useful rule that the probability of successful eruption was directly related to the proportion of the
third molar that was extending beyond the anterior border of the ramus. If half of the third molar
was hidden behind the ramus, there was a 50% chance of eruption. In my correspondence with Dr.
T.M. Graber, his work indicates that there are many factors involved in the eruption of third molars,
including the direction of eruption. This is the reason that we can only discuss the probability of
eruption as a function of space available. We cannot predict it with certainty. Graber feels for this
reason those who expect proper eruption routinely as a consequence of bicuspid extraction will be
disappointed.
A definitive work on this subject was presented by Dr. Patrick Turley at the 1974 meeting of
NIDR in New York. 4 Turley, using 75 orthodontically treated cases, evaluated several methods of
measuring space available. He found the most useful to be the distance from the center of the ramus
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Article Text 2
at Xi point to the distal of the second molar at maturity (Fig. 1).
This measurement neatly grouped cases with impacted third molars (bad), third molars erupted in
good occlusion (good), and third molars erupted but not in good occlusion (marginal) (Fig. 2).
The mean distances were approximately 21mm of space available for impacted, 25mm for
marginal, and 30mm for erupted in occlusion. A curve was drawn from this data to define the
probability of impaction as a function of space available (Fig. 3).
This curve was then used on a sample of 75 untreated individuals (Foundation for Orthodontic
Research sample) to predict the occurrence of impaction or eruption among them. This showed good
agreement between impactions predicted by the curve and actually observed (Table 2).
With the probability curves verified, we may now answer the question— What effect will making
additional space available have on the likelihood of eruption? Taking different points along the
chart (Fig. 3) we see that 7mm of additional space, the width of a bicuspid, decreases the chance of
impaction by about 70%. You must be concerned with anchorage requirements, but clinicians may
use the rule of thumb that 1mm additional space improves the chance of eruption by 10%. However,
if the incisors are to be retracted or if there is crowding, there would be considerably less space
available. For example, if we were to remove 4mm of crowding and move the lower incisor
lingually 2mm in an extraction case, this would deduct 4mm from the 7mm, leaving only a 30%
improvement in the likelihood of eruption.
Does Nonextraction Treatment Hurt Chances of Eruption of the Lower Third Molars?
Once again, it is an individual case according to the objects and problems of treatment. There are
cases where the entire lower arch is to be moved forward. This would create more space and
increase the chance of proper eruption. However, those techniques which tend to upright the lower
molar may cause a distal positioning of the lower molar of 1-2mm which, according to the chart,
would decrease the probability of eruption by 10-20%.
What is the Effect of Headgear Therapy?
We have found, in general, that the less space available for the upper third molars as measured
from the pterygoid vertical (Fig. 1), the less chance of occlusion with the lower third molar. If the
upper molars are moved distally, this will reduce the space available for the upper third molars. As a
general rule, at least 18mm between the distal of the first molar and the PTV is required for proper
eruption of the upper third molars. If less space than that is expected, the prognosis is poor. As an
additional point, cases with less than 14mm have shown poor eruption of second molars, causing
potential relapse and TMJ disorders.
Can Impaction Be Predicted?
Nothing biological can be predicted with absolute certainty. However, Figure 3 clearly shows that
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Article Text 3
if we know the distance from the ramus to the second molar, we know the probability of impaction.
If we could predict this distance, we could foresee the likelihood of impaction. At this stage,
computerized growth prediction methods are capable of predicting the space available to a standard
error of 2.8mm.5 This 2.8mm error might be enough to change a patient from the impacted group to
the marginal group, or from the marginal group to the good occlusion group, but will not change a
prognosis from impacted to good occlusion, since there is a 10mm difference between the mean of
the impacted group and the mean of the good occlusion group. Other methods of growth prediction
are available. Ricketts has published a manual method, Dr. Lysle Johnston has constructed a grid,
and one could produce his own method using the University of Michigan atlas or the Bolton work.
Figure 4 shows the probability of impaction as a function of a space available prediction made at
age 8. It can be seen that many will have a 50-50 chance, but some will have as high as an 80% or as
low as a 20% chance of impaction. It should be noted that a patient with more than a 50%
probability of impaction has almost no chance of eruption into good occlusion. At best, if his teeth
do erupt they will be marginal and probably will have to be removed eventually. However, space
available is affected by orthodontic treatment and no prediction should be made until a thorough
orthodontic workup is done which shows the expected movements of the lower molars. This
requires a complete Visual Treatment Objective, as outlined in the December 1975 JCO, page 776.
In order to determine the final position of the lower molars, we must determine the position of the
chin in space at the end of treatment and the position of the lower incisor, the amount of crowding,
the possibility of buccal expansion, and the necessity for extraction. Any one of these factors could
change the answer. If a complete orthodontic workup is done and a growth prediction made, in order
to predict space available the probability chart (Fig. 4) can be used to determine the possibility of
impaction or eruption into good or marginal occlusion.
If We Foresee Problems With the Third Molars, What Can Be Done About It
Beforehand?
As long ago as 1929, Dr. C. Bowdler Henry in England experimented with enucleation of third
molar buds prior to calcification. After studying thousands of children's skulls, he determined that
the bud of the lower third molar is accessible through a "window" at age eight or nine without
cutting into bone (Fig. 5).
He described an operation for enucleation which requires only a matter of one or two minutes per
side. Henry performed 3000 such operations at Royal General Hospital in London. He has taken
thousands of followup x-rays, which were offered to us for study, and no adverse side effects have
been reported.
Ricketts came to the same conclusion independently about ten years ago. He could find few oral
surgeons willing to perform the operation, since the anatomy of the eight-year-old was quite
unknown to them. Ricketts himself has performed over 200 enucleations in his office and has
reported no problems. He reports that the operation normally takes less than five minutes per side
using only a mandibular block, and that the patient has on occasion returned to school the same day.
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Third molar enucleation seems to be quite feasible and far less traumatic than waiting for an
impaction. Courses are now available in the technique (U.C.L.A. Extension, P.O. Box 24901, Los
Angeles, Calif. 90024).
In a recent report, Schwarze6 reported a significant reduction in lower first molar mesial
movement following third molar germectomy in patients from 13 to 22 years of age. He attributes
anterior crowding to excessive mesial drift of the lateral segments and considers third molar
germectomy to be a prophylactic procedure against anterior crowding. The surgery seems to have
been more difficult at ages 13-22 than others are describing at age 8.
What Are the Potential Gains and Risks of Third Molar Enucleation?
The gains are quite obvious. If, after a thorough orthodontic diagnosis, the patient can be
predicted to have better than a 50% chance of impaction and less than a 10% chance of eruption into
normal occlusion, he can be spared considerable trauma through enucleation. He may also be spared
the possibility of damage to his second molars. Even if the teeth were not impacted, but erupted
marginally, they stand a high chance (33%) of causing orthodontic relapse and a greater chance of
having to be removed eventually due to other dental problems such as pericoronitis, TMJ
disturbances, and caries.
On the other hand, this argument should not be construed to advocate the prophylactic removal of
third molars in all individuals. If we expect sufficient space for the third molars (30mm) there is no
use removing a perfectly useful tooth. Third molars have been cited as necessary to provide normal
vertical support. In addition, it will be easier to care for the third molar and very few problems (less
than 20%) are found in people who have adequate space. Additionally, caries-prone individuals can
be recognized in the early years and they may need the third molars later on to replace first or
second molars or for use as bridge abutments. Anderson, et al 7 in a study at the Burlington Growth
Center has determined that the possibility of loss of the second molar is approximately 10% and
increases with lower socioeconomic status. It is not felt that the incidence of caries was higher in the
lower socioeconomic groups, but that the money or inclination was not available for restorative
procedures. If enucleation is considered, the patient should be admonished to continue his regular
dental checkups and, therefore, should be a patient who can be expected to carry on a program of
dental hygiene. It would not be recommended, as a general rule, for the lower socioeconomic
groups, unless their future dental care were insured. With proper care, the risk of loss of a first or
second molar is less than 10% and not in the order of the previous risks we discussed, especially if
that individual is predicted to have a high probability of impaction.
One of the old legends is that the third molar is necessary for proper mandibular growth. In
performing these enucleations for the last ten years, Ricketts has not found evidence of such
occurrences. Enunlu8 of Istanbul, Turkey enucleated a first permanent molar on dogs and found
essentially normal mandibular development, the only difference being about 1mm on the side with
the extracted tooth.
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Article Text 5
A much more emotional and difficult problem to quantify concerns the relative likelihood of cyst
formation with and without enucleation. Cysts due to epithelial remnants have been reported by
Shira. The percentage of occurrence in the population is not determined, but is undoubtedly quite
small. Some pathologists would consider that enucleation would incur a high risk of cyst formation
if any epithelial tissue were allowed to remain after the operation. Others would conclude that the
probability of leaving epithelial tissue is no greater during enucleation at age eight than it would be
at a later date, such as 18, and certainly no greater than if the tooth were allowed to remain
impacted. Due to the rarity of this event, it cannot be quantified. It is known that it did not occur in
any of the 3000 enucleations done in the last 45 years by Henry. Enucleation of bicuspids has been
practiced for many years and, to my knowledge, difficulties with cysts have not been reported. The
orthodontist or oral surgeon would be well advised, however, as a precaution, to take followup
x-rays postoperatively to assure that nothing has been left behind.
ROBERT J. SCHULHOF
President, Rocky Mountain Data Systems, Inc.
FIGURES
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Footnotes 6
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume Apr
Fig. 1
Fig. 1 Key measurements used for evaluating probability of successful eruption of third molars. Lower molar— Xi point
to distal of second molar. Upper molar— PTV to distal of first molar.
Fig. 2
Fig. 2 Distance from Xi point to the second molar differentiates among cases that were impacted, erupted but not in
occlusion, and erupted in occlusion. (From Turley, P.K.: A computerized method of forecasting third molar space in the
mandibular arch. Unpublished paper presented at 1974 NIDR Meeting.)
278
Figures 7
Fig. 3
Fig. 3 Third molar probability. Space available measured from center of ramus to the second molar.
279
Figures 8
Fig. 4
Fig. 4 Third molar probability based on prediction at age eight. Space available measured from center of ramus to the
second molar.
Fig. 5
Fig. 5 A t age eight, bud of lower third molar is accessible through a "window" anterior to the ascending ramus, which
allows enucleation without cutting into bone.
280
Figures 9
TABLES
Table 1
Table 2
References
1. Bjork, A.: Mandibular growth and third molar impaction, Acta Odontologica Scandinavia, Vol. 14: 231-72,
November, 1956.
2. Vego, LeRoy: A longitudinal study of mandibular arch perimeter The Angle Orthodontist, Vol. XXXII, No. 3 —
July, 1962.
3. Kaplan, R.G.: Mandibular third molars and postretention crowding. American Journal Of Orthodontics, Volume 66,
281
References 10
No. 4, October 1974.
4. Turley, Patrick K.: A computerized method of forecasting third molar space in the mandibular arch. Paper read at
NIDR Meeting, 1974.
5. Schulhof, R.J. and Bagha. L.: A statistical evaluation of the Ricketts and Johnston growth-forecasting methods.
American Journal Of Orthodontics, Vol. 67, No. 3, March 1975.
6. Schwarze, C.W.: The influence of third molar germectomy— a comparative long-term study, Trans. Third Intl. Ortho.
Cong. — 1973, p. 551.
7. Anderson, D.L.: Socioeconomic status, loss of teeth, and participation in a dental study. Journal Of Public Health
Dentistry, Vol . 34, No. 2 — Spring Issue.
8. Enunlu, H.: Early Extraction of Molars, Trans. Europ. Orth. Soc., 47:439-449, 1971.
282
References 11
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Apr(282 - 303): The Straight-Wire Appliance . Case Histories: Non-Extraction

Case Histories: Non-Extraction
(This is the third article in this series. The first two installments appeared in the February and
March issues of JCO.)
Having talked for two installments in this series about the Six Keys and the Straight-Wire
Appliance, let's see now how well the SWA fits teeth together without wirebending (except reverse
and accentuated curves).
In the next article we'll examine some extraction cases. Right now we'll look at four
non-extraction cases that have some interesting qualities. You'll find that two of the following
reports deal with Class II Division 1's, and two with Class II, Division 2 type problems fairly typical
of the ones you encounter. Case I made minor history in my own book by being the first case
completed with a full upper unit of the new appliance. Case II was the first to be started and
completed with a full upper and lower strap-up of the Standard SWA. The third and fourth are more
recently completed cases.
CASE 1
Age 13 years, 1 month. Caucasian, female, no health problems.
Diagnosis
Bilateral (Angle) Class II dental malocclusion. 9mm overbite and overjet. 3mm curve of Spee.
ANB 2°.
Treatment Plan
Full-band upper teeth with .022  .028 prototype Straight-Wire Appliance. Band lower teeth fully
with .022  .028 standard edgewise appliance. (Lower SWA brackets were not available at the time
this patient was started.) Cervical Kloehn type headgear to the upper molars, 14 hours daily
(prescribed in an attempt to drive the upper teeth distally, and to discourage forward growth of the
maxilla).
Treatment
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Article Text 1
After six months of treatment with

headgear and .018 archwires with reverse and accentuated curves, a Class I molar relationship was
achieved .
One year into treatment. The archwires

are .018  .025 rectangular wires with reverse and accentuated curves. Class II elastics were worn
for four weeks during this period to achieve Super-Class I molar relationship and end-to-end
anterior relationship.
At 13½ months, following the wearing of Class II elastics at night only

for six weeks, active treatment was terminated and the upper archwire removed to permit the teeth
to relapse to a more normal position.
Note the lineup of slots in the upper

Straight-Wire brackets in the posterior segments, and the lack of lineup of slots in lower posterior
edgewise brackets. (The posterior edgewise brackets radiate occlusally as they progress distally, as
described in the second article in this series.) Also note lingual torque in lower posterior wire.
At 14 months, partial debanding was started.
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Article Text 2
Total debanding occurred one month

later and teeth were allowed to continue settling.
At 16½ months, an upper Hawley and a lower four-to-four retainer were placed.
Here is the case one year after active

treatment.
And here it is five years and four months after active treatment.
At this time, functional occlusion in

right lateral excursion shows right side working and left side balancing occlusion. Note cuspid rise
on right side, anterior protection and posterior disclusion.
Functional occlusion in left lateral excursion

shows left side working and right side balancing occlusion. Note cuspid rise on left side, anterior
protection and posterior disclusion.
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Article Text 3
Functional occlusion in protrusive shows upper cuspids lifting off lower first bicuspids, anterior
protection and posterior disclusion.
Comments
Active treatment time was 14 months, 1 day. Favorable growth occurred at precisely the right
time. There was no advancement of the lower incisors. Facial, aesthetic, cephalometric and static
occlusion goals (the Six Keys) were reached. Functional results appear to be good, although some
wear of the upper left cuspid occurred. No bends, other than accentuated curves, were placed in the
upper wire during treatment. Typical edgewise in/out, torque, and tip bends were installed in the
lower wires where appropriate, as well as reverse curve.
This was the first case to be completed with a full upper Standard Straight-Wire Appliance. The
brackets were prototype (machined rather than cast, and without identification or bicuspid gingival
tie-wing step-out), but the results were encouraging and provided evidence that full development of
the appliance would be justified. These brackets cost me $1,000 apiece, but it was worth it to me
when I saw the bracket slots 0° in error at conclusion of active treatment. This is what I was looking
for.
CASE 2
Age 14 years, 10 months. Caucasian, female, physically mature, no health problems.
Diagnosis
A unilateral Class II Division 2 problem (left side). 3mm midline deviation. Curve of Spee,
2.5mm. ANB 4°. No growth anticipated, because of age and physical maturity of the patient.
Aesthetically, the teeth look good despite the malocclusion. It would be better to decline treatment if
removal of teeth were necessary; but treatment appears justified, if the malocclusion can be resolved
with stable results and without removal of tooth units.
Treatment Plan
Full-band with Standard SWA, .022  .028. Schedule headgear 24 hrs/day to correct the molar
relationship and provide space for retracting the anterior teeth. Class III mechanics for two months,
to level curve of Spee with as little advancement of lower incisors as possible. Sequential use of
.014, .016, .018, .018  .025 wires.
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Article Text 4
Treatment
After one month of treatment with headgear and .016 round archwires with reverse and
accentuated curves. Headgear was prescribed 24 hours per day, but was being worn 14-20 hours
daily.
Three months later, the archwires are

.018 round with reverse and accentuated curves. Headgear worn 18-20 hours daily.
Seven months into treatment. Tie-back

spring is retracting anterior teeth into space created by headgear. Upper and lower second permanent
molars are now banded. Right molar is Super-Class I, left molar nearing Class I. Archwires are .018
 .025 rectangular wires with reverse and accentuated curves. Headgear being worn 14-20 hours
daily, with Class III elastics to keep lower anteriors from flaring as reverse curve in lower arch
flattens curve of Spee.
Reciprocal Class II and Class III elastics

were prescribed to correct the midline.
At eleven months into treatment, these mechanics were continued to achieve a 2mm
overtreatment of the midline.
After thirteen months of treatment with

the midline overcorrected, active treatment was stopped and the upper archwire and lower posterior
archwires were removed to allow the teeth to settle. A lower anterior sectional wire is in place.
Upper and lower SWA bracket slots can be sited down. Lower SW brackets do not radiate
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Article Text 5
occlusally as edgewise do (see Case I).
Two weeks later, bands were partially

removed.
The teeth were allowed to continue

settling. After another two weeks, the case was fully debanded and an upper Hawley and a lower
four-to-four retainer placed. The retainers were removed 25 months after completion of active
treatment.
At this time, functional occlusion in

right lateral excursion shows right side working and left side balancing occlusion; cuspid rise on
right side; anterior protection and posterior disclusion.
Functional occlusion in left lateral excursion shows left

side working and right side balancing occlusion; cuspid rise on left side; anterior protection and
posterior disclusion.
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Article Text 6
Functional occlusion in protrusive shows upper cuspid lift off lower first bicuspids; anterior
protection, posterior disclusion.
Comments
Treatment was effective (active treatment: 12 months, 26 days) and the cephalometric goal was
reached as well as the Six Keys and functional objectives. Two years post-retention, the results
remain stable. The static and functional results were the best I'd ever achieved, and it was done
without bending the wire once (other than reverse and accentuated curves).
It was because no growth was anticipated that the problem was approached dentally. That meant
prolonged treatment if headgear wear was to be minimal. The patient— although 14, female and
attractive— was up to the task. She and I agreed to charge ahead and try to resolve the problem in
the shortest time possible. She wore headgear 14 to 20 hours daily for seven months. (It was cervical
headgear. Today, if starting over, I would prescribe high-pull instead, as recommended by Dr. Fred
Schudy.)
CASE 3
Age 11 years, 8 months. Caucasian, female, no health problems.
Diagnosis
A bilateral Class II skeletal and dental malocclusion with minimal crowding. 6mm overjet and
overbite. Curve of Spee 4mm, ANB 6°, with the skeletal error in the lower jaw. SN to mandibular
plane angle fairly steep.,42°. Lower incisor to NB, 8mm; pogonion, 0°. Patient facially full in dental
area.
Treatment Plan
Full-band with Standard SWA. High-pull headgear to upper molars 24 hrs/day. Consider
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Article Text 7
extractions if headgear approach ineffective.
Treatment
At ten months into treatment, progress models were taken. Archwires are .0195 Wildcat wires.
High-pull headgear has been worn 18-22 hours daily for nine months.
And here are progress models

fifteen months into treatment. Archwires are .018  .025 rectangular wires. Headgear is being worn
at night only.
Debanding occurred four months

later and a positioner was prescribed. Here is the patient five months after the completion of active
treatment, with the positioner being worn at night only.
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Article Text 8
At that time, functional occlusion in

right lateral excursion shows right side working and left side balancing occlusion; cuspid rise on

Functional occlusion in protrusive shows upper cuspid

lift off lower first bicuspids; anterior protection and posterior disclusion.
Comments
The patient wore the headgear as prescribed. ANB was reduced to 3.5°. Integrity of the lower
incisors was maintained. There was facial improvement as a result of retraction of the maxilla and
the maxillary teeth. Further facial improvement might have resulted from the removal of bicuspids,
but I'm happy with her face and so are she and her parents.
No bends were placed in any of the archwires other than accentuated and reverse curves to
control the overbite. Although a high-pull headgear was worn exclusively, most of the growth was
downward.
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Article Text 9
Cephalometric, aesthetic, facial, static (Six Key) and functional goals were achieved.
A conservative non-extraction approach was chosen because of patient's expressed willingness to

wear headgear. SWA brackets were now available in medium twin Siamese; these were used
throughout.
CASE 4
Age 11 years, 1 month. Caucasian, female, normal health.
Diagnosis
Class II Division 2 malocclusion. Lower incisors crowded, 7mm. Curve of Spee, 3mm. Overbite,
4mm. Patient's face in good balance. ANB, 6° with skeletal discrepancy in lower jaw.
Treatment Plan
Two-stage treatment, because of 6° ANB. Non-extraction approach, because crowding below can
be resolved by advancing the lower incisors by relieving overbite; and the Class II dental and
skeletal relationship can be resolved with headgear. Initially, band upper first permanent molars and
prescribe high-pull headgear 24 hours/day. Full-band with .022  .028 Standard SWA when a Class
I molar relationship is achieved.
Treatment
During the first stage of treatment, the patient had worn a headgear at night for 11 months to treat
the skeletal discrepancy, with only upper first permanent molars banded. At the initial appointment
of the second stage, the patient was full-banded and an .0175 Wildcat upper wire and an .014 round
lower wire were placed.
Two months later (after a total of 13

months into treatment) upper and lower .016 round archwires were placed. Subsequently, we went
to .018 round and then to .018  .025 rectangular archwires, while awaiting the eruption of the
upper second permanent molars. After we had waited six months they still had not erupted far
enough to band, so we stopped active treatment at this time out of consideration for the patient.
Eight months after active treatment ended, the patient is wearing an upper Hawley retainer at
night only and a lower four-to-four fixed retainer (removed for photograph).
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Article Text 10
At this time, functional occlusion

in right lateral excursion shows right side working and left side balancing occlusion; cuspid rise on

Functional occlusion in protrusive shows that, although the patient has anterior protection and
posterior disclusion, the upper cuspid does not ride on the lower first bicuspid.
Comments
Favorable mandibular growth as well as distally driving the maxilla and maxillary teeth were the
keys to treatment success. The lower incisors were advanced 2mm as per treatment plan. The facial
profile remained good. Static (Six Key) and functional occlusal objectives were reached; so were
facial, aesthetic and cephalometric goals.
No bends were placed in any of the archwires save accentuated and reverse curves for bite
opening.
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Article Text 11
Full banding with the Standard SWA occurred 9 months after a Class I molar relationship was
achieved through conscientious headgear wear. The second stage of treatment took two years and
one month because we waited over six months in vain to get on the upper "12-year" molars. A
decision was made to deband because it appeared it would be some time before those molars would
be fully available for banding.
FIGURES
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Article Text 12
Case 1a
Case I Beginning Records
294
Figures 13
Case 1b
Case I Final Records
295
Figures 14
Case 2a
Case II Beginning Records
296
Figures 15
Case 2b
Case II Final Records
297
Figures 16
Case 3a
Case III Beginning Records
298
Figures 17
Case 3b
Case III Final Records
299
Figures 18
Case 4a
Case IV Beginning Records
300
Figures 19
Case 4b
Case IV Final Records
301
Figures 20
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Apr(304 - 304): Technique Clinic: Rotating Springs for Mandibular Incisors
1976 Apr: Technique Clinic: Rotating Springs for Mandibular

Incisors
1976 April( Apr) Volume 69 Pages 304-304 304
technique clinic
ROTATING SPRINGS FOR MANDIBULAR INCISORS
Preformed rotating springs are excellent for cuspids and premolars, but frequently the arms are too
long for use on mandibular anterior teeth. When that is the case, grasping the spring through the lumen
of the helix and turning the arm an additional half-turn shortens the spring to fit. The shortened springs
work very well in narrow areas where the standard springs do not fit.
Grasping the helix.
Spring before (left) and after (right) shortening.
304
Article Text 1
MAY 1976, VOL. 10 / ISSUE 5

Blueprint for Economic Survival in Orthodontics 340
Overhead Projection — An Adjunct to Orthodontic Treatment 354
The Straight-Wire Appliance. Case Histories: Extraction 360
JCO Interviews: Drs. Samuel Pruzansky and Howard Aduss on Cleft Lip and
Palate
380
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 May(337 -): 338 THE EDITOR'S CORNER
the editor's corner

In a pair of articles, Orthodontic Economic Indicators in the April issue and Blueprint for
Economic Survival in Orthodontics in this issue, I have tried to show the effect on orthodontic
practice of three variables over which we have no control — decline in the child population,
increase in the number of practitioners doing orthodontics, and inflation — and three variables over
which we do have some control — increasing fees, controlling costs, and adding new patients.
Reasonable conclusions may be drawn on how these variables will affect the economics of
orthodontics in the next ten years and what this will mean to the activity and income of the average
orthodontic practice. Constructing an economic practice model demonstrates the interplay of these
factors and suggests specific records and record-keeping methods that orthodontists need in order to
know the present condition and trends in the economy of their own practice and make some
educated judgments about its future health. The purpose in doing this is not only to have a finger on
the pulse of the practice, but to be able to know where the imbalances in the variables may be
occurring or about to occur and to know what adjustments to make in order to restore the economic
balance of the practice.
Orthodontics has been a growth situation and its economic trends for a long time have been
upward. In that situation, few orthodontists saw a need to maintain a group of records which would
confirm this. My worst fear is that orthodontists will not recognize soon enough that the economic
trends are reversing in their practice and to know how to locate the sources of the problem and how
to make adjustments to put the practice back in balance.
It is awfully late along if the only response the orthodontist has to an economic crisis in his
practice is to raise fees. Raising fees is one of the important adjustments, but success will lie in
knowing when to do it, how to do it and how much to do it, and these are related to the weight of the
fee in the balance of economic variables.
I detect far too much of a head-in-the-sand posture on the part of orthodontists. There is a feeling
on the part of many that this will all go away somehow, when it is possible to determine that it is not
all going to go away. There is a feeling on the part of many that somehow increased third party
insurance coverage and increased adult orthodontic treatment will take care of everything, when it is
possible to surmise that this is not necessarily so. There is a feeling on the part of many that there is
not much point in spending time on the uncontrollable variables since we can't control them anyway,
when it is clear that adjustments in the variables that you can control must be in response to the
movement of those you cannot control. There is a feeling on the part of many that they will
somehow manage to survive all right for the remaining time they will be in practice and not worry
about what will happen afterward, when it can be demonstrated that serious imbalances in practice
economics may appear in two to ten years depending on the conditions in an individual practice.
Establishing and maintaining the records suggested in the Blueprint article make sense just for
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Article Text 1
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 May(337 -): 338 THE EDITOR'S CORNER
the management of a profit-making enterprise. There is no virtue in ignoring profitability. In

addition, even if your practice trends are up when the average trends are down, it would be
foolhardy to assume that yours will automatically continue to be upward. It would be more
responsive to the situation to set up an early warning system, to keep the records and follow your
trends, so that you can recognize an imbalance before it is serious and know what adjustment to
make in an effort to correct it.
If one were aware of the existence of a practice decline right now, it should be given an A1
priority. It would be appropriate to close up the office if necessary in order to constitute a complete
set of records for the past five years and evaluate what they tell you and what to do about what they
tell you.
I believe that orthodontists who monitor the economic information about their practices and who
are prepared to make suitable adjustments to imbalances as they occur will not have a problem of
economic survival. However, those who deprive themselves of advance awareness of economic
trends in their practices are unnecessarily placing themselves in grave jeopardy of survival.
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Article Text 2
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 May(340 - 353): Blueprint for Economic Survival in Orthodontics
Blueprint for ECONOMIC SURVIVAL in

Orthodontics
EUGENE L. GOTTLIEB, DDS
From statistics of population, the number of practitioners doing orthodontics, and the inflation
rate, a picture can be drawn of the economic condition of the average orthodontic practice and what
it is likely to be in the next ten years (see Orthodontic Economic Indicators, April 1976 JCO) .
That information demonstrates the potential economic problems of the specialty, but it is
inadequate ammunition for the survival of the individual orthodontist. Each orthodontist must
assemble his own data bank of information pertaining to his practice. Today's orthodontist needs to
know a lot more information about the economics of his practice than he has been accustomed to
want or to have.
Economic Practice Model
Table 1 is an economic model of a hypothetical practice. While the figures are hypothetical, the
principle is applicable to all and the suggestion is that everyone construct a model of his own
practice.
The interplay of the factors demonstrated in Table 1 determines the present health and future
prospects of the practice. It is these factors that each orthodontist must monitor for his practice,
creating flow charts and graphs of each one and continuing them for the rest of his practice life.
While it is easier to begin today to keep such records, it will repay the time invested to go back into
your records at least five years to create some flow and an accurate picture of the trends in your
practice. Here is what you need to know about your practice: gross income, number of patients, size
of fees, costs, net income, and the inflation rate.
From this information you will be able to construct an economic model of your practice, to know
its trends, and to be able to make reasonable projections about its future.
Gross Income
Gross income is simple to chart from past tax records or past ledgers. It is not enough to chart a
single figure for gross income. It is also necessary to construct gross income flow charts (Table 2),
because they permit you to project what future gross income may be expected from cases already
under treatment— fees that have been contracted for but not yet earned or received. This is done by
laying out future payments in the ledger when a contract is begun. This maintains projections of
future income already on the books and tells you how much gross income will be required to be
added to what you've already got to achieve whatever gross income you may be intending to
achieve, on a monthly basis. The projections can be entered in pencil and inked over when payment
is made.
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Gross income declines tend to accelerate if you don't do anything about them, and they tend for a
year to be masked by long term contracts which remain to be earned and paid.
Gross income is a function of the number of patients and the size of fees.
Number of Patients
The number of patient starts is one barometer of practice condition, but it is not the only one or
even the best one. The flow of patients prior to start and the number of starts, plus the flow of
patients in treatment and post-treatment are the EKG of orthodontic practice. A breakdown of this
information into children under 18 and adults is significant to tell you how much you are depending
on that declining child population.
Monthly records of referrals and source of referrals, consultations, diagnostic studies, starts and
observations prior to start give you your referral rate, referral source activity, conversion to start
rate, your actual starts, and your backlog of patients getting ready to start (Table 3).
You can see what the trends of these interrelated events have been and, as you continue to
monitor them, you can perceive what is currently happening and in what direction your practice is
moving. From them you can establish whether it is realistic to expect an increase in the number of
patient starts next year. If all the pre-start information is in a downward trend, you would have
reason to believe that the opposite may be true. If you decide that the number of patient starts will
not increase or is actually declining, the alternatives are to practice build, to raise fees, to lower
costs, or to accept a lower living standard.
If your conversion rate has been 100% or close to it, you might have confidence that you can
raise fees, even in a level or declining pre-start experience. If you are meeting resistance in your
present location to your present fee schedule, you might be less confident about increasing fees.
Size of Fees
Many orthodontists tend to think of their maximum fee or their most usual full treatment fee as
their fee. Fees vary in any practice according to the service and it is important to establish what
one's fees for various services are. Otherwise, when it comes time to consider fee increases, there
could be a lot of guesswork involved and an uneven response to the economic needs of the practice.
The size of the fee is within the orthodontist's control and, apart from a consumer resistance factor,
it ought to be related to its place in the balance of all the other economic factors demonstrated in
Table 1.
In addition, it is important to keep records of fees contracted for in each month. The reason for
this is that the number of starts is only an indication of patient activity and not of the income value
of each start. One case may be a full treatment case, another may be a partial treatment case, and
another may be a 2-phase treatment case. Dealing as we do, with relatively small numbers of
patients, there can be a variation in income according to the kinds of cases that are started. So,
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contracts written is superior to patient starts as an economic indicator (Table 4) and you need
records of both.
This flow chart is simple to maintain as follows:

JAN FEB MAR
Balance Fees 100,000 102,000
Unearned or
Unpaid
Contracts Written 12,000
Gross Income 10,000
If you decide that your fees can not be raised, the alternatives are to practice build, to lower costs,
or to accept a lower standard of living.
Costs
Establish flow patterns for costs in 10 or 12 or 15 categories of expense— as you have them in
your ledger for tax purposes (Table 5). You have to know what your costs are if you are going to be
able to make an adjustment in this variable in your practice model.
In addition, it is important to know percentages of increases in cost from year to year. These will
be used, as will be demonstrated, when you consider how to determine what next year's gross
income should be to maintain or improve your standard of living.
If you decide that your costs cannot be reduced, your alternatives are to practice build, to increase
fees, or to accept a lower standard of living.
Net Income
Net income is derived by deducting costs from gross income. Most orthodontists look at their
gross income as a measure of their success and financial well-being, whereas it is net income that is
the important figure— net income after taxes. It is important to know the effect of taxes, so all three
should be monitored— net income, income taxes, and net income after taxes. Tax information is
simple to find in past tax returns, State and Federal, and Municipal if any. All this is included in the
economic model of your practice (Table 6).
To be somewhat accurate about the loss of purchasing power and the purchasing power of net
income after taxes, keep in mind that roughly half the net income must be subjected to two years of
inflation and the other half to only one year.
Taxes
Income tax figures used in this article and the previous one are rule of thumb estimates of Federal
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Article Text 3
income taxes. The figures do not include State income taxes or Municipal income taxes where they
apply. These vary considerably around the country and your actual tax figures for all three levels of
income tax must be used for your income tax figure in your model of your practice. Income taxes
are an additional squeeze on the orthodontist because, as he has to make more income to keep up
with increased costs and inflation, he must pay higher taxes on the higher income and, therefore
must earn even more.
Inflation
The real value of your after-tax net income is its purchasing power. This is determined, with
reference to the past year or any previous year, by subtracting the cost of living increase from the net
income after taxes.
Figures for cost of living are available from your local office of the U.S. Bureau of Labor
Statistics on a monthly basis in the form of the consumer price index. To determine the percent of
change in any period of time subtract the two figures from one another and divide the difference by
the earlier figure.
Some orthodontists believe that they have overcome inflation by raising their fees the amount of
last year's inflation. To demonstrate the error of accommodating only to last year's inflation, let me
cite a hypothetical example.
The inflation rate from December 1970 to December 1975 was 39.6%. Let us assume that the
income tax rates were unchanged. Orthodontist A, noting that his gross income in 1971 was
$100,000 and in 1975 was $140,000, figures that his income has gone up 40% while inflation has
gone up slightly less than 40% and that he has more than compensated for inflation. Let us see if he
has. In Table 7, the assumption is made that his net income/cost ratio in 1971 was 60/40 and that his
costs increased at only 5% a year or 25% in the five-year period. These are undoubtedly low figures.
His $100,000 gross income in 1971 at a net income/cost ratio of 60/40 resulted in a net income after
taxes of $38,000. His $140,000 gross income in 1975 at a net income/cost ratio of 50/50 (due to
increases in cost at 5% a year) resulted in a net income after taxes of $42,280. Now subtract the
factor of 39.6% inflation in the five-year period and in comparison to the $38,000 in 1971, the
purchasing power of his 1975 take-home income is $25,547.
$1000 Gross Income
– 500 Expenses (50%)
———
—
500 Net Income Before Taxes
– 200 Income Tax
———
—
300 Net Income After Taxes
– 119 Inflation (39.6% of $300)
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———
—
$181 Purchasing Power of Each
$1000 of Gross Income
$38,000
——— = $209,944
—
181
To restore the net purchasing power to the 1971 level, he would have to have earned a gross
income of $210,000 in 1975. A method of determining this is to calculate a factor for $1000 and
divide that factor into the $38,000. Thus:
Following this formula, you can figure the income necessary to recover the purchasing power to
any previous time.
In the example shown, if the fee were the only adjustment that the orthodontist could make, it
should have increased from $1000 in 1971 to $2100 in 1975 just to maintain his purchasing power.
In that example, we started with a net income/cost ratio of 60/40. That is a low estimate for costs,
and it was followed by only a 5% annual increase in costs. If anything, the 1975 figures would
actually not be as favorable as shown on the chart.
It is extremely important for you to make this chart for yourself using actual figures from your
own practice as follows (We will assume that you are comparing the last two years, but you can
compare any two years. Just be sure that the inflation rate is calculated for the time period chosen):
1974 1975
Gross Income ––––– –––––
––– –––
minus
Expenses ––––– –––––
––– –––
equals
Net Income
Before Taxes ––––– –––––
––– –––
minus
Taxes ––––– –––––
––– –––
equals
Net Income
After Taxes ––––– –––––
––– –––
minus
Inflation 74-75
@ 7% –––––
–––
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Article Text 5
equals
Purchasing Power
Compared to 1974 –––––
–––
This chart permits you to calculate what the 1975 gross income should have been to restore the
1974 purchasing power. To figure what the gross income should be in 1976, you have to add a
contingency.
The Contingency
If you use the restored purchasing power figure for 1975 in 1976, you are not taking into account
what your increased costs and erosion of inflation will be in 1976. The contingency is a combination
of two estimates— what the government estimates next year's inflation rate will be plus what your
average annual increase in costs has been. When the contingency is added to the 1975 restored
purchasing power gross income, your 1976 gross income requirement is projected. Each year a new
model is constructed based on figures from your practice for the previous year and a new
contingency is added to arrive at a new projection.
To guard against some large miscalculation in expected inflation, the cost of living figures can be
monitored monthly. If inflation starts to rise sharply, you become aware of it early and have the
opportunity to adjust for it, if necessary, before the end of the year.
Theory Versus Reality
The purpose in keeping all these records and in making these calculations from them is to give
you an accurate picture of past trends, present condition and future possibilities in your practice. It
would be a misuse of this material if one were to concentrate on any one aspect of it and, for
example, conclude that a large fee increase was required or all was lost. We are operating in a real
world with factors of consumer resistance and increasing competition to contend with. The beauty
of monitoring practice information is that it permits you to make prudent adjustments in your
practice variables.
For most orthodontists to maintain or increase their standard of living it will be necessary to find
a balance among three variables of increasing fees, controlling costs and adding new patients. A
combination of these are the only adjustments he has, over which he has some control, in his effort
to maintain or improve his standard of living. Simultaneously, this effort is being affected by three
variables over which the orthodontist has no control — the changes in the birth rate, the number of
orthodontists and others doing orthodontics, and the inflation rate. Let us examine these two groups
and evaluate what the possibilities of each factor are.
EVALUATING THE CONTROLLABLE VARIABLES
Increasing Fees
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We have seen that orthodontists did not increase fees in a systematic way in the past and
preferred to increase their standard of living— in an orthodontic economy of more children, fewer
orthodontists and a low inflation rate— by increasing their case load. They preferred to work harder,
to employ more people, to be more efficient, and treat more patients while keeping their fee level
down. This was commendable in an open-ended patient market. It isn't going to work for everybody
if the orthodontic market continues a closing trend.
However, there are problems about increasing fees. We have neglected the fee area for so long in
terms of the function of the fee in producing the purchasing power required to support a needed or
desired standard of living, that many of us have a large gap to fill and it is questionable that it can be
done all at once. On top of that, we have felt so defensive about our fees at the level that they have
been at, that we feel even now that we are pricing ourselves out of the market. And indeed we might
price ourselves out of the market if we were to try to add a contingency of 18% a year, which
increased costs and inflation may require.
As orthodontic fees rise, they come under a certain amount of pressure just because of their size,
without reference to the value of the service. This is mitigated somewhat by open-ended fees quoted
as an initial fee and so-much a month to completion. In the previous article, we have seen the
devastating effect on the purchasing power of the orthodontist's net income after taxes of extending
contracts over periods of time longer than one year, due to increased costs and inflation. If
open-ended fees are used, the orthodontist must control his costs and tie his fee installments to the
cost of living on an annual or possibly a monthly basis.
For many orthodontists, fixed fees have seemed easier to present, easier for the patient to accept,
and easier to administer. The only way that fixed fees will work in the present economic climate is
to limit the fixed commitment on the orthodontist's part. Here are a few suggested ways:
1. By tying contracted payments after one year to the cost of living.
2. By limiting the orthodontist's commitment to one year and renegotiating at that time.
3. By being paid the entire fee in advance. This one, which may sound
unpromising, may be the best. It could be acomplished with a bank plan. The patient takes out a loan
and pays the bank with interest. The orthodontist can invest the fee at interest and overcome the
erosion of inflation. Suitable ground rules can be made to assure an equitable arrangement in the
event of premature termination.
These are not perfect solutions to the problem, but they are reasonable possibilities of
overcoming most or all of the eroding effect of inflation. They do not compensate for increases in
costs.
Controlling Costs
Reducing costs may be one of the most significant factors in the orthodontist's economy because
fee increases may not be able to keep up with cost increases such as we have been experiencing in
the last several years. Charting costs permits you to evaluate each cost and to see which, if any, can
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be reduced.
The most likely area for reducing costs is in salaries, which are the largest single cost in most
practices. Using the practice model, it is possible to calculate what adjustment in the balance of the
orthodontist's economy can be contributed by a given change in the salary area.
One of the important aspects of monitoring patient flow in treatment and minimizing delinquency
of cooperation and staying on schedule is that it may pay to compress office time down so that it can
be handled by part-time employees who work less than 20 hours a week, are on an hourly wage,
earn less and do not qualify for fringe benefits.
Adding New Patients
Practice building must receive major attention in every practice. Your flow charts will tell you
about the trends in your practice. Are the pre-start and start figures holding up? Or are they level?
Or declining? Are your active patients level, your post-treatment patients rising, and your referrals
declining? Are you doing everything you can to maximize dental referrals? Patient referrals? Other
professional sources, such as pediatricians? Are you preparing yourself for adult orthodontics and
educating your referral sources about adult orthodontics?
Adult orthodontics presently comprises 10% of the average orthodontic practice. There are at
present 39 million people between the ages of 7 and 17 and 125 million between 18 and 64. In the
next ten years, while the 18-64 group will increase by almost 20%, the 7-17 group will decline 10%
and the 7-17 population per orthodontist will decline approximately 50%. If you figure that as many
people have been exiting from the 7-17 group with orthodontic treatment needs equal to those who
received treatment, there is a large unmet need in the adult population and a potential for a
substantial increase in the number of adult patients in orthodontic practices. Stimulating interest
among adults will be a major mission for orthodontists as individuals and as a group. An important
step in this direction could be the encouragement of third party coverage for adult orthodontic
treatment.
Third party activity in dentistry, and orthodontics, is increasing. There are now 25 million people
covered for dental benefits and it is estimated that that figure will reach 60 million by 1980.
However, it would be a mistake to assume that third party insurance for orthodontic treatment for
children and possibly for adults will be a panacea. We must recognize that while third party
coverage has been burgeoning to 25 million people covered for dental benefits, the average
orthodontic practice is declining and, at last report, we still have only 20% of those who cannot
afford dental care who visit the dentist regularly and 50% of those who can afford it. The
government is rethinking a universal national health plan and it is unclear at this time when such a
plan may be enacted and what form it might take.
It is questionable whether third party programs can generate new patients as rapidly as the child
population per orthodontist is declining; whether possible increased utilization by children and
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adults can equalize the dropoff in child patients in the next ten years. Even if it were equaized, we
would still have increased costs and inflation to contend with.
Public relations programs to encourage increased utilization of orthodontic care by all segments
of the population would be in the public interest. However, there is no organized public relations
program for this purpose on any significant scale. Indeed, the ADA would likely oppose a program
for orthodontics by orthodontists; and for orthodontists to pay for an adequate program on behalf of
others would be counterproductive. It would not seem as if we could expect a great deal from this
approach in the near future.
Competition with others who do orthodontics is one area in which the orthodontist could increase
the number of his patients. The practice of orthodontics should be limited to those with full graduate
university training. It is not reasonable to assume that this will happen soon, but it will happen
sooner if orthodontists support that position. We must stop conceding orthodontic treatment to those
with inadequate training in orthodontics. We must also be sure that we educate ourselves further and
we stop conceding adult orthodontics to periodontists, occlusion to prosthodontists, and TMJ to oral
surgeons and prosthodontists. These are all patients whom we have been content to see treated
elsewhere and whom we must now retrieve. Early treatment could also be a significant factor.
Efficiency has always been useful in orthodontics in order to compress one's time either to be able
to treat more patients or to make time available for other things. For some it has meant reaching
one's potential case load in one location and opening one or more satellite offices to extend one's
services to an additional population group, to increase one's total case load and gross income.
Efficiency is still a valid concept, but the idea that working efficiently, working harder, using more
auxiliary personnel, opening one or more satellite offices will always result in more patients and
increased gross income has to be reexamined in light of the economic circumstances we have been
discussing.
We are probably going to see many more satellite offices and in some unlikely places such as
very small communities to which an orthodontist may travel less than one day a week. In a sense,
bringing orthodontic treatment to localities that have not previously had it will be an improvement.
However, too fractionated a service has its detriments and it can be expensive to establish a fully
equipped satellite office. In addition, the child population per orthodontist is declining and one
orthodontist only counts for one, even if he is in two or three places. Actually, opening satellite
offices will be an effort to get an average share if one is not doing so in his present location, or to
get more than one share.
Under the economic circumstances we face, there are arrangements other than setting up your
own office that are worth considering. In opening a satellite office, especially in a smaller
community, it might be wise to consider subletting from a busy GP. This might not only save you
money, but could give you a faster start in the community and also increase the percentage of adult
patients because of the built-in referral system. Subletting from a GP has its detriments and they
include the fact that one is not likely to get referrals from other GPs in the area. Also, a
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disagreement with your landlord could create a difficult situation. You are too dependent on one
relationship
An alternative which has some of the same characteristics is to join a mixed dental group on a
part-time or full-time basis. This might be a percent better because it would be on a more formal
basis. However, there are not very many mixed dental groups and forming one is not a simple or
inexpensive matter.
Additional Steps to Increase Income
What else can an orthodontist do to increase his income? Stop giving away what you are trying
to sell.
It is more important than ever for orthodontists to control delinquencies in the accomplishment of
both treatment and payment. Records must be kept to maximize knowledge of delinquency,
accompanied by procedures to minimize their occurrence and to manage them if they do occur.
If delinquency in payment does occur, there must be a service charge to make up for the loss in
purchasing power. If delinquency in treatment extends the treatment time, there must be a
pre-arrangement to continue a monthly maintenance fee.
Free treatment should be eliminated except to dentists who refer cases to you or whom you
expect to refer cases to you. No more free treatment to other dentists, physicians, relatives,
clergymen, politicians, teachers, pharmacists, accountants. And, no more trading of services. The
orthodontist will almost always be at a disadvantage in trading services. At least keep track of what
you are giving away, including supposed referring dentists, and evaluate it periodically.
Free consultations, diagnoses, x-rays, appliances and retainers must all be eliminated.
We must stop assuming more responsibility for the orthodontic treatment of children of divorce
than their parents are willing to assume.
We must stop making lenient transfer arrangements on the supposition that we have an obligation
to other orthodontists or to the image of orthodontics or to the public. Orthodontists cannot afford to
make free diagnostic examinations and supply free appliances, to say nothing of extended periods of
free or low-fee treatment for transfer cases. Every patient must carry his weight. I believe that better
management will not only minimize delinquencies of fee payment, but also expose delinquencies of
treatment accomplishment and cooperation before transfer does. When all patients are on their
proper flow schedule, the seeming inequities of transfer will disappear.
The practice of open-ended retention arrangements made at the start of treatment should be
discontinued. Regardless of whether one considers that open-ended retention is appropriate, it is
economically unsound to include retention in a fixed fee or to make a fee arrangement for retention
prior to treatment and 2-5 years in advance of some of these retention visits. It should be established
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at the time of contract that there will be a visit fee for retention visits.
EVALUATING THE UNCONTROLLABLE VARIABLES
The Birth Rate
The birth rate may reverse its present trend and increase again. This may be influenced by the
scare over the possible carcinogenic effect of "the pill" and by the fact that the number of women of
child-bearing age has been swelled by the World War II baby crop. However, even if the trend
should exactly reverse itself, in 1986 the number of 7-17 year-olds would average only 3,238,000
per year and the number of 7-14 year-olds would average 3,165,000 per year. So, it would require a
birth rate beyond expectation to make a significant difference to us.
The Number of Orthodontists and Others Doing Orthodontics
There may be a reduction in the number of orthodontic graduates. This is a real possibility,
especially if information is made available to dental students regarding the economics or orthodontic
practice. However, if the number of orthodontic graduates were only half the present rate, by 1986
there would still be 8400 orthodontists.
In terms of the number of children available per orthodontist, possible, but optimistic, increase in
births and a decrease in orthodontists would result in 380 children per orthodontist in 1986, without
the dilution of orthodontic treatment by pedodontists and GPs. If there will be 1500 pedodontists in
1986 and they average 50% orthodontics, they would dilute the children available per orthodontist to
349. If GPs averaged 5 orthodontic cases a year, it would further dilute this figure to 299. This is on
the basis of trends that are optimistic.
If practices were to remain 90% devoted to children, in order to start 100 cases a year, an
orthodontist on the average would have to start 30% of those available to him. Evidence seems to
indicate that we have not been starting children at that rate.
If full university graduate training were required to practice orthodontics, this would eliminate
the pedodontist and GP dilutions in large measure, and to achieve 100 starts a year the orthodontist
would have to start on the average about 24% of the children available to him. We are probably not
achieving that rate in too many locations at the present time.
The Inflation Rate
The inflation rate may decrease. There is evidence that the rate for 1976 will be approximately
6% compared to 7% in 1975 and 12% in 1974. However, all of these are high compared to the years
prior to 1970.
Conclusions
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Even a reasonably fortuitous combination of an increase in the birth rate and a decrease in the
number of orthodontic graduates cannot be classified as a major factor toward the improvement of
the economics of orthodontic practice. Nor would a levelling at the current rate of inflation.
If orthodontists continue competing with other orthodontists, as well as with pedodontists and
GPs, in the child population for 90% of their practices, then efforts at practice building and opening
satellite offices in an effort to gain more patients will be blunted because an increasing number of
practitioners will be competing for a declining or level or, at best, a slightly improving number of
children. The hope and expectation from practice building and opening satellite offices as far as
economics is concerned is that these efforts would result in a higher utilization rate and this is a
significant goal.
Adult orthodontic treatment has important potential for increasing the average orthodontic case
load. However, such a small number of adults is being treated now, that it will take a major
individual and group effort to increase the number in a major way in a short period of time.
Third party programs will undoubtedly expand and become a larger factor in orthodontic practice
than they are now. We have seen that it is doubtful that third party programs for children and,
possibly, for adults will have an effect equal to the decline in the child population in the next ten
years.
All of these factors together, especially if each one moves in a favorable direction, can have an
improving effect on orthodontic economics. However, the factors which would seem to have the
most immediate potential are practice building; increasing fees and nullifying the effect of inflation
by tying fees to the inflation rate; and reducing costs and trying to nullify the annual increase in
costs.
Without neglecting any factor which has the potential to improve the economics of orthodontic
practice, it would be most beneficial to concentrate on the areas which are likely to produce the most
beneficial effect the soonest, and over which we have some control, because we are talking about an
economic problem with a time frame urgency of two to ten years.
There are obviously variations in different parts of the country and in different communities, and
some practices have a better starting net income/cost ratio than others. There may be some
orthodontists who will practice through the next ten years substantially the same way as they have,
but for most orthodontists in the next ten years, financial success and even survival in practice will
depend on how soon one is aware of the imbalances in the variables in his practice and how well
one is able to make balancing adjustments in them.
Keeping the records that have been recommended only requires systematizing information that
should already exist somewhere in the practice records. But, keeping those records will permit an
ongoing knowledge of the present condition and future prospects of the practice and will indicate,
when fashioned into a practice model, what adjustments in the variables will satisfy the bottom
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line— the achievement of the needed or desired standard of living for the orthodontist and the
continued solvency of his practice.
TABLES
Table 1
Table 2
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Tables 13
Table 3
Table 4
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Tables 14
Table 5
Table 6
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Tables 15
Table 7
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Tables 16
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 May(354 - 357): Overhead Projection An Adjunct to Orthodontic Treatment
OVERHEAD PROJECTION
An Adjunct to Orthodontic Treatment
LEONARD S. FISHMAN, DDS
Overhead projection of prepared transparencies offers an opportunity for improved delivery of
treatment in a busy practice by rapid retrieval of information at the chair on a routine visit basis.
The Equipment
A standard overhead projector can be used at each treatment chair location. These machines are
available at any audiovisual supply dealer. I use Bell and Howell Model 301 ( Fig. 1).
The projector should deliver sufficient illumination on the screen without altering existing room
light requirements. The projector lens should yield an image without any significant distortion.
Convenience features include the ability to switch immediately to a new projection bulb when the
present one burns out, without having to open the working hot projector. Automatic thermostatic
turn-off control is desirable. It allows the light to be turned off, leaving the cooling fan operating.
The fan then automatically shuts off when the projector has cooled.
Projection transparencies are easily created, using a heat processing duplicating machine and heat
sensitive transparency material. Heat processing duplicating machines, such as the 3M #209, are
already in many offices, being used as office duplicating or billing machines. Transparency material
is also available from 3M. Many background and image colors are available for color-coding. The 8
 10 transparencies are mounted in inexpensive cardboard frames, available from any local
audiovisual dealer, for projection and easy filing.
Information Provided
The objective is to create a transparency for each patient that provides routine treatment
information at the chair. Additional information is added to the transparency as treatment
progresses. Only occasionally is additional information required from other record sources.
Here is how the transparencies are used in our office routine:

A. Patient's transparency is removed from file by receptionist-secretary. Current date is stamped
along cardboard frame. Transparency is handed to patient.
B. Patient brings transparency to treatment chair and places transparency on overhead projector.
C. During treatment, projection is viewed, and pertinent notes are added to the transparency. A more
detailed outline of the treatment visit is recorded on the cardboard frame under the stamped date.
This is done for legal reasons and is otherwise rarely referred to.
D. After treatment, patient returns transparency to receptionist.
The projectors and screens are easily adapted to a variety of office setups. Images can be
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projected against walls or hanging screens. The screens can be colored and add to office decor. As
much magnification as possible should be obtained and the projection path should not interfere with
objects or personnel. If the projection lens and screen are at different heights, the screen must be
angled to eliminate the "keystone effect" and provide a focused image over the entire projection area
(Fig. 2).
Transparency Fabrication
Here are the basic steps used in my office to create a transparency. The nature of the material
placed on the transparency would, of course, vary for other orthodontists.
1. After the case has been diagnosed and the treatment plan has been established, the following
information is penciled on a printed worksheet (Fig. 3):
a. A cephalometric tracing, penciled on acetate, is mounted and taped. Notation of skeletal,
dental, and soft tissue problems, and treatment objectives are marked on the tracing.
b. Before-treatment cephalometric measurements.
c. Teeth planned for extraction; anchorage setup required; notes regarding caries, ectopic
eruption, etc.
d. Date active treatment was initiated, case number, model number, dentist's name, etc.
e. Original mandibular cuspid-to-cuspid measurement and maxillary and mandibular molar width
measurements for use with Brader arch form guides.
f. Original Angle molar relationships for right and left sides.
g. Original rotations and crossbite relationships are illustrated diagrammatically.
h. Band sizes.
i. Information regarding skeletal growth pattern, derived from wrist x-ray.
j. Coded fee information.
Areas are left for current and future treatment notes and additional cephalometric tracings to be
inserted as therapy progresses.
2. The prepared worksheet and the transparency film are passed through the thermal transparency
maker.
3. Transparency is taped into the cardboard holder, labeled, and filed adjacent to the
business-receptionist area.
4. Notes pertaining to band sizes, treatment, caries, oral hygiene, etc. are added to the transparency
as therapy progresses (Fig. 4). Additional progress cephalometric tracings and measurements are
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also easily added during treatment. For this purpose, special acetate marking pens are used to
provide a permanent record in a variety of colors.
Conclusion
Overhead projection of prepared patient transparencies can provide rapid and easily used
information retrieval. Treatment efficiency is improved and the goal of quality orthodontic treatment
is assisted. It also lends itself nicely to patient and parent education, and the technique is adaptable
to existing physical facilities of all treatment rooms.
FIGURES
Fig. 1
Fig. 1 Overhead projector in use.
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Figures 3
Fig. 2
Fig. 2 Keystone effect and its correction by angling screen.
Fig. 3
Fig. 3 Worksheet with notations corresponding to text.
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Figures 4
Fig. 4
Fig. 4 Transparency after treatment is in progress.
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Figures 5
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 May(360 - 379): The Straight-Wire Appliance. Case Histories: Extraction

Extraction Brackets and "Classification of
Treatment"
An understanding of Straight-Wire orthodontic treatment must encompass more than just the
basic "Standard" Straight-Wire Appliance, because the total concept has other integrated elements.
Earlier installments in this series have discussed the "Six Keys" reflected in the appliance's
preprogramming, the sites and terminology involved in the essential new bracket-placement method,
and the Standard SWA and its clinical use. This chapter presents two more of the concept's
components.
Because of its name, some orthodontists surmise that the SWA treats most cases without archwire
bends. It does— if used in accordance with the design plan. The Standard SWA is primarily for
nonextraction cases, so it is right for about half of our patients. Beyond those, it can be and is used
by some doctors for extraction cases; but this application requires the use also of auxiliaries or first
order archwire bends, for anti-rotation, plus second order bends for anti-tip.
How They're Different
SWA extraction brackets, like Standard SWA brackets, have built-in tip, torque and in/out. In
addition, they provide two functions not needed in the Standard brackets: anti-tip and anti-rotation.
Without being too technical about it, here are the special problems of extraction cases and how they
are solved by these brackets:
When we translate a tooth, we have no way of applying a force exactly where it should exert
itself for maximum efficiency — because we cannot attach a bracket at the tooth's center of
resistance (the focal point of resistance to movement). Instead, the bracket takes hold of an available
point or a limited area on the crown. The LA-point is the best we can do (see JCO, March) but with
all its virtues it is still, from an engineering standpoint, the "wrong" place, in two ways.
(1) Ideally, the focus of force should be more centrally and apically located — where the nucleus
of resistance lies. Since our primary forces are applied at the buccal surface of the crown, when we
pull or push mesiodistally the tooth rotates, just as a cue ball does when you apply "English." SWA
extraction brackets compensate for this tendency during bodily tooth movement.
However, there is an additional factor to be considered. When active treatment is completed, the
buccal surfaces of teeth naturally rotate toward the extraction site. This occurs in serial extraction
cases before treatment, and in most extraction cases after treatment, even if space closure and root
paralleling were completed. SWA extraction bracket design has foreseen this too, and has provided
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the right increment of anti-rotation to compensate for the predictable post-treatment phenomenon.
Anti-rotation is accomplished by the bracket as a function of the slot's horizontal relationship to

the bracket base (Fig. 1 D, F, H). The amount of anti-rotation needed, up to 6°, is proportional to the
distance the tooth is to be moved. Anti-rotation in the bracket reduces the need for rotational
auxiliaries and/or first order archwire bends to counter the rotation. This design provision does not
present the disadvantages that accompany off-center bracket placement (JCO, March).
(2) Now think about the same factors in connection with mesiodistal tip. Since resistance to
movement lies below the cemento-enamel junction, no bracket can be aligned with the center of
resistance. Brackets have to be placed too occlusally, i.e., on the crown. Therefore, when an
orthodontist pulls or pushes at that point of attachment with a traditional edgewise appliance, he
applies force directly to the crown, and the root tags along behind it, unless he uses second order
archwire bends or angulates the bracket on the tooth.
SWA bracket features overcome this imbalance of effect during translation. Furthermore,
overtreatment is built into the bracket so that when it is removed, the root's natural rebound will
complete a net effect that leaves the tooth with the desired degree of tip (Fig. 1 C, E and G).
Is 100 percent precision always achieved in the final net effect? Of course not. The state of
orthodontic science (or "art" if you prefer) is a long way from enabling us to manage compound
forces and individual tissue conditions (or individual patients) with flawless control. But
anti-rotation and anti-tip features provided in the extraction brackets accomplish chores that the
doctor must otherwise attend to by archwire manipulation, and to a large extent by guess and by
golly.
Up to a maximum of 4°, the amount of anti-tip chosen (by selection of the proper extraction
bracket) should be proportional to the distance the tooth is to be translated. When a doctor uses
Standard SWA brackets in extraction cases, he must apply (in addition to anti-rotation measures)
second order archwire bends, or tipping of the bracket on the crown (which has undesirable effects;
see JCO, March). Extraction brackets will permit such cases to be treated for the most part with
unbent archwires.
Three Increments Needed
We said that up to specified maximums, the amounts of anti-tip and anti-rotation needed are
proportional to the distance of translation. We assume a minimum distance of 2 mm. Not counting
the Standard SWA (for non-extraction cases), there are three brackets designed for each posterior
tooth type except upper molars, for which there are four (Fig. 2). The three are designated
Minimum, Medium and Maximum, as in Fig. 1 and 2.
Minimum extraction brackets have 2° more tip than do Standard SWA brackets, and 2°
anti-rotation. They are designed for teeth that require up to 2 mm of translation. Medium extraction
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brackets have 3° more tip than Standard brackets, and 4° of anti-rotation built-in. They are for use
with teeth requiring 3 or 4 mm of translation. Maximum brackets contain 4° of additional tip and 6°
of anti-rotation, and are for teeth requiring 5 mm or more of translation. There are only three
categories of translation distance, in millimeters: two or less, three or four, and five or more.
"Minimum" brackets are also recommended for a tooth bordering on an extraction site but not
itself translated, to mate it better with an adjacent tooth that was translated.
Incisor Bracket Sets
As best shown by Steiner 1, the inclination (torque) requirement of incisors is directly related to
the ANB angle. Post-treatment ANB angles are predictable within a few degrees, for most patients.
Therefore, the proper incisor torque can be determined at the beginning of treatment.
SWA design accommodates these requirements with three sets of incisor brackets, designated A,
S and C, with S representing Standard. Set A is for ANB angles of more than 5°. Set S is for ANB
of 0° to 5°. Set C is for ANB of less than 0° (Fig. 3).
"CLASSIFICATION OF TREATMENT"
As explained above, the design relation of "Minimum", "Medium" or "Maximum" brackets to a

given tooth is simplicity itself. It involves only the distance of translation. Similarly, the three
incisor bracket sets are readily related to ANB.
But, relating brackets to the range of malocclusions that we ordinarily deal with provides an
opportunity for some rethinking about orthodontic diagnosis and treatment planning.
Angle's classification of malocclusion has served the specialty well and will continue to do so. It
does not, however, indicate the degree of difficulty of a case. Another approach — here proposed
— can be beneficial in evaluating a problem and prescribing for it, as well as in providing a fair and
rational basis for fee determination. This supplementary rating or ranking may also give us a better
perspective on our total body of work, bringing into focus the distribution of challenges, the areas
where more research is needed, or some aspect that hasn't occurred to any of us yet.
Angle's classic taxonomy does not help in the assignment of sophisticated brackets to individual
teeth, because it does not specify the extent of crowding involved. In contrast, the following analysis
organizes problems in terms of the orthodontic (not orthopedic) treatment required. It is basically
simple, but specific enough for use in bracket assignment. It is not all-inclusive; there will always be
the unusuals — the roughly 10 percent of patients who do not fit into the routine, who defy simple
classification, who therefore call upon the specialist to utilize fully his knowledge, talents and
judgment for the special handling their cases require. But the Classification of Treatment covers
those 90 percent who can be classified and helped in a relatively standardized manner. The concept
is compatible with and analogous to the Straight-Wire Appliance concept, for it is usable with little
modification in a high percentage of cases.
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This approach divides cases into three categories: Class I, Class II and Class II-Classic. Each of
these is then subdivided into more definitive types.
Class I cases are those that have an Angle Class I molar relationship. Class II cases are those with
an Angle Class II molar relationship and lower arch length problems. Class II-Classic also deals
with Angle Class II molars, but only those cases with no lower arch length problems and the lower
anteriors in good relationship to the face.
(Angle Class III problems are infrequent. Moderate ones are treated with the Standard SWA or
with the appropriate Class I Extraction Series or extraction brackets. Severe Class III cases, after
surgery, can be dealt with like any other cases in assigning brackets or series.)
Easy enough so far? Class I and II have the same meanings as Angle's Class I and II
denominations, except that Class II cases with well aligned lower arches, and lower anteriors in
good facial relationship, are called Class II-Classic.
Now for more specific, subordinate groupings within the Classes. Our "Types" are determined by
the amount of crowding and/or protrusion found in the lower dental arch. In Class I cases the upper
dentition is considered as much in error as the lower, even though the upper may be protrusive
instead of crowded.
The proposed classification can be used with any cephalometric analysis. Just measure the
amount of crowding in the lower dental arch. If you feel the lower incisors are too far forward,
measure the amount of retraction you want. Then add to the existing crowding 2 mm for every 1 mm
of planned retraction. The sum of the two numbers (along with molar relationship) determines the
Classification of Treatment for that case (Fig. 4).
Identification and Assignment
Every SWA bracket is readily identifiable as to the tooth type it serves. In addition, the brackets
are organized into sets (Fig. 3) and series (Fig. 4, and Classification of Treatment table). These are
referred to with numerals and letters that match each such combination of brackets with the
Classification for which it is designed. This permits immediate selection of the brackets most
suitable for resolving a particular problem.
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This classification is organized for easy remembering. So is the labeling of recommended bracket
series. Types A, B and C always have crowding of 7,10 and 14 mm, respectively. Series S, in all
three Classes, indicates Standard Straight-Wire brackets (for non-extraction cases). Type l-D is
unique— a Class I case requiring extraction of four second bicuspids. In Class II Classic, neither
crowding or protrusion of the lower arch ever exists, but two of the Classic Types require
extractions (either two upper first bicuspids or four first bicuspids) .
This classification is organized for easy remembering. So is the labeling of recommended bracket
series. Types A, B and C always have crowding of 7,10 and 14 mm, respectively. Series S, in all
three Classes, indicates Standard Straight-Wire brackets (for non-extraction cases). Type I-D is
unique— a Class I case requiring extraction of four second bicuspids. In Class II Classic, neither
crowding or protrusion of the lower arch ever exists, but two of the Classic Types require
extractions (either two upper first bicuspids or four first bicuspids) .
Sometimes it is necessary to construct one's own series from the total list of brackets available
individually (Fig. 2). This would occur, for example, if you had a patient who required translation of
teeth but whose malocclusion fit none of Classification of Treatment categories. She would be one
of the "10 percent," perhaps with unilateral asymmetries.
The advantage of the series, however, is that instead of composing bracket selections
note-by-note each time, a doctor can just select "chords" (series), each of which already includes the
desired harmonious notes. Or he can combine an upper set or series with a different lower set or
series.
As for availability, Series 1-C and Series II-Classic As for availability, Series 1-C and Series
4|4
II-Classic S are being used routinely in my office and others. Series 1-D is in production and the
4|4
manufacturer says it is soon to be released. As mentioned earlier, all others are expected to be
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available by the end of this year.
Fig. 4 shows diagrammatically the complete Classification of Treatment and the appropriate
bracket series.
Inventory
Keeping all of these series available on seamless bands would not be practical for all one-doctor
practices, nor even for some multiple-doctor offices. However, an inventory of the most frequently
used series is easily justifiable. Dr. Ronald H. Roth has found that a high percentage of his cases are
well served by Set C brackets for upper anteriors, Set S for the lower anteriors and Series II-Classic
4|4
As for availability, Series 1-C and Series II-Classic 4|4 for the posteriors. This has become known as
"the Roth set-up". (Roth has an article in press, entitled "Five-Year Clinical Evaluation of the
Andrews Straight-Wire Appliance." 2 He is willing to provide a reprint to those sending a
self-addressed stamped envelope.)
Inventory is, of course, no problem for those using the indirect technique, or direct bonding —
both of which are methods that make available the full array of the Series for maximum utilization
of the total Straight-Wire concept.
Case Reports
CASE 1
This was the first case ever treated with a Straight-Wire Appliance extraction bracket. The case
let me test that bracket against the Standard SWA bracket used on the other side. Every effort was
made to activate the two equally.
The malocclusion was Class I-C. Except for the upper left cuspid, Standard SWA brackets were
used. Bracket slot-size was .022 × .028. The extraction bracket was a "Maximum".
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Note: In the first grouping of the following photographs, the occlusal views have been "reversed" in
printing, to make them easier to relate to the buccal views. In all treatment photos, a dot identifies
the cuspid that has the extraction bracket.
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Beginning of active treatment, three weeks

after banding. Standard Straight-Wire bracket on upper right cuspid, Maximum extraction bracket
on upper left cuspid. Upper molars backed-up with headgear. Bull loops in place and activated.
2½ months into treatment. Retraction

response is about equal for both upper cuspids.
(5 months.) Upper right cuspid is beginning

to tip (crown preceding root) and is rotating unfavorably. Space is only half closed. Upper left
cuspid has been restrained from rotation. Its translation is completed; its root has nicely preceded the
crown.
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(8 months, 2 weeks.) .018 upper continuous

unbent archwire placed and tied back. Both cuspid crowns are fully retracted. Left cuspid is
obviously more favorably angulated than the right. Right cuspid is still rotated, and root is not yet
distal to crown. Right extraction site is closed. Left cuspid is not yet over-rotated. Note deflection in
.016 round wire, corresponding to anti-rotation in bracket. Left extraction site remains closed.
(10½ months.) Rectangular .018 × .025

straight upper wire is in place to further activate the slots. Tieback springs are consolidating spaces.
Left cuspid bracket continues to be fully expressed, holding tooth in a favorably over-rotated
position. Interestingly, the extraction site on the right side is opening, as a result of the crown's
mesial tip as the root moves distally. Upper archwire is tied back to close space.
One year into treatment. Both cuspids

looking good, but left looks better. Both extraction sites are closed. Right cuspid is not as favorably
over-rotated or tipped as is the left.
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(1 year, 9 months, 3 weeks.) Cuspids are

equally over-rotated. Left cuspid still appears better in tip; right cuspid, even though angulated 11°,
still is too upright. Wires were removed six weeks previously (except lower anterior sectional) to
permit settling before debanding. Debanding occurred at this appointment.
5 months and 18 days after active

treatment. A lower retainer had been worn the first two months, an upper retainer made but not
worn. Right cuspid, even though a Standard Straight-Wire bracket with 11° tip was used, appears
too upright. Left cuspid, retracted with a Straight-Wire Maximum extraction bracket (11 + 4 = 15°
tip), appears much more comfortable and natural.
1 year and 10 days post-treatment. No

retainers worn for 10 months. Left cuspid still looks better than right, and also has the better contact
with lateral incisor.
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Same date. Cuspid rise scheme of occlusion prevails,

with exception of anterior protection in the lateral excursions.
CASE 2
This review shows the use of Maximum lower posterior brackets. Let's begin with a basis for
comparison, by first looking at a lower arch being treated with typical edgewise brackets. Then we'll
examine a very similar case using SWA extraction brackets.
This case was referred to me after two years of orthodontic treatment, banded through the
"six-year" molars. Originally the patient had a Class II malocclusion, and her first doctor used an
edgewise appliance. The photos show traditional orthodontics — in treatment approach, appliance
and response of the teeth. Undesirable tipping of cuspids, bicuspids and molars into the extraction
site is evident. Class II mechanics, from the "six-year" molars, and translation have also resulted in
undesirable rotation of lower bicuspids and molars. Second permanent molars are not banded, and
have rotated during mesial drift. From this point, it would take a lot of talent and wirebending to
bring this case to completion, using edgewise.
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Article Text 12
Straight-Wire Appliance brackets (artist's

4|4
conception) for a Class II-Classic 4|4
malocclusion, showing Maximum brackets on lower posterior
teeth.
This archwire represents the second order archwire bends

necessary if edgewise or Standard SWA brackets are used instead of these extraction brackets —
which have built-in anti-tip and anti-rotation features.
Here is a Straight-Wire Appliance case very

similar to the edgewise case in previous picture.
This patient was started with Standard SWA brackets and treated 10 months before lower
posterior Maximum extraction brackets first became available and were installed at this
appointment. (For brevity in this article, let's refer to these extraction brackets as E-3s. The duration
of treatment mentioned with the following illustrations refers to the time-span after this
appointment.) Above, Maximum (E-3) brackets are in place on lower bicuspids and molars, with
.018 unbent round wire.
3½ months later, .018 × .025 unbent

rectangular archwire. Reciprocal tiebacks. Class II elastics being worn. Posterior teeth are upright
and not rotated, even though they have been translated mesially.
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Article Text 13
Six months after placement of E-3s.
I like the positions of lower bicuspids and molars. Bicuspid and cuspid roots are nicely paralleled.
Spaces are closed. No undesirable rotations, but anti-rotation (built into brackets) has not yet been
fully expressed, so archwire has been dropped down to .016 round, to permit that to occur.
Nine months into treatment. Cuspids and

bicuspids are sufficiently over-rotated, and posterior teeth appear slightly over-tipped — a result of
full expression of the overtreatment. Therefore, except for an incisor sectional, lower wire has been
removed to permit settling prior to band removal.
Three weeks later, the lower bicuspid

bands are removed in preparation for a lower bicuspid-to-bicuspid fixed lingual retainer.
Ten months and one week after

extraction bracket placement, the bands are removed to prepare for lower fixed retainer.
Crowns appear to have good angulation; spaces are closed; over-rotation has been adequately
anticipated by the treatment built into appliance instead of requiring archwire manipulation.
Clinically used here for the first time, these extraction brackets looked promising.
FIGURES
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Article Text 14
Fig. 1
Fig. 1 Example of Straight- Wire Appliance "Standard" and extraction brackets. These are for upper right cuspids. A
and B: Standard SWA bracket, for non-extraction cases. Bilaterally symmetrical. Note the 11° slot-tip, normal for this
tooth. C and D: "Minimum" bracket (E-1), has 11° of tip + 2° of anti-tip = 13° total tip; and 2° of antirotation. Designed for
cuspids adjacent to extraction sites or requiring translation of up to 2 mm. E and F: Medium bracket (E-2), has 11° tip +
3° anti-tip = 14° total tip; and 4° anti-rotation. Designed for cuspids requiring 3 to 4 mm of translation. G and H:
"Maximum" bracket (E-3). Its 15° slot-tip and 6° anti-rotation are for cuspids requiring translation of 5 mm or more. Four
degrees of anti-tip and six of anti-rotation are the maximums provided, on the assumption that more of either would be
beyond the rebound potential of any tooth. The anti-rotation feature does not affect the in/out feature of the SWA. All
extraction brackets have an identifying groove on the buccal surface of the occlusal end of the tie-wings; and notches
on occlusal side of bases identify brackets as Minimum, Medium or Maximum.
374
Figures 15
Fig. 2
Fig. 2 List of SWA brackets.
Fig. 3
Fig. 3 Anterior bracket sets. Degrees of torque are shown. Slot tip and in/out are the same in all three sets.
375
Figures 16
Fig. 4
Fig. 4 This representation of the Classification of Treatment omits drawings of the non-extraction examples. The
extraction brackets assigned to each type are indicated by the numbers on the teeth. (1=Minimum, 2=Medium,
3=Maximum.) The Class I cases do not show the upper teeth because uppers would have the same bracket
requirements as lowers. The anterior teeth are without bracket designation because brackets will be selected on the
basis of the predicted ANB at the conclusion of treatment. Posterior teeth that have no bracket assignment are to be
assigned Standard brackets because no mesial translation is required. Explanation of two examples: Class I-C (14mm
crowded or 7mm protrusive, or any combination of the two totaling a 14mm arch length discrepancy): Four first
bicuspids are to be extracted and the case assigned Class I-C series brackets. Each of the four cuspids requires
refraction of 7mm, so each requires "maximum" extraction brackets (indicated by numeral 3). The second bicuspids are
assigned "minimum" extraction brackets (symbol 1), not because they are to be moved (they aren't) but because they
are next to the extraction site, and minimum extraction brackets aid in mating the second bicuspids to the cuspids,
which will have been moved. The molars are assigned Standard SWA because no translation is required. Extraoral
4|4
4|4
376
Figures 17
4|4
forces are required; lingual wires would be helpful. Class Il-Classic 4|4 (Class II molar relationship, with the lower
anteriors in good relationship to the face and in good alignment): Extracting four bicuspids permits reciprocal movement
of the upper incisors and cuspids distally, and the lower posteriors mesially. Maximum extraction brackets are required
on the upper cuspids and lower posteriors. Minimum brackets on the upper second bicuspids and lower cuspids will aid
in better mating of these teeth with those translating to them. The upper molar brackets are assigned Standard brackets
because they are not involved in translation. Anterior bracket sets will be assigned in accordance with the predicted
ANB at the conclusion of treatment.
References
1. Steiner, C. C.: Cephalometrics in Clinical Practice. Angle Orthodontist, 29:8.
2. Roth, R. H.: Five-Year Clinical Evaluation of the Andrews Straight-Wire Appliance. Scheduled for 1976 publication.
377
References 18
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 May(380 - 395): JCO Interviews: Drs. Samuel Pruzansky and Howard Aduss on Cleft Lip and Palat
jco/interviews
Drs. Samuel Pruzansky & Howard Aduss on
CLEFT LIP AND PALATE
Cleft palate treatment remains one of the areas in orthodontics that seems vague and instills a
feeling of uncertainty and insecurity in us. To shed some sorely needed light on this subject, the JCO
invited the team of Drs. Samuel Pruzansky and Howard Aduss to discuss cleft lip and palate.
Both Drs. Pruzansky and Aduss have had vast experience in their specialized field. The Center
for Craniofacial Anomalies at the University of Illinois is world renowned. There, these two men
have developed a methodology and team approach that has become a model for similar clinics and
centers.
I had the good fortune to visit this Center and can attest to the great services rendered. There has
been an enormous amount of research and development undertaken here, and their publications are
too numerous to mention.
The stature of orthodontics has been enhanced by the efforts of Drs. Pruzansky and Aduss. The
JCO is extremely pleased to bring their knowledge to our readers.
SIDNEY BRANDT, DDS, Interviews Editor

DR. BRANDT What was the attraction for you to devote yourself to cleft palate therapy in an
interdisciplinary setting?
DR. PRUZANSKY Most professionals are overtrained for what they do in their daily practice and
undertrained in terms of their potential to help the patient. In clinical practice, problem solving can
become routine and one's intellect and educational background begin to suffer from disuse atrophy.
Now, imagine a clinical setting in which everything you ever learned in science becomes
applicable. Do you remember learning about mitosis and meiosis back in Biology 101? Well, you
cannot begin to understand cytogenetics unless you review such basics. Molecular biology, cell
physiology, immunology, genetics and so forth compel even middle-aged fellows like myself to
become eternal students. The excitement of our freshman years has never left us. I consider myself
fortunate that nothing I have ever learned has been wasted and all of it has been applicable to my
chosen career.
When I was given the task of organizing the longitudinal growth study, I was quick to recognize
the opportunity and made a commitment to stick with it. Except for the period of 1953-55, when I
was at the National Institute of Health, I have been associated with the Center from its inception in
February, 1949. Even during my appointment at N.I.H., I was permitted to commute to the
University of Illinois to continue the longitudinal growth studies.
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DR. ADUSS I joined the Center in 1962 following completion of my graduate studies at Eastman
where I was influenced by Dr. Subtelny who had been associated with the Center and Dr. Pruzansky .
DR. BRANDT What specialties of medicine and dentistry are represented on the Center staff ?
DR. PRUZANSKY The Center has departmental status within the Abraham Lincoln School of
Medicine of the University of Illinois and its clinics are units of the University Hospital. Members
of the professional staff hold appointments in at least one department of the several colleges of the
Medical Center. Since the Center is the organizer of a consortium of collaborating institutions
within the region, we have the advantage of drawing on various resources for consultants and
collaborators for specific projects.
Core staff include the following appointments from the School of Medicine: 1 ophthalmologist, 2
otolaryngologists, 1 pediatrician, 2 plastic surgeons, 2 speech pathologists, 1 audiologist, 1
psychologist, and a research associate in computer science . My appointment is that of Professor of
Orthodontics in the Department of Pediatrics.
Other core staff hold appointments in the College of Dentistry: 1 orthodontist (Dr. Aduss), 2
prosthodontists, 1 biostatistician, and 1 physical anthropologist.
The School of Associated Medical Sciences and the College of Nursing are represented by 2
medical artists and 2 nurses. In addition, we have technicians to assist with radiography,
photography, television, and electronic data processing.
Among the non-salaried active collaborators drawn from other departments and institutions we
can list dermatology, radiology with special competence in tomography of the temporal bone and
computerized axial tomography, genetics, neurology and neurosurgery.
Professional staff, paramedical and paradental personnel, as well as clerical staff, are invited to
attend and participate in weekly staff conferences. Thus, everyone who has contact with patients and
their families develops an awareness and concern that facilitates patient care and makes visits to the
Center a pleasant experience.
DR. BRANDT Why is this complete team approach so necessary?
DR. PRUZANSKY A child with a congenital or acquired malformation of the craniofacial complex
has intertwined problems that demand the integrated services of many specialists in dentistry,
medicine, nursing, behavioral sciences, and special education over a prolonged period to achieve
optimal habilitation. To meet these special needs in health care delivery, as well as provide a forum
for continuing education, the team approach became an inescapable necessity.
DR. ADUSS The team determines what the problems are, develops a data base unique to each
patient, and collectively determines a treatment plan with appropriate priorities and sequences of
care. One or more staff are designated to consult with the family and patient to interpret the team's
recommendations. Periodically, the staff reviews the progress notes as a group and, when necessary,
modifies the treatment plan.
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DR. BRANDT What types of deformities are handled at the Center?

DR. PRUZANSKY At first, we served only patients with cleft lip and palate. However, two things
happened to enlarge our scope. First, as a University-based clinic, it was inevitable that the more
complicated cases, patients with clefts and other malformations, would be referred to us.
As our interests and skills enlarged, patients with a wide variety of craniofacial anomalies were
referred to us irrespective of whether they had a cleft lip or palate.
Currently, our referrals seem to be divided equally between patients with cleft lip and palate and
those with various syndromes such as craniofacial synostosis, otocraniofacial syndromes,
chromosomal disorders, and nearly all children with abnormal faces from the clinics and wards of
the hospital.
In addition, we maintain a clinic for maxillofacial prosthetics and a training program for medical
artists, who are taught to design and fabricate prostheses under dental and medical supervision.
Most of the patients on this service have undergone ablative surgery in the treatment of cancer.
DR. BRANDT What is the orthodontist's contribution to the team effort?
DR. PRUZANSKY The orthodontist is disciplined to obtain detailed data on the initial state of the
patient and avoid cookbook routines in treatment. Analysis of photographs, study casts and
radiographs forces upon him the recognition of individuality. Since he deals with a growing patient,
the orthodontist is conditioned to think in the fourth dimension of time and, therefore, monitor
growth and effectiveness of treatment. Because of this discipline, the orthodontist is a potential
pacemaker for the team.
DR. ADUSS In combined orthodontic-surgical treatment, the orthodontist must have an overview of
the total treatment plan and guide orthodontic treatment in accord with surgical objectives. At the
Center, the tradition is for the orthodontist to carry his participation into the operating room so that
his knowledge and skills are immediately available to the surgeon. The orthodontist gains by
observation of the pathology during surgical exposure.
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Following orthodontic treatment, fixed prosthesis replaces congenitally

missing teeth in line of bilateral cleft, restores hypoplastic central incisors, immobilizes the movable
premaxilla, and retains the orthodontic repositioning. Precislon attachments on lingual of the
prosthesis retain removable obturator that closes the oronasal fistula. (Prosthesis by H.O. Gold,
DDS.)
DR. BRANDT Is there a research section at the Center?
DR. PRUZANSKY The Center is committed primarily to clinical research designed to shed light on
the causes of birth defects, in hope of their prevention and toward the improvement of treatment. Of
course, certain types of research must be carried out in the laboratory, utilizing experimental
animals. From time to time, the Center undertakes such projects in collaboration with established
laboratories.
The Center also maintains a data bank for the storage, retrieval, and analysis of information by
electronic data processing.
DR. BRANDT How many types of clefts are there?
DR. PRUZANSKY Clefts may involve the lip only on one or both sides. The lip and palate may be
involved in varying degree on one or both sides. The palate alone may be cleft. These differences
are readily identifiable by direct examination.
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Genetically, two separate groupings have been delineated. One includes cleft lip with or without
cleft palate. The second is confined to clefts of the palate without cleft lip.
Clefts of the palate vary in length and width. Some may involve all of the hard and soft palate;
some only part of the hard and soft palate; and others may be limited to the soft palate. As a result of
the communication between the nasal and oral cavities, a wide range of functions, including speech,
may be impaired.
Clefts in association with known syndromes merit separate categorization because of variable
modes of inheritance which have a bearing on genetic counseling. For example, clefts of lip pits are
inherited as an autosomal dominant trait with a 50% risk of recurrence.
DR. BRANDT What is the general incidence of clefts?
DR. PRUZANSKY The mean reported incidence of cleft lip and palate in Caucasian populations is
approximately one per 1000 live births. There is good reason to believe that there is considerable
underreporting and an estimate of one per 600 might be more realistic.
DR. BRANDT Is there a difference of incidence based on racial or ethnic background?

DR. PRUZANSKY Yes. There is a high incidence among the Mongolian races including Japanese,
Eskimos and American Indians. The mean incidence for Japanese is 1.7 per 1000 births. Curiously,
the Caucasians in Iceland have an incidence of 1.78 per 1000 births. In Hawaii, offspring of crosses
between races differing in frequency of clefts have an intermediate frequency. Blacks appear to have
a lower risk than Caucasians for clefts with a frequency of 0.41 per 1000 births (Am. J. Hum. Genet.
22:336, 1970).
DR. BRANDT Do all cleft palate patients have similar types of facial characteristics?
DR. PRUZANSKY No. A child with a cleft is first of all a child. His genetic and environmental
background may affect his predisposition to malocclusion as in any other child. The problems
relating to the cleft are overlaid on these individual differences.
DR. BRANDT What effect does surgery of the lip have on facial lines?
DR. ADUSS Where there is a cleft of the lip and palate, repair of the lip acts to mold the palatal
shelves in varying degrees, to an extent which we believe is predictable and manageable. In the past,
improper reconstruction of the soft tissue produced a tight, scarred upper lip which restrained
maxillary growth.
DR. BRANDT How much change in profile can orthodontic treatment cause in these cases?
DR. ADUSS The orthodontist can rotate bone segments, often torquing the entire premaxilla;
expand the palate by movement of bony segments; reduce overclosure and, thereby, improve the
skeletal profile.
As a general rule, we suggest that secondary correction of the profilar soft tissue by the plastic
surgeon should follow correction of the skeletal-dental base by the orthodontist.
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In a complete bilateral cleft lip in which the surgeon has set back the premaxilla in infancy with a
resultant midface convexity, there are certain limitations.
Changes in the convexity for patient with the

bilateral cleft lip and palate. Orthodontic treatment aligned the dentition and facilitated prosthetic
reconstruction. Note gradual resolution of facial convexity due in large measure to favorable
mandibular growth and restrained growth of premaxilla following lip repair. (From Friede &
Pruzansky, Plast. Reconstr. Surg. 1972.)
DR. BRANDT In your analysis, what measurement and angles do you routinely record on cleft
patients?
DR. ADUSS These do not differ from those I use in planning treatment for any other orthodontic
patient with two exceptions. First, the presence of supernumerary teeth or severely rotated teeth or
both often modify the roentgenographic point A. In measuring convexity initially, point A would be
selected arbitrarily. Following alignment of the anteriors, point A is more typical in its appearance.
The second difference is in the evaluation of convexity in young children with bilateral clefts.
Here, the most anterior point on the premaxilla is the reference point in determining profile
convexity or midface protrusion.
DR.PRUZANSKY In addition, we pay particular attention to the length and thickness of the soft
palate and the depth of the nasopharyngeal port, since this has relevance to the control of
hypernasality. Size of tonsils and adenoids, the configuration of the cranial base and upper cervical
spine, and tongue posture are also relevant in cephalometric analysis.
DR.BRANDT Do you order a head-plate on newborn children with clefts?

DR.PRUZANSKY Our Center developed the feasibility of roentgen cephalometry of infants and
young children by designing an appropriate cephalometer and by introducing a safe and effective
method for sedation.
DR.BRANDT What do you measure?

DR.PRUZANSKY That depends on the problem. Often, the task is to measure cranial size, shape
and intracranial volume. Where there is respiratory distress, questions regarding the adequacy of the
airway and changes subsequent to growth become crucial. Growth patterns need to be determined.
For example, in the case of a micrognathic mandible, can we anticipate spontaneous catch-up
growth, or is the condition growing worse, or is it remaining unchanged? Such information is crucial
to treatment planning.
In dealing with complete bilateral cleft lip and palate, the degree of protrusion of the premaxilla
is prognostic and guides treatment planning and parental counseling.
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DR.BRANDT Do cleft palate patients have similar growth patterns? DR.ADUSS Our studies have
demonstrated that they have the same patterns of growth as noncleft patients.
DR.BRANDT Is your mechanotherapy planned on the basis of the growth pattern?
DR.ADUSS With the same emphasis as in noncleft children. In craniofacial synostosis where there
is a failure of midfacial growth, or in cases of mandibular prognathism, mechanotherapy is modified
in accord with the planned osteotomies. As a result of consultation between orthodontist and
surgeon, orthodontic treatment is designed to provide for occlusal interdigitation following surgical
repositioning of the jaws.
DR.BRANDT Do you use serial tracings for this?

DR.ADUSS A great deal of emphasis is placed on tracings to identify a failure of growth or
overgrowth. Using the previous examples of midface hypoplasia or mandibular overdevelopment,
serial tracings allow us to predict the extent of the deformity and to time treatment.
DR.BRANDT Just how important is cephalometrics in general in analyzing cleft cases?

DR.ADUSS Cephalometrics is an indispensable diagnostic tool in our treatment planning, in
defining growth patterns, in locating the position of teeth, and in determining the presence of
supernumerary teeth.
Probably the single most important phase of cleft palate habilitation is the evaluation of
velopharyngeal adequacy. The lateral projection taken during phonation allows us to evaluate
velopharyngeal function. Good velopharyngeal function and good speech is the primary goal of all
cleft palate habilitation. Many of us get along with faces that are not beautiful, but the inability to
communicate is a much more severe handicap.
DR. BRANDT What additional things may you see in the cephalometric x-rays?
DR. ADUSS The most common aberrations observed on the lateral film are the distortions of the
anterior surface of the maxilla due to rotations and supernumerary teeth. From the frontal film, we
can visualize the aberrant morphology of the nasal chambers, the flattening of the inferior turbinate
on the side of the cleft in complete unilateral clefts, the deviation of the septum, and the appearance
of the cleft itself. Variations within the nasal cavity and floor affect arch form.
In bilateral clefts, it is often possible to see the premaxillary vomerine suture on the lateral film.
In correcting lingually tipped incisors, their orthodontic uprighting may be accompanied by rotation
of the premaxilla around the suture.
Our staff has reported a high frequency of craniovertebral malformations visible on the lateral
film.
DR. BRANDT Do you observe mostly minus ANB differences in cleft patients?
DR. PRUZANSKY The assumption of midface concavity as an inevitable sequel in cleft lip and
palate does not apply to the present generation. In complete bilateral cleft lip and palate, the major
problem that we encounter is midface protrusion or facial skeletal convexity.
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DR. BRANDT Can ANB differences be resolved in these patients as in noncleft patients?
DR. PRUZANSKY The majority of patients with clefts can be managed by conservative
orthodontic mechanotherapy . In extreme cases, we have to resort to mandibular setback or midface
advancement (LeFort I osteotomy) or a combination of both. You might be surprised to learn that a
significant number of children with clefts are treated with extraoral anchorage to correct maxillary
protrusion.
DR. BRANDT Apparently you don't see a predominance of Class III tendencies?
DR. PRUZANSKY No. There is no group tendency toward Class III. As in the general population,
children with clefts manifest a wide range of malocclusion. However, in cleft lip and palate, we are
likely to encounter a greater frequency of crossbite. The incisors adjacent to the cleft are more likely
to be malposed and hypoplastic. The lateral incisor in the cleft site may be missing, deformed or
duplicated. There is a higher frequency of missing teeth, such as premolars, in children with clefts.
DR. BRANDT Are teeth along the cleft site a special problem?
DR. ADUSS The most common findings are rotated teeth along the margins of the cleft with some
palatal displacement. This is particularly true for the canine. When these teeth are brought labially
and the rotation corrected, there may be a limited amount of bone along the margins of the cleft. In
this situation, stability of tooth position after orthodontic treatment will depend on a fixed
prosthesis, a bone graft across the cleft, or a fixed prothesis replacing missing teeth with or without
a secondary bone graft. The decision to bone graft depends on the size of the residual defect.
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Complete left unilateral cleft lip and palate before treatment, after
orthodontic treatment, and after prosthetic reconstruction and fixation. (Prosthesis by H.O. Gold,
DDS.)
DR. BRANDT Is there anything inherent in cleft malocclusions that allows for expansion of
intercanine width?
DR. ADUSS The same rules that govern intercanine width in noncleft patients apply to cleft
patients with the caution that the canine may have limited bony support at the medial margin of the
cleft. The orthodontist has the advantage in being able to move bony segments to correct crossbites
without stressing the periodontal tissues.
DR. BRANDT Do you do any rapid palatal expansion in the primary dentition in cleft cases?
DR. PRUZANSKY The decision to treat crossbite in the primary dentition is based on anatomical
severity and functional disability. If we find functional displacement of the lower jaw and there is an
impediment to speech, early orthodontic intervention is recommended.
DR. BRANDT What appliance would you use?

DR .PRUZANSKY We prefer fixed palatal expanders such as the Arnold expander for correction
of crossbites in the primary dentition. Occasionally, expansion may be impeded by the overlap of the
premaxilla as in unilateral clefts. In such instances, we resort to banding several teeth and expand in
the region of the cleft first, to unlock the segments.
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DR. BRANDT How do you retain the expansion?

DR. PRUZANSKY At times, we use fixed retention with a lingual arch soldered to bands cemented
to the primary second molars. Less than 20% of patients with complete unilateral or bilateral cleft
lip and palate are treated in the primary dentition.
Serial records at complete bilateral cleft lip and

palate requiring premaxillary setback due to unfavorable growth pattern. Preoperative casts show
extreme overbite and overjet with normal occlusion of buccal segments following preliminary
expansion. Cast resection (right) to guide the plastic surgeon and to construct a rectangular archwire
for tixation. Note the premaxilla was elevated and torqued as well as set back. (From Pruzansky &
Aduss, Plast. Surg. 1972.)
DR. BRANDT What are the criteria for rapid palatal expansion in the
permanent dentition in cleft patients?
DR. ADUSS The rule of thumb that might be applied is to use this procedure where the entire
maxillary arch is lingual or palatal to the mandibular arch.
DR. BRANDT What appliance would be used?

DR. ADUSS Whereas the Arnold expander is preferred in the primary or early mixed dentition, in
the adult dentition, we use a jackscrew type of appliance soldered to bands. However, using the rule
of thumb just mentioned, there are relatively few patients who require rapid palatal expansion, More
often, expansion is completed with the same appliance that is used to align the teeth. This appliance
is well tolerated by even the youngest patients and is generally limited to expansion of dental units.
In selected cases, it is possible to eliminate the use of a retainer by overexpanding the maxillary arch
and then the expansion is maintained by interdigitation of the teeth.
DR. BRANDT Is there an age factor that would limit rapid palatal expansion in cleft cases?
DR. ADUSS We have not found age to be a limiting factor in palatal expansion. As you know, the
repaired palate is not closed by bony fusion, but by soft tissue approximation. Therefore, palatal
expansion acts on the cleft segements and the connecting scarred soft tissue. Fusion of the
midpalatal suture following rapid palatal expansion does not apply in cleft cases.
DR. BRANDT Let us assume an eight-year-old patient presents with a mixed dentition, crowded
upper and lower incisors, unilateral cleft, and a tooth in the line of the cleft. Would you prescribe
any type of serial extraction procedure?
DR. ADUSS The same rules governing arch length deficiency and serial extraction in nonclefts
apply to children with clefts.
DR. BRANDT Should there be an immediate resolution of the tooth in the cleft?
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DR. ADUSS If it is a canine or lateral, it will probably be brought into alignment later. If it is a
supernumerary, which is more likely, I do not recommend that it be removed unless it interferes with
the movement of other teeth. The supernumerary will erupt in time and, because of its generally
diminutive root, can be extracted readily. Also, the supernumerary carries a certain amount of
supporting bone, which reduces the gap in the residual alveolar cleft and can be used to reposition
teeth in the permanent dentition.
DR. BRANDT Would such a patient be a candidate for rapid palatal expansion?
DR. ADUSS Expansion would be governed by the degree of "collapse" of the maxillary arch.
DR. BRANDT Is it better to delay orthodontic intervention?

DR. ADUSS That decision would be based on evaluation of the cephalometric films, particularly on
the stage of dental development and the pattern of eruption of the permanent teeth. In this
eight-year-old, treatment would be deferred.
DR. BRANDT Now suppose an older child presented with a cleft palate, adult dentition, crowded
anterior teeth, has had lip surgery perhaps two or three times, with or without a tooth in line of the
cleft. Is this type of malocclusion treatable?
DR. ADUSS Yes.
DR. BRANDT What do you look for in planning the mechanotherapy?

DR. ADUSS We apply the same diagnostic criteria as in the noncleft case. The fact that there were
two or three surgical procedures on the lip implies a "tight lip". This would govern the amount that
maxillary anteriors can be advanced and/or indicate that some type of permanent retainer will have
to be used to maintain their advancement.
DR. BRANDT Would you consider expansion?

DR. ADUSS Expansion would be considered only if there was a functional occlusal interference.
DR. BRANDT Are there any special criteria for extraction of teeth in cleft cases?
DR. PRUZANSKY Keeping in mind that there is a relatively higher frequency of congenitally
missing premolars in cleft cases, the same diagnostic principles and mechanotherapy utilized in
noncleft cases apply equally to cleft cases with the following exceptions:
1. The orthodontist can move bony segments where there are no serious limitations imposed by
excess scarring or excision of tissue, and 2. More elaborate retention may be required such as
multi-unit fixed prostheses to replace missing teeth in the line of the cleft, compensate for
hypoplastic incisors adjacent to the cleft, and retain expanded canines. Ideally, such prostheses
should include the first premolar on the side of the cleft and the two central incisors.
Incidentally, one of the common errors we observe in treatment of the permanent dentition in
patients with clefts is the failure to extract premolars in the lower arch. Such extraction not only
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compensates for intrinsic arch length deficiency, but also narrows the lower arch and facilitates
congruency with the maxillary arch. We frequently extract in the mandibular arch while maintaining
a full complement in the maxilla.
DR. BRANDT Are cleft palate patients more cooperative than others?
DR. ADUSS These children are the same as any other, with the additional problem of a cleft.
Modern surgical techniques have reduced the need for multiple procedures and hospitalizations. The
iatrogenically produced midfacial hypoplasia is the mark of another generation. Good speech is the
rule, with hypernasal "cleft palate speech" the exception. So, we are generally dealing with just
another child with some different kinds of tooth problems.
DR. BRANDT Is there an ideal time to initiate active treatment for these patients?
DR. PRUZANSKY No. Just as in treatment of noncleft patients, variation is the rule and each case
has to be evaluated individually. Some clefts of the palate can be operated successfully at one year
and a few even earlier. Most are operated between 18 and 30 months of age. Occasionally, some
clefts are extraordinarily wide and so deficient in palatal tissue as to preclude surgery and depend on
prosthetic speech aids for habilitation.
DR. BRANDT Do you recommend orthodontic management of newborn children with cleft defects?
DR. ADUSS No, we do not recommend such management. There is sufficient evidence in the
literature indicating that presurgical maxillary orthopedics has not proven to be the cure-all for
patients with clefts. Indeed, for certain parameters, those children that did not receive any
orthopedic management have done better than those that have. Advocates of early management have
claimed that it will provide everything from psychological support for the parents to the prevention
of crossbite.
DR. PRUZANSKY I should like to comment on the debate regarding orthodontic management of
newborns with clefts. In 1964, I published a dissent (Cleft Palate Journal, April 1964) which took
issue with the prevailing enthusiasm for presurgical maxillary orthopedics and primary bone
grafting. Since then, primary bone grafting has largely been discredited and abandoned, even by its
earliest and most ardent enthusiasts. There remain some pockets of sup port for presurgical
orthopedics and they publish papers with statistics to support the benefits of their treatment. While
this is no place to debate the accuracy of their contention, it is regrettable that the argument centers
on numbers and not on mechanisms by which success or failure occur. Our own research has
attempted to clarify mechanisms. Regrettably, some of our colleagues are more preoccupied with
how to treat a given condition than to ask why it occurred in the first place. To know the cause is to
be guided to the remedy.
DR. BRANDT Is early or late initiation of appliance therapy a factor in the stability of the treated
case?
DR. PRUZANSKY Delay in treatment of a collapsed maxillary arch results in abnormal forces of
occlusion producing secondary complications in the mandibular arch. In our experience with older
untreated cases, most of our efforts are directed toward mandibular arch correction.
391
Article Text
DR. BRANDT What can you say about the general stability of orthodontically treated cleft palate
patients?
DR. PRUZANSKY Not all clefts are alike and neither are all children. Therefore, generalizations
are hazardous. Also, the experience of one Center does not necessarily apply to all Centers, simply
because of regional differences in surgical philosophy and techniques. Within these limitations, we
can say that the prognosis for the child born with a cleft in 1975 is infinitely better than for one born
in 1945.
Of course, there are special problems. What to do with the "floating" premaxilla perplexes most
surgeons and orthodontists. In most instances, fixation can be achieved with a fixed bridge that
includes canines and first premolars on either side, as well as the centrals. Such fixation, of course,
is deferred until early adulthood.
DR. BRANDT What is your usual retention procedure?
DR. ADUSS Our usual retention sequence is a maxillary Hawley-type retainer with additional
clasps around those teeth that were severely rotated and adjoin the cleft. The retainer also includes
prosthetic teeth to replace missing teeth in the line of the cleft.
Whether the retainer is placed on the day of the appliance is removed or a few days later depends
upon the expansion that was necessary, the interdigitation that has been achieved, and the severity of
the rotations. Most often, the retainers are placed the same day appliances are removed.
Retainers are worn for at least two years in those cases that have no edentulous areas or until the
dentist can construct a suitable fixed prosthesis to replace missing teeth and add stability to the
upper arch.
DR. BRANDT Are there times when surgical-orthodontic procedures are indicated for cleft
patients?
DR. ADUSS Combined surgical-orthodontic procedures are not as common in cleft cases as they
are in other craniofacial anomalies such as Apert and Crouzon syndromes and the otocraniofacial
syndromes. In these syndromes, presurgical orthodontics followed by osteotomies are required to
achieve acceptable cosmetic and functional results. Treatment planning in these cases relies on close
cooperation between the orthodontist and plastic surgeon. Within our group, the surgeon and
orthodontist spend a great deal of time identifying the specific features of the anomaly, outlining the
results that can be achieved orthodontically and the surgical requirements. At the time of surgery,
the orthodontist works with the surgeon in placing the disarticulated parts into their new position.
The same principles apply to the occasional older patient with a cleft who had been treated years
ago.
DR. BRANDT What are the indications for surgical-orthodontic intervention?
DR. ADUSS Surgical-orthodontics is indicated when the requirements of the case exceeds the limits
of orthodontic treatment. I dislike being this general in my answer, but each case must be decided on
an individual basis. It might be better to suggest that surgical-orthodontics should be considered
when acceptable and stable maxillomandibular relations cannot be achieved by conventional
392
Article Text
methods within a reasonable period of time.
Case prior to mandibular resection. Edgewise appliance modified for

intermaxillary fixation. Vertical spurs are ball clasps. Solder joints are purposely full to provide
smooth, rounded surface for wire fixation.
DR. BRANDT Is the appliance strap-up modified for these procedures?

DR. ADUSS Wherever possible, we prefer a full edgewise appliance modified with soldered
vertical spurs for intermaxillary and intercranial fixation.
In all surgical-orthodontic procedures, we align the maxillary and mandibular dentition and
perfect intra-arch occlusal relationships so that at the time of surgery the final occlusion can be
achieved. This is done to avoid the use of plastic splints between the teeth particularly in midfacial
advancements where overbite is purposely exaggerated at the time of surgery, and also because there
is nothing more discouraging to a patient than to undergo orthodontic treatment followed by surgery
and 6-8 weeks of intermaxillary fixation, and then to have to continue with orthodontic treatment.
Following cessation of intermaxillary fixation, we prefer to remove all appliances and begin
retention.
DR. BRANDT What kinds of surgical procedures are done?
DR. ADUSS The operations that require orthodontic preparation before surgery include correction
of mandibular prognathism, the LeFort procedures that involve advancement of the midface, and
combinations of these procedures for patients with hemifacial microsomia. These combined
procedures result in excellent maxillomandibular relationships and occlusion with improved
function and esthetics.
A note of caution is warranted concerning these procedures. Diagnosis includes not only
assessment of the facial profile or maxillomandibular relationships, but evaluation of the airway,
assessment of the velopharyngeal mechanism, and the potential for velopharyngeal incompetence
following midfacial advancement. These are but a few of the morphologic considerations that
concern the orthodontist. If we superimpose the emotional and psychosocial impact on the family
and the involvement of the ophthalmologist, pediatrician, anesthesiologist, and surgeon, to mention
only a part of team, it is my feeling that surgical-orthodontic procedures belong in a Center where
complete assessment can be done both pre- and post-operatively.
DR. BRANDT Is surgical-orthodontics performed only on older patients?
DR. PRUZANSKY The major surgical osteotomies have been performed largely on older patients.
There are several reasons for this, including the fact that donor sites for bone grafts are larger and
393
Article Text
pose less hazard to continued growth. However, midface advancement is imperative for some small
children, particularly those with craniofacial dysostosis, who are at risk for blindness because of
their shallow orbits, and who may develop cor pulmonale because of epipharyngeal obstruction.
Severe deformity may also pose a profound psychosocial handicap, inhibiting social and educational
advancement. As a result, several preschool age children have been operated at our Center.
Increasingly, this type of surgery is being performed on selected series of young children.
DR. BRANDT Are there any problems maintaining the vitality of teeth following surgical
intervention?
DR. PRUZANSKY We have been surprised by the relative infrequency of disturbed dental vitality.
In large measure, we attribute this to careful planning and execution of the osteotomies, as well as
Nature's benevolence.
DR. BRANDT Does growth prediction analysis apply in cleft patients?

DR. ADUSS There are a number of studies of craniofacial growth in cleft patients from infancy
through adolescence. Many are based on cephalometric measurements from the data bank of the
Center at the University of Illinois. Craniofacial growth in children with clefts does not differ
significantly from noncleft children. Therefore, I see no reason why the same growth prediction
analysis cannot be applied.
DR. BRANDT Do you feel that newborns with cleft defects belong in large centers such as yours,
rather than in private offices?
DR. ADUSS There are a great number of physicians and dentists capable of treating children with
clefts. However, no single specialist is sufficiently skilled to provide in-depth evaluation of the
multiple habilitative needs of the child with a cleft or other type of craniofacial malformation.
The University Center can provide these diagnostic services and the various specialties, working
together, can decide on the priority of patient need and the sequence of treatment procedures. The
University Center can also function as a treatment facility, particularly for those special services not
locally available to the patient. I visualize the University Center as a diagnostic center; as a
treatment planning center, providing guidelines for the private clinician who refers his patient for
evaluation or for the clinics within a hospital; and as a point of reference for the patient and his
family in terms of overall and long term care.
And, finally, the Center bridges the communication gap between the medical disciplines involved
in habilitation and between the clinicians, as a group, and the family. In other words, the specialist
involved in a specific procedure at a particular time can better counsel the patient and family when
he understands not only what his task is, but how it relates to the overall habilitative program.
DR. BRANDT Are there enough trained and experienced teachers in your field?
DR. PRUZANSKY No.
DR. BRANDT Do you think this problem will be overcome?
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Article Text
DR. PRUZANSKY Since the number of Centers will always be less than the number of graduate
programs, the solution to teacher shortage resides in regionalization. For example, in the city of
Chicago our faculty could serve as a resource to the various graduate programs in the metropolitan
area and beyond. To a limited extent this arrangement is already in operation. Unfortunately,
institutional chauvinism is a considerable barrier to effective collaboration.
DR. BRANDT Is the training in this area for graduate students in orthodontic programs adequate?
DR. PRUZANSKY Regrettably, no. Teachers and students have a blind spot in this regard. They
reason that most practitioners will see few such cases and, therefore, the subject does not merit
much time in the curriculum. However, the knowledge to be gained from the study of these
problems transcends the patient with a cleft and applies to a wider range of more common problems.
Invariably, graduate students who have flowed through our Center on an elective basis tell us how
much they have been enriched by the experience.
DR. ADUSS By and large, orthodontic students receive the basic information in embryology,
anatomy, physiology, growth and development etc., in dental school and in their graduate training
programs to understand the cleft lip and palate anomaly and many other craniofacial malformations.
If I were to recommend additions to the graduate curriculum, I would place greater emphasis on the
study of craniofacial malformations, for these represent Nature's experiments on man. Through
better understanding of the abnormal, we gain increased insight into the normal.
DR. BRANDT Gentlemen, thank you for your thoughtful and eloquent presentation of this
important subject.
PRUZANSKY
ADUSS
395
Footnotes
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume May
396
Footnotes
JUNE 1976, VOL. 10 / ISSUE 6

The Straight-Wire Appliance: Extraction Series Brackets 425
Copying 35mm Slides 444
Word Processing: A Step Toward Painless Dental Communication 446
JCO Interviews: Dr. Richard A. Riedel on Retention and Relapse 454
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Jun(409 -): 410 THE EDITOR'S CORNER
the editor's corner

If you agree that there is a need for renewed efforts at practice building in light of a growing
economic threat to orthodontic practice and if you further agree that there are evidences of a
growing discontent on the part of the public and/or on the part of public leadership figures in
government, unions, and consumer groups; and that this discontent is based in part on an erosion of
the image of professional people and its replacement by an image of a businessman whose primary
concern is money— then we ought to talk about "the invisible man".
The invisible man is the doctor who has delegated everything and has all but lost contact with his
patients and parents, and their dentists. He communicates with referring dentists with form letters
and check-off cards. Often, they don't even know that he has. They rarely communicate with him
about patients and frequently can't find the letters and notes he sent them. The fault may not be
entirely on their side. Everyone would benefit if more time were spent on dentists.
Parents like the doctor to present the case, to give them progress reports, to make the
post-treatment report. There has been a tendency to delegate all of these to an assistant or to
eliminate them entirely, which could be one of the greatest practice administration errors we could
make.
TALK WITH CHILDREN, the poster says, AND SEE THAT EACH DAY EACH CHILD
ENJOYS SOME SMALL SUCCESSES AND SOME RECOGNITION AS A PERSON. Is there a
better expression of the caring relationship between an orthodontist and his patient?
Now is not a time to downgrade the business aspect of orthodontic practice. It anything, we need
a better knowledge of business and a better application of modern business management methods.
However, it is an error to make the business of practice an end in itself, rather than a means to an
end, which is to free the doctor from spending time inefficiently and on matters that can be handled
by auxiliary personnel or machines. It is not clear that we always knew what we were freeing the
doctor for. Carried to an illogical conclusion, it frees the doctor to do absolutely nothing.
Frequently, far from freeing the doctor, it entangled him in a large organization whose saving grace
was that it permitted treatment of more patents and that there were more patients to treat.
While it is important to have a staff that conveys the image of an efficient, friendly and caring
organization, it is as important for the doctor to participate in this to the fullest extent that his time
and talent will allow, and one purpose of the efficient staff is to free him to spend more time in
direct contact with patients, parents, and dentists. It really boils down to an assessment of the
strengths and weaknesses of the doctor and his staff. If a doctor is a super mechanic and a poor
communicator it would be counterproductive to replace him with an inferior mechanic and make his
chief task communication. On the other hand, if he could be replaced with a satisfactory mechanic
and assign certain communications to a staff member who communicates well, then there are
enough additional areas for the doctor to be involved in, many of which depend on his visibility.
409
Article Text 1
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Jun(409 -): 410 THE EDITOR'S CORNER
If the doctor has the time, here are some areas outside of actual treatment that he could be
concerned with: the economic flow of his practice; patient care, patient flow, patient success; patient
and parent involvement, education and communication; dentist appreciation, dentist communication,
dentist education; post-treatment evaluation; feedback from patients, parents, and dentists;
self-improvement through continuing education in orthodontics, management, allied fields, study
club activity, attending meetings, taking courses, and reading a wide variety of literature in
orthodontics, allied fields and matters of general interest outside of dentistry; clinical research;
public relations in its promotional sense in one's practice and in the community.
It is a survival factor for us to live an image of a doctor who really cares about the professional
and personal problems of his patients, their parents and dentists, and his staff; and to get rid of "the
invisible man".
410
Article Text 2
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Jun(425 - 441): The Straight-Wire Appliance: Extraction Series Brackets
THE STRAIGHT-WIRE APPLIANCE Extraction

Series Brackets
In the April issue of JCO we showed four non-extraction cases during treatment with the
Standard version of the Straight-Wire Appliance. The May installment described a proposed
"Classification of Treatment" system, as well as extraction brackets and extraction Series, and
reported two cases in which some prototype SWA extraction brackets were tested.
This month's issue and the next will each present two cases selected to illustrate the application of
complete extraction Series. (A Series is a coordinated group of brackets designed to resolve a given
problem with the smallest possible number of archwire bends.) In the second case below, lack of the
optimum Series made it necessary, late in treatment, to put some second order bends of minimal
magnitude into the archwires.
CASE I
In the SWA extraction Series used here, the first permanent molar and cuspid brackets were the
first that had tie-wings extended for use as hooks, providing a mechanical advantage that effectively
conveys force closer to the middle of the root, thus contributing to more efficient translation. Such
tie-wings also provide an easy way to apply force to cuspids; and by moving the force system away
from the gingival portions of the crowns they reduce the decalcification potential.
History
Age 15 years, 5 months. Caucasian, male, no health problems.
425
Article Text 1

Diagnosis
Class Class I-B; 10mm of crowding in the lower arch. (See May issue of JCO for explanation of
classifications.) Primarily a dental problem, although ANB is 5°. Cuspids are badly out of
alignment, some with root mesial to crown. Lower incisors are in good relationship to face.
Treatment Plan
Remove four first bicuspids to obtain space for retraction of cuspids 5mm, with posterior teeth
moving forward 2mm in each quadrant. High-pull Kloehn headgear required in upper arch, and .036
426
Article Text 2
lingual wire to the first permanent molars below, to hold molars until cuspids have moved 3mm.
Then discontinue headgear and lingual wire, and reciprocally close remaining 4mm of space (the
cuspids moving distally 2mm and the posterior teeth mesially 2mm).
Slot .022  .028. Extraction Series I-B would be optimum for this case but is not available, so
substitute Series I-C, the "closest" series available for the Class I-B problem.
Treatment
Active treatment begins with .0175

Wildcat archwires, and a lower lingual wire.
The high-pull Kloehn headgear to the upper first permanent molars is to be worn 14 hours daily.
"Maximum" extraction brackets are on the cuspids, "Minimum" extraction brackets on the second
bicuspids, Standard SWA brackets on all other teeth.
Two months later we change to .018

"orange" Australian archwire.
After these photos, cuspids are ligated— as they should have been at the first appointment—
passively, to the first permanent molars, to discourage mesial tip of cuspids and advancement of
anterior teeth. (A cuspid root should precede its crown in movement toward the extraction site. At
the pivot point, which coincides with the LA-point, defined in earlier installments, the body of the
crown should remain in place, allowing proper tip of the crown before actual translation begins.)
427
Article Text 3
After five months of treatment, we place

.018  .025 archwires.
Cuspid crowns have been retracted 3mm but their roots are not yet preceding the crowns. Pletcher
springs are attached and lightly activated on the right side, from first permanent molars to cuspids,
to promote distal root movement. A new prototype spring is being tested on the left side. And you
can see, K2 AlastiKs are installed from archwire hooks to second permanent molars to offset any
tendency of the incisors to flare as the cuspids are being uprighted. The lower lingual archwire is
removed. The headgear is still being worn 14 hours/day as a precautionary measure.
A ceph tracing two months

later shows lower anteriors at 7.5mm to NB, but 4mm of extraction site space remains in each
quadrant.
Treatment objective is to have lower incisors at 5mm to NB at conclusion of treatment.

Reciprocally closing spaces now will accomplish that. Headgear is discontinued at this appointment,
and the tie-back springs fully activated .
428
Article Text 4
After 7½ months of treatment, Pletcher

springs are again attached from the first permanent molar hooks to the cuspid hooks. They are fully
activated to promote pure translation. K2 AlastiKs are attached from the second permanent molars
to the archwire hooks, to apply closing forces to the molars and incisors. Steiner rotation springs are
placed on the distal portion of the first permanent molar brackets to resist rotation.
The extraction spaces are closed, in 11

months.
We take a headfilm.
The lower incisors are at 5.5mm, ANB has improved to 2.5° (from 5°). Inclination of upper and
lower incisors is favorable.
429
Article Text 5
A month later, we fine-tune.
Rotation springs are applied where needed. Second order bends are required in upper and lower
molar areas because the proper extraction brackets (Medium) are not available. Extraction spaces
are lightly held with AlastiKs and Ormolast chains from the first permanent molar hooks to the
archwire hooks above, and to the cuspid bracket hooks below.
At 1 year 4½ months, active treatment is

completed. Bands are removed and a positioner impression taken.
Positioner has been worn six weeks.
430
Article Text 6
The patient is put through basic functional excursions,

and the next three rows of photographs show functional occlusion. Cuspid rise goals have been
reached.
431
Article Text 7

Comments
The use of tie-wing hooks proved to be convenient and effective, so will become a feature of all
SWA extraction brackets.
432
Article Text 8
ANB was reduced from 5° to 2°; point A moved back 2° and point B forward 1°. The patient's
face remained good because the favorable (5mm) relationship of lower incisor to NB was
maintained.
Since high-pull headgear was worn and Class III mechanics were not used, I was surprised at the
change of occlusal plane to SN, from 16° to 9°.
Active treatment time was 1 year, 4½ months. Straight archwires were used throughout treatment,
with the exception that minimal posterior second order bends were required in the final archwire
because Minimum extraction brackets were not available for molars or second bicuspids. Static and
functional occlusal objectives were reached, as well as facial and dental aesthetic goals.
CASE II
History
Age 12 years, 5 months. Caucasian, female, no health problems.
Diagnosis
ANB 6°. A combination skeletal-dental problem— maxillae protrusive, and a dental double
protrusion. Half-way between Class I and Class II: a Class I½-B. (Lower arch is considered 10mm
"crowded" because incisors are to be retracted 5mm.)
Treatment Plan
Remove four first bicuspids. Retract anterior teeth 5mm of the available 7mm (from 9° to 4° to
NB). Reduce ANB to as close to 2° as possible. High-pull Kloehn headgear and Class III mechanics
to be worn 24 hours/day for approximately five months. After incisors are retracted, headgear to be
worn at night until ANB problem is resolved.
Objective to be achieved in two stages: Initially retract six anterior teeth 3mm into the 7mm of
extraction site space, with continuous closing mechanics supported by headgear and Class III
mechanics. Headgear and Class III mechanics can then be stopped and the remaining 4mm of
extraction space in each quadrant closed reciprocally. Anteriors will move distally 2mm and
posteriors forward the other 2mm.
433
Article Text 9
Case II Beginning Records

Treatment
434
Article Text 10
Two months into treatment,

therapy with headgear and Class III mechanics begins.
The .018 archwire is shown lightly tied back with K2 AlastiKs. This permits cuspid uprighting
without mesial crown tip that would flare the incisors.
Fifteen weeks later, .018  .025

archwires are installed with continuous closing mechanics, backed up by headgear and Class III
mechanics.
The teeth are translating nicely. There are no bends in the archwires.
435
Article Text 11
At nine months the continuous

closing mechanics are being maintained with AlastiKs and Ormolasts.
We take a progress headfilm.
The film shows excellent progress. Molar relationship is Class I. ANB is down from 6° to 4°.
Lower incisors have retracted to 5mm to NB. Extraction spaces are almost closed. So we will
discontinue headgear and Class III mechanics at next appointment.
436
Article Text 12
Spaces are closed after some 13

months of treatment.
Only fine-tuning remains. No bends, other than reverse and accentuated curves, have been used.
Four months later we reduce

archwire to .018, to permit controlled settling.
Active treatment ends at 1 year, 8

months.
We have partially debanded, but will maintain extraction site closure by ligating the remaining
brackets. We make retainer impressions at this appointment.
437
Article Text 13
Here you can see the lower

five-to-five fixed lingual retainer, installed seven weeks ago.
An upper retainer is being worn at night. Cuspids and bicuspids show that the counter-rotation
feature of the extraction brackets has been fully expressed. Centric occlusion and centric relation are
one and the same. The reaching of functional goals is evident in the next three rows of photographs.
438
Article Text 14
Case II Final Records
439
Article Text 15
Comments
ANB was reduced from 6° to 2°. Lower incisor to NB was reduced from 9mm to 4mm. The
occlusal plane changed from 12° to SN, to 5°, apparently because of Class III mechanics. The
mandible grew forward but not downward. There was good facial and dental aesthetic change, along
with arrival at static and functional occlusion goals. Active treatment time, 1 year, 8 months.
(TO BE CONTINUED)
440
Article Text 16
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Jun(444 -): 445 Copying 35mm Slides
The Vario-Dupliscope.
Copying 35mm Slides

LAWRENCE N. ROUFF, DDS
It is often desirable, as in transferring a patient, to be able to send duplicate slides rather than the
originals. It may also be desirable to make black and white prints directly from color slides for table
clinics or study group presentations, rather than having to send the originals out to a lab to have
internegatives and then black and white prints made.
The Vario-Dupliscope
A simple attachment for almost any 35mm camera is the Vario-Dupliscope (Spiratone, Inc.,
135-06 Northern Blvd., Flushing, N.Y. 11354.)
Samples of black and white

prints from color slides.
This is a single unit which mounts directly on the camera and is designed specifically for
duplicating 35mm slides. Magnification is adjustable from 1:1 to 2.5:1, which means that a cropped
portion of the slide only one-half inch square can be enlarged to a full 35mm size.
444
Article Text 1
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Jun(444 -): 445 Copying 35mm Slides
The Vario-Dupliscope is quick and easy to use:

1. Attach to camera.
2. Set desired magnification.
3. Attach any electronic flash to camera and place in front of Dupliscope. The distance between
flash and scope will vary with the intensity (guide #) of the flash and the speed of the film used.
This distance is, for example, 18" if Tri-X film is used with an electronic flash having a guide
number of 60.
4. Make sure that camera is set for speed synchronous with flash, for example Nikkormat 1/125,
Pentax 1/60, etc.
5. Take photo. No need to focus as Dupliscope is preset. Black and white film such as Tri-X or
Plus-X is used for black and white prints. Kodachrome 2 film is used for color slide duplication.
445
Article Text 2
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Jun(446 - 453): Word Processing: A Step Toward Painless Dental Communication
WORD PROCESSING: A STEP TOWARD

PAINLESS DENTAL COMMUNICATIONS
GABRIEL S. CARLIN
Dr. C.E. Kavanaugh is an orthodontist in Kansas City, and while his practice is specialized, many
of its inherent problems are not. One particular problem is the need to constantly and consistently
control administrative and clerical costs at a time when his output of written communications is
increasing steadily. This economic consciousness has led Dr. Kavanaugh to research the field of
modern office technology and has resulted in his discovery of the most rapidly expanding segment
of this field— word processing.
The term "word processing" can take a different meaning for each user, depending on the
application. Coined by IBM in the mid-1960's, it has become a generic term— a catchall to describe
just about any system that enhances or speeds the paper flow in offices. A good general definition
would be: the transformation of ideas and information into a readable form of communication
through the management of procedures, equipment and personnel .
Machines classified as word processing equipment vary. Many offices now include systems
utilizing techniques such as xeroxgraphy, facsimile, optical character recognition, phototypesetting
and micrographics. Add to these the list of text-editing typewriters, CRT display text editors,
dictation equipment, computer time-shared text-editing units, and shared logic systems, and it's
enough to confound and confuse even the professional office manager.
Application to Orthodontics
Suffice to say that in the practice of dentistry, most of these technologies are both unnecessary
and impractical. But orthodontists, like other dental specialists who recognize the value of effective
written communications in their practice, can look upon word processing as a tool for increasing the
efficiency and output of the written word without sacrificing administrative professionalism. And,
as a result, they should view it as a valuable time saver, and in the long run, money saver.
The dilemma faced by Dr. Kavanaugh, certainly common to the practice of orthodontics,
concerns the specter of prolonged treatment caused by lack of patient understanding and
cooperation. To help assure that the patient, and in most cases, the parents are adequately informed
of the prescribed treatment, treatment schedule, and required at-home procedures, he has developed
and relies on a program of personal written communications.
"I can sit with a patient and parent," he relates, "fully describe the recommended treatment,
outline the fee and payment schedule, answer all questions, and in two days they will have forgotten
most of what I outlined; except the fee. As a review and permanent reminder, I follow up each
conference with a personal letter in which I restate the program and emphasize the key points. This
has proven invaluable in assuring that the schedule is met, and the procedures are followed
446
Article Text 1
correctly. If additional charges are necessary due to lack of cooperation, this letter can also often
serve as justification."
While this communication program has its value, it also has its drawback; specifically, the
amount of time Dr. Kavanaugh must spend outside the treatment room to dictate what can be a
lengthy document, and the clerical time necessary to type it. Shackled by time and choking on
paperwork, Dr. Kavanaugh has turned to word processing in the form of a small, portable
text-editing system— the 900 Word Master.
The Word Master
The unit, manufactured by Savin Business Machines Corporation, consists of a base plate which
is attached to an IBM Selectric I or Selectric II typewriter, and a desktop console unit through which
the operator controls the system's functions (Fig. 1). When typing, the keystrokes are recorded on a
magnetic tape cassette in the console. Any revisions, deletions, additions or corrections can be
inserted onto the tape, and the unit automatically types the edited document at 150 words per minute.
A review of Dr. Kavanaugh's correspondence showed that, over a period of time, several general
texts repeated themselves in great frequency. Often, all that differentiated one letter from another
was certain variable information, such as references to time, fee quotations, and personalized
information such as the patient's name or parent's name.
Utilizing the tape cassette format of the 900, Dr. Kavanaugh created a cassette library, consisting
of a variety of standard format letters which covered most treatment programs. Each letter was
recorded onto a cassette, with stop codes inserted where variable information is required. The stop
code is simply an electronic impulse which tells the typewriter to stop typing at that point. In
addition, it tells the console that a stop code has been reached, and a light on the console informs the
operator that variable information should be inserted at this point. After typing in the information,
the operator simply pushes a button and the letter is continued, automatically (Fig. 2).
An appropriate reference index, with each letter given a number corresponding to the cassette on
which it could be found, was also developed.
"Now, following a conference, I need only tell my secretary the reference number of the letter I
want to send, and the variables," Dr. Kavanaugh relates. "She locates the proper cassette, places it in
the console, pushes a button, and the letter types itself while I have returned to the treatment room
and she goes about her other duties. In a matter of five minutes I have produced a letter that
previously required at least a half-hour. But most important, I have maintained my program of
encouraging patient cooperation through effective communications."
Orthodontists can use technology such as this for many other applications, and they do as we
shall see, but let's look for a moment at the economic impact of word processing. The cost of
clerical and secretarial support in today's office, whether a giant multinational corporation or a
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one-man office, can be seen in the following analogies.
Relative Cost Factor
Experts report that twenty-five years ago, the average typist in a small office was producing 55 to
60 words per minute and was paid about $45 a week. Today, the same typist is still producing 55 to
60 words per minute, but is paid $140 per week. Time and motion consultants will tell you that 60
words of actual mechanical typing speed, when taking into account restarts on letters, the time spent
making corrections, editing, and interruptions, nets out to only 15 words per minute of final speed. It
is easy to understand why businesses readily accept the increased speed and accuracy possible
through word processing.
Another important statistic is supplied by Datapro Research Corporation, an independent office

systems analysis firm. They estimate that a secretary spending just half a day typing, which is
usually the case in non-group practice where she has multiple duties, can produce about 30,000 lines
of typing a year. Coupled with the average salary stated above, she is being paid about 24 cents per
line. Equipped with a text-editing automatic typing system, she can produce 105,000 to 120,000
lines per year, at a salary cost of only 6 to 8 cents per line.
Thus, if we take the Word Master as an example, for a modest investment of about $5,000, an
office can easily triple and often quadruple its secretarial output for less than it would cost to hire
even one additional person, and without requiring additional time from current personnel. Equally as
important in the average dental office, there would be no additional space requirements.
Communication Need
If we recognize the positive economics of word processing, we still must justify the need. Let's
look for a moment at another problem common to specialized dentistry— the need to maintain
warm, personal and professional relationships with those on whom the orthodontist depends for his
livelihood. Let's talk about referrals.
An orthodontist in Southern California observes, "If you're a dentist, or a patient, or a personal

friend, and you make the consideration of referring a patient to a specialist, you deserve a
professional acknowledgement. In today's increasingly complex and impersonal society, that
acknowledgement must be original, sincere and personalized. There is absolutely no excuse for
skimming over or neglecting this courtesy."
To project the professionalism and maintain the relationships he feels are so vital to his practice,
this orthodontist has developed a twofold approach. He sets aside a few minutes each day to
telephone and personally acknowledge referrals, and then follows up with a thoughtful personal
note. To do this effectively, he utilizes word processing.
"Prior to purchasing an automatic text-editing typewriter system," he explains, "I would spend a
great deal of time dictating these letters. At one time, I was relying on preprinted form letters and
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cards where my secretary needed only to fill in the name and address and the name of the referred
patient. Then one day I referred a patient to another specialist and received a mimeographed
acknowledgement. It was sloppily printed and seemed so matter-of-fact that I immediately began to
search for a better way to handle my own routine."
With the 900 Word Master, this dentist can now send out personalized acknowledgements each
day. He has created a tape cassette library and reference index for this purpose, and supplements it
with a progress report library which he utilizes to keep referring dentists posted on the treatment
programs for their patients.
Both of the applications we have discussed deal with written communications in the form of
correspondence. A typical tape cassette library ( Fig. 3) might include five or six different thank
you's for referral letters; appointment confirmations; post conference letters; confirmation of
financial arrangements for transfer patients; lack of cooperation letters to parents; headgear
instructions; rubber band therapy information; delinquent payment reminders, and more (Fig. 4).
Additional Use
We have seen how this modern technology can be of value in saving time, enhancing
professionalism, and solving problems. For the specialist involved in orthodontic research and
education, who spends time preparing and presenting lengthy professional and scientific papers, the
editing capabilities of word processing add still another dimension to its usefulness.
Dr. Eugene Friedman, an oral surgeon with offices in Massapequa Park, New York, talks about
this application.
"I originally invested in word processing as a time saver in filling out boilerplate communications
such as insurance claim forms, preoperative hospital orders, consent for photograph forms, and
other standard format documents," he says. "I quickly discovered that our text-editing system was
just as valuable when applied to the professional and technical papers I prepare."
These documents are usually quite lengthy, with a myriad of highly technical verbiage and
complex composition features such as inset paragraphs and footnotes. They usually go through five
or six drafts before they are in final form. It was extremely time consuming and costly for Dr.
Friedman's secretary to completely retype the documents every time he made a revision, added a
footnote, or transposed a paragraph.
"Word processing allows my secretary to type the first draft and record it on the cassette. As I
edit, she simply inputs the corrections onto the tape and with the push of a button, retypes the entire
document, in correct final copy, at 150 words per minute.
Word processing is changing the face of modern office procedures and it does have highly
beneficial applications for orthodontists at a time when professionalism and administrative economy
and efficiency are vital concerns. Need and cost justifications must be made by each individual, and
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even in its many varied forms, word processing is not for everyone. But for the specialist concerned
with office costs, personnel time, and the impact of his written communications, it should be viewed
as modern technology that can help take much of the pain out of dental administration.
GABRIEL S. CARLIN
Executive Vice-President Savin Business Machines

Corporation, Valhalla, N.Y. 10595.
FIGURES
Fig. 1
Fig. 1 Savin 900 Word Master word processing system.
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Figures 5
Fig. 2
Fig. 2 Sample letter stored on tape cassette, with stop codes indicated (above) and finished letter (below).
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Figures 6
Fig. 3
Fig. 3 Savin Word Master word processing tape cassette library.
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Figures 7
Fig. 4
Fig. 4 Index of sample orthodontic Communications program.
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Figures 8
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Jun(454 - 472): JCO Interviews: Dr. Richard A. Riedel on Retention and Relapse
jco/interviews
DR. RICHARD A. RIEDEL on Retention and
Relapse
Retention and relapse are major topics of discussion whenever orthodontists congregate. Dick
Riedel is an author, teacher, practitioner, lecturer, researcher, and among the subjects for which he
is internationally renowned are retention and relapse. He is Professor of Orthodontics at the
University of Washington and authored the chapter on Retention in Graber and Swain's Current
Orthodontic Concepts and Techniques. We feel fortunate to interview him for the readers of JCO.

DR. BRANDT Why do teeth relapse after orthodontic therapy?
DR. RIEDEL Relapse, as defined by Webster, is "to slip or fall back to a former condition,
especially after improvement or seeming improvement." It seems to me that the word is too harsh a
description of the changes that follow orthodontic treatment. I would prefer to use the term
"post-treatment adjustment". A multiplicity of factors cause post-treatment adjustment including
musculature, differential growth, the periodontal fiber apparatus, etc.
DR. BRANDT Do wisdom teeth play a part?

DR. RIEDEL They may play a part. It is not clear what their influence is, but certainly they do not
contribute in large part to the development of crowding in either arch or the relapse into a Class II or
Class III relationship. Their eruption may cause changes in occlusion and they may provide local
disruptive influences to periodontal health.
DR. BRANDT Does early treatment, by taking advantage of growth spurts, mean less relapse?
DR. RIEDEL Whatever treatment is accomplished by restraining maxillary growth would
seemingly be irreversible and not likely to relapse.
DR. BRANDT Are the muscles permanently altered by early dental changes, resulting in better
muscle balance and tooth stability?
DR. RIEDEL No doubt musculature must accommodate to growth changes or vice versa. Whether
these changes result in better muscle balance in the treated individual is difficult to identify.
DR. BRANDT Will serial extraction improve the chances for a more stable dentition?
DR. RIEDEL If you are referring to serial extraction without the need for mechanical interference
(which is rare) then, indeed, it would seem likely that dentitions that have never required
mechanotherapy would be much less likely to change posttreatment than those that have had the
interference of orthodontic treatment. I subscribe to the theory that if teeth have never been allowed
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to become malaligned they would be much less likely to tend to become malaligned in later life.
Having treated many malocclusions that were preceded by a serial extraction program, I feel that the
serial extraction program contributed materially to the simplicity of orthodontic therapy required
later. Possibly early extraction reduces the likelihood for relapse, if one can identify the pattern of
development of the occlusion during the serial extraction phases and follow it during
mechanotherapy.
DR. BRANDT For what types of malocclusions do you prescribe serial extraction ?
DR. RIEDEL They can all be reduced to one escription— mandibular arch length shortage. The
type of serial extraction may be varied dependent upon the degree of mandibular arch length
shortage, including such extractions as mandibular first premolars, mandibular second premolars
and/or mandibular incisors. Often, at orthodontic meetings and in the literature, reference is made to
the techniques of cuspid retraction. "How do you retract your cuspids?" I frequently respond —
"With the natural cuspid retractor, i.e., remove the premolars." It is obvious, to those who trace
cephalometric films, that the maxillary canine consistently will erupt in a downward and backward
direction in serial extraction cases with little tipping distally and, given enough time and space, will
assume a relatively parallel relationship with the second premolar. Try the "natural cuspid retractor"
in your next extraction case.
DR. BRANDT If teeth are moved rapidly, does this affect the resistance to revert back toward the
original position?
DR. RIEDEL I doubt that a handful of orthodontists could agree on what constitutes rapid tooth
movement. Much less would they agree on the tendency for the teeth to revert back to their original
positions following such "rapid" therapy. There is no scientific evidence behind the hypothesis.
DR. BRANDT Conversely, if treatment is prolonged in order to gain elements of growth

increments, what does that do to stability?
DR. RIEDEL I don't know. However, I could speculate that prolonged orthodontic treatment would
be more likely to be related to root resorption and periodontal destruction and also decalcification,
caries, etc. The relationship between treatment time and post-treatment stability has never been
satisfactorily documented.
DR. BRANDT How much does normal occlusion and intercuspation contribute toward stable tooth
positions?
DR. RIEDEL Every orthodontist has an objective of developing normal occlusion. However, that
normal occlusion may be only temporary, since teeth can be put into positions not acceptable to the
surrounding orofacial environment, such as protrusion of maxillary and/or mandibular dentitions
(the kinds of things that happen from prolonged use of Class II and Class III elastics). On the other
hand, I believe that we must constantly be revising our definition of a perfectly normal occlusion to
include not only stability of alignment, but periodontal health.
DR. BRANDT The literature is replete with recommendations to place the teeth into harmonious
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"muscle balance" to gain a lasting result. How can an orthodontist know teeth are actually in that
type of balance on clinical inspection?
DR. RIEDEL A position of the teeth in "harmonious muscle balance" may be possible to identify
post-treatment in the adult, in the absence of any significant post-treatment change. However, when
we talk about harmonious muscle balance in the growing child, it is almost impossible to identify
that position until growth and development have been completed. The complicating factor being the
quantity and direction of growth which takes place posttreatment. Quantifying harmonious muscle
balance is an almost impossible task until growth and development have been completed.
DR. BRANDT Have there been any new studies or information that has changed your mind about
not violating the original intercuspid width?
DR. RIEDEL I would suggest that, in general terms, after the mandibular canines are fully erupted
it is undesirable to attempt to change mandibular intercanine width. However, there are possible
exceptions to this rule: a) If mandibular canines have erupted into a severely lingually locked
position, one might even describe it as an "impacted" position, it would be logical to expect to be
able to increase mandibular intercanine width and expect such increases to be maintained. b) There
is some evidence to suggest that in the Class II Division 2 type of malocclusion, where extraction in
the mandibular arch has been performed (i.e., first or second mandibular bicuspids), that mandibular
intercanine width may be increased and may be expected to be maintained. c) I believe that there are
certain types of malocclusions, which I would describe as having a Class II Division 2 incisor
relationship, in which mandibular intercanine width may be increased and be expected to maintain
such an increase. I am by no means certain of the potential for this possibility. The malocclusion
may be Class I with a Class II Division 2 anterior characteristic, or Class II with that same
characteristic, but apparently there are certain malocclusions in whose mandibular arches,
mandibular intercanine width can be increased and be expected to be maintained. I believe these
cases are relatively few in number— perhaps I even could describe them as exceptional. If one were
to apply a generalized rule of thumb, I think it would be to attempt to maintain the original
mandibular intercanine width as presented by the patient in the original malocclusion.
DR. BRANDT If the mandibular intercuspid width were preserved, would that guarantee that the
mandibular incisors would not recrowd?
DR. RIEDEL There are no guarantees resultant from orthodontic treatment. We have documented a
consistent reduction in mandibular arch length, almost without regard for the type of malocclusion
involved. Oftentimes this reduction includes crowding in the mandibular incisor area. The foregoing
statement applies not only to treated orthodontic cases, but to untreated individuals as well. I would
further suggest that crowding, related to a decrease in mandibular intercanine width post-treatment,
might be reduced if mandibular intercanine width were not increased during orthodontic therapy. I
would further suggest that the removal of mandibular first or mandibular second bicuspids is not
always, and perhaps is not usually related to relieving mandibular anterior incisor crowding in the
long term.
DR. BRANDT Does bringing the lower cuspids distally into the spaces previously occupied by the
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first bicuspids create a greater latitude for widening the canines?

DR. RIEDEL I know of only one postretention study which attempted to identify the results of
retracting mandibular canines relative to mandibular incisor crowding and that was done by Kermit
Welch at the University of Washington. Dr. Welch was not able to identify any correlation between
the amount of distal mandibular canine movement and increases in mandibular intercanine width
post-retention.
DR. BRANDT When the lower canines are expanded, does it have the automatic secondary effect
of expanding the upper canines too?
DR. RIEDEL There has not been particular interest in the changes in the maxillary intercanine
width. They seem to be potentially much less limited than changes in the mandibular intercanine
width. I believe that the maxilla and maxillary dentition can be moved mesially, distally, buccally
and lingually to a much less restricted degree than the mandible or mandibular dentition .
DR. BRANDT Would it be permissable to expand the upper cuspids first, on the chance this would
allow for a more stable expanded lower intercanine dimension?
DR. RIEDEL We really haven't any evidence to substantiate or deny that possibility. The only study
that I know of was that conducted by Matthews who suggested that the early correction of deep
overbite might allow for greater increase in mandibular intercanine width than what one might
normally expect. Long-term studies in that direction have not been conducted.
DR. BRANDT There has been a "swing" toward more nonextraction treatment these past few years.
Can such treatment be successful if the mandibular cuspids had been widened ?
DR. RIEDEL I believe that the so-called "swing" toward nonextraction treatment has resulted from
the identification of the fact that the removal of mandibular first bicuspids does not necessarily
result in stability of the mandibular anterior incisor segment. This is not to suggest that
nonextraction treatment results in greater stability in that area, but the results esthetically, in certain
cases, may be more satisfactory if extraction has not been a part of orthodontic therapy. If, with
mandibular bicuspid extraction, it is necessary or desirable to increase mandibular intercanine width,
it all too often results in crowding in the mandibular incisor area. Perhaps we are extracting the
wrong teeth?
DR. BRANDT What about intermolar width? What liberties can an orthodontist take with this
measurement?
DR. RIEDEL I believe that intermolar width is not nearly as critical, in terms of treatment change
and posttreatment relapse, as mandibular intercanine width. It has been demonstrated that
mandibular and maxillary intermolar widths can be increased and/or decreased and remain stable
post-treatment. Perhaps maxillary intermolar width is even more susceptible to treatment increase
and posttreatment stability.
DR. BRANDT Many practitioners, following the teachings of Tweed, treated the lower incisors to
±3° to the mandibular plane in an attempt to stabilize the teeth. Now there are many who attempt to
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bring the mandibular anteriors ±2mm to the APo line, for more stable and esthetic considerations.
Are these valid recommendations?
DR. RIEDEL Preselected angulations and positions for mandibular anterior teeth in any individual
case seems to be fraught with danger. One can probably generalize that the best direction to move
the mandibular anterior segment is in a lingual-occlusal direction, for that is in accord with normal
developmental changes. There are, however, malocclusions which present with potential exemptions
to this rule of thumb, such as those individuals who have what Mills described as an everted lower
lip.
I believe that we can and should use normal standards for mandibular incisor position as a guide
to satisfactory relationships. However, as to stability relative to these guides, we have little or no
real evidence. Stability and facial esthetics are not necessarily correlated. What is so wrong about
accepting the position of the mandibular anterior segment as presented as likely the most stable
position for that particular anterior segment? Perhaps we should add to that the likelihood that this
anterior segment will migrate in a lingual and upward direction with growth. In summary, I am
suggesting that it is unrealistic to treat to mean cephalometric angles or linear measurements. We
should be more responsive to the individual problems and conditions that patients present.
DR. BRANDT Gaining arch length with headgear is a controversial subject. Can the upper molars
be driven distally?
DR. RIEDEL It is clearly evident from both animal and human experimentation that the maxillary
dentition can be moved distally. It is also quite clear that the maxilla itself is susceptible to distal
traction, relative to the cranium.
DR. BRANDT Will they stay there?

DR. RIEDEL All of the evidence to date suggests that the dentition tends to relapse in an anterior
direction, but it is not clear that the maxillae themselves tend to relapse in that direction. I suppose
that the degree to which one influences the maxilla may be related to the stability of the correction
in an anterior-posterior direction. It is not clear that the degree to which one influences the maxillary
dentition is related to stability in an A-P direction, although we do have some information from
Badell on patients who were treated in part with full-time combination headgear.
DR. BRANDT Does it matter what type of headgear is applied and for how long?
DR. RIEDEL I do not believe that the amount, time, nor the direction of force is related to the
degree of stability inherent in correction of anterior-posterior discrepancies of the maxilla or
maxillary dentition. I believe that it is necessary and desirable for the orthodontist to respond to the
individual variation presented by the patient during orthodontic treatment. It would seem logical that
the force should be applied in an upward and backward direction. We, as orthodontists, should
become observers of the changes that develop in our patients, posttreatment, and we should apply
appropriate therapy in response to those post-treatment changes, such as headgear, activators, etc.
DR. BRANDT Do deep anterior overbites treated to an edge-to-edge position remain that way?
DR. RIEDEL There is little or no doubt that deep overbites treated to an edge-to-edge relationship
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will probably change. They change in response to post-treatment growth directional changes. If such
changes are in a vertical direction, as noted by Simons and Joondeph, then overbite corrections will
probably be maintained. If, however, subsequent to treatment, horizontal growth prevails, then
overbite correction may be subject to posttreatment relapse. Furthermore, if edge-to-edge incisor
relationships have been produced at the expense of protruding the mandibular dentition, then almost
surely relapse can be expected. The orthodontist must be a constant monitor of treatment and
post-treatment growth changes.
DR. BRANDT Can you give our readers an assessment of overcorrection?

DR. RIEDEL Overcorrection is a kind of orthodontic safety valve for many malocclusal
relationships, but I suggest that it is not a perfect answer for many problems that occur after the
correction of malocclusion, particularly those related to growth.
DR. BRANDT What should all of these facts you have given us tell us? Does it imply we are very
limited in what can be accomplished in the routine treatment of malocclusions? Referring to the
works of Hayes Nance, "Limitations of Orthodontic Treatment," American Journal of Orthodontics,
May, 1947, and Abraham Goldstein "The Dominance of the Morphologic Pattern," Angle
Orthodontist, Oct. 1953, both of the articles attempted to spell out the limitations orthodontists have
as to where they can move teeth. Are these theses still valid?
DR. RIEDEL I have yet to see the original suggestions of Hayes Nance scientifically disputed.
Specifically, I have seen little evidence to suggest that mandibular arch length can be permanently
increased. In fact, most of the evidence to date suggests the contrary. There are certain documented
exceptions. Note that early research efforts in cephalometrics suggested that orthodontic treatment
was confined to modification of the alveolar process. More recent research has definitely
documented that the whole skeletal-dental system can and is affected by orthodontic therapy. It is
apparent that the maxillary bones are very liable to displacement in a variety of directions,
depending upon the direction, intensity, and duration of the forces applied to them. As to the
dominance of the morphological pattern, simply on the basis of logic, if one were not able to modify
that pattern, then of course, it would be impossible to correct a Class II or a Class III malocclusion
and expect that correction to be maintained. We have ample evidence that this isn't true.
Orthodontists are restricted by the inherent morphology of the mandible and mandibular dentition,
however, their characteristics are not necessarily immutable. Some types of malocclusions
apparently present potentials for modification and change of both the morphology of the mandible
and mandibular dentition and possibly its relation to the rest of the dentofacial skeleton. We have
not yet been able to consistently modify the direction and/or amount of mandibular growth with any
real predictability or confidence in a stable correction. Witness the ability of the Milwaukee brace to
modify both the growth and morphology of the mandible (albeit, these modifications may not
necessarily be of a desirable nature), but they do indicate the potential to modify mandibular growth
and morphology.
DR. BRANDT In severely crowded mandibular incisor cases, having narrowed arch forms, do you
still recommend the removal of lower incisors, matched with the extraction of upper bicuspids or
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laterals?
DR. RIEDEL In severely crowded mandibular incisor cases I believe that the removal of one or
more mandibular incisors is the only logical direction which may allow stability of the mandibular
dental anterior arch without continued retention. The failure to provide for a stable alignment with
first bicuspid extraction has been documented time and time again. I believe that bicuspid extraction
may be desirable in many cases, but it is not a panacea. It does not satisfy correction of the problem
presented by severely crowded mandibular dentitions. Of course, the removal of mandibular incisors
frequently presents tooth size discrepancy problems relative to the maxillary arch, and therein lies
the chief disadvantage. Probably the best matching pattern occurs when maxillary lateral incisors
and mandibular lateral incisors can be removed in concert. Such a pattern of extraction may not be
desirable in many instances from an esthetic viewpoint, hence, the consistent tooth size discrepancy
pattern problem which crops up when, say, maxillary first or second bicuspids are removed instead
of maxillary lateral incisors in combination with mandibular incisor extraction.
A case in which two lower incisors were extracted.
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DR. BRANDT Is there as much recrowding in the lower arch when lower laterals are removed in
these cases?
DR. RIEDEL I have accumulated only a few records of patients more than 10 years out of retention
in whose mandibular arches two incisors have been removed. It is only, therefore, an opinion that I
offer that these arches generally are much less crowded postretention than similar cases in which
premolars have been extracted. It is true that crowding does recur in the mandibular anterior area
post-retention in some cases in which incisors have been removed. I would suggest that it is not so
much crowding as it is rerotation of mandibular cuspids and remaining incisors. I would hope that
the so-called "sulcus slice" might prevent the recurrence of this type of malrelationship in future
cases of this type. A few of the very nicely aligned mandibular arches that I have seen post-retention
have occurred in mandibular incisor extraction cases. On the other hand, a few of the very well
aligned mandibular anterior segments that I have seen have also been evident in cases in which
mandibular bicuspids have been removed, or in cases treated without extraction. The diagnostic test
for this type of extraction is to attempt a setup, maintaining the original mandibular intercanine
width and, generally speaking, the arch form which the patient presents. If this cannot be done with
bicuspid extraction, then one should delve into the possibilities of the removal of one or two
mandibular incisors instead. In one case, three mandibular incisors were removed. This case is not
out of retention and there is no assurance that perfect alignment will be maintained. In fact, I suspect
that with one incisor remaining, it may be more likely that it will break contact with the canines
and/or rotate.
DR. BRANDT Do you think the removal of one mandibular incisor creates problems in
interdigitation? In overbite?
DR. RIEDEL I think the answer is obvious. In the presence of a normal maxillary anterior to
mandibular anterior tooth size relationship, certainly the removal of one mandibular incisor would
create a tooth size discrepancy. However, not infrequently, patients present with deficient maxillary
lateral incisors, in which case the removal of one mandibular incisor might provide a desirable
anterior arch relationship and overbite would be a minimal problem. The potential for a harmonious
tooth size relationship with the removal of one mandibular incisor can be predicted by applying the
Bolton formula for tooth size discrepancies, and by testing with a pretreatment setup.
DR. BRANDT Do you recommend the removal of maxillary incisors for orthodontic purposes?
DR. RIEDEL I guess the answer is that when one or more maxillary incisors are missing and when
one or both maxillary lateral incisors are peg-shaped. However, even under those circumstances one
has to balance the potential for restoring a peg lateral versus the problems created by closing such
spaces, i.e., the different shape and color inherent in the maxillary canine, the development of a
tooth size discrepancy in that area, etc. Since I believe that the maxillary arch and maxillary
dentition are more tractable to our ministrations, I would prefer not to remove maxillary incisors in
situations where these incisors are of good quality and morphology.
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A case in which three lower incisors were

extracted.
DR. BRANDT How much of a problem is space reopening across an upper or lower incisal
extraction site?
DR. RIEDEL I have seen a case in which the mandibular lateral incisors were removed and the
patient for several years had a persistent tendency for spacing between the mandibular canine and
the mandibular central. However, this same patient, 10 years post-retention, showed no space in the
extraction site. This has been quite consistent with almost all of the cases 10 years post-retention in
the mandibular arch. However, that is not to suggest that the same holds true for the maxillary
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anterior area. In fact, one of the consistent problems which we have identified in cases in which
maxillary lateral incisors were either absent or removed is a tendency for space to occur between the
maxillary canine and maxillary central incisor postretention. These problems seem to be related to
cases in which the patient presented with spacing rather than those in which crowding was present
in the maxillary anterior area. Sectioning of the transeptal apparatus may provide additional stability
in these cases, but that has not yet been proven. Spaces in the maxillary anterior area may be
disturbing to patients from an esthetic standpoint, however, the creation of a space and replacement
with bridges may also be disturbing to patients, particularly relative to color matching problems,
tissue irritation, the need for replacement, etc.
DR. BRANDT How stable are treated open bites?

DR. RIEDEL One of our graduate students has recently completed a study of 100 patients
presenting with anterior open bite in an attempt to identify what happens to these patients
postretention. His findings would suggest that approximately 33% of these patients have some
degree of anterior open bite post-retention. I would have expected a much higher percentage.
DR. BRANDT Do they hold differently in dental and skeletal open bites?
DR. RIEDEL I do not believe that we have a satisfactory definition of dental and skeletal open bite.
DR. BRANDT Do you suggest treatment plans to create an overbite?

DR. RIEDEL From a tooth size and arch relationship standpoint, it is difficult to overcorrect a
patient's anterior open bite into a deep overbite without problems developing in the posterior and
anterior occlusion.
DR. BRANDT Your studies seem to indicate that in Class II Division 2 the clinician can expand the
mandibular intercanine width with confidence that it will maintain itself. Can you expand on this
concept?
DR. RIEDEL We have merely suggested, on the basis of data accumulated, that the Class II
Division 2 mandibular arch may permit a modicum of increase in intercanine width and that the
Class II Division 2 malocclusion may show less tendency for arch length shortening, post-retention,
than other types of malocclusion studied. I am not suggesting that we should generalize that all
Class II Division 2 malocclusions can be expanded in the mandibular arch and be expected to
maintain such expansion. Perhaps we have to examine this question more carefully and that is
exactly what we are attempting to do. It is interesting, however, to observe reports of treated cases in
the orthodontic journals to identify how many of these cases are Class II Division 2 malocclusions.
Certainly the percentage of occurrence of this type of malocclusion is disproportionately represented
in successful case reports by various authors. Perhaps the very existence of a Class II Division 2
malocclusion suggests a different kind of muscular relationship of lips and/or tongue to the
dentition, which may allow for a different type of response in the treatment of this malocclusion. I
have noted recently that Class I malocclusions, with what I might describe as Class II Division 2
anterior relationship seem also to allow for expansion in the mandibular intercanine area, and we
are having a further look at this phenomena. May be it's the Class II Divison 2 extraction case that
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Article Text 10
holds the greatest potential for intercanine width increases and those increases are probably in the
order of 1-3mm.
DR. BRANDT Would you please discuss the general stability of treated Class III malocclusions?
DR. RIEDEL I don't believe that I'm the one who can answer this question. We have had so few
Class III malocclusions in our 10-year post-retention records that it would be presumptuous of me to
make any generalized comment about them. Unfortunately, the records of surgically corrected cases
are in very short supply and most of those corrected orthodontically were probably not true Class III
malocclusions, but rather Class I malocclusions with an anterior crossbite and mandibular shift.
DR. BRANDT Are there any types of Class II malocclusions that maintain themselves better than
others?
DR. RIEDEL Possibly the well-treated cases .
DR. BRANDT Do high angle cases show more tendencies toward relapse?
DR. RIEDEL We have never been able to differentiate satisfactorily between states of stability
and/or relapse in high or low angle cases. I suspect that a high or low mandibular plane angle is
really not a very important feature relative to the potential stability of a corrected malocclusion. We
do suspect, however, that if the high mandibular plane angle is a development related to
predominantly vertical growth, that relapse in anterior overbite may be a minimal problem and
conversely, that if a low mandibular plane angle is related primarily to horizontal growth
post-treatment, that overbite or the recurrence of a deep overbite may indeed be a problem.
DR. BRANDT Under what circumstances do you recommend stripping?

DR. RIEDEL I believe that stripping should be resorted to in instances in which tooth size
discrepancies exist, if such stripping can provide for a more satisfactory tooth size relationship.
DR. BRANDT What is the maximum amount of enamel that can be safely removed?
DR. RIEDEL I believe that stripping should be limited to removal of some of the interproximal
enamel, but not all. Dr. Bolton suggests that as much as 3½mm of enamel can be removed from the
maxillary anterior 6 teeth. I believe that this is about the maximum that one could expect to remove
without getting into the possible problems of exposing dentine and subsequent discoloration and
possibly sensitivity. I believe that about 3mm is a maximum that can be removed from the
mandibular anterior 6 teeth without similar problems.
DR. BRANDT Are you concerned about potential periodontal breakdown because of stripping
procedures?
DR. RIEDEL I doubt that stripping is closely related to that potential problem. Excessive root
approximation is not likely to occur when one has removed ½mm of enamel from each of two
neighboring anterior teeth. Now, as far as the so-called reproximation procedures, relative to
improving stability in the mandibular anterior segment, I think that we will have to stand back and
wait a while and examine cases well out of retention, before we can suggest that this is a desirable
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procedure to improve mandibular anterior segment stability. In fact, personally, I have a bit of
skepticism relative to the "reproximation" procedures and improvement of stability of alignment of
these teeth. A few of us in the Northwest have been stripping mandibular teeth for years in an effort
to reduce congestion in that area, but I'm not so sure that that stripping has been eminently
successful.
DR. BRANDT Should the orthodontist equilibrate? If so, when?

DR. RIEDEL I am certainly no expert in the field of equilibration of occlusion. However, I believe
that the orthodontist should identify the requirements of a satisfactory occlusion and that gross
prematurities should be removed during orthodontic treatment. A definitive equilibration should
probably be restricted to the post-treatment period and not completed until a reasonably stable
dentition has been identified. This is not to say that the individual must be completely through
growing, but those who have and are undergoing a considerable change should probably be
equilibrated much more carefully and more or less minimally until the dentition has achieved a
relatively stable relationship. Both Wendell Wylie and Coenraad Moorrees have made suggestions
concerning the amount of equilibration the orthodontist should provide for his treated orthodontic
patients and both of them are worth reading. At the risk of being repetitious I would suggest that a
carefully constructed setup will identify, for the orthodontist, areas for equilibration in the corrected
malocclusion. Static setups do not identify requirements of functional needs and that sort of thing
should be done in the mouth, or by use of casts mounted on a fully adjustable articulator. The most
obvious requirements occur in relation to balancing interference. These can be identified during
treatment and can be eliminated either by treatment procedures or by subsequent posttreatment
equilibration. Also, centric occlusion/centric relation discrepancies can be identified at any time
during treatment and should be corrected prior to removal of appliances.
DR. BRANDT There are advocates of cutting the periodontal fibers on lower incisors in an effort to
prevent recrowding and overlapping. What is your opinion of this approach?
DR. RIEDEL The work of Edwards, relative to the transeptal fiber apparatus, suggests to every
orthodontist that it would be desirable to do a "sulcus slice" procedure in every instance of rotation
correction and I can't imagine why orthodontists do not resort to this procedure more frequently. As
to the effectiveness of this procedure relative to recrowding, as mentioned previously. I have serious
reservations and a bit of skepticism as to the potential utility in stabilizing a dentition.
DR. BRANDT Just how do you define orthodontic retention?

DR. RIEDEL A direct and very simple answer is that retention is a holding process. It is not a
process of making change but rather a procedure designed simply to hold. I would suggest that what
we know least is the requirement of duration of retention. That is, we know very little about the
effects of prolonged retention versus relatively short retention in any given kind of malocclusion in
terms of the ultimate stability of the dentition.
DR. BRANDT Several outstanding orthodontic teachers have stated that treatment properly
accomplished should never require mechanical retention. Were they correct?
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DR. RIEDEL I would suggest that retention is not an indication of failure during treatment but
rather, the realization that certain types of orthodontic correction are prone to change posttreatment,
possibly due to histologic and functional causes. We have ample evidence that the tissue apparatus,
musculature, etc. require periods of time for reorganization and readaptation. Continued growth may
have an effect on the stability of corrected malocclusions and perhaps the orthodontist should
continue his responsibility until the patient has essentially ceased to grow. I would really like to
meet the orthodontist who is able to consistently treat his cases to a condition and position in which
the teeth do not require any retention for some period of time following removal of active
appliances. One might choose to leave deactivated appliances in place for 6 to 8 months after the
essence of orthodontic correction has been completed, but I think this would be unfortunate for most
orthodontic patients.
DR. BRANDT When you have decided to use mechanical retention, how do you decide how long
to use it?
DR. RIEDEL In general terms, we attempt to reduce the amount of time that a patient wears a
removable retainer in a gradual way. For instance, I suggest that they use removable appliances on a
full-time basis for at least 3 to 6 months and then we begin periods of removal for perhaps 4 to 8
hours out of 24. The patient can identify whether, in replacing the retainer, the appliances seem tight
and where such tightness occurs. This might suggest a relapse tendency or a modification necessary
in the appliance. We try to reduce the time of retention for any given patient and to identify relapse
tendencies that might require prolonged retention. The requirements for retention should be
discussed with the patient and parent prior to the institution of orthodontic treatment. In some cases
I predict that a prolonged retention period will be necessary or desirable, and in others it may be
minimal or perhaps not necessary .
DR. BRANDT What determines when you need permanent retention?

DR. RIEDEL That type of situation arises in certain instances, in which, from an arch width
standpoint, extraction would be indicated and yet from a facial esthetic standpoint, extraction should
not be performed. I do not suggest that I have some type of treatment that will solve the problem,
but rather that, if the patient wishes to maintain more or less ideal alignment, permanent retention is
the only way that stability can be accomplished. Being a realist, I believe that there are very few
individuals who actually continue on a so-called "permanent retention" program. However, we
discuss the alternatives in terms of the return of crowding, malalignment, etc. versus the business of
maintaining prolonged retention .
DR. BRANDT If the decision has been made to use "prolonged retention" and a Hawley is worn
during sleeping hours, is there a danger of creating a periodontal problem by the constant movement
of some teeth back and forth?
DR. RIEDEL I do believe, indeed, that periodontal problems can be generated by intermittent
retentive force applications in which teeth are allowed to move back and forth. However, it would
be desirable to maintain retention over periods sufficient to prevent the back and forth changes. A
cooperative testing between orthodontist and patient can probably identify the amount of time that is
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Article Text 13
required to maintain a relatively stable situation. If that time is 100%, then 100% it should be. If the
time is only 20%, then let 20% suffice. The time requirement should be established on an individual
basis. Generalizations really should not be made.
DR. BRANDT Do you occasionally feel confident enough to omit retention altogether?
DR. RIEDEL Yes, there are some malocclusions presenting with excellent alignment in the
mandibular arch which has not been changed during treatment and which we choose to observe
periodically rather than use any form of retention. This may also be true in a maxillary arch. Some
of the malocclusions least requiring retention are those cases in which serial extraction procedures
have been carried out and the treatment procedures are primarily aimed at paralleling roots in
extraction sites. In some of these cases crowding and rotations were never existent and I would
expect that they would be cases in which minimal or no retention might be required. It is my
contention that if teeth have never been crowded or rotated that they would be much less likely to do
so following orthodontic treatment, provided that we have not greatly disturbed the relationship of
the dentitions to their respective bases in the process of treatment.
DR. BRANDT Under what circumstances do you prescribe removables and when do you advocate
fixed retainers?
DR. RIEDEL The removable appliances have the obvious advantage that they can be removed,
cleaned, replaced and adjusted. On the other hand, the fixed appliance has the advantage that it
cannot be removed and consequently requires almost no patient cooperation. From a realistic
standpoint, I believe that it would be desirable to, at some point after orthodontic treatment, arrive at
a retention stage during which the patient can remove the appliances to identify potential relapse
problems. The removable retainer has a much lesser liability for damage to both teeth and
periodontium. I don't know of a satisfactory fixed appliance for maxillary retention. I do believe that
the mandibular cuspid-to-cuspid or bicuspid-to-bicuspid lingual wire may serve for varying periods
of time to stabilize mandibular dentition until one has resolved the problem of the third molar and/or
resolved problems related to growth changes. The fixed appliance obviously does require constant
observation, replacement if necessary and final resolution, which, to my way of thinking, means
ultimately its removal. In some patients, having identified a potential lack of cooperation, we may
use fixed retention, particularly in the mandibular arch, which, of course, does not require patient
cooperation. Fixed retention is used particularly in the nonextraction case in which slight increases
in arch length have been produced and/or increases in mandibular intercanine width.
DR. BRANDT Are retainers placed immediately after band removal, or do you suggest waiting
until the teeth settle for a while?
DR. RIEDEL In instances where I construct a fixed retentive device, such as the cuspid-to-cuspid
or bicuspid-to-bicuspid wire, we attempt to place that appliance within a week of removal of
mandibular bands. The same is true relative to the placement of the maxillary removal retainer. I do
not remove all of the bands at one time. I usually remove maxillary and mandibular incisor bands
and bicuspid bands and close spaces between molars by use of a light rubber elastic from molar to
molar through cuspid brackets. The remaining spaces are those left by the cuspid and molar bands.
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These spaces may be closed in the construction of the appliance or spontaneously.
DR. BRANDT In the mandible, do you suggest a soldered cuspid-to-cuspid or bicuspid-to-bicuspid

instead of a Hawley?
DR. RIEDEL I almost never use a Hawley type of mandibular removable appliance. I prefer a
Dohner or Lande splint with buccal and lingual acrylic because the mandibular removable Hawley
type retainers, with time, simply seem to "float" in an occlusal direction. The mandibular dentition
reduces in arch length and/or constricts. If one wants to be secure about retaining mandibular
anterior alignment, a fixed lingual wire is much more satisfactory.
DR. BRANDT Some justify prescribing a soldered cuspid-to-cuspid retainer for some ten years
after debanding because terminal growth can cause recrowding of lower incisors.
DR. RIEDEL I'm not so sure that prolonged growth changes cause recrowding of the lower incisor.
I would not at all be surprised that the direction of growth of the mandibular dentition does
contribute to that likelihood. We have examined many patients 10 or more years post-retention and
one thing is consistent — there is a generalized tendency for mandibular arch length shortening in
the post-retention period. Whether this is related to post-treatment growth changes is not clear.
However, the soldered cuspid-to-cuspid or bicuspid-to-bicuspid may provide security in maintaining
stability. The need for continuation of a headgear is dependent upon the individual. Some patients
may not grow at all after orthodontic treatment. Others may grow for 10 or 15 years.
DR. BRANDT Is there a preference for a cuspid-to-cuspid over a bicuspid-to-bicuspid?

DR. RIEDEL My decision in this regard is usually dependent upon whether the cuspids and/or
premolars have presented with rotations prior to treatment. If the canines were badly rotated prior to
treatment I would much prefer to fix the appliance from cuspid to cuspid. If the premolars were
rotated prior to treatment I would rather resort to tying them together. In general, I would prefer the
shorter distance for it is subject to less distortion.
DR. BRANDT How often do you service these units?

DR. RIEDEL Any fixed appliance should be observed periodically, every 3 to 4 months, for
closeness of fit, distortion of the lingual wire etc.
DR. BRANDT Where does the positioner fit into your practice?
DR. RIEDEL I frequently resort to the positioner as a detailing appliance to settle treated
malocclusions. I do attempt to identify patients who have been particularly cooperative during the
treatment procedure before resorting to the construction of a positioner. There is one type of case in
particular which I like to use a positioner and that is the patient who presents with an anterior open
bite. The reason, of course, is that the positioner would screen the tongue and the lips. I believe, too,
that the positioner presents the orthodontist with an excellent opportunity for identifying the
possible detailed modifications of the occlusion that can be produced and also the limitations of
those details.
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Article Text 15
DR. BRANDT Do you have any objections to prescribing the positioner as a retainer for an
indefinite period of time?
DR. RIEDEL Yes indeed. I believe that the positioner should be resorted to for a very limited
period of time and be followed by removable retainers or fixed retainers. Most patients simply will
not continue to effectively use a positioner for long periods of time. I observe patients very carefully
while using a positioner to identify whether it is being employed successfully or whether, in fact,
patients are not using the positioner adequately. Ask any post-orthodontic patient how much time he
or she has used a positioner and I am sure you will get a clue as to its potential worth.
DR. BRANDT What is the usual length of time these are worn?
DR. RIEDEL I suggest to the patient that a positioner should be worn intensely over a short period
of time such as a 3 day weekend on a full time basis. Then 4-6 hours per day for 2 weeks. Following
that we may resort to removable retainers almost immediately.
DR. BRANDT If you are confronted with a recurring rotation of the maxillary lateral incisor, as for
an example, one in an original Class II Division 2, what would you do to secure the tooth?
DR. RIEDEL I would suggest the "sulcus slice" provided that the tooth has been properly
realigned. To accomplish that realignment it may be necessary to resort to rebanding, it might be
possible to use a Hawley retainer, in which the retainer has been constructed with the tooth
repositioned.
DR. BRANDT When you plan to retain a patient who had a deep anterior overbite, what do you
include in that retainer to keep the bite open?
DR. RIEDEL A bite plane on the maxillary retainer.
DR. BRANDT Do you retain open bites?

DR. RIEDEL Yes, I attempt to retain open bites differently in several respects. I use the positioner
more frequently in open bite cases. Maxillary retainer construction is such that wires do not cross
the occlusal, but are contoured distal to the second molar. In addition, the bulk of the palatal portion
of the plate is usually removed. No bite plane is used and a groove may be cut in the area of the
lingual papillae to remind the patient about tongue positioning.
DR. BRANDT Have you ever included a slot in the palate of an upper Hawley to try to train the
tongue from prying into the anterior part of the mouth?
DR. RIEDEL Instead of a slot, I have included a depression in the area of the lingual papillae with
the objective of attempting to direct the tip of the tongue to that area.
DR. BRANDT Do you have a special method of holding diastemas between the maxillary central
incisors together after treatment?
DR. RIEDEL In certain persistent relapses, I have resorted to lingual soldered pinlays, but rarely.
Calvin Case originated that idea in his book in 1920 in which he described lingual staples to
stabilize persistent diastema problems.
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Article Text 16
DR. BRANDT What relapse indications should an orthodontist look for on post-treatment x-rays?
DR. RIEDEL He may identify a mesial drift tendency in the maxillary dentition. If that is the case,
he might try a distal force to maxillary dentition. If he identifies that mandibular dentition is
relapsing in a posterior direction, such a tendency might suggest the use of one of the myofunctional
appliances, such as the Andresen appliance, to maintain the relationship of the mandibular dentition
to the mandible.
DR. BRANDT How significant is an interincisal angle of 135° as a treatment goal?

DR. RIEDEL In ideal occlusions, Bolton identified the relationship of maxillary to mandibular
incisors as being approximately parallel on the labial surfaces (178°). However, I believe that it is
not important to measure axial relationships as determined from incisal edge to apex. I have
indicated in the chapter on Retention in the Graber text that incisor relationships of 135°, more or
less, may not indicate the true nature of the functional relationship of the labial of the lower incisor
against the lingual of the maxillary incisor, which is the important consideration from a functional
standpoint. Whether this relationship is important from a stability standpoint is unknown.
Posttreatment growth changes are probably more important relative to the stability of anterior
overbite than the question of absolute incisor inclination.
DR. BRANDT How significant is root torquing the long axis of the upper central incisors 100° -
110° to SN as a treatment goal?
DR. RIEDEL Again, this question is one which is probably going to be related to or determined by
subsequent post-treatment growth changes. The absolute relationship of the maxillary incisors to SN
is probably not overly important as a single measure relative to stability.
DR. BRANDT Can maxillary and mandibular incisors be intruded and stay intruded?
DR. RIEDEL I am not at all certain that I can answer this question in a simple straightforward way.
I believe that maxillary and mandibular incisors can be intruded and may remain intruded
post-treatment. The fact is that the maxillary incisors are probably less frequently being intruded in
the process of treatment and therefore we have fewer opportunities to identify the relative stability
subsequent to treatment. The mandibular incisors are frequently intruded and not infrequently have
remained intruded subsequent to treatment, particularly in the more adult dentitions, when growth
does not occur following the completion of orthodontic treatment.
DR. BRANDT If molars are extruded during treatment, will they be "driven" back into their sockets
by muscle pressure, or do they tend to stay extruded?
DR. RIEDEL There may be posttreatment change which includes intrusion of molars to some
minimal degree, i.e., something in the order of 1/2 to 1 mm of intrusion under normal muscular
pressure. I have not seen much more than that and it would be my considered opinion that maxillary
and mandibular posterior teeth once extruded are likely, essentially, to remain extruded.
DR. BRANDT If the occlusal cant is altered in treatment, will it revert?
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Article Text 17
DR. RIEDEL In a growing individual it will probably tend to revert back to its original inclination
or less, which is typical of the natural change in the occlusal plane.
DR. BRANDT Which teeth change as the cant reverts?

DR. RIEDEL I suppose the typical changes that occur are related to the discontinuation of Class II
elastics, which might allow maxillary posterior teeth to extrude and mandibular anterior teeth to do
likewise.
DR. BRANDT Will the behavior of the cant vary in steep angle or low angle cases?
DR. RIEDEL I doubt that the change in the occlusal plane is dictated by the steep or low
mandibular plane angle, but the tendency is generally for a resumption of the inclination originally
presented by the patient, or less.
DR. BRANDT Dick, I want to thank you on behalf of our readers for a most clear discussion on the
various aspects of retention and relapse. Let's do one thing before we go, and give the readers your
reference bibliography on this important subject.
RIEDEL
References
1.Badell, M.C.: A serial cephalometric evaluation of extraoral combined high-pull traction and cervical traction to the
maxilla, University of Washington Thesis, 1975.
2.Boese, L.R.: Increased stability of orthodontically rotated teeth following Gingivectomy in Macaca nemestrina. A.J.O.
56:273-291, September, 1969.
471
References 18
3.Bolton, W.A.: Disharmony in tooth size and its relation to the analysis and treatment of malocclusion. A.O.
28:113-130, 1958.
4.Bolton, W.A.: The clinical application of a tooth size analysis. A.J.O. 48:504-529, July, 1962.
5.Dierkes, D.D.: An investigation of the mandibular third molars in orthodontic cases. A.O. 45:207-212, July, 1975.
6.Eastham, R.M.: An evaluation of stabilizing appliances for Milwaukee brace patients. A.J.O. 60:445-477, November,
1971.
7.Edwards, J.G.: A study of the periodontium during orthodontic rotation of teeth. Am. J. Ortho. 54:931-932, 1968.
8.Elder, J. and Tuenge, R.: Cephalometric and histologic changes produced by extra-oral high pull traction to the
maxilla in Macaca mulatta. A.J.O. 66:599-617 and 618-644, December, 1974.
9.Gile, R. A.: A longitudinal cephalometric evaluation of orthodontically treated anterior open bite cases, Thesis,
University of Washington, 1972.
10.Graber T.M., Editor: Current orthodontic concepts and techniques, W.B. Saunders Co., Philadelphia, Pennsylvania,
1969.
11.Joondeph, D.R. and McNeill, R.W.: Congenitally absent second premolars: An interceptive approach. A.J.O.
59:50-66, January, 1971.
12.Kaplan, R.G.: Mandibular third molars and post-retention crowding. A.J.O. 66:411-430, October, 1974.
13.Kaplan, R.G.: Some factors related to mandibular third molar impaction. A.O. 45:153-158, July, 1975.
14.Matthews, R.: Clinical management and supportive rationale in early orthodontic therapy. A.O. 31:35-52, 1961.
15.Mills, J.R.E.: The long term results of the proclination of lower incisors. Brit. Dent. J. 120:355-363, 1966.
16.Moorrees, C.: Occlusion. J. of Perio. 38:751-760, 1967.
17.Nordquist, G.G. and McNeill, R.W.: Orthodontic vs. restorative treatment of the congenitally absent lateral incisor—
Long term periodontal and occlusal evaluation. Jrnl. of Perio. 46:139-143, Mar., 1975.
18.Riedel, R.A.: A post-retention evaluation A.O. 44:194-212, July, 1974.
19.Shapiro, P.A.: Mandibular dental arch form and dimension. A.J.O. 66:58-70, 1974.
20.Simons, M.E. and Joondeph, D.R.: Change in overbite: A ten year post-retention study. A.J.O. 64:346-367, 1973.
21.Storey, E.: Tissue response to the movement of bones. A.J.O. 64:229-247, September, 1973.
22.Swanson, W., Riedel, R., D'Anna, J.: Postretention study: Incidence and stability of rotated teeth in humans. A.O.
45:198-203, July, 1975.
23.Weinstein, S.: Third molar implications in orthodontics. J.A.D.A. 82:819-823, 1971.
24.Welch, K.N.: A study of treatment and postretention dimensional changes in mandibular dental arches, Thesis,
472
References 19
University of Washington, 1965.
25.Wylie, W.: Functional occlusion, a major objective of dentistry. Oral Surg., Oral Med., Oral Path., 9:1069-1075,
1956.
473
References 20
JULY 1976, VOL. 10 / ISSUE 7

The Straight-Wire Appliance: Extraction Series Brackets (Continued) 507
The Importance of Interbracket Width in Orthodontic Tooth Movement 530
Special Considerations for Adult Orthodontics 535
Adaptability of the Twin-Wire Appliance to Modern Day Orthodontics 546
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Jul(505 -): 506 THE EDITOR'S CORNER
THE EDITOR'S CORNER

An orthodontist can largely overcome the eroding effect of inflation on his purchasing power by
tying his fee structure to the annual inflation rate or by being paid in advance and investing the
money at the going rate. He can also affect his annual increase in costs to some extent and he can
attempt to avoid decreases in gross income by practice building and by raising fees. Without
underestimating the importance of any of these factors or of a favorable combination of these
factors, we can learn something from a study of the relative detrimental effect of cost increase, gross
income decrease, and a combination of the two; and from a computation of what fee increase is
necessary to restore one's "take home pay" if cost increases continue and gross income decreases
continue.
A 10% decrease in gross income is 10% that you never see and it can be equal to 15% to 30%
decrease in net income, depending on the circumstances. A 10% cost increase on the other hand
results in just half that much decrease in net, because costs are tax deductible, generally at the 50%
level.
If you were to try to make up for annual 10% cost increases by fees alone, it would require a
5-6% fee increase annually to do it. If you were to try to make up for an annual 10% gross income
decrease by fee increase alone, it would require better than a 10% annual increase to do it. A
combination of these two is additive and it would take a 16-17% a year fee increase to make up for a
10% cost increase and 10% gross income decline.
In actual numbers, if you have a case fee of $1500 it would only need to be raised to $1850 over a
period of four years to make up for an annual 10% cost increase. However, to make up for an annual
10% gross income decrease, the $1500 fee would have to be increased to $2240 over a four-year
period. To make up for both together, the $1500 fee would have to be increased to $2760 in four
years.
Even at a low level of inflation, costs are going to go up and, while they can be controlled to
some extent, there is an irreducible minimum for operating a practice, and cutting costs too much
can be counterproductive.
505
Article Text 1
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Jul(505 -): 506 THE EDITOR'S CORNER
the real damage is done to a practice by a decline in starts and a decline in gross income. That is
harder to take care of with fee increases and may be less and less reduced by cost savings. So, the
message is loud and clear. Practice build. Compete. Pay attention to the economic variables in you r
practice . Set up that early warning system and have a blueprint for survival.
506
Article Text 2
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Jul(507 - 529): The Straight-Wire Appliance: Extraction Series Brackets (Continued)
THE STRAIGHT-WIRE APPLIANCE Extraction

Series Brackets(Cont.)
This installment completes a grouping of cases treated with SWA extraction Series. The first two
of these cases were reported in the June issue.
CASE III
History
Age 15 years, six months. Caucasian, male, no health problems.
Diagnosis
Class II-A 7mm crowding. 6.5° skeletal discrepancy.
Treatment Plan
Extract four first bicuspids. Class III elastics to be worn in conjunction with high-pull Kloehn
headgear 14 hours/day, to store energy (anchorage) by retracting lower anterior teeth in preparation
for Class II mechanics. The headgear will also help resolve ANB discrepancy, and offset Class III
elastics. As the Class II-A Series is not available, use Class II-Classic "four first bicuspid" Series
(see May installment). Maximum extraction brackets on lower molars and second bicuspids, and
upper cuspids. Minimum extraction brackets on upper second bicuspids and lower cuspids. Standard
SWA brackets on all other teeth. (For lower molars, bicuspids and cuspids, Medium extraction
brackets would be ideal, but are not available.)
507
Article Text 1
Case III Beginning Records

Treatment
One month into treatment, the .016 archwires are tied back from first permanent molars to the
archwire hooks, to discourage the cuspid crown from moving mesially while the root moves distally.
508
Article Text 2
At the next visit we will place

.018 archwires and initiate Class III mechanics.
A cephalometric tracing less than 3 months later shows lower incisors have moved from 8° to
NB, to 4.5°. Class III progress is good.
Now we move to .018.025 archwires, Pletcher springs

from the upper first permanent molars to the archwire hooks, and K2 AlastiKs from upper second
permanent molars to archwire hooks.
509
Article Text 3
In the lower arch, only K2 AlastiKs are

being used because the cuspid roots are lagging, and greater force would just promote undesirable
tipping. The tip built into the bracket will encourage the root apex to catch up with the crown. The
AlastiK is strong enough to restrain the crown from reciprocally tipping forward, but not strong
enough to retract the crown.
Two months later, upper spaces are being held closed by lightly activated Pletcher springs. They
have been ligated to Steiner rotation springs which have been connected to the distal portion of the
first permanent molar brackets to prevent rotations.
510
Article Text 4
The position of the lower cuspid roots is

enough improved to permit gentle activation of the lower springs, to encourage final space closure
in the lower arch. Strong reverse curves and accentuated curves have been placed in the archwires to
reduce the overbite. Class II elastics are initiated at this appointment.
The overbite, one year into treatment, has been greatly reduced.
511
Article Text 5
Archwire size is reduced to .018 round

for additional temporary flexibility, full-bracket engagement for tip, and better control of several
rotations. The upper archwire is lightly tied back with a ligature wire from the first permanent molar
to an Ormolast on the archwire hook. A Steiner rotation spring is on the mesial portion of the lower
right cuspid bracket.
Six weeks later, the upper arch is looking good.
512
Article Text 6
Unbent .018.025 archwire, with

reverse curve, has been resumed in the lower arch.
But progress is never automatic for an orthodontist. One month later, repositioning of the lower
left bicuspid requires placement of an .0195 Wildcat archwire for full bracket engagement.
In the center view, this wire had not yet
513
Article Text 7
been fully ligated. (In this group and the next two, a minor timespan occurred in getting all the
photos.)
After one more month, an .018.025 archwire is again brought into use in the lower arch, for
final tooth positioning.
Debanding appointment was at 1 year,

61/2 months of treatment. And we take impressions for a positioner.
514
Article Text 8
Now 51/2 months have elapsed since

band removal.
The next three rows of pictures below

show functional occlusion goals achieved.
515
Article Text 9
516
Article Text 10
Case III Final Records

Comments
In the 1 year, 6 1/2 months of active treatment this case required, ANB was reduced from 6.5° to
4.5°. The lower jaw grew forward 1.5mm; the upper jaw moved back .5mm. Lower incisor to NB
changed from 8mm to 7mm to NB. Occlusal and mandibular planes remained stable. Favorable
facial and dental aesthetic changes occurred and static and functional occlusal goals were reached.
No archwire bends, other than reverse and accentuated curves, were required in this case.
CASE IV
517
Article Text 11
History
Age 12 years, 3 months. Caucasian, male, no health problems.
Diagnosis
ANB 6.5°. Maxillary dental protrusion. Angle Class II molar relationship. Effective 14mm of
lower crowding. Class II-C
Treatment Plan
Extract four first bicuspids. High-pull Kloehn headgear 24 hours/day for approximately 14
months. Class III mechanics until lower extraction sites are fully closed. Straight-Wire Appliance
Series II-C Standard SWA brackets on molars and incisors; Minimum extraction brackets on lower
second bicuspids; Maximum extraction brackets on cuspids.
518
Article Text 12
Case IV Beginning Records

Treatment
Six months after treatment began, the extraction site spaces are nearly closed.
519
Article Text 13
The lower anterior teeth have been

retracted, whicIh is good, but they have been extruded by the Class III elastics, which is not so good.
(The .018 archwires have not proven sufficiently rigid to support the closing and the Class III
mechanics, but we'll try them a while longer.)
Headfilm taken the same day shows that the lower incisors have been retracted from 6mm to NB,
to 2mm. ANB has been reduced slightly.
Counting on help from growth, I

decided to change to Class II mechanics. (Later, with hindsight, that decision didn't look too good.)
Strong reverse and accentuated curves are called for. High-pull headgear is still indicated to
continue the ANB improvement.
Three months later we move to .018 Australian orange "Special- +" which is somewhat more
rigid.
520
Article Text 14
After 13 months of treatment, another

headfilm was taken.
Lower incisors are now at 4 to NB,

showing the effect of the Class II elastics. Molar relationship is approaching Class I. The facial
profile has greatly improved. ANB is 4°, so high-pull headgear is still indicated and Class II
mechanics can still be used with discretion. The overbite remains excessive.
.018.025 lower archwire comes into use nine weeks later, with strong reverse curves. The deep
overbite is showing improvement.
In another eight weeks a headfilm shows

that overjet, overbite and ANB require further treatment.
521
Article Text 15
Accentuated and reverse curves are

indicated, as well as continued orthopedic use of headgear, because ANB has reverted to 5°.
Six weeks later, overbite has continued to improve.
But all lower teeth have moved forward

farther than planned, so mild second order bends are required now in the lower archwire. This
would not have been necessary early in treatment, if I had banked less on growth, and stayed with
Class III mechanics until the lower incisors reached 0mm to NB before starting Class II mechanics.
All four quadrants have been tied back from the first permanent molars to the archwire hooks.
Pletcher springs are in use where spaces exist, and Ormolast chain to preserve full space closure.
The first permanent molars are supported with Steiner springs to prevent unwanted rotation during
the tie-back procedure.
In another 2 months, Class II mechanics have produced a Super Class I occlusion.
522
Article Text 16
The reverse and accentuated curves

have produced a normal overbite and overjet. All four quandrants are ligated from first permanent
molars to archwire hooks to preserve space closure.
Active treatment ended in 1 year 11 1/2 months.
Archwires have been removed to permit

settling prior to debanding. Brackets on teeth adjacent to extraction sites are ligated buccally and
lingually to preserve space closure.
Six weeks later, upper teeth have been partially debanded to permit further settling.
.018 archwire is back in lower arch to

correct a minor rotation. Teeth adjacent to upper extraction sites remain ligated. We take a lower
retainer impression now. At the next appointment, we will take positioner impressions.
523
Article Text 17
Case IV Final Records

After four weeks of positioner wear, static (Six Key) and functional goals have been achieved.
524
Article Text 18
Comments
My original cephalometric goal planned for the lower incisor to be at 4mm to NB. The ANB was
predicted to approach 2°. It was reasonable to expect the advancement of point B as a result of
mandibular growth. Most of the treatment objectives were reached, including favorable facial and
dental aesthetics and good static and functional occlusion. The cephalometric objectives were not
quite fulfilled, because— as mentioned earlier— when expected growth did not occur, I did not
respond with additional Class III mechanics, which would have stored up enough energy
(anchorage) in the lower arch to compensate for the lack of growth. However, the lower incisors are
only .5mm forward of their original position, so stability should not be a problem.
(TO BE CONTINUED)
Class II-C
Note: This case would traditionally be designated Class II,

maximum anchorage. Identification as "Class II-C is drawn
from the Classification of Treatment described in the May
installment. As for the finding of 14mm of crowding, it can be
factored this way: (a) The lower anteriors need 41/2mm of
additional space on each side to relieve the arch length
discrepancy. 4 1/22 = 9mm. (b) Correction of the lower
protrusion (from 6mm to NB to 4mm to NB) requires 4mm of
525
Footnotes 19
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume Jul
additional arch length space. (c) Treatment will include

flattening of curve of Spee, costing 1/2mm of effective arch
length on each side. 9+ 4 + 1 = 14mm. For convenience in
planning the additional space to be provided in the lower
arch, I summarize it all as "crowding".
526
Footnotes 20
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Jul(530 - 534): The Importance of Interbracket Width in Orthodontic Tooth Movement
The importance of interbracket width in

orthodontic tooth movement
THOMAS D. CREEKMORE, DDS
Stiffness, strength and range are the most basic elastic properties of wire. Strength is a measure of
how strong a force the wire will take before it permanently deforms. Range is a measure of how far
the wire may be bent before it permanently deforms. Given a wire of sufficient strength and range
for deflections involved in orthodontic archwire adjustments and engagements, stiffness is the next
most important property.
Wire Stiffness
Stiffness is a measure of the amount of force required to bend a wire a certain distance. The
greater the force, the farther the wire will bend. The stiffer the wire, the more force it takes to bend
it and the more force it will deliver.
In order to assess the influence of interbracket width on the stiffness of orthodontic wires, first
let's examine some of the factors that affect stiffness.
1. Wire manufacture— the material from which the wire is made, including the alloy formula, its
hardness, and the state of heat treatment affect strength, range and stiffness. For the purposes of this
discussion this factor is kept constant by considering that the same wire is used throughout.
2. Size of wire—
A. Round wire — stiffness is proportional to the fourth power of diameter. A 22 mil (.022") wire
requires sixteen times as much force to deflect it the same distance as an 11 mil wire. A force of one
pound is required to bend an .022 wire the same distance as one ounce of force will bend an .011
wire.
B. Rectangular wire— stiffness is directly proportional to width and proportional to the cube of
thickness. Doubling width doubles stiffness. Doubling thickness increases stiffness by eight times.
Table 1 shows values that can be used to compare the stiffness of any wires of the dimensions
shown, as long as the wires being compared are made of the same material. To compare any two
wires, one must find the values in the appropriate column and compare the two figures. The ratio of
the two figures is the comparative stiffness.
These values are absolute physical constants of the cross section. They are completely
independent of the physical properties of the structural material and the form of the mechanism in
which they are used. Such other factors affect stiffness in their own right, in addition to these
properties of the cross section.
530
Article Text
Example: The value for an 11 mil wire in column 2 is 719; for a 22 mil wire it is 11,500. 11,500
÷ 719 = 16. A 22 mil wire is 16 times as stiff as an 11 mil wire .
Comparing Stiffness of Wires
The figures from Table 1 show that a 16 mil wire is 3 times, an 18 mil wire is 5 times, and a 20
mil wire is 7 times as stiff as a 12 mil wire. The same force applied to these wires gives 3 times, 5
times and 7 times the deflection in an .012 wire. An 18 mil wire is 1.6 times as stiff as a 16 mil wire
and is about the same as a 1616 wire. A 20 mil wire is about the same stiffness as a 16 22
rectangular wire.
An 1825 wire is 1.6 times as stiff as a 16x22 wire for both bending and torsion. A 22 28 wire is
2 times as stiff as an 18 25 and 3.3 times a 1622. A 17 22 wire is about 3 times as stiff as an .016
round wire.
It is interesting to note that a 16 22 or 1825 bent on their edgewise plane (22 16 or 2518) is
twice as stiff as bent flatwise. This is why rectangular wires are so ineffective for rotating teeth .
3. Length of span— each type of beam has its own characteristic stiffness, strength and range.
These depend not only on the type of beam but on its length. Length of span affects the function of
all beam types in exactly the same way, so it can be considered a separate characteristic.
A. Bending— Stiffness is inversely proportional to the cube of length ( Fig. 1). The beam on the
right, twice as long as the beam on the left, is deflected eight times as far by the same force. If it
requires a half a pound of force to deflect a wire a certain distance, one ounce of force will deflect
the same wire the same distance if the length of span is doubled.
B. Torsion — Stiffness is inversely proportional to length ( Fig. 2). Doubling the length will
cause the ends to twist twice as far with the same force. It will take only one-half as much force to
twist the double-length section the same number of degrees as the short section.
The size of wire and its influence on force and tooth movement is well known and considered by
every orthodontist. However, the tremendous influence of length of span seems to have been
underestimated. For the orthodontist, length of span is interbracket width and tying an adjacent
bracket is the equivalent of loading a cantilever beam.
Interbracket Width
Interbracket width is the distance between brackets. This distance changes throughout treatment
as the teeth move and varies around the arches from the variations in tooth size. Also, the brackets
are on the labial surface of the teeth, making interbracket distances greater than the actual tooth size.
For illustrative purposes, the factors that affect interbracket width will be considered to be tooth size
and bracket width.
531
Article Text
Bracket widths vary from manufacturer to manufacturer. For comparative purposes the following
widths are used: single bracket = 50 mils; standard twin = 135 mils; extra wide twin = 180 mils;
intermediate twin = 100 mils.
Interbracket width increase (column 7) = single (column 6) twin (column 5), ie., relative
interbracket width with single brackets if interbracket width with twins = 1.
Decrease in stiffness for bending (column 8) = [interbracket width increase (column 7)] 3.
Decrease in stiffness for torsion (column 9) = [interbracket width increase (column 7)].
Comparing Single Brackets and Twin Brackets
From Table 2 it can be seen that single interbracket widths range from 1.4 times twin interbracket
width, depending on the size of the teeth and the width of the brackets. These interbracket width
increases result in stiffness decreases ranging from a factor of 2.74 to 13 times. Standard twin
brackets (135 mils) on 9mm teeth require 2.74 times as much force to get the same deflection as
with single brackets. If extra wide brackets (180 mils) are placed on the same 9mm teeth the force
jumps to 5.36 times that with single brackets, ie., a 4 oz force in single brackets requires 11 oz in
standard twins and 21 oz (1 lb. 5 oz.) with extra wide twins. On 7mm teeth, standard twins require
4.1 times as much force as singles and jumps to 13 times if extra wide twins are used instead of
single brackets, ie., a 4 oz force in singles requires 1 lb in standard twins and 31/4 lbs in extra wide
twins. Surprisingly, light forces and amounts of tooth movements per adjustment depend more on
interbracket width than archwire size.
For comparative purposes between different sized wires in single brackets and twin brackets, a
single interbracket width 1.5 times the twin interbracket width will be used. This 50% increase in
interbracket width decreases stiffness by a factor of (1.5) 3 = 3.37 times for bending and 1.5 times for
torsion. This means that a force that will level a tooth 1/2mm in twins will level a tooth 1.7mm in
singles (if within elastic limits of wire). A force that would produce 5° torque in twins would
produce 71/2° torque in singles.
Table 3 compares the stiffness of any of the wires listed with the additional influence of
interbracket width.
Relating Wire Diameter to Interbracket Width
From Table 3, for an initial archwire, a 12 mil wire in twins (1,017 in column 2) is slightly stiffer
than a 16 mil wire in singles (955 in column 3), ie., a 16 mil wire tied into single brackets would
produce about the same forces and tooth movements as a 12 mil wire in twin brackets. In actual
clinical practice with the New Torqued Appliance, an 18 25 Steiner spring wing bracket appliance,
the most frequently used initial archwire is an .016 round wire. A 14 mil wire in twins (1,886) is
24% stiffer than an 18 in singles (1,529). A 16 mil wire in twins is 38% stiffer than a 20 mil wire
and 20% stiffer than 17 22 rectangular wire in singles. It is easier to tie in a 17 22 rectangular wire
532
Article Text
after an .016 round in single brackets, than it is to tie in an .016 round after an .012 round in twin
brackets.
The second archwire in manipulating the New Torqued Appliance is a 17 22 rectangular
archwire. This wire provides excellent torque, tip and leveling capabilities and is used for closing
arch length, opening arch length, stabilizing, torquing, sectional and utility type archwires.
A 16 16 in twins (5,461) is 51% stiffer in bending than an 1825 in singles (3,605). However,
the 1825 in singles (16,329 in column 5) is 80% stiffer for torquing than a 16 16 in twins (9,906 in
column 4). A 16 22 in twins is twice as stiff in bending and about the same for torquing as an
1825 in singles.
The third or finishing archwire with the NTA is an 18 25. This wire captures all of the tip and
torque built into the bracket yet is still easier on the teeth for individual adjustments and levelling
than a 1622 in twins.
A 22 28 in twins is 6.9 times stiffer in bending and 2.9 times as stiff for torquing as an 18 25 in
singles. From a clinical point of view a 22 28 is far too stiff and only the smallest adjustments can
be made without exerting too much force for either bending or torquing.
Additional Clinical Considerations
The advantages of single brackets over twin brackets in increased bending and torquing action
has been shown. Single brackets have disadvantages too. Narrow width brackets have virtually no
rotational capability or control whatsoever. This rotation disadvantage has been changed to an
advantage with the addition of rotation wings or levers to the bracket, especially flexible wings. Not
only do the rotation wings enhance rotational movements and control throughout treatment, they can
also be adjusted to overrotate, if desired, or to compensate for improper bracket placement of the
tooth. The wings do not interfere with interbracket width for tipping or torquing action. (Slotted or
anti-tip wings do interfere.)
Another disadvantage of the narrow width brackets is in tipping control (Fig. 161, p. 188—
Thurow) which is related to archwire size and slot width. The graph shows that a 16 mil wire in an
18 slot would have about 3° "play" and increases to about 7° "play" with a 12 mil wire. In actual
practice, due to manufacturing tolerances, the "play" is even greater than the graph shows. It can
also be seen that "play" approaches zero as the size of the wire approaches the size of the slot. In
order to achieve the desired tooth position without uprighting auxiliaries the final archwire size
should approximate the size of the bracket slot.
For torquing action with rectangular wires, whether single or twin bracket, "play" is also related
to slot width and archwire size. "Play" is not influenced by bracket width. Here again the "play"
approaches zero as the size of the wire approaches the size of the slot. Then, for optimum torque
control from the archwire (not torquing auxiliaries), whether single or twin bracket, wire size should
533
Article Text
approximate slot size.
In clinical practice, an 1825 archwire in 1825 Steiner Spring wing brackets is an excellent
finishing archwire because of the tip and torque control. This wire is also an excellent "working"
wire for leveling, torquing and individual tooth adjustments and is very easy to tie in. Why? An
1825 in single brackets is one-half as stiff as a 16 22 in twins for bending and the same stiffness
for torquing.
Bracket width makes more difference in force and tooth movement than the entire range of usable
edgewise archwire sizes. An 1825 wire is only 2.2 times as stiff as a 16 16 wire. Compare this to
the 3.37 stiffness factor for the difference between single brackets and twin brackets.
In orthodontics, we need less force with greater tooth movements. The first place to start this
quest is in the selection of the bracket that is attached to the teeth. If this is overlooked or
underestimated then the greatest mistake has already been made.
Acknowledgement — Much of the technical data in this article is based on material in Edgewise
Orthodontics by Dr. Raymond C. Thurow, C.V. Mosby Company, St. Louis, Mo.
FIGURES
Fig. 1
Fig. 1 Stiffness is inversely proportional to the cube of the length. The beam on the right, twice as long as the beam on
the left, is deflected eight times as far by the same load. (From Thurow, R.C., Edgewise Orthodontics, Third Edition,
C.V. Mosby Company, St. Louis, Mo.)
534
Figures
Fig. 2
Fig. 2 Doubling the length of a wire will double its working range in torsion. For torsion, stiffness is inversely
proportional to length. (From Thurow, R.C., Edgewise Orthodontics, Third Edition, C.V. Mosby Company, St. Louis, Mo.)
TABLES
Table 1
Table 2
535
Tables
Table 3
536
Tables
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Jul(535 - 545): Special Considerations for Adult Orthodontics
Special considerations for

ADULT ORTODENTICS
ROBERT C. CHIAPPONE, DDS
Adult orthodontics is becoming a larger proportion of many practices. We are beginning to see
more articles in our literature on subjects such as direct bonding and surgery, aimed at making
orthodontic treatment easier and more suitable for adults.
However, there are special considerations for adults that we must explore if we are going to
deliver to them the same high quality of orthodontics we deliver to our adolescent patients.
Diagnosis, treatment mechanics and, most importantly, finishing must all be altered in the adult
patient.
Adult patients come to us after years of using and abusing their dentitions. Their teeth have more
wear facets, shorter cusps and shallower fossae than these same teeth had when they erupted into the
mouth (Fig. 1). Many have had extensive dental work: amalgams; crowns or inlays which may be
nicely carved, but with cusp locations and groove directions that have nothing to do with the
mandibular movements of that mouth. Bridges and partial dentures present an entirely different
challenge in orthodontic treatment.
A high percentage of adult patients come to us with either full-blown temporomandibular pain
dysfunction syndrome or with a subacute condition with all the signs, but without the subjective
symptoms as yet.
If we are careful in our history taking on these adult patients, we find that many of them consume
high quantities of aspirin during a given day. Also, it is not uncommon to find that many have
chronic neckaches, backaches, and even earaches. The TMJ examination form used in my office for
routine adult examination is the form developed for the University of California Dental School at
San Francisco (Fig. 2).
Another common finding from our dental history is pain in some of the posterior teeth that cannot
be related to any past dentistry or any x-ray findings. It may be related to stress, frequently seen in
adults, which seems to magnify the smallest occlusal prematurity.
These patients are often bruxaters or clenchers. Because of this, they have strain or trismus in the
muscles of mastication and along the whole kinetic chain of muscles supporting the head and neck,
which makes it extremely difficult for us to locate centric relation occlusion during our examination.
All of these above findings are very common in the temporomandibular pain dysfunction patient.
The trouble we fall into sometimes in diagnosing adult patients is that we do not take an adequate
history and we do not discover that they are indeed suffering from subacute TMJ problems. We get
535
Article Text 1
into treatment and then find that our diagnosis was incomplete, that actually there was a sufficient
slide of the mandible to doom the case to failure. A centric slide can mean a difference between
extraction and/or surgery in adult patients.
Diagnosis
The hardest thing for the orthodontist to do in evaluating a patient during the diagnostic phase is
to train himself to look at the teeth last. If we teach ourselves to look at the teeth last, and to do the
other evaluations mentioned here, we then find when we come to the teeth we have a much clearer
view of what is, in fact, the problem before us. If however, our gaze is at the teeth first, we tend to
forget everything else and go directly into tooth movement.
Additional diagnostic procedures that we should consider in our adult patients are:
1. A full TMJ series of x-rays. These films are of extreme importance, as they often help us to
understand how much relief our adult patient is going to receive, if indeed they are suffering from
headaches or neckaches or muscle strain. It is not at all uncommon to find in these adult patients
either a flattening at the condyle head or arthritis or both. Also, a rupture of the disc can be
suspected any time the joint space is extremely closed.
In essence, the importance of these TMJ films is:
1. to examine the joints for pathology, and
2. to be able to compare the beginning films with progress films. It is essential that the x-ray
equipment position the head to give us the ability to look at the same anatomy on the exact same
x-ray slices on successive films, so that we can be sure that the changes we see are due to treatment
and not due to different x-ray positioning.
The technique we use is that used at the University of California Dental School. It goes by the
name of "Corrected Cephalometric Tomographs".
Scout films are done on the patient to determine the exact angle that the heads of the condyles
make with the midsagittal plane of the face, so that the slice of the tomograph can be down the
center of the head perpendicular to its axis.
2. Muscle Examination. A full muscle examination to identify tender muscles around the head and
neck area is not only helpful in diagnosing the patient's overall problem, but is a great aid in reading
the joint x-rays properly (Fig. 3).
The muscles that should be palpated during examinations are:
a. Masseter— belly, origin and insertion .
b. Internal pterygoid— the patient is asked to open as wide as possible and these muscles are
palpated just medial to the tuberosity. If the patient has any bruxating habits, this muscle will
normally be tender.
c. Temporalis— all three bellys.
d. Sternocleidomastoid— origin, insertion and entire length.
536
Article Text 2
e. External pterygoid— this muscle is extremely difficult to palpate, but by placing pressure behind
the upper retromolar area, compression of tissue against the external pterygoid may elicit a painful
response if the muscle is tender.
f. Digastric— both bellys.
The muscles of mastication in their pathways of referred pain are extremely interesting. The
reader would be well advised to read the works of Janet Travell in the Journal of Prosthetic
Dentistry, July-August 1960.
3. Splint Therapy. If patients have extremely tender muscles of mastication and have enough other
TMJ symptoms, it sometimes is advantageous to place some kind of repositioning splint (Fig. 4) to
allow the muscles of mastication to relax and thereby allow the mandible to rest into its centric
relation. This sometimes is helpful in convincing the adult patient that they have a more serious
dental problem, since upon beginning splint therapy many of them start to experience a relaxation
and comfort around their head and neck area that they had long since forgotten.
It has been my experience in the past, using conventional orthodontic diagnostic procedures, to
diagnose an adult orthodontic problem as Class I only to get into treatment and find through
relaxation induced by treatment mechanics that the patient was truly a skeletal Class II. So, proper
diagnosis of centric relation occlusion is of paramount importance before treatment is begun.
4. A Full Pantographic Tracing. There are those who advocate a full pantographic tracing and
mounting on a fully adjustable articulator before beginning treatment, but this kind of information is
needed more at detailing and finishing than at diagnosing. In my experience, with proper location of
centric relation and proper diagnostic procedure, this has not been necessary in diagnosis, except in
most extreme cases. Certainly, surgery should never be considered on an adult unless the case is
mounted beforehand.
If a practitioner is careful in doing "terminal hinge dentistry", being extremely careful in his
mechanotherapy to finish each case in centric relation, then the advantages that can be garnered
from a full pantographic tracing lie in detailing the case; for example, in positioning the anterior
teeth for the proper anterior overbite to insure proper lift-off in all excursions.
5. Stress Evaluation. Stress increases the severity of symptoms associated with occlusal problems.
The adult patient, especially the female adult patient with TMJ signs and symptoms should be
evaluated regarding her exposure to stress and her handling of stress. A helpful tool for you and
your patient is to ask the patient to keep a stress diary, recording each day how they are feeling,
when they have headaches, when they feel uptight; and to try to identify the events just prior to these
times which may have caused the stress to occur. In this way, the patient is able to identify events in
their lives which are giving them the most stress — husbands, jobs, children. By identifying the
stress, the patient is able to know when she is going to have problems and is then able to cope with
them in some way, either by trying to avoid the situation altogether or at least being prepared for the
eventualities that are about to befall her.
Perhaps the most important contribution of the practitioner towards stress reduction in his patient
is instilling in the patient the confidence that he understands their problem and is in a position to
537
Article Text 3
heal their occlusal disease. Of course, this confidence must be well founded, because nothing
backfires harder than confidence once placed and failed.
6. Diet Evaluation. We also find it helpful, especially with TMJ-ortho patients, to take a diet
evaluation of adult patients. People who are tender in their chewing muscles, whose teeth hurt, are
more likely to become hypoglycemic during the daytime, because they are eating softer foods which
are normally higher in refined carbohydrates. The body reaction to the initial hyperglycemia
produces hypoclycemia. If the patient is in a hypoglycemic valley, it is likely that their symptoms are
going to be much more severe than if they were at a normal blood level.
I am indebted to Dr. Karl Nishimura of Tustin, California for opening my eyes in the area of
stress reduction and diet control in adult patients.
7. Conferences With Allied Practitioners. If there is extreme wear on the teeth or missing teeth that
will have to be replaced later, it may be very helpful to seek a consultation with the dentist or with
the prosthodontist prior to beginning the case. Knowing the prosthetic limitations and problems
sometimes helps to decide whether to close spaces caused by missing teeth or to leave the spaces
open for future bridgework.
Certainly, if there are deep periodontal pockets, a consultation with a periodontist is indicated
before treatment is begun. I would advocate a periodontal consultation and deep scaling in any adult
mouth prior to beginning orthodontic treatment.
Finding Centric Relation
Using mandibular manipulation, we must "romance" centric relation occlusion from our patients
at each appointment. The technique used is important. If the mandible is not supported (Fig. 5), the
patient will go immediately into centric occlusion or "Sunday bite" (Fig. 6), rather than centric
relation occlusion (Fig. 7).
There are various methods of obtaining centric relation (or terminal hinge) position (Fig. 8).
The important features of a satisfactory method are:

1. Support for the gonial angle.
2. Gentle pressure backward and slightly downward on the chin.
3. Slow closure by the patient until the first "feather light" contact.
A criticism of obtaining terminal hinge closure in this way has been that if the chin is pushed
distally, then the condyles were surely going distally as well. This is not the case. Because of the
joint capsule and ligament, downward and distal pressure at the chin allows the condyles to go up
and back, seating them in the glenoid fossae (Fig. 9).
Suggested reading on this subject can be found in an excellent text on occlusion entitled
"Evaluation, Diagnosis and Treatment of Occlusal Problems" by Dr. Peter Dawson (Mosby).
Treatment Mechanics
538
Article Text 4
Are teeth harder to move in the adult patient? Does orthodontic treatment take longer in the adult
patient? Is it more difficult to torque, or to do any kind of root movement in the adult patient? Can
impacted canines be brought into the mouth in the adult patient?
The only limitation that I have found in adult treatment is in initiating tooth movement. This may
take a few more weeks than in an adolescent. But once treatment has begun, progress can be as fast
or faster in the adult patient due to the excellent cooperation we receive from the adult patients.
Finishing
The finishing phase of treatment needs our greatest attention if we are to attain the highest degree
of stability of tooth position and occlusion, and the greatest benefits in terms of esthetics and dental
health.
In diagnosing, we often find that the skeletal demands and the tooth size demands do not
coincide, which is the rationale for extraction. In finishing, we often find that tooth morphology —
cusp type, groove direction, number of cusps on the six-year molar — does not correspond to the
skeletal demands of the temporomandibular joint, as the shape of the joint has its influence on the
path of the mandible during its chewing cycle.
If our patient has a shallow protrusive path and a shallow anterior overbite and very high
posterior cusps, the chances of protrusive interference in the molar region becomes very high (Fig.
10).
Factors controlling protrusive guidance are:

1. Protrusive path of condyles.
2. Occlusal plane.
3. Overbite.
4. Cusp height of posterior teeth.
These factors will probably not be coordinated and orthodontic treatment alone will probably not
accomplish that. Occlusal adjustment will put all four factors in harmony. However, crowns and
onlays may also be needed .
If there is also an immediate Bennett side shift, but because of the abuse of this adult dentition
the cuspids have already been worn flat and the patient has had a crown placed with very long
lingual cusps on the molar, again the chances for balancing interference in the molar section become
very high.
Here are two examples in which tooth morphology and joint or skeletal morphology do not
coincide, to the detriment of the whole gnathostomatic system and hence to the patient.
How then can we expect the teeth and temporomandibular joint as a determinant of tooth
539
Article Text 5
position to be coordinated? How can we expect the adult dentition with its wear and with its
restorations to have tooth morphology, in terms of shape of cusps and direction of grooves, to allow
us to finish our cases with a maximum intercuspation in centric and with no interferences in lateral
function?
It is because of factors such as these that every adult case should be mounted on a fully
adjustable articulator following debanding and finished with full occlusal equilibration (Fig. 11).
Sometimes, it is necessary for teeth to be rebuilt as well, and these patients have to be referred to a
competent dentist after orthodontic treatment.
If we follow these procedures, we can expect our adult cases will have a high degree of stability
in final tooth position and in centric relation occlusion. Also, the improvement in gingival health
will be marked, once the occlusal traumas have been removed. Joint "pops" either cease or diminish
and, most surprisingly, tongue thrust seems to stop almost immediately upon the elimination of
occlusal stress and trauma. An explanation may be that prior to treatment, when the occlusion was
harmful, the tongue was placed between the teeth as a protective cushion; whereas at the end of
treatment with the whole gnathostomatic system in balance, there is no longer a need for such a
cushion and the tongue thrust disappears.
Rationale For Occlusal Adjustment
Occlusal equilibration is a controversial subject. One group expounds intraoral adjustments,

while another claims that occlusal adjustment should only be attempted using the fully adjustable
articulator. Yet, to deny the efficacy of intraoral occlusal adjustment is to turn one's back on a very
successful technique used in many parts of the country.
Every practitioner who has been involved in full mouth occlusal adjustment has found that a great
deal of relief is experienced by the patients, but oftentimes these patients will return a month or two
months or six months later with the same occlusal prematurities that we thought we had adjusted
away. What, then, is good occlusal adjustment? It appears to me that the criteria for good occlusal
adjustment must be these: 1 ) Conservation of tooth enamel. 2) Adjustment of tooth enamel without
going through into the sensitive dentin, except in the most extreme cases. 3) A high degree of
stability in centric relation occlusion, without recurrence of mandibular slide. 4) Relief of all TMJ
pain dysfunction symptoms.
While an intraoral adjustment will certainly meet all these criteria, it has been the experience of
those who have used both techniques, that occlusal adjustment done off of a fully adjustable
articulator will produce the highest degree of stability in the highest percentage of cases (Fig. 12).
Another reason for doing the equilibration adjustment on an articulator first is that oftentimes a
case looks extremely simple in the mouth, but it is found on the articulator that it cannot be done by
equilibration and that other modes of treatment must be done first.
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Article Text 6
Conclusion
I think our adult patients provide us the opportunity to render the greatest service possible in
orthodontics. We do not have to wait for these patients to grow up to see the improvements in
gingival contour and condition, the improvement in speech and swallowing and the lessening of
trismus and discomfort in the muscles of mastication and the other muscles in the head and neck
area.
FIGURES
Fig. 1
Fig. 1 Extensive wear in adult dentition.
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Figures 7
Fig. 2
Fig. 2 TMJ Examination Form ( developed for University of California Dental School at San Francisco )
542
Figures 8
Fig. 3
Fig. 3 Muscle examination.

A. Masseter.
B. Internal Pterygoid.
C. Anterior Belly Temporalis.
D. Middle Belly Temporalis.
E. Posterior Belly Temporalis.
F. Sternocleidomastoid.
G. Trapezius.
543
Figures 9
Fig. 4
Fig. 4 Repositioning splint.
Fig. 5
Fig. 5 Improper manipulation lacks mandibular support.
Fig. 6
Fig. 6 Centric occlusion or "Sunday bite".
544
Figures 10
Fig. 7
Fig. 7 Same case as in Figure 6 equilibrated in centric (left) and the resulting centric relation occlusion (right).
Fig. 8
Fig. 8 Three satisfactory methods of manipulation with mandibular support.
Fig. 9
Fig. 9 Demonstration of the concept of upward and backward seating of the condyle with distal pressure on chin.
545
Figures 11
Fig. 10
Fig. 10 Condylar guidance. The only difference between 1 A and 2A is that the condylar guidance is steeper in 1A. The
result of this is that there is no molar interference in protrusive in 1B, while there is molar interference and possible TMJ
problems in 2B due to the shallow condylar guidance. The situation in 2B needs either equilibration to shorten posterior
cusps (without losing
Fig. 11
Fig. 11 Adult case mounted on Denar D5a Fully Adjustable Articulator.
546
Figures 12
Fig. 12
Fig. 12 Example of an occlusal adjustment done off of a fully adjustable articulator.
547
Figures 13
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Jul(546 - 555): Adaptability of the Twin-Wire Appliance to Modern Day Orthodontics
Adaptability of the Twin Wire Appliance to

Modern Day Orthodontics
JOHN E. JOHNSON, DDS
This is a demonstration of the twin-wire appliance and its adaptability to modern day
orthodontics. The appliance components of the twin-wire mechanism are as developed by Dr.
Joseph E. Johnson: the twin-wire labial arch, the .011  .022 flat-wire arch, the cap and channel
bracket, anterior and posterior coil springs, and the tubular, staple, and passive lingual arches.
Refinements and additions to the twin-wire philosophy of treatment will be amply documented in
the case reports which will be presented.
The Johnson twin-wire appliance utilizes light continuous forces for the movement of teeth in
units, without rigidly binding the archwires in the brackets. As a result, there is minimum tissue
damage, pain, and root resorption.
Dr. Johnson made three discoveries in reference to Class II division 1 cases:
1. If the maxillary molars were moved 1/16" to 1/8" distally and the anterior teeth were retracted, it
would not be necessary to move the mandibular anterior teeth so far labially.
2. The dental arches did not need to be expanded as much as previous methods had indicated.
3. In the average case, very little tooth movement was necessary to accomplish the desired results.
He then needed to design an appliance that would accomplish the movements of teeth he had
determined were necessary from his arch-predetermining procedure. With these goals in mind, he
had the inspiration for the development of the twin-wire mechanism. We might say that Dr. Joseph
E. Johnson was the father of our present day light wire techniques.
Detailed accounts of the construction of the twin-wire labial arch and the making of the anterior
and posterior coil springs have been published by Dr. Joseph E. Johnson, Dr. E.E. Sheppard, and Dr.
Paul Geoffrion. Therefore, only a photographic sequence on the twin-wire labial arch will be shown
(Fig. 1).
The cap and channel bracket (Fig. 2) is most commonly used with the twin-wire mechanism. This
bracket eliminates the time-consuming task of tying ligatures and exhibits a high degree of
efficiency. In correcting irregularities of the anterior teeth, the bracket slides along the twin-wire
and permits the teeth to be aligned. In using this bracket, an archwire can be removed and replaced
within three minutes.
The original bracket, as designed by Dr. Johnson, was welded parallel to the incisal edge of the
band. Today, these brackets can be obtained with any angulation desired. In the future, it is
anticipated that these brackets will be available with torqued channels. Angulated brackets with
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Article Text 1
torque would greatly enhance the efficiency of the twin-wire arch and the .011  .022 flat-wire arch.
LINGUAL APPLIANCES
The soldered lingual arches, commonly used with the twin-wire technique, are the tubular lingual,
the staple lingual, and the passive lingual arch. Their primary functions are molar anchorage control,
and expansion in the bicuspid and molar segments, if desirable. The proper construction and correct
use of these lingual appliances cannot be overstressed in the twin-wire technique. As with the
twin-wire labial arch, the lingual appliances appear to be simple in design and construction; but,
with improper handling and use, they can be a tool of destruction and failure.
With the use of light wires, molar anchorage control is absolutely essential. In order to obtain
maximum control, the lingual appliances are soldered to the molar bands for rigidity and stability. It
is my belief that molar stability is the most important factor involved, even though it may be
necessary to remake the lingual appliance in a few cases.
The use of these lingual appliances is of paramount importance in the majority of cases until all
movements of the anterior teeth have been accomplished. If they are not used properly, molar
anchorage control will be severely Impaired by tipping the molars mesiodistally or labiolingually.
Both the tubular lingual appliance and the staple lingual appliance were designed by Dr. Johnson
about 1940. The tubular lingual is used principally for molar stability in the maxillary arch, as well
as for expansion in the molar and bicuspid areas.
Construction of the Tubular Lingual Appliance
An .020 brass separating wire is adapted to the lingual from 2nd molar to 2nd molar to establish
the length of the tube (Fig. 3A), and another from the distal of first bicuspid to distal of first
bicuspid to establish the length of the reinforcing mid-section wire within the tube (Fig. 3B).
The brass wire is straightened. A tube (.040 O.D., .020 I.D.) is cut to the length of the longer
measuring wire, and an .020 steel wire is cut the length of the mid-section measuring wire. The .020
wire is inserted into the tube until it is an equal distance from both ends of the tube. This will
prevent fracturing of the tube when right angle bends are made mesial to the first bicuspids.
The completed tube is adapted to the model. Markings distal to the first bicuspids indicate the
position of the reinforcing wire within the tube (Fig. 3C).
A split tube (.036 O.D., .018 I.D.) is used to insure a good soldering joint of the tube to the molar
band. The lingual tube is left extending distal to the molar band to prevent solder and flux from
entering the distal portion of the tube. An .020 stop is also soldered mesial to the first bicuspid. This
stop will prevent the auxiliary spring wire from occlusal displacement (Fig. 3D).
At this time, the buccal tubes are soldered to the molar bands. The tubes must be soldered so that
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Article Text 2
they will lie in the same horizontal plane (Fig. 3E). If expansion is desirable in the bicuspid area, the
tubes are left away from the buccal surfaces of the bicuspids. After the buccal tubes have been
properly aligned, the appliance is removed from the model, polished, and is ready for the wrapping
of the auxiliary spring wire.
An .020 hard stainless steel wire is inserted into the distal portion of the tube until it contacts the
reinforcing wire of the mid-section. It is then removed; this portion is flattened with a disc; distal to
the flattened portion, the wire is recurved gingivally and contoured to lie in close proximity to the
molar band to avoid irritation to the tongue (Fig. 3F).
The flattened end is reinserted into the tube, a 90° turn is made in the .020 wire toward the
occlusal, and a flat-beaked plier is used to compress the tube against the flattened portion (Fig. 3G).
Then, a 360° turn is made in the .020 wire. A modified #31 Baker plier ( Fig. 3H) is used to grasp
the wrapped portion of the .020 wire, and the wire is bent toward the occlusal (Fig. 3I). The
completed tubular lingual appliance is ready for insertion (Fig. 3J).
Since the tubular lingual arch is a fixed appliance, it cannot be removed for adjustment. The
amount of expansion desired is placed in the .020 wire before cementation and will be active for a
considerable period of time. It exerts a gentle force which does not exceed 2 1/2 ounces. It is not used
to correct mesially or distally tipped molars or molars which are rotated. These must be corrected
first.
Not only is the appliance used for expansion in the bicuspid area, it is also ideally suited to move
lingually erupting cuspids labially.
Construction of the Staple Lingual Appliance
Dr. E.E. Sheppard has published a very adequate description of the construction of the staple
lingual. Therefore, only a brief account will be presented with some personal comments.
An .040 wire is adapted to the lingual of the mandibular arch. It must contact the anterior teeth
and lie as far gingivally as possible without severe impingement on the soft tissue. In the bicuspid
area, the main body wire lies 11/2mm lingually from the bicuspid teeth to allow the .020 auxiliary
spring wire to lie between the .040 wire and the teeth. The .040 lingual arch wire is then soldered to
the molar bands. An .022  .028 flat wire "staple spur" is soldered to the main body wire (Fig. 4).
The primary function of the "staple spur" is to prevent occlusal or gingival displacement of the
auxiliary spring; and it aids in the stability of the lingual arch because it lies in the embrasure
between the first and second bicuspid teeth.
The buccal tubes are soldered to the molar bands. The lingual appliance is removed from the
work model and polished. Then, an .020 wire is formed in the same general contour as the main
body wire. This .020 auxiliary spring wire must be soldered inferiorly and distally to the main body
548
Article Text 3
wire (Fig. 5).
If the .020 wire is soldered directly and inferiorly under the .040 wire instead of inferiorly and
distally, it will not fit properly in the mouth.
The staple lingual appliance is a fixed appliance, which has maximum rigidity for molar
anchorage, making it ideally suited and effective for expansion in the bicuspid area. It is most
commonly used in the mandibular arch .
ADVANTAGES AND DISADVANTAGES OF THE TWIN-WIRE MECHANISM
Advantages
The twin-wire appliance exerts light and constant forces over a long period of time and produces
as near a physiologic tooth movement as it is possible to achieve with an appliance. An x-ray survey
of one hundred of my patients, selected at random, who had been treated with this appliance,
showed only five percent with slight to moderate apical root resorption.
Utilizing the cap and channel bracket, a narrow band may be used. Parents and patients often
remark about the neatness of the bands and labial arch.
Bite planes are practically eliminated, since one of the outstanding attributes of the appliance is
its ability to open deep overbites.
This appliance enables a tooth to be moved in any direction— labial, lingual, mesial, distal,
intrusion, extrusion, and rotation. Bodily movement may be accomplished in certain situations .
Molars can be moved distally without extraoral forces, but if the orthodontist prefers to use
extraoral forces, they may be used in conjunction with this appliance.
For correction of irregularities of the anterior teeth, the twin-wire labial arch is probably the most
efficient of all labial arches in use today.
When the twin-wire labial arch is inserted into the molar buccal tubes, each arch assumes its own
normal symmetrical shape. This is a unique accomplishment of the twin-wire mechanism, since all
dental arches are not uniform.
Disadvantages
The main disadvantage of the twin-wire appliance is its apparent simplicity. It was referred to in
the past as an "automatic" appliance. One of the definitions of "automatic" is "done without thought
or attention". It is certainly a delusion to think of this appliance as being simple or automatic, or to
think that the four molars and eight incisor teeth are the only ones on which bands are placed.
In certain cases, the maxillary incisors are too upright after treatment by present-day
549
Article Text 4
cephalometric standards. The anterior root torquing auxiliary developed by Dr. J. Reeves can be
used with a torqued .011  .022 flat wire to correct this deficiency (Fig. 6).
The Kitchton torquing auxiliary can also be used for torquing anterior teeth efficiently.
Flaring of mandibular incisors or intrusion of mandibular bicuspids can occur very rapidly when
using Class II elastic traction. The principle reasons are:
1. Elastic force over five ounces used over an extended period of time. Elastic traction should
never exceed four and one-half ounces except in crossbite situations.
2. Improper lingual arch construction .
3. Nonextraction diagnosis to correct a malocclusion where extraction is definitely indicated.
In some extraction cases, it is more advantageous to resort to other methods, more efficient than
the twin-wire mechanism alone, for levelling of the dental arch and to upright bicuspids.
If molars are rotated or tipped mesially or distally, a correction should be made prior to beginning
treatment with the twin-arch mechanism.
CASE REPORTS
The case reports have been selected to demonstrate general principles rather than fixed routines.
There is not a stereotype treatment for various types of malocclusions. No two cases are alike, any
more than two faces or physical statures are exact duplicates.
CASE I
Class II division 2 (Angle) Malocclusion
The patient was a male aged 13 years, 3 months. The posterior teeth on the right side were in
Class II relationship, while those on the left side were in an end-to-end relationship. The maxillary
left first bicuspid was in labial crossbite. There was a moderate amount of crowding of the
mandibular anterior teeth and the arch form was square.
Intraoral roentgenograms revealed a normal,
550
Article Text 5
healthy dentition. The face was well-balanced at rest position, which is usually a favorable
characteristic in the majority of Class II division 2 malocclusions.
The cephalometric findings were characteristic. The maxilla was slightly anterior to cranial
anatomy (83°); the mandible was posterior to cranial anatomy (77°). As would be expected, upper
central to NA was low (6°), and there was a lingual axial inclination of the lower incisors with lower
central to NB at 20°. The interincisal angle of 148.5° was excessive, which would indicate the
upright position of maxillary and mandibular incisor teeth. The rather high GoGn to SN angle
(36.5°) would indicate a somewhat short ascending ramus.
Treatment
In deep overbite cases, the twin-wire arch is adjusted to lie gingivally to the anterior teeth in both
arches so that, when the archwire is locked in the brackets of the anterior teeth, it will exert an
intrusive force.
Lingual appliances are essential to prevent tipping of the molar teeth. In

the mandibular arch the cuspid teeth must be banded in order to intrude the incisors. Since no
expansion was desirable in the maxillary arch, a plain lingual (.040) was constructed so it would lie
away from the first bicuspid on the left side, but in close contact with the second bicuspid. The
buccal tube on the left side was soldered to the molar band so that, after the end section of the labial
arch was placed in the tube, the end section would be. compressed against the first bicuspid to move
it lingually and aid in the correction of the crossbite. (All occlusal photographs are mirror images
and, therefore, reversed.)
In the mandibular arch, the finger spring of the staple

lingual appliance was adjusted to move the mandibular left first bicuspid labially. Note the end tube
was 2mm labial to the first bicuspid to allow room for the movement, while the end tubes on the
right side in both arches were approximating the bicuspids but not in close contact. This illustrates
well the critical alignment necessary in the placement of the buccal tubes, anteroposteriorly and
buccolingually. Inaccuracies in the position of the buccal tubes may seriously alter or destroy the
effectiveness of the twin-wire mechanism .
After placement of the initial .010 archwires, they were crimped where teeth were rotated, to
prevent patient discomfort.
551
Article Text 6
Class II elastics with a force of 3 1/2 ounces

were inserted at the beginning of treatment.
After seven months of treatment, in which time the maxillary archwire had been changed four
times and the mandibular archwire three times, the bite had been opened considerably and the
anterior teeth were in better alignment. The maxillary lingual appliance was removed and a band
was made for the lower right cuspid to move it distally with a .0056 mid-section coil spring.
Simultaneously, .009 posterior coil springs were used to move the molar teeth distally. Although
there was a Class I relationship on the left side, the posterior coil springs were compressed four
ounces on each side. Due to the reciprocal action of the posterior coil springs against the anterior
teeth, the Class II elastic traction was increased to 4 1/2 ounces to prevent labial movement of the
maxillary anterior teeth.
In two months, note the distal movement of the

right cuspid and the bicuspids and molars on both sides. The maxillary right cuspid band was
removed along with the posterior coil springs, and a new archwire was inserted with a mid-section
coil spring compressed against the left lateral incisor with two ounces of force. Class II elastics with
21/2 ounces of force were now resumed, and with the space between the right cuspid and lateral, the
midline was now ready for correction with the aid of a diagonal elastic.
An overcorrection of the midline was noted one

month later and elastics were discontinued. Six weeks after that, a normal midline relationship was
evident.
Four months after a normal midline relationship was

established and seventeen months from the beginning of treatment, the appliances were removed .
Final models revealed that the Class II molar relationship had been corrected, together with the
midline discrepancy. The overbite had been significantly reduced. Good symmetry was obtained in
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Article Text 7
both arches. From appliance removal to final records, there was an increase of 1mm in overbite .
Cephalometric analysis revealed that there was

a 3° reduction of the ANB angle and favorable growth of the mandible. There had been a slight
forward positioning of mandibular incisors, which was desirable in this case. A significant increase
in the upper incisor to NA had taken place (from 6° to 19°). The interincisal angle decreased from
148.5° to 132.5°.
A tooth
positioner was used during the retention period.
(TO BE CONTINUED)
FIGURES
553
Article Text 8
Fig. 1
Fig. 1 Twin-wire labial arch.
Fig. 2
Fig. 2 Cap and channel bracket.
554
Figures 9
Fig. 3
Fig. 3 Construction of the tubular lingual appliance.
555
Figures 10
Fig. 4
Fig. 4 Staple and its use in the staple lingual appliance.
Fig. 5
Fig. 5 Auxiliary spring soldered correctly to staple lingual.
Fig. 6
556
Figures 11
Fig. 6 Reeves torquing auxiliary on .011 x .022 flat-wire labial.
557
Figures 12
AUGUST 1976, VOL. 10 / ISSUE 8

Mobile Storage Systems 589
Orthodontic Feedback 596
Direct Bonding With Directon Adhesive 601
Adaptability of the Twin-Wire Appliance to Modern Day Orthodontics (Part 2) 610
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Aug(579 -): 580 THE EDITOR'S CORNER
the editor's corner

Practice building is the single most important factor in the orthodontist's financial well-being. It
is the difference between one orthodontist doing well in a community and another doing poorly. It is
the difference between one orthodontist staying in a community and another leaving. It has become
the difference between survival or actual failure in orthodontic practice. There are orthodontists
whose practices have failed, who have had to go to work for another practitioner or institution, or
move to what is hoped are greener fields, or who have returned to general practice.
A profile of the average orthodontist who has failed in practice is revealing. He is not
incompetent in orthodontics. To the contrary, he has frequently been a skillful operator and a
creative individual. His problem almost to a man has been that he was a loner, he was not
gregarious, he did not relate well to people — meaning patients, parents and dentists — and he had
not the slightest idea of how to compensate for these deficiencies in practice building. Each one
watched helplessly as his practice went dry.
Professions have traditionally attracted bright students who could succeed in the courses and who
were drawn to an occupation that depended on their brain power. Often these were introverted
individuals. In times when the volume of patients per doctor was high, such people were successful
in orthodontics in spite of themselves. As the volume of patients per orthodontist declines and will
continue to decline, the practice of this type of individual is among those affected first, because he
never really did anything about practice building and does not know how to go about it now.
Know Thyself is the first principle of L.D. Pankey and should be the first principle of every
orthodontist. For, whether you decide that you are one of these vulnerable introverted individuals,
you may be a non-introvert who has neglected practice building. So, each of us should take stock of
how we are doing in the practice building area: how we are relating to patients, parents and dentists;
what our practice building efforts are now; how effective they are; what our capability is in practice
building; what do we know about practice building; what steps should we start taking today to
improve our practice building effort.
What to do? As you would with any building, make a plan. As you would with any other building
planning, either borrow ideas from other people or hire a building consultant. We have orthodontists
who are unusually successful at practice building and who write about it and lecture about it. Read
everything you can. Take their lectures. There are also practice consultants who can accelerate the
process of practice building. If my practice was declining and I didn't know what to do about it, I
would do all of these things including finding the best practice consultant that I could.
You may need help in evaluating whether your community is the one you should be practice
building in. Is the tax structure in your community driving businesses away? Has the child
population disappeared? Has the affluent portion of the population moved elsewhere?
579
Article Text 1
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Aug(579 -): 580 THE EDITOR'S CORNER
Have your referring dentists retired or cut down? Do you have no relationship with the new crop
of young dentists in town? Should you take on one of the young orthodontic graduates and through
him establish a relationship with both the younger dentists and the younger community in general?
Have so many orthodontists moved into town that there cannot possibly be enough patients to go
around? Someone is going to have to leave sooner or later and it will be the one who couldn't build
his practice.
It may be impossible or even undesirable to try to change one's personality. However, it would be
both possible and desirable to use that brain power to do some studying, to take some courses to try
to understand human interrelationships better and some of the simple and rewarding positive actions
involved in how to win friends and influence people.
It also requires an evaluation of your office and your staff. Is it the kind of physical and personal
environment that you would look forward to visiting? Do you have the right people on your staff?
Can they be retrained or must they be replaced? Do you know what the right people are?
Have you scorned all those motivational methods such as changing decor, bulletin boards, photos,
prizes, poster contests? Is your office dull? Do you keep lines of communication open with patients
and parents with intreatment progress reports and posttreatment evaluation consultations? Do you
keep lines of communication open with dentists in any way other than dull, repetitive letters?
In the months and years ahead, nothing is going to be more important to orthodontists than
ongoing practice evaluation and strenuous practice building. Survival as an orthodontist could easily
depend on how soon and how well this is understood and undertaken.
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Article Text 2
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Aug(589 - 593): Mobile Storage Systems
Mobile Storage Systems

DON E. LAHRMAN, DDS
A wheel mounted mobile storage system in which the units shuttle sideways on tracks and
compact together to require only one access aisle at a time help control costs in an orthodontic office
by utilizing space to best advantage.
In conventional storage, there are multiple aisle spaces. By eliminating all wasted aisles and by
planning the shelving to suit the size of the model boxes or other storage, floor space for shelf
storage can be reduced by 46% (Fig. 1)
For model box storage, each unit should be no wider than two model boxes end-to-end. The
model boxes used should be uniform, if possible.
Fullspace System
The mobile storage system I use is called Fullspace by Lundia Myers Industries, Inc. My units are
6'2" high, six feet deep, and each unit is two feet wide. My entire storage system is approximately
fifteen feet long— two feet on one open end unit, one foot on the other end unit and six mobile units
which are each two feet wide. The open end unit could be closed with paneling, but since my units
are in the basement, I saw no reason to close it (Fig. 2).
The units could go as high as ten feet or as low as four feet. Several accessories are available
including stackable drawer units and tape racks, filing shelves, and fascia panels which improve the
appearance especially if the units are in the operatory. The one aisle space can be closed by a door
attached to one of the mobile units.
The shelves are laminated wood and completely adjustable (Fig. 3). Each shelf can hold a
distributed load of 500 pounds, which is more than adequate for one shelf full of model boxes.
Why do we use wood? Wood is probably the best material for storage systems because of its
strength and resiliency. Wood sags so that you can detect an overload before the shelf breaks. Metal
shelves kink when they pass their proportional limit. Wood is kind to materials stored. It resists
condensation by absorbing and evaporating moisture, so there is no drippage which may be a factor
in basement storage. It is also rust and corrosion proof, and non-slip. There is just enough of a
friction factor so that materials will not "walk off" the shelf in response to street vibration. Wood is
also nonconductive, quiet and decorative.
The Lundia units move on a cradle system consisting of two side rails and a central monorail
which is the main support. While these steel strips can be set into masonry or on wood, a solid floor
gives less chance of binding. If the system is planned before building construction, the rails can be
buried to avoid tripping problems. However, if this is not done, the rails only protrude an inch and a
half to two inches and my assistants have not found this to be a problem.
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Operation of the Mobile Units
One pound of force moves about 100 pounds of cabinet in the standard system. My lightest
assistant weighs 95 pounds and she can move all six units with one arm. An electrically operated
system is available, but is not normally needed in an orthodontic office. Since it doesn't take much
force to move the units, an assistant does not move one unit at a time. She grabs the handle of the
unit she wants and moves a whole group at one time (Fig. 4).
There are bumpers at the bottom of the units to keep them from crashing together. They also keep
the units about an inch and a half apart and prevent the handles of model boxes on one shelf from
grabbing those on the facing shelf.
The system is prefabricated and assembled in the office. It can also be moved at any time by
taking up the track and removing the end units. If space permits, storage can be increased by moving
the end unit, adding track material, and adding mobile units.
Most of these units will vary in cost, depending on the height and width. Costs will run around
$300 to $400 for stationary end units, and $400 to $500 for the mobile units. Track and accessories
are additional.
Although the six mobile units and two end units that I have will hold 4400 model boxes, I still do
not have them filled. We are using the empty storage space for additional types of storage ( Fig. 5).
This system has helped me organize my practice, not only for model box storage, but for inventory
control, and it looks beautiful.
SpaceSaver System
Mobile storage units are also available from SpaceSaver Corporation. These are also wheel
mounted mobile storage carriages which shuttle on tracks and have one aisle and will accept either
existing or new shelving. In a recent installation, this space conserving method reduced storage floor
space in an orthodontic office in half while shelf capacity was increased by 167 lineal feet compared
to previously used stationary shelving which required many aisles.
In this installation, there were four manually operated SpaceSaver units each one nine feet long
and eight and a half feet high located in the treatment area for greater efficiency. They have a
capacity of 2000 pounds of study models on each carriage. (Fig. 6).
It requires only several pounds of force to move one or more carriages to open the work aisle due
to the balanced design of the aluminum carriage members, hot-rolled steel tracks, and precision
ball-bearing carriage wheels. This permits a smooth, quiet operation according to SpaceSaver
Corporation (Fig. 7). Carpeted flooring is flush with steel tracks for walk-in safety or for using a
service cart.
This installation, which cost $5400 installed, will pay for itself in eight years, through the
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reduction of over 110 square feet of floor space at a rental cost of $6.30 per square foot per year.
Other savings include heat, lighting and air-conditioning utility costs, which now average around
$2.00 per square foot per year.
The office in which the SpaceSaver units were installed covered 2500 square feet, with one 9 ×
12 section devoted to the mobile storage carriages. Prior to that, the study models were kept on fixed
shelving and occupied double the present space— the equivalent of two 9 × 12 square foot floor
areas.
Lundia Myers Industries, Inc.
Lundia Myers Industries, Inc., P.O. Box 309, Decatur, Illinois.
SpaceSaver Corporation
SpaceSaver Corporation, 1450 Janesville Avenue, Fort

Atkinson, Wisconsin 53538.
FIGURES
Fig. 1
Fig. 1 Conventional arrangement of open shelving with six permanent aisles and a main aisle requires 351 square feet
(left) . Mobile storage using the same amount of shelving with only one aisle requires only 188.5 square feet, a saving
of 46% in floor space (right). (Diagram courtesy Lundia, Myers Industries, Inc, Decatur, Illinois)
591
Figures 3
Fig. 2
Fig. 2 Fullspace mobile storage in the author's office basement.
Fig. 3
Fig. 3 Wooden shelving in Fullspace storage cabinets.
592
Figures 4
Fig. 4
Fig. 4 Mobile cabinets slide easily on tracks.
Fig. 5
Fig. 5 Mobile storage used for supplies.
593
Figures 5
Fig. 6
Fig. 6 SpaceSaver mobile cabinet installation. (Photos courtesy SpaceSaver Corp., Fort Atkinson, Wisconsin)
Fig. 7
Fig. 7 SpaceSaver units slide easily on tracks to open storage aisle. (Photos courtesy SpaceSaver Corp., Fort
Atkinson, Wisconsin)
594
Figures 6
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Aug(596 - 600): Orthodontic Feedback
ORTHODONTIC FEEDBACK
R.S. CALLENDER, DDS
ALTON BARBOUR, PHD
PETER NORTHOUSE, PHD
BRUCE NASSAU, MA
"Feedback" is a word that has emerged in our professional and technical language in the past 20
years and has gained a lot of currency as persons have become increasingly concerned about
accuracy in communication. Formerly, this was a word that was used to describe a phenomenon in
radio-electronics. We have all experienced electronic feedback as the shrill noise the sound system
makes in an auditorium when the speaker stands too close to the microphone. The term "feedback"
as applied to human communication is a way to regulate the messages in the system, whether it be a
two-person system or a complex organization.
A human communication system needs to know "how it's doing" in order to do it correctly or to
do it better. Feedback is the answer to the question, "How am I doing?" A person who receives
feedback knows how the other person experiences him and has the answer to the "how am I doing"
question. He is then in a better position to regulate the human system in the direction it needs to go
because he is better informed and can be more responsive to the people involved.
To respond effectively to the needs of his patients, an orthodontist needs valid and reliable
feedback, regularly and systematically, about how he is conducting his practice. If he is to change
his way of operating, to reduce patient dissatisfaction or to take advantage of the strengths of his
practice, he needs to know what those strengths and dissatisfactions are. Sometimes, he will receive
this information spontaneously, but most often he will not. Those who spontaneously provide
feedback cannot be assumed to be typical of the rest of the practice. Their very volunteering makes
them atypical. In addition, people are more prone to report compliments than complaints. People
who have complaints, quite often simply do not come back and, since the doctor is uninformed
about the area of the complaint, he is unaware of its existence and unable to correct it. Information
needs to be solicited from those who would ordinarily remain silent in order to obtain and evaluate a
more valid and representative response.
Some highly perceptive individuals are able to "read" feedback in the behavior of people around
them and make adjustments and responses accordingly, but even the most perceptive individuals
have difficulty "reading" the behavior of others and drawing reliable conclusions. Moreover,
attitudes and opinions about the doctor, the practice and the care of patients are not observable.
Since we cannot see what people think, we must ask them.
Opinion Questionnaire
As any social scientist knows, if you don't ask the right questions, you don't get the right answers.
This investigation was designed to ask those "right questions" in order to gather useful information
about the attitudes of patients and parents toward treatment in my practice.
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Article Text 1
A patient-parent opinion survey was conducted utilizing a short-form, 3-page, 19-item

questionnaire. An instrument was constructed which could be read and easily understood by a
preteenager and yet have validity for an adult. This instrument takes less than 10 minutes to
complete and can be tabulated by secretarial or clerical staff. The research can be conducted,
yielding valuable information for the practice, at very little expense — for little more than the cost
of mailing and tabulation by a nonprofessional at a convenient time. Trends can be identified and
helpful suggestions for improvement in the care and treatment of patients can be gleaned from the
responses.
The questionnaire sought information and opinions in the following areas:

1. Results of treatment.
2. Handling by office staff and auxiliaries.
3. Convenience of office procedures.
4. Evaluation of benefits relative to costs and inconveniences.
5. Comparison of patients' and parents' expectations and satisfactions.
The questionnaire, devised by Dr. Alton Barbour of the University of Denver and Dr. Peter
Northouse of Western Michigan University, is in two forms, one for parents and one for patients
(see following pages).
The Survey
Two hundred patient-parent combinations were sent questionnaires with a cover letter explaining
the purpose of the investigation and instructing patients and parents to complete their forms
separately. 178 forms (89 patient-parent pairs) were returned.
In response to the item about who referred the patient to the office, 74 pairs were in agreement
that a dentist had done the referral; only 15 pairs disagreed, but among them 8 said that the dentist
and a friend had done the referring. This demonstrates the importance of the dentist in referrals in
my practice.
Eighty-three pairs agreed and only 6 pairs disagreed about who had made the decision to see an
orthodontist. 54 pairs said that both parents decided; 8 pairs reported that the mother decided. This
emphasizes the fact that only rarely is the child consulted or involved in the decision about seeking
treatment.
In spite of the lack of child involvement in the decision to see the orthodontist, 65 pairs were
agreed that the child wanted to go to the office for treatment. Only 10 pairs were in agreement that
the child did not want to go. This may mean that, once the decison was made by the parents, the
parents were very convincing and the child was quick to accept it, or that the child independently
could see the need for treatment and found it an agreeable decision.
Forty-nine pairs agreed that there were no fears or worries about coming to the office, while 18
597
Article Text 2
pairs agreed that there were some anxieties, mostly about the discomfort of treatment.
598
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Article Text 4
Information About Treatment
Two-thirds of the patients received treatment for two years or more; one-third received treatment
for between one and two years; only one pair reported receiving treatment for a lesser period.
Eighty pairs were in agreement that the child was glad that he or she had come for treatment.
Typical comments: "My teeth are now straight." "I like the way my teeth look." "The final results
were worth the discomfort."
Eighty pairs were in agreement that the treatment accomplished what it was supposed to. Nine
pairs were not in agreement on this item. A typical response: "His bite was off and we can see that it
was corrected."
Seventy pairs agreed that the child had followed instructions, and only four agreed that the child
had not followed instructions. Fifteen pairs were not in agreement on this item. As to which
instruction was most difficult to follow, the wearing of headgear was most frequently mentioned.
Other responses: "Regular changing of bands." "Not eating some foods I was told not to."
"Brushing."
In response to whether the treatment had improved the child's appearance, 84 pairs agreed that it
had, and one pair agreed that it had not. Four pairs were disagreed on this item. A typical comment:
"Not only changed overbite and straightened teeth, but changed shape of the face for the better."
Seventy-nine pairs were agreed that they would recommend the office to others and one pair were
agreed that they would not. Nine pairs were not in agreement on this item. Typical comment: "Feel
it is a well organized office and capable of achieving best results."
About Personnel and Services
Seventy-seven pairs agreed that they were well taken care of in the office and none were agreed
that they had not been. Most reported averaging a 15-minute to half-hour wait, although some
reported waiting as long as an hour.
Seventy-six pairs agreed that the dental health instruction was effective. None agreed that it was
not. Typical comment: "Has developed good brushing habits."
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Article Text 5
Seventy-eight pairs agreed that the operatory auxiliaries had done their jobs well. None were
agreed that they had not. Some typical adverse responses: "They could have been more gentle."
"Some were a little rough."
Eighty-one pairs were agreed that the orthodontist had done his job well and none were agreed
that he had not.
Eighty pairs agreed that they trusted him and none reported that they did not. Moreover, 56 pairs
claimed that they felt friendly toward the orthodontist and only 2 pairs were agreed that they did not
feel friendly toward him. Many parents and patients knew the doctor's first name.
Additional Suggestions and Comments
Asked for additional suggestions and comments, 52 persons responded. Twelve of these made
additional positive comments about treatment received. Other comments in descending order of
frequency were:
1. The need for more communication with parents. (12)
2. The need to be less rough. (8)
3. Problems with appointments. (4)
4. The expense of treatment. (3)
Conclusions
If one wanted to use this questionnaire to find out about the attitudes of his patients, the
procedure is simple. The instrument is available and can be used with permission. Because of the
limited use of the questionnaire, no standard scores have been established and no generalizations
from the results are possible. Nevertheless, orthodontists can benefit from the utilization of a
questionnaire such as this, and other social and behavioral science approaches.
One implication currently being worked on by the authors is uncovering the attitudes of patients
toward orthodontic care and dental hygiene, so that those with negative attitudes can receive special
attention, increasing the probability of successful treatment. A second implication is the relation of
orthodontic treatment to improved self esteem and self image. This is an extremely important
consideration which has received virtually no attention, but indications are that when an orthodontist
is treating teeth, far more than the teeth are being affected. In this study, the responses of patients
and parents to treatment they received were uncovered quickly, easily, and inexpensively. This is a
benefit derived from the utilization of survey construction and research to obtain feedback on
patient and parent attitudes toward treatment in an orthodontic office.
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Article Text 6
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Aug(601 - 609): Direct Bonding With Directon Adhesive
Direct Bonding with Directon Adhesive

WILLIAM W. BARNARD, DDS
Direct bonding began in the author's office thirty-three months ago, and early success led to
increasing numbers of teeth being bonded. To date, 177 patients have enjoyed the benefits of direct
bonding with Directon, 2311 teeth having been bonded. In the earliest trials, only maxillary incisors
were bonded, but as experience was gained, bonding was extended to all maxillary and mandibular
anteriors and bicuspids, and occasionally molars. During the last two years, there has been no
selection of patients for bonding; every patient started in active treatment has had all necessary
maxillary and mandibular attachments bonded, with the usual exception of those on molars.
Maxillary molars and mandibular molars with long clinical crowns are bonded in cases which do not
require headgear, lingual arches, or lip bumpers, and in which treatment is expected to require less
than 15 months.
Plastic brackets were used on the earliest patients, but it was soon found that these brackets failed
quite regularly, and metal brackets of various types have been used on the great majority of patients.
Plastic brackets are now used only on maxillary incisors of adult patients who refuse to have
orthodontic treatment with metal brackets.
The author uses an .018 slot edgewise technique, and there have been no technique compromises
to favor direct bonded teeth. Full size rectangular wires are routinely used for torque control and
correction and, when necessary, high-pull headgear is applied to the maxillary archwire in the
incisor region. It has been found that the few bond failures which occur are very rarely due to
appliance forces, but are usually related to patient carelessness in eating. A few patients have been
responsible for many of the bond failures, and a large number of patients have had no failures at all.
Table 1 summarizes the author's experience with direct bonding of brackets using Directon adhesive.
Advantages of Direct Bonding
Early experience in appliance placement demonstrated several of the advantages of direct

bonding — patient comfort, improved esthetics, the ability to easily secure attachments on impacted
and partially erupted teeth, and the easy bonding of difficult-to-band teeth such as shovel shaped
incisors and peg laterals.
As active treatment was completed on many patients, other advantages began to stand out as most
important. These are: the elimination of decalcification under appliances, the elimination of
considerable gingival irritation, the ability to place brackets very precisely for root canal and the
elimination of most archwire bends, the ability to keep extraction spaces completely closed for many
months while the appliance is in place, and the elimination of band space between teeth. Direct
bonding has facilitated complete, detailed finishing of cases, so that there is no uncontrolled space
closure, and very little "settling" is necessary .
The author has also found that direct bonding requires considerably less time than banding and is
601
Article Text 1
much more enjoyable, mainly because of the ease of precision bracket placement.
Advantages of Directon Adhesive
Directon has a controlled flow to a feather-edge on the tooth, and the edge of the adhesive is
gradually worn away by tooth brushing. This means that there is no ledge or step at the adhesive
margin as is the case with adhesives that have greater initial viscosity or that flow for some time and
slump to form a ledge adjacent to the gingiva. Directon does not require troublesome finishing of
cement margins after adhesive set, nor does it encourage a thin line of plaque accumulation at the
cement margin which can result in a "bulls-eye" pattern of decalcification, even in patients who
practice good hygiene.
Directon has a gradual set over a period of about 40 seconds (at 75°F air temperature) and
although the bracket position may be adjusted for about 20 seconds without adversely affecting the
bond, the adhesive has enough body to prevent slump or bracket sliding after about 5 seconds. These
are the characteristics which contribute to very precise bracket placement. (Adhesive is "prepared"
for one bracket at a time.) Another advantage of Directon is its economy — 2300 teeth have been
bonded for about $150.00 worth of adhesive, and no heater, activating light or other special
equipment is necessary.
Bonding Preliminaries (Fig. 1)
Teeth to be bonded are polished with a commercial non-fluoride prophy paste, with particular
attention to newly erupted teeth which may have adherent remnants of a thin organic surface
membrane.
Lips and cheeks are retracted with modified photographic lip retractors held in place by an
aluminum neck bow. The plastic lip retractors were bent after slow heating over a Bunsen burner.
The neck bow was originated by Dr. Phil Borges of Vallejo, California.
Conditioning liquid supplied with the Directon kit (phosphoric acid) is applied with a modified
model airplane paint brush. A similar brush is used later to apply the primer liquid. These brushes,
made by the Testor Co., are available at variety stores and hobby shops. The nylon bristles are cut
short to about 5mm long. The bristles hold only a small amount of liquid, thus giving good control
of liquid application and economy of liquid use. After 60 seconds of etching, the teeth are spray
rinsed, air dried, and visually checked for complete etching. Any remaining organic membrane is
removed with a scaler, and another 60-second application of conditioner is made. The entire labial
surface of each tooth should be a very dull, chalky white when air dried after the conditioning
procedure. In a few patients with very resistant enamel, a third application has been made. If, after
conditioning, there is any wetting of the prepared tooth surfaces by saliva, crevicular fluid, or blood,
the tooth is merely washed and dried with water spray and air immediately before the primer is
applied (next step). Occasionally the phosphoric acid causes bleeding from inflamed gingival
tissues, and if a continuous air blast will not keep the blood from the bonding site, Premier
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Hemodent is applied and rinsed off between the etching and priming steps.
Directon primer liquid is applied using a light touch with another modified brush. From this time
until the adhesive has covered the tooth surface, air is applied as necessary to maintain a completely
dry, uncontaminated surface. Complete etching and drying and absence of contamination are
essential to success, and Directon's quick set and one-by-one bracket application permit good
control of gingival oozing with an air blast in difficult situations, such as impacted or partially
erupted teeth.
Bracket Application Procedure (Fig. 2)
The bracket to be bonded is held in a pair of modified spring-locking soldering tweezers, and a
suitable amount of cement powder (acrylic polymer) is piled on the under side of the bracket base.
In the case of a perforated bracket base, which would allow the adhesive to flow through and clog
the bracket, the powder is piled on the tip of a spatula specially modified to hold the correct amount
of powder. The cement liquid (acrylic monomer) is then applied drop-by-drop to wet the small pile
of powder. The edge of the bracket or spatula tip is then touched to the prepared tooth surface,
which permits the thinnest part of the adhesive mix to "flash" across the entire labial surface of the
tooth. If a spatula is being used, the remaining thicker adhesive mix is quickly applied to the base of
the bracket (held in the tweezers), and the bracket is positioned on the wetted tooth surface. If the
adhesive has been mixed on the bracket base rather than on the spatula, the bracket is applied to the
tooth surface after allowing several seconds of setting after the "flashing". The adhesive will be
quite viscous by the time the bracket is on the tooth, and the bracket will not slide on its own, but its
position may be adjusted for another 10-15 seconds.
A Woodson instrument is used to adjust bracket position and to hold the bracket for about 20-30
seconds in cases of partially erupted teeth where the gingiva is actually displaced somewhat by the
bracket. In these cases, which are quite common with bicuspids in 10-12 year olds, the gingival
crevice is held open with an air blast, adhesive is "flashed" into the area, and the bracket is slid
under the marginal gingiva and held in place until the adhesive has set. Directon's fast set is
obviously an advantage when dealing with these teeth.
Allowing the thinnest part of the adhesive mix to "flash" across the entire tooth surface is
important to strong bonding. The thin mix spreads readily, creating a large bonding area, and
presumably penetrates deeply into the etched enamel surface. If an excessive amount of adhesive
"flashes" into interproximal areas, it may be blown away with an air blast just before the bracket is
placed on the tooth.
The cement liquid is very volatile and is the most expensive component of the adhesive system. It
is stored without waste and dispensed very precisely from a disposable tuberculin syringe with a
blunted needle. These inexpensive syringes last through many bondings. If a bit of polymer powder
causes an obstruction at the needle tip, a ligature wire can be used to easily clear the lumen.
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Article Text 3
The bulk of the author's experience with metal brackets has been with edgewise brackets welded
to TP round perforated bases, thus the spatula technique has been most used. Perforated or screen
bases with a solid shield between the bracket and base are now commercially available, so the
simpler, preferred method of mixing powder and liquid on the bracket base can be used.
The author welds brackets off-center on the base, displaced about a millimeter to the gingival.
This arrangement puts the brackets farther from occlusion and diminishes the probability of failure
from forces of occlusion. The bracket-base combination has an increased mechanical advantage to
resist the peeling mode of failure brought about by vertical occlusal forces applied to the bracket.
Brackets must be out of occlusion. Sometimes wings must be ground slightly, and in severe deep
bite cases, bite plates are occasionally placed at the time of bonding.
Post-bonding Procedures
Occasionally, it is apparent after bracket placement that there is an inadequate amount of

adhesive, and additional adhesive powder can be activated with liquid on the tip of a Woodson
instrument and then applied to the deficient area (Fig. 3). This technique is very valuable when the
bracket has been moved after the adhesive has begun to set. The author feels that bond strength is
adequate in this case if additional material is added to any areas where the setting adhesive has been
torn or disrupted. The Woodson instrument is also useful for applying adhesive when bonding
retainers, splints, or other devices to teeth.
On teeth with small clinical crowns, adhesive may flow into interproximal areas or build up a
ledge adjacent to the gingiva. An explorer is used while the adhesive is soft to remove material in
these areas (Fig. 4). A cutting motion, directed away from the cement bulk, is used. This step is very
important to prevent plaque traps. If there is any question about adhesive "bridging" two teeth, floss
is passed through the contact while the material is still soft (Fig. 5). The explorer can also be used at
this time to remove any adhesive which may have come through a perforated base and clogged part
of the bracket.
From this point on, the bonded tooth may be wet, but force is not applied to the bracket for 10-15
minutes. Working at a relaxed pace, the author and one assistant accomplish the entire bonding
procedure for 20 teeth in 30-60 minutes, depending on the size of the oral opening, size of clinical
crowns, etc.
In the event of bond failure, any remaining cement is removed from the tooth with a scaler, and
the tooth is prepared and bonded as if it were a virgin tooth.
Debonding Procedure (Fig. 6)
Attention to proper bracket removal is just as vital to success as is attention to bracket placement.
Careless removal can result in rough enamel surfaces which certainly detract from the perfection of
a finished case.
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Bracket bases are carefully sheared away from the tooth with a sharp pin cutter. Care is exercised
to prevent the sharpened tips from scratching the enamel surface.
On teeth with rounded surfaces, remaining adhesive can usually be carefully "nibbled" away with
a sharp Rocky Mountain band removing plier. Again, extreme care is necessary to avoid gouging the
tooth surface. It is best to avoid using this plier on any of the flat surfaced teeth because, in the
author's experience, the bond is much stronger, and sometimes the adhesive will actually pull away
small bits of enamel. Any time the adhesive is difficult to remove with this plier, it should not be
used.
A large round bur is used to remove cement on the flat surfaced teeth. This bur will cut through
the plastic adhesive, but will not mar the enamel. If used with a light touch, it leaves a smooth,
natural looking surface with no defects to evidence the bonding which has been done.
A Black's scaler and a sharp spoon (as used for caries removal) are now used to remove any
remaining adhesive in interproximal or gingival areas.
The teeth are polished with a fluoride-type prophy paste.
Other Bonding Applications
In addition to brackets and tubes on bases, about 180 plastic and metal buttons have been bonded
to lingual surfaces of teeth, a number of fixed retainers have been bonded (Fig. 7), and several
uprighting devices have been bonded to occlusal surfaces of impacted second molars (Fig. 8).
Conclusion
Direct bonding of brackets and other attachments with Directon adhesive has been practiced by
the author for nearly three years, with good success. The overall failure rate for brackets in service
for up to 24 months has been 5.1%. Currently all teeth except molars are bonded in all patients. In
favorable situations, molars are also bonded. Direct bonding has proved to be an aid to practice
efficiency and enjoyment, as well as a factor leading to increased quality of finished cases.
FIGURES
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Article Text 5
Fig. 1
Fig. 1 Bonding preliminaries. A. Setup. B. Retractors in place. C. Prophylaxis. D. Etching. E. Spray Rinse. F. Primer
application.
606
Figures 6
Fig. 2
Fig. 2 Bracket application procedure.
607
Figures 7
Fig. 3
Fig. 3 Mixing adhesive on tip of Woodson instrument (left) and applying to a deficient area (right).
Fig. 4
Fig. 4 Removing excess cement in gingival and interproximal areas with explorer.
608
Figures 8
Fig. 5
Fig. 5 Clearing contact with floss.
609
Figures 9
Fig. 6
Fig. 6 Debonding procedure. A. Shearing bracket from tooth with pin cutter. B. "Nibbling" away cement with band
removing plier. C. Large round bur used for cement removal. D. Excavating spoon used to remove cement in gingival
and interproximal areas.
Fig. 7
Fig. 7 Stainless steel screen bonded to lingual of teeth for retention of rotations and space closure. Cement was
applied with a Woodson instrument, then trimmed after set with round and fissure burs.
610
Figures 10
Fig. 8
Fig. 8 Uprighting spring bonded to occlusal surface of second molar. Bonded part of wire was bent in an "L" shape to fit
pattern of grooves. After adhesive set, spring was activated by bending just mesial to coil with small three-beak plier.
TABLES
Table 1
611
Tables 11
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Aug(610 - 618): Adaptability of the Twin-Wire Appliance to Modern Day Orthodontics (Part 2)
Adaptability of the Twin-Wire Appliance to

Modern Day Orthodontics [Part 2]
JOHN E. JOHNSON, DDS
Part 1 of this article appeared in the July issue of JCO. In this installment, two additional cases are
presented to demonstrate refinements in the twin-wire appliance therapy, adapting it to modern day
orthodontic concepts.
CASE 2
Class II division 1 (Angle) Malocclusion

The patient was a male aged 13 years, 2 months. The maxillary arch was V-shaped, which is
typical of a great number of Class II division 1 cases, with a slight constriction in the bicuspid area.
The anterior teeth in both the maxillary and mandibular arches were in supraversion which, along
with an infraversion of the molar teeth, contributed to the deep overbite. The mandibular anterior
teeth were striking the palatal rugae. There was a 10mm overjet. The maxillary right first bicuspid
was in buccal crossbite. In the mandibular arch, there were minor broken contacts of the anterior
teeth and a lingual inclination of the bicuspids.
The patient had an extremely short upper lip and the maxillary incisors were resting on the lower
lip.
The cephalometric analysis showed the maxillary and mandibular denture bases both posterior to
cranial anatomy (SNA 76°, SNB 71°). Interincisal angle was 131°, which was difficult to reconcile
with the visual appearance of the anterior teeth. Breaking this angle down into its component parts,
the maxillary central incisors were 28° to the NA plane and 7mm linearly. These teeth were tipped
more labially than is normal. The mandibular anterior teeth were tipped lingually (16° and 3.5mm to
NB). The apparent normal interincisal angle of 131° was a result of the labial tipping of the
maxillary incisors and lingual tipping of the mandibular incisors. With the near normal GoGn to SN
of 35° and the Y axis of 58.5°, favorable growth of the mandible may possibly be anticipated. As a
hereditary characteristic, from both his mother and father, the patient did not exhibit a
well-developed symphysis.
Treatment
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Article Text 1
From a complete appraisal, it was decided to

treat this case nonextraction. It was felt that the lower anterior teeth could be moved labially and still
have good basal bone support.
Bands with cap and channel brackets were placed on the maxillary four incisors and the
mandibular six anterior teeth. Since there were no rotations to correct in the maxillary arch, a .011
twin-wire arch with hooks and .0056 mid-section coil springs were used to begin treatment, along
with Class II elastic traction of 3½ ounces. The .0056 mid-section coil springs distal to the laterals
were used on the maxillary twin-wire arch to consolidate space between the anterior teeth and to
prevent the end tubes from sliding out of the molar buccal tubes.
Before the archwires were placed, it was essential to make sure the end tubes of the twin-wire
arch could slide freely in the buccal tubes to permit the procumbency of the maxillary teeth to be
reduced with Class II elastic traction. Because of the minor irregularity of the lower incisors, an .010
twin-wire arch was placed on the mandibular teeth.
Since expansion, or lingual-buccal uprighting, was

desirable in the bicuspid areas, a tubular lingual was used in the maxillary arch and a staple lingual
was used in the mandibular arch.
The amount of expansion which was desirable in the

lingual appliances was determined before cementation. The force exerted by these finger springs did
not exceed 2½ ounces. The amount of expansion desired in the finger spring in the mandibular arch
is well illustrated since the bicuspids had not completely erupted. As these teeth did erupt, the finger
spring was placed lingual to them. Here is the amount of lingual-buccal uprighting (expansion) after
five months of treatment.
611
Article Text 2
A significant reduction of the

procumbency of the maxillary anterior teeth and an end-to-end relationship of the anterior teeth was
seen after eight months of treatment.
A temporary open bite occurred on the right side due to the lingual movement of the maxillary
anterior teeth, which compressed the cuspids and bicuspids between the anterior teeth and molars,
causing them to intrude. Vertical development in the mandibular molar area also contributed to the
temporary open bite. The open bite, which generally occurs in cases of this type, is favorable
because it unlocks the bicuspids and cuspids which are in Class II relationship and, after the
posterior coil springs are placed, the molars and bicuspids can very easily be moved distally.
Of course, when the posterior coil springs are placed, the lingual appliance is removed and a .011
× .022 flat-wire arch with lingual torque is usually used to aid in preventing distal tipping of the
maxillary molars when the coil springs are compressed against them. The torquing action of this
archwire aids in preventing the "tucking in" appearance of the maxillary incisors. Coil springs are
compressed against the buccal tubes with a force of four ounces and the Class II elastic traction is
increased to 4½ ounces. When the posterior coil springs have been activated to move the molars
distally, it is essential to employ Class II elastic traction to counteract the force of the coil springs
against the anterior teeth. If the patient fails to wear the elastics continuously, the anterior teeth will
move labially. This procedure in the use of posterior coil springs must be followed precisely. The
force exerted by the coil springs cannot exceed the force of the Class II elastics.
In the next five weeks, the distal

movement of the maxillary teeth has been overworked into a Class III relationship. Notice the
spacing between the maxillary molars and second bicuspids.
The posterior coils and the archwire were removed and replaced with a plain .011 twin-wire arch
with 3/8" mid-section coils. Class II elastic traction was discontinued.
In the next three weeks, the maxillary

molars and the unbanded bicuspids were allowed to find their natural occlusion with the mandibular
arch.
Overworking a Class II division 1 case in the manner described above was always emphasized
emphatically by Dr. Joseph E. Johnson.
612
Article Text 3
Since the lower first bicuspids were

slightly rotated, bands with Broussard brackets were placed on these teeth. Alastiks were stretched
from the bicuspids over the distal ends of the buccal tubes. Three months later, there was a better
interlocking of the bicuspids and molars.
In most cases, appliances are left in place

three to five months after all tooth movements have been completed. If additional treatment is
necessary, the appliances are still in place, and any problems which may arise during retention can
be anticipated. Total active treatment time was sixteen months. The patient was given a rubber tooth
positioner which was bulky in the anterior segment with a high labial flange, and the patient was
taught lip exercises to lengthen the short upper lip. Final models, taken three years after active
treatment, illustrate a stable Class I molar relationship, improved arch form, and increased vertical
dimension due to a decrease in overbite.
The
post-treatment cephalometric tracing revealed a reduction of the ANB angle from 5° to 3°. It would
have been more desirable to have used a root torquing auxiliary along with the torqued .011 × .022
flat-wire arch, since the upper incisor to NA angle had been reduced to 19°. There had been some
613
Article Text 4
forward positioning of the lower incisors, but they remained stable three years after active treatment.
Occlusal plane to SN angle had not increased. The composite revealed that there had been
substantial mandibular growth which was more vertical than horizontal. There had not been any
substantial forward growth of maxilla.
CASE 3
Class II division 1 (Angle) Bimaxillary

Protrusion
The patient was a female aged 10 years, 9 months. There was a Class II molar relationship on the
right side and a Class I relationship on the left side, due to the premature loss of the deciduous
second molar with mesial movement of the mandibular first molar, which had blocked out the
second bicuspid. There were 10mm of overjet, a deep overbite, and crowding of the anterior
segments.
The malocclusion prevented the patient from closing her lips, except under strain and, as a result,
the lips were parted most of the time. Both lips were full and anterior to the Ricketts soft tissue
profile line.
Cephalometric analysis showed a large ANB difference of 6.5° and the maxilla and mandible
were posterior to cranial anatomy (SNA 77.5°, SNB 71°). The occlusal plane to SN angle (22.5°)
was large and, therefore, effort had to be made not to increase this angle. With a low interincisal
angle (107°) and upper incisor to NA of 33° and lower incisor to NB of 33°, along with high linear
measurements, a severe procumbency was indicated.
A diagnostic setup was made with extraction of the four first bicuspids. It was evident that a
complete reduction of the anterior procumbency could not be obtained. Therefore, there would
probably be some compromise in the final results for this severe bimaxillary protrusion.
There was gingival recession on the mandibular right central incisor. Digital palpation of the oral
vestibule indicated a marked discrepancy in tooth-to-denture base relationship. This case required
maximum stability of the molars in both arches.
Treatment
614
Article Text 5
A fixed soldered lingual appliance (.040)

was used in the maxillary arch. A staple lingual appliance was used in the mandibular arch for
stability and to upright the lingually erupting left second bicuspid.
The first step in treatment was to move both the maxillary and mandibular cuspids into the
extraction spaces, with .0056 mid-section coil springs between the laterals and cuspids. The second
step was to reduce the procumbency of the maxillary incisors with Class II elastics until they
contacted the mandibular incisors. After these movements had been achieved, both Class II and
Class III elastics were used simultaneously to further reduce the labial version of the maxillary and
mandibular incisors. If the lingual appliances are not maintained until these movements have
occurred, the buccal segments would move mesially, with the use of elastics, before the anterior
teeth can correct their labial inclination. Here is the case after six months of active treatment.
One year from the beginning of

treatment, the lingual appliances were removed. To establish a Class I molar and cuspid relationship
on the right side, a posterior coil spring was used to move the molar distally and a mid-section coil
was used at the same time to move the cuspid distally.
The midline was corrected in the same

manner as described in Case 1 (JCO, July 1976). The maxillary cuspid bands were removed and
Class II elastics were used to retract the maxillary incisors further. Here is the case ready for band
removal. Active treatment had been eighteen months.
615
Article Text 6
The patient was given Hawley type

retainers. Final models, taken three years after treatment, show a stable result with good arch
symmetry, although there was a slight relapse of the maxillary left lateral incisor and an overjet of
2mm was present.
The
cephalometric analysis showed a reduction of the ANB angle from 6° to 3°. This was principally
due to favorable horizontal growth of the mandible. Interincisal angle increased from 107° to
122.5°. Occlusal plane angle was not increased even though Class II mechanics were used.
The fullness of the lips was significantly reduced. The lower lip was on the Ricketts soft tissue
line and the upper lip was 3mm posterior.
The composite tracing revealed a very favorable growth pattern had occurred. There was an equal
amount of vertical and horizontal growth of the mandible.
This type of malocclusion is probably the most difficult to manage properly with the twin-wire
appliance.
616
Article Text 7
SEPTEMBER 1976, VOL. 10 / ISSUE 9

The Modular Self-Locking Appliance System A Variation in the Combination
Technique
653
Correcting and Preventing the Overbite of Malpractice Claims 661
Round Table Discussion: The Future of Orthodontics 668
The Bioplast Positioner 692
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Sep(637 -): 638 THE EDITOR'S CORNER
the editor's corner

There is a basic philosophical disagreement between most orthodontists and organized general
practitioners and pedodontists. It has always been the policy of organized dentistry, and this is
reflected in the state dental practice acts, that a dentist is licensed to perform any and all dental
procedures. It is left to his own good judgment whether he is capable to perform a treatment or not.
The disagreement that orthodontists have with this principle is not on a basis that all orthodontists
are saints and all GPs and pedodontists sinners. It is simply that the public is not served nor
orthodontics advanced by allowing untrained or undertrained practitioners to perform it. It would be
interesting to know how many general practicing dentists and pedodontists would or could support
the ADA contention and even more interesting to know to whom they would entrust the orthodontic
treatment of their own child.
Nevertheless, in a recent issue of the National News of the Academy of General Dentistry, the
following item appeared under the title "AAO Eliminates Discriminatory Dental Care Policy"—
"The House of Delegates of the American Association of Orthodontists (AAO) recently amended
one of its major policies on dental care programs to recommend that orthodontic treatment under
prepaid programs not be limited solely to orthodontists.
The concept of amending this policy was discussed by the Academy's Executive Committee when
it had a one-day meeting with the officers of the AAO in St. Louis, Mo. on April 1, 1976.
The AAO's previous "Policy Relative to Dental Care Programs (Item 5)" stated the following:
"The practice of orthodontics is a special area of dentistry demanding additional study, training, and
experience. Therefore, orthodontic treatment under prepaid programs and publicly funded programs
should be rendered by those having the qualifications necessary for announcement of limitation of
practice approved by the House of Delegates of the American Dental Association whenever and
wherever possible."
The italicized section of this statement was rescinded by the AAO House, so the newly adopted
statement adopted on April 28 reads:
"The practice of orthodontics is a special area of dentistry demanding additional study, training
and experience. Therefore, orthodontic treatment should be rendered by those having the
qualifications necessary."
If the former policy was discriminatory, the latter one is indiscriminate. This is a step backward.
We will not gain credibility with the public and with public activists— in the form of legislators,
union leaders, and consumer advocates— when we agree to principles and practices that are not in
the public interest. Because, if we endorse the principle of "caveat emptor" in the doctor/patient
relationship, we are jeopardizing our remaining mechanism of professional credibility — which is
637
Article Text 1
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Sep(637 -): 638 THE EDITOR'S CORNER
peer review— and we are consigning the future of this question to the courts. Some day some judge
is going to decide that performing procedures you know little or nothing about is malpractice. If we
would contemplate that occurrence without making strenuous efforts to prevent it, we are not
entitled to the public trust and privileged position that we enjoy; nor will we be permitted to sustain
it.
Leaving the problem to be solved by the courts or even by peer review groups endorses
consideration after the fact, after someone may feel that malpractice was performed upon him.
If a GP or a pedodontist has full orthodontic graduate university training, there is no question

about his right to practice orthodontics. If he has less, the day may be fast approaching when he may
be open to malpractice charges. The patient has a right to assume that a dentist who performs certain
procedures is qualified to do so by education and training. All of dentistry is headed for possible
ignominy if we continue to profess that any dentist can do anything he pleases in dentistry.
In defining educational requirements in orthodontics as a full two-year graduate university

program, one must add "or its equivalent" to recognize that some outstanding individuals might
achieve a high level of competence through other training, including preceptorship. If so, there has
to be something equivalent to state board examination in orthodontics to test their competence,
which leads us back to specialty licensure of a qualifying nature for all practitioners of orthodontics,
with orthodontic treatment restricted to those holding the specialty license.
If we are to insist on stringent educational requirements, there must be a reasonable availability of

education opportunity. This may be counter to a mood or even a movement to constrict orthodontic
class size in light of the increasing number of orthodontists and decreasing number of children.
Publicizing the economic problems in orthodontic practice would be a responsible way to influence
this factor.
Similarly, publicizing to dentists and dental students the sophistication of orthodontic treatment
should deter many who otherwise do not know what they do not know.
Finally, publicizing to the public the differences between a trained orthodontist and an untrained
dentist who offers to do orthodontics would be a responsible endeavor in the public Interest.
We presently have two levels of orthodontic treatment in this country and we should not in any
way contribute to its continuance.
638
Article Text 2
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Sep(653 - 660): The Modular Self-Locking Appliance System A Variation in the Combination Tech
THE MODULAR SELF LOCKING APPLIANCE

SYSTEM
A Variation in the Combination Technique
MAXWELL S. FOGEL, DDS
JACK M. MAGILL, DDS
For years, we have been involved in organizing a treatment system which fosters an
uncomplicated technical approach for patients of all ages and incomes. Our key objective was to
treat greater numbers, better, faster, and easier, at lower cost; to utilize highly trained
paraprofessionals wherever possible; and to use appliances which can achieve the optimum biologic
response. It is our aim to simplify and design teaching disciplines for the attainment of clinical
excellence, so that orthodontic graduates will be able to respond to the current and future pressures
from our health oriented society for more and better comprehensive health care.
Rationale
Efficient management of an orthodontic practice requires that specific and realistic precepts be
followed. We believe these to be:
1. A sensible approach toward an ideal result, considering genetic and biologic limitations of growth
response, type and size of tooth material, patient cooperation, patient comfort, age and general
health.
2. Simplicity of technique with the absolute precision factors reduced to flexible and reasonable
tolerances.
When inserted in place, it is essential that the appliance should be a natural. power plant from
which long range continuous energy can be derived for correcting, in an uncomplicated manner,
such common malpositions as rotations, intrusions, extrusions, crossbites, midline disharmonies,
and locked-out and partially erupted teeth. Also, the forces which may emanate from such an
appliance should have the ability to act efficiently in correcting defective axial inclinations.
Naturally, in order to effect these changes with complete authority and minimal adjustment, one
must use an unusually adaptable appliance. Although it is virtually impossible for one single wire or
one set of modifications to execute all the required tooth movements, it is possible to arrange a
comprehensive single basic appliance unit on a band to accommodate the simple combination of a
few wires for adequate performance of these corrections.
In order to satisfactorily complete treatment as routinely as possible, a standard order of

procedure must be followed. This can only be done if the entire treatment plan is divided into a
series of orderly steps. Allowing small defects in tooth position to accumulate may entail so many
complex correctional details that an acceptable end result can be obtained only through arduous
efforts. Not until each phase is thoroughly completed to the operator's best ability should the next
objective be sought.
653
Article Text 1
Treatment must be compartmentalized by means of check lists for each major stage. Final
objectives must be:
• Overbite correction as close as possible to an edge-to-edge anterior relationship.
• Class I molar relationship.
• Uncrowding of incisors.
• Closure of anterior spaces.

3. The manual aspects of the technique must be uniformly designed so that the average skills of both
professional and auxiliary personnel can be fully utilized.
4. An uncomplicated diagnostic system utilizing clinically proven factors concerning type of skeletal
framework and its future potential of growth and development; the style of soft tissue covering in
accordance with type and severity of malocclusion. We must also evaluate the significance of lower
incisor position as related to mandibular plane and, even more important, to Pogonion and soft
tissue chin. In a severe malocclusion, a cephalometric progress check is made to appraise the
position of lower incisors. Through clinical experience we know that the relation of the mandibular
incisors to the AP plane and/or the Frankfort mandibular plane angle plays a major role in the
production of optimal facial esthetics. However, there are exceptions to the rule, as in cases of
dominant chin point or other compensatory dentofacial architectural growth phenomena. Hard and
soft tissue ingredients in the lower third of the face are probably the most significant diagnostic
criteria to consider.
Simplicity, Economy and Flexibility
In this Bicentennial year, it is appropriate to go back into history and bring to mind the genius Eli
Whitney who, while watching untrained workmen fumble with the parts of his cotton gin, realized
that he had to put his own skill in every untaught hand; and, to do this, he had to substitute his own
skills by means of simplified assembly of parts. Assemblage was made precise by certain guides,
stops, and automatic devices. Thus, the relatively unskilled and semiskilled were able to become
proficient in a comparatively short time and produce correct and effective end results. Whitney
stressed three major factors which are pertinent to our efforts— simplicity, economy and flexibility.
Translated in terms of production, this actually meant quality, quantity, standardization and
inter-changeability of parts.
This philosophy was exactly the motivation behind our new approach to the Modular
Self-Locking System (Fig. 1). This article deals with a practical, time-saving method, embodying
the most current and significant principles of a light round wire technique, although differing
specifically by employing a system of modular components.
Modular Self-Locking Appliance System
654
Article Text 2
This method, which is a light wire system using a single pivotal bracket or twin self-locking low
frictional attachments, has clinically demonstrated simplified and securely controlled mechanics for
individual and collective tooth movements to attain optimum end results. Development of an
adaptable appliance receptacle makes possible the utilization of the best features of the original
Combination Technique with the new and improved clinical procedures.
The insert bracket, which has already received popular acclaim as a single bracket attachment,
has now become the cornerstone of a new and completely practical round wire technique by
combining it with a twin self-locking modular attachment. Thus, the simple self-locking insert
bracket can function singly or in combination to produce efficient, biologically responsive,
controlled tooth movement.
Both single and double insert brackets, with self-locking components, offer a long-awaited,
simple and practical time-saving feature by completely eliminating ligature tying and repeated pin
placement. An added factor is the versatility of this unique method of directing tooth movement in
all planes, in most instances without the use of time-consuming application of multiple spring
auxiliaries.
The horizontal slot has been included in the receptable to accommodate the orthodontist who still
desires this facility. Otherwise, the horizontal slot is not used during regular treatment.
Insert Bracket (Fig. 2)
The principal module is the Insert Bracket, which is now made of a special soft stainless steel and
appears able to withstand the various demands made upon it. The stainless steel insert bracket does
not undergo electrolytic changes, although it possesses the desired quality of softness, which brass
has. Steel is stronger, generally lasting throughout treatment, and can be opened and closed as many
times as necessary.
The elements of the insert bracket are:

Archwire chamber (.025"). For maximum performance in light wire therapy, the round archwires
float freely in the .025 chamber. The chamber is strategically placed in relation to bracket wings,
permitting adequate tipping of the archwire, setting in motion less restricted tooth movements.
Beaks are flared, forming a funnel-shaped entrance for the wire. Beaks can be opened and closed for
containment and release of the wire.
Insert slot (.020" ). Entrance formed by shape of beaks, facilitates easy access for archwire.
Slot apex (.012"). Constricted portion of funnel, permits snapping in and retention of wire prior to
closure of beaks .
Seat. Base of insert bracket which rests in the grooved wing of the receptacle for stability.
Stem. Extension of insert bracket fits into the vertical slot and holds insert bracket in position when
bent at right angle.
General thickness (.018").
Bracket head (.070"  .070"). Overall length (.235" ).
655
Article Text 3
Placement of Insert Bracket
The stainless steel insert bracket is easily fitted into the vertical slot of the receptacle. The stem is
cinched (Fig. 3) and bent laterally with a light wire plier or a dull ligature cutter, pressed snugly
under the wing and against the side wall of the receptacle.
Removal of the insert bracket is also a quick and easy procedure. The stem is staightened and cut;
the head is grasped with the flat end of a dull ligature cutting plier; the insert bracket is removed,
using the receptacle wing as a fulcrum.
The biologically oriented, low frictional and free sliding, self-locking insert bracket has been in
use clinically for about fifteen years. Therefore, this is obviously a most proven component of the
Modified Combination Technique.
Figure 4 demonstrates the adequate tipping movements and free flowing movement of the
attachment along the archwire.
In this technique, we have completely eliminated the edgewise archwire with its constricting
influences, the menial chore of wire ligation and the binding effects of ligation.
A natural progression of this self-locking, snap-in technique ( Fig. 1) demonstrating the modular
system, begins with the single insert bracket used in the Combination Technique and changes to a
double insert bracket in the same receptacle, to continue the relatively low frictional, high
performing biomechanical tooth movement process to the completion of treatment.
Receptacle (Fig. 5)
The receptacle is made in three sizes — Small (.150"), Medium (.180"), Wide (.200")— and is
contoured for specific teeth in the anterior and posterior segments. The three vertical slots
accommodate insert brackets and auxiliaries. A single slot is used in the early stages and both mesial
and distal slots are used in the finishing stages. Because the vertical slots accommodate the insert
brackets and auxiliary springs, the receptacles must not be contoured, lest the slots be narrowed or
distorted causing difficulty of component insertion. Blockage of vertical slots must be scrupulously
avoided during cementation or bonding. This may be avoided by use of wax in slot openings, use of
elastic rings around wings of receptacle, and placement of insert bracket prior to cementation.
As previously mentioned, the horizontal slot is an elective feature to satisfy those operators who
may still be unsure of handling the modular self-locking concept in its totality.
It is suggested that the receptacle be placed toward the incisal edge of the band in order to
provide sufficient metal backing for the insert bracket (Fig. 6).
The receptacles are routinely spot welded to the bands in two strategic locations, namely the tabs
and the body of the attachment (Fig. 7).
656
Article Text 4
Receptacles are also available in either clear or tooth-colored plastic (Fig. 8). It is our belief that
bonding of either plastic or metal brackets is a unique innovation. However, from our experience, it
has not met with universal application in routine cases. We have found moderate success in bonding
upper incisors and cuspids and, occasionally, lower incisors. Clear plastic brackets are well accepted
by adult patients. Nevertheless, these brackets should be used with reservations regarding their
durability and the patient must be thorougly oriented to their weaknesses as well as to their benefits.
Molar Tube Attachment
The oval or slightly flat molar tube with mesial hook is an important component of the Modified
Combination Technique (Fig. 9).
The action of the tip-back bend in the light round wire as it behaves in the buccal tube and its
effect on the positioning of the molars is directly related to the shape of the buccal tube. Garcia and
Brandt have shown that there is less lingualization (rolling in) and unfavorable rotation of molars
with the oval or flat tube than with round tubes (Fig. 10).
It has been amply demonstrated that a tip-back bend, also known as a resistance or anchorage
bend, when placed in a round wire becomes a modified toe-in, whereas the oval tube resists this
action (Fig. 11).
Molar control and anchorage are definitely more favorable with the oval buccal tube. The oval
tube now has a vertical slot to assist in molar uprighting or increased molar resistance, when
necessary.
Insertion of Light Wire Into Insert Bracket
The .014, .016 or .018 round archwire is snapped into the insert bracket with mild finger pressure
(Fig. 12). In special situations involving major malpositions of certain teeth, a wire director may be
used to guide the archwire into the insert slot, where it is quickly and easily snap-locked into the
circular insert chamber.
Finally, closure of the insert bracket beaks is accomplished by gently using How pliers ( Fig. 13).
Usually, the cuspid insert brackets are closed first, followed by the four incisor teeth, a remarkably
simple and rapid procedure.
Removal of Archwire From Insert Bracket
If the archwire is not to be re-used, it is practical to cut the wire interproximally and slip each
segment out of the light wire insert bracket. It is strongly recommended that the used archwire be
cut, removed and discarded, because of the simplicity of light wire fabrication and the ease and
rapidity of its insertion with the snap-in insert bracket. Re-using the old archwire is a waste of time,
since most of the vital qualities of the wire have already been dissipated.
657
Article Text 5
Should it be necessary to preserve the existing archwire, removal is accomplished by opening the
insert bracket with an insert spreader (Fig. 14). The insert spreader, an .012 flat-bladed instrument,
is carefully fitted into the insert slot and simply pushed forward, opening the slot to its original
dimension and preparing the release of the wire. The archwire is snapped out of the slot, using a
scaler (Fig. 15) which acts as a miniature crowbar, effectively and gently disengaging the archwire
without distorting it.
(TO BE CONTINUED)
FIGURES
658
Article Text 6
Fig. 1
Fig. 1 Modular Self-Locking System. A. Receptacle. B. Single insert. C. Twin insert. D. Snapping archwire into inserts.
E. Inserts closed.
659
Figures 7
Fig. 2
Fig. 2 Light wire insert bracket parts and dimensions.
Fig. 3
Fig. 3 Placement of insert bracket. End bent up snugly against side of receptacle .
660
Figures 8
Fig. 4
Fig. 4 Archwire freedom in insert bracket.
Fig. 5
Fig. 5 Front and rear views of receptacle.
Fig. 6
Fig. 6 Placing receptacle toward incisal edge of band provides sufficient backing for insert brackets.
661
Figures 9
Fig. 7
Fig. 7 Receptacle spot welds.
Fig. 8
Fig. 8 Modular plastic brackets.
Fig. 9
Fig. 9 Oval molar tubes of Modified Combination Technique.
662
Figures 10
Fig. 10
Fig. 10 Demonstration of action of tipback bend inserted into round and oval tubes.
Fig. 11
Fig. 11 Unfavorable rotation of molar following insertion of tip-back into round molar tube (After Garcia, F. G., Oval
Tubes for First Molar Anchorage, J. Clin. Ortho. Vl, May 1972).
Fig. 12
Fig. 12 Archwire snapped into insert bracket with mild finger pressure.
663
Figures 11
Fig. 13
Fig. 13 Closure of insert bracket beaks with How plier.
Fig. 14
Fig. 14 Insert spreader in position to open insert bracket.
Fig. 15
Fig. 15 Scaler used to snap archwire out of opened slot.
664
Figures 12
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Sep(661 - 665): Correcting and Preventing the Overbite of Malpractice Claims
correcting and preventing

the OVERBITE of MALPRACTICE CLAIMS
FREDERICK W. BRADLEY, LLB
Good rapport is the most important single factor in preventing "misunderstandings" from
becoming "malpractice". Since an orthodontist primarily treats children, he must not only have a
good rapport with the patient, but also with the parents who are paying the bills and giving the
consent for the treatment. Lack of rapport is the reason for certain individual practitioners becoming
"repeaters" as defendants. Unfortunately, it is not unusual that an abrupt manner or unkind remark
on the part of the dentist has been a precipitating factor in a lawsuit.
Notwithstanding scheduled consultations prior to commencement of any new treatment, a

patient's confidence in himself and the dentist can be supported by taking the time for a few words
with each patient even if the scheduling is tight or behind. "After all, it is far better for a dentist to
take a minute to talk with a patient than to have to spend an hour with his lawyer discussing the
latest lawsuit filed by one of his alienated patients."
As an extension of the good relationship being developed between the dentist and the patient, the
receptionist and dental assistants must not only maintain a professional appearance, but also show
that they too care about the patient. Diplomacy on the telephone, as well as in the office, by the
dental assistants has not only prevented the loss of patients through disagreements, but has
prevented disagreements from becoming malpractice claims.
Informed Consent
The allegation of lack of informed consent is one of the most frequent issues on which a
plaintiff-patient bases his claim of malpractice. The appellate courts through their decisions have set
forth certain guidelines which, if followed, can prevent or contain a suit for an untoward result
because the patient did not know the possible complications (risks), nor were the alternative
procedures or treatment discussed with him.
Some years ago, informed consent was governed by the standard practice in the community, as
established by medical witnesses. In other words, if other dentists did not make the same
disclosures, you did not have to. Rather than have the physicians and dentists vested with absolute
discretion in this regard, the California Supreme Court in the case of Cobbs v. Grant has changed
this policy. In this decision, the court set out four fundamental principles as follows:
1. Patients are unlearned in the medical-dental sciences.
2. The patient has the right to exercise control over his own body.
3. Therefore, his consent to treatment must be informed.
661
Article Text 1
4. The patient has an abject dependance on his physician or dentist for the information that he
needs for this decision-making process.
At the present time in California the duty to disclose is not wholly dependent upon the standard
practice in the community, but rather stems in part from a duty imposed by law which allows a jury
to resolve this issue through the use of common sense without reference to what a medical expert
might say about the standards in his community. Upon the decision in Cobbs v. Grant, the following
is the 1972 revision for the California jury instruction which governs the issue in this regard.
BAJI 6.11 (1972 Revision)

REALITY OF CONSENT-PHYSICIAN'S DUTY
OF DISCLOSURE
"It is the duty of a physician or surgeon to disclose to his patient all relevant information to
enable the patient to make an informed decision regarding the proposed operation or treatment.
There is no duty to discuss minor risks inherent in common procedures, when such procedures
very seldom result in serious ill effects.
However, when a procedure inherently involves a known risk of death or serious bodily harm, it
is the physician's or surgeon's duty to disclose to his patient the possibility of such outcome and to
explain in lay terms the complications that might possibly occur. The physician or surgeon must also
disclose such additional information as a skilled practitioner of good standing would under the same
or similar circumstances.
(There is no duty to make disclosure of risks when the patient requests that he not be so informed
or where the procedure is simple and the danger remote and commonly understood to be remote.)
(Also, a physician or surgeon has no duty of disclosure beyond that required of physicians and
surgeons of good standing in the same or similar locality when he relies upon facts which would
demonstrate to a reasonable man that the disclosure would so seriously upset the patient that the
patient would not have been able to rationally weigh the risks of refusing to undergo the
recommended [treatment] [operation].)
Notwithstanding the patient's consent to a proposed treatment or operation, failure of the

physician or surgeon to inform the patient as stated in this instruction before obtaining such consent
is negligence and renders the physician or surgeon subject to liability for any injury [proximately]
[legally] resulting from the [treatment] [operation] if a reasonably prudent person in the patient's
position would not have consented to the [treatment] [operation] if he had been adequately informed
of all the significant perils."
Limits on Necessary Disclosure
As you can see from the jury instruction on informed consent, there are limits on necessary
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disclosure. If the patient prefers not to have you "parade the horribles", then note the record that the
patient requested he not be so informed. If the procedure is simple and the danger remote, there is
no duty to inform the patient. For example, should a patient sustain mandibular and/or lingual
paresthesia from the administration of an anesthetic where such possible complication was not
discussed, one defense would be that such administration of anesthetic is routine and simple for the
dentist with a remote possibility of nerve involvement and commonly understood to be remote in the
dental profession.
A mini-course in dentistry with a discussion of all possible complications is not required and the
final test on the matter of disclosure is that the patient must prove that he would have refused
treatment had he been informed of the risk which eventuated. The jury applies the objective test of
what a reasonably prudent person in the patient's position would have decided, even if adequately
informed of all significant complications. If there was no reasonable alternative procedure but to
proceed with the treatment, notwithstanding any possible complications, then "lack of informed
consent" would be of no consequence as respects liability for dental malpractice
Nevertheless, an orthodontist should inform his patient (parent) of the possible complications so
that the patient and parents are fully informed and can give a knowledgeable consent prior to the
commencement of treatment. At the same time alternate choices or procedures, if any, should be
discussed.
Actual time set aside for a consultation with the patient (parent) prior to the commencement of
treatment is among the strongest evidence that the complications were discussed before consent to
the treatment was given. The next step should be a notation on the chart that a consultation was had
with the patient and the complications of the procedure discussed without mentioning any specifics.
Sometimes too sophisticated an approach can backfire. For example, the dentist could set forth a list
of complications and even go so far as have the patient and/or parent initial it, but think of the
embarrassment if the patient developed a complication that was not on the list. The standard-brief
all purpose consent form for the patient's (parent's) signature in and of itself will provide no
protection to a claim for "lack of informed consent". However, if time has actually been set aside
and utilized for a consultation prior to commencement of treatment and the record noted in general
terms that the complications and alternate procedures were discussed, then the dated signature of the
patient (parent) on the standard consent form would be credible evidence that in fact he did get the
word.
Standard of Care
Perfection is not required and a dentist need not and should not guarantee successful treatment.
"It is possible for a dentist to err in judgment or to be unsuccessful in his treatment without being
negligent". What is required is that the dentist have that degree of learning and skill ordinarily
possessed by other dentists of good standing, practicing in the same or a similar locality and under
similar circumstances, and to use the care and skill ordinarily exercised in like cases by reputable
members of his profession, using reasonable diligence and his best judgment in the exercise of his
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skill and application of his learning in an effort to accomplish the purpose for which he is employed.
A failure to perform any such duty is negligence that is called malpractice which gives rise to a
cause of action against the dentist when the patient is injured as a proximate cause of the breach of
this duty.
In the event that a dentist does guarantee success to his patient and thereafter fails to satisfy, he
exposes himself to a cause of action for breach of oral contract, even though the dental treatment
was within the standard of care. In orthodontics, just as in prosthodontics where aesthetics play an
important role in whether or not the patient is happy with the result, it would be extremely foolish to
make any promises that must withstand the subjective test of the patient. Furthermore, liability
assumed by the dentist under any such contract or agreement is generally excluded from
professional liability coverage and in California there is a two year statute of limitations for oral
contract, compared to one year for negligence.
Record Keeping
Good records are the first line of defense in a claim of malpractice. With complete records that
are comprehensive and detailed, a dentist's testimony is more worthy of belief in recalling the events
surrounding the treatment.
Signed health histories should be obtained, reviewed with the patient by the dentist and
periodically updated, redated and resigned. Taking and preserving x-rays are of paramount
importance. Except where necessary for insurance billing purposes, the cost of the x-rays should be
included in the charge for consultation-examination. In any event, the x-rays should be considered
the property of the dentist and not the patient. When it is necessary for the x-rays to be sent to
another dentist, it should be done only on the condition that they be returned and the forwarding of
said x-rays should be done through the dental offices and not by the patient. Of course, duplication
of the x-rays affords maximum protection.
In a case involving orthodontic care, four front teeth had been lost and the rest were loose.
Unfortunately, no x-rays had been taken for two and a half years following the placement of
orthodontic bands. Consequently, root resorption and bone loss went undetected until it was too late.
The patient's expert witness not only testified that it was below the standard of care for having failed
to take periodic x-rays, but also that less force should have been used with this adult patient.
Not only should the patient's major complaints be recorded on each visit, telephoned complaints
should be noted in the record with the advice given. Notations should be made where the patient
fails to cooperate with the dentist in the treatment plan.
If a patient fails to return for completion of treatment he should either be telephoned and the
record noted or a letter sent to him explaining the need for further treatment and the complications
that may occur if he does not return or contact another dentist.
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In addition to noting in the records the specific procedures or precautions followed because of the
particular patient's state of health with respect to allergies, illnesses, or injuries, the chart should
contain a complete record of all prescriptions. Furthermore, an accident, injury or untoward result
should be immediately communicated to the patient with the chart being noted that he was informed.
Only when the patient knows of an injury that may give rise to a malpractice action does the statute
of limitations begin to run.
Records should never be altered and once a claim is made, they should be considered "frozen". If
it is necessary to make a change, a light line may be drawn through the previous entry, so that it can
still be read in addition to the alteration that is dated and initialed. The credibility of the dentist's
entire history and testimony can be shattered by a suspicious alteration.
Finally, even inactive or old patients' records with x-rays should be kept as long as possible. If
"old" records cannot be stored indefinitely, approximately twelve years would be the next choice.
Consultations
It is the duty of a dentist, when necessary, to refer his patient to a specialist or recommend the
assistance of a specialist. If the treating dentist fails to perform that duty and undertakes or continues
to perform professional services without the aid of a specialist, then he must have the knowledge
and skill ordinarily possessed and exercise the care and skill ordinarily used by specialists in good
standing in the same field and in the same or similar locality and under similar circumstances. A
failure to perform any such duty is negligence that is called malpractice.
For example, if an examination and x-rays indicate periodontal disease, a consultation and/or
referral should be considered or the treating dentist will be held to the standard of care for a
periodontist should he continue the treatment. If a consultation is recommended but declined by the
patient, the chart should be noted accordingly.
Collection Procedures
Since some malpractice suits arise out of cross-complaints in collection suits for unpaid dental
bills, the dentist should personally review all accounts prior to turning them over to a collection
agency. While you have a right to be paid for dental work even when the treatment is not successful,
you should at least know that you may trigger a malpractice action through enforcing collection
against unhappy patients.
Conclusion
Remember that it is easier to remove a tooth from the mouth than it is a foot. In observing dental
care and treatment administered by other dentists, diplomacy and discretion should be used in
discussing such care and treatment with the patient. While you should not "sweep it under the rug"
when you observe potential malpractice, you should at least look at the case with understanding and
compassion, realizing that you are reviewing it after the fact and the other dentist may have been in
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a different situation. When in doubt as to how to handle a case where the prior dentist performed
below the standard of practice, call your county dental society for advice.
Again, attorneys should not dictate the way you practice. If you continue to give good care, have
a good rapport with the patient, schedule recall appointments, have good records and have
consultations whenever necessary, you should not have to worry about the attorney.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Sep(668 - 691): Round Table Discussion: The Future of Orthodontics
rouund table
The Future of Orthodontics
THE PANEL:
DR. HARRY L. DOUGHERTY
DR. T. M. GRABER
DR. JOHN M. GREWE
DR. HAROLD T. PERRY
DR. RICHARD A. RIEDEL
Orthodontists are confronted with a number of complex problems and issues they have not faced
before. There is lack of unanimity as to how best to solve these problems. A sage once said, "The
only constant in life is change." No one doubts that profound changes are here and more are
coming. For orthodontists, these changes are economic, political and social. We need guidance
concerning which to accept, which to oppose, which to encourage. To help us to do this, JCO has
invited five chairmen of orthodontic departments across the country to discuss the problems and the
changes in their area of expertise and to indicate their opinions about how these will affect the
future of orthodontics.
DR. BRANDT Will the solo practitioner be operating pretty much the same in the future as he is
today?
DR. DOUGHERTY Perhaps not. Economics, political environment, legal responsibility and third
party programs make group practice a likely possibility for the future, perhaps in the next ten years.
DR. GRABER There is a trend toward groups. Opening a solo practice is difficult now. If HMO
experiments are extended to include routine private practices, the solo practitioner may have to go to
smaller and more isolated communities which cannot support HMO's.
DR. GREWE Solo practices will diminish. There will be both more group orthodontic practices as
well as groups encompassing all of the specialties. There are, today, orthodontic practices that are
models of what most practices will be like in 20 years.
DR. PERRY Within ten to fifteen years, the economy, Big Brother, insurance plans, supply
controls, etc. will subtly encourage group practice.
DR. RIEDEL There will be a decreasing emphasis on solo practice. There will be more groups.
Auxiliaries will be employed to a much greater extent. This is all happening now.
DR. BRANDT If auxiliary personnel take over the mechanical tasks in orthodontics, what will the
role of the orthodontist be?
DR. PERRY He'd better be in charge of quality control, parental complaints, and malpractice
premium payments.
DR. RIEDEL The orthodontist will become a sophisticated diagnostician, a progressive analyst of
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treatment procedures, a critical assessor of treatment results, and a careful observer of post-retention
stability.
DR. DOUGHERTY Supervise and diagnose.
DR. GRABER The primary role of the orthodontist is that of an applied biologist and diagnostician.
The services reserved by him are those which he has the unique ability to perform— that only he
can perform, based upon his training and experience.
DR. GREWE The orthodontist will diagnose, establish treatment objectives, the treatment plan,
prescribe treatment, evaluate treatment, manage personnel, and perform technical tasks.
DR. BRANDT Dr. Joseph Kauffman has written: "The extension of auxiliary functions is a
creeping process of professional disembowelment. If continued, we will produce two kinds of
legalized practitioners, upper level, professional, and lower level, craft." Can he be right?
DR. RIEDEL I suppose he could be right. However, I see professionals who are nothing more than
mechanical craftsmen at the present time.
DR. DOUGHERTY He is right.
DR. GRABER I disagree strongly with Dr. Kauffman on auxiliary function. Integrity and common
sense should restrict the use to legitimate and supervised endeavor, and not allow mushrooming of
an undirected lower level of dental service. Service should be improved, not deteriorated. Patients
will benefit in service and economics. The key is proper supervision, peer review, and keeping the
highest standards.
DR. GREWE Perhaps Dr. Kauffman is right.
DR. PERRY I agree with Dr. Kauffman. It is a dangerous trend that efficiency forces upon us. We
cannot put the personality and body of a child upon an assembly line. If we do, the patient might end
up with "straight teeth", but a very debased evaluation of us and our specialty.
DR. BRANDT Since orthodontists' earning power has decreased, the number of applicants for
postdoctoral positions has dropped significantly. What is your comment on that?
DR. DOUGHERTY The effect of motel courses and the urge to do orthodontics by the generalists
and childrens' dentists has made an impact. The effect of court decisions on malpractice is now
remedying the situation in California, at least.
DR. GRABER The decrease in the number of applicants may reflect the reduced economic
advantage today for dentistry in general. More men are going into endodontics, which now has the
highest per capita income of any dental specialty. It is an expression of supply and demand.
DR. GREWE There is an overproduction of orthodontists and we should consider dropping the
total number of positions in the United States.
DR PERRY It's another example of the marketplace concept. If, however, monetary return is not
the primary professional goal and service to a specialty is, the change will not affect the dedicated,
happy specialist or graduate student.
DR. RIEDEL The law of supply and demand is beginning to work. Graduating dental students will
probably seek to enter specialties that have the greatest demand for their services. The graduate
applicant will probably look to the best quality program, rather than just any program.
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DR. BRANDT Should orthodontists concentrate more on adult treatment?

DR. GRABER We should not over-concentrate too strongly on adult treatment. There are not
enough cases documented to justify some of the claims and the effort and expense. The health
claims are particularly questionable and stability is more of a problem. Retention is often
semipermanent. Proper balance is the word.
DR. GREWE Yes, in all facets— orthodontists, surgical-orthodontics, adjunctive care to
periodontic and crown and bridge therapy. Orthodontic care is not strictly for the adolescent.
DR. PERRY I believe that more knowledge, records and treatment of these problems are a
prerequisite of our contemporary specialty, in relation to periodontal problems. However, much can
be done in surgical-orthodontic procedures.
DR. RIEDEL Yes, with some emphasis on surgical-orthodontics. However, don't forget adjunctive
orthodontic services for periodontics and restorative dentistry.
DR. DOUGHERTY Orthodontics is a total discipline and it makes no difference whether the
patient is young or old.
DR. BRANDT Do you feel that organized orthodontics could help the solo practitioner increase his
patient load by undertaking a massive public relations campaign, done with dignity and
thoughtfulness, directed at the consuming public— instructing them to "see your orthodontist"?
DR. PERRY This is a loaded gun. The best PR in the world is the individual personal performance
in community, office, academia, and professional service.
DR. RIEDEL I do believe a public awareness campaign would have a certain amount of utility in
informing the public of the potential for orthodontic treatment for children, adults, etc.
DR. DOUGHERTY Perhaps, but the best impact will come from the dental profession as a whole.
DR. GRABER Orthodontics and the public would profit by a massive public relations program,
done with dignity and thoughtfulness, outlining the information about orthodontics as a specialty.
DR. GREWE Yes, not only to increase patient load, but to teach the consumer how to seek care
from an orthodontist, who and what an orthodontist is, the difference in education between a general
practitioner, pedodontist, periodontist, etc. This is the type of public awareness that is necessary for
orthodontics and orthodontists.
DR. BRANDT Plastic surgeons issue a booklet which outlines the education and qualifications
necessary to become a plastic surgeon. Why not have organized orthodontics do the same thing?
DR. RIEDEL Yes, why not?
DR. DOUGHERTY They do in some areas. The individual practitioner does this. However, he
treads a thin line, since it is considered unethical.
DR. GRABER This is needed immediately, in this period of changing times and concepts, and the
need for education of the public.
DR. GREWE A number of orthodontists already do this. It is a good thought.
DR. PERRY This is possible, but be sure that all those who pass out the brochures have all the
qualifications listed, or the public will be mislead.
DR. BRANDT Is there sufficient evidence that group practice is capable of providing cheaper,
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better and more comprehensive dental service?

DR. GRABER Yes. Medicine is a good model. The theme is the team.
DR. GREWE There may be some evidence, but I am not sure this is so.
DR. RIEDEL There is little evidence of a better service. A group is probably more versatile, but
not necessarily more comprehensive or better. There is no evidence of reduced costs. Increased costs
follow increased space, auxiliary help, etc. Increased income generates more taxes. To summarize
— more people provide more service, but it is not necessarily better.
DR. DOUGHERTY Comprehensive, yes. I am not sure it is always cheaper or better.
DR. BRANDT In what way do you see external influences on orthodontic practice creating change
in the mode of practice?
DR. GREWE One can only guess what will happen in the future to the economy, cultural values,
government involvement in health care, etc.
DR. PERRY You could write a book about this one and it would only apply to a few. There will be
more paper-work .
DR. RIEDEL One of these forces is health care insurance. How it is administered and received by
the public will influence orthodontic practice. The general state of the economy will be a factor.
How these factors are going to change is uncertain. I suspect health care insurance will only increase
in volume and coverage.
DR. GRABER These forces are in a state of flux. If socialized medicine is introduced, specialty
practice will change. Third party payments, peer review, the lack of abundant supply of patients will
change the manner of practice. There will be more groups, more associations, orthodontic
internships, and more orthodontists avail
able for career teaching and research.
DR. BRANDT Approximately 30% of recent dental school graduates are enrolled in post-doctoral
programs. Is the dental profession overspecialized?
DR. PERRY Some of our colleagues in dentistry and dental education believe we are
overspecialized, but I believe that the marketplace, supply and demand, would change that if it were
so.
DR. RIEDEL I doubt that the profession is overspecialized. The complexities of the various fields
of dental specialty training require a great deal of time. It is impossible for a dentist to know all the
fields of dentistry; hence the emphasis on certain fields is desirable. Rather than trying to teach a
little about everything, perhaps we would do better to teach an individual everything about a little bit.
DR. DOUGHERTY Dentistry is overspecialized in some areas.
DR. GRABER I do not feel that dentistry is overspecialized, but it is fragmented. With the
three-year dental school program, more people will be going into various specialties. Orthodontics,
oral surgery and periodontics are true specialties. I do not consider pedodontics, endodontics,
prosthodontics and dental radiology as true specialties .
DR. GREWE In Europe, there are basically two dental areas that are considered specialties,
orthodontics and oral surgery. In the U.S.A., other specialties have been recognized. The increase in
the number of students that go into graduate programs has gotten to a point that we will shortly be
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overspecialized. The economy will even us out. There will be fewer students who will go into the
various specialties and more will go into general practice.
DR. BRANDT If dentistry is to be more responsive to the public in providing comprehensive care
to a larger segment of the population, can this be accomplished if so many dental students enter
specialty classes?
DR. RIEDEL I do not read comprehensive dental care as meaning the individual dentist must
provide for all the needs of the individual patient. I see a team effort as much more productive and
potentially useful relative to the overall needs of patients.
DR. DOUGHERTY Yes. Specialists generally provide a more efficient and knowledgeable service,
especially in orthodontics and in maxillofacial and oral surgery.
DR. GRABER Despite more people entering specialty programs, it is possible to provide
comprehensive care for a larger segment of the population, if practices are run more efficiently and
if more auxiliary personnel are utilized.
DR. GREWE We will soon see a peaking in the number of dental students in specialty programs in
the United States. Some postdoctoral programs have already been reduced, and this is not easy for a
university to recommend or accomplish.
DR. PERRY Yes. The added efficiency of the office, use of auxiliaries, and new techniques all
have contributed to more extensive patient care and increased patient loads. In comprehensive care,
the specialties are also needed.
DR. BRANDT If the birth rate continues-to decline, would you recommend scaling down the output
of orthodontists?
DR. DOUGHERTY No, we are still lagging in expert care of malocclusion.
DR. GRABER I would recommend scaling down the annual output of orthodontists on a long term
basis.
DR. GREWE Yes, I would recommend a decrease in the output of orthodontists, but based on a
number of factors, not just the decline in birth rate.
DR. PERRY I believe the marketplace will level any plethora or paucity of dentists, preachers,
teachers, engineers, etc.
DR. RIEDEL I don't think I should attempt to answer that question. There are more facets about the
incidence of malocclusion, the provision of services to the population, the effects of preventive
measures.
DR. BRANDT Would you advocate a moratorium on specialty programs, including orthodontics?
DR. GRABER I would certainly not advocate a moratorium on specialty programs. I would slightly
reduce the number being trained annually, but not cut out entire programs.
DR. GREWE Yes, There is no need for new dental schools to start new orthodontic programs (or
oral surgery, periodontics, etc.) in states where the need does not exist. For example, the new dental
school in Southern Illinois or the new dental school in San Antonio, Texas.
DR. PERRY No.
DR. RIEDEL At this point, I do not believe a moratorium is advisable. The law of supply and
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demand will determine what a dental school graduate will do. If a moratorium were imposed, it
would imply serious problems in retaining graduate faculty. Who would continue to supervise and
care for patients?
DR. DOUGHERTY No, it would serve no purpose.
DR. BRANDT Are orthodontic graduate programs pricing themselves out of the market?
DR. DOUGHERTY No more so than other postgraduate courses, with the exception that most
orthodontic graduate students receive no stipend.
DR. GRABER Yes, graduate programs are pricing themselves out of the market. I believe that
orthodontic graduate students should have the same opportunities other postdoctoral programs,
notably pedodontics, have. Residency programs for orthodontists should be developed complete
with salaries, etc.
DR. GREWE This is more of a problem in private institutions. I suspect there will be increasing
desire and interest in providing students with a resident salary or stipend that will help defray the
costs of education.
DR. PERRY Regretfully, our program at Northwestern is near that point. We lose many excellent
applicants when they learn the tuition, fees, cost of living in Chicago, etc.
DR. RIEDEL It is the same as in the undergraduate school. If the government and dental schools do
not support the graduate programs, they will be priced out.
DR. BRANDT Do you feel that the federal government will have as profound an effect on
orthodontic education as it presently does on general dental education?
DR. GRABER Not the same effect. Orthodontics is considered more a luxury service than a
necessity. It is not tied as strongly to the financial apron strings of the federal government. This may
change with third party participation.
DR. PERRY I believe it will in time. Some of the schools are nearly 75% federally subsidized, and
when the hand that feeds you tells you what to do, you either do so or lose your support.
DR. RIEDEL The federal government has had an effect on the dental school structure and will
probably continue to do so. As long as we are dependent on the government, we will be controlled
by the government. Without federal help, dental education programs would not survive. With
federal help, there will be government control. The effect on orthodontists will be similar to the
effect on all other areas of dentistry.
DR. DOUGHERTY Yes, through money, legislation, and welfare programs. Presently,
orthodontics is the least monied specialty with fewer grants to students and teachers.
DR. BRANDT Since generalists' income has been increasing at a more favorable rate than that of
the specialist, will the trend toward specialization change?
DR. PERRY Yes.
DR. RIEDEL Yes. The equalizer in the democratic system is the law of supply and demand.
DR. DOUGHERTY Not necessarily. There are men who are always inspired by the challenge of
orthodontics and the biology of the stomatognathic system.
DR. GRABER There will be a trend away from solo practice and from orthodontic specialization
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due to economic considerations. The reduced number of applicants for orthodontics, the apparently
increased difficulty in filling a practice, tied to the recent recession with reduced income — all
indicate the "bloom is off the rose".
DR. GREWE I think there will be fewer postgraduate positions available in all the specialties in
1980.
DR. BRANDT In previous years, most candidates for orthodontic training were required to have
some experience in general practice. Should some general practice experience be prerequisite to
specializing?
DR. RIEDEL It would be desirable, but from a practical standpoint, the outstanding students will
find a place in a graduate program easily. Perhaps we should attempt to provide general practice
experience during predoctoral training.
DR. DOUGHERTY I don't think it is necessary. Our poorest performers are those who have been
in general practice longest or who have formulated preconceived ideas about orthodontics by
dabbling.
DR. GRABER Ideally, a couple of years of general practice before going into orthodontics would
be valuable. In practice, with the reduced demand for orthodontic training and with the competition,
I feel that proper predoctoral training should be able to qualify the orthodontic specialist fairly well,
without the additional practice requirement.
DR. GREWE Several factors must be considered: 1 ) Many of the students no longer go into
service, 2) the practice of orthodontics is not as appealing as it was, 3) there are other specialty
programs competing for the same candidates, 4) the total number of places available for orthodontic
education has increased in the last decade. Idealistically, it might be better to insist on some general
practice, but pragmatically it would be better to take students who are potentially good orthodontists
right from dental education programs.
DR. PERRY It seems impractical and unsound financially to ask a man to finance a general
practice for a few years, sell it, leave his home to return to the indebtedness of graduate education. It
is more fair to accept the man directly from dental school.
DR. BRANDT Is there justification for nonorthodontists to perform orthodontic treatment?
DR. DOUGHERTY No If they are to label the treatment orthodontic, then the patient should
expect competency.
DR. GRABER Yes, preventive and interceptive orthodontics are within their domain. Limited
procedures such as closing diastemas, correcting crossbites, uprighting teeth for restorative
bridgework, etc. are within the purview of the generalist. I do not feel the pedodontist has an
"inherent right" to handle comprehensive procedures because he joined with orthodontists in
learning growth and development. If nonorthodontists want to do comprehensive orthodontics, they
must have the same training. For this reason, we recommend a minimum of three years graduate
training to allow pedodontists to do just that. A course of this nature is offered at the University of
Chicago.
DR. GREWE Yes, there is justification for nonorthodontists to perform various phases of
orthodontic treatment. Example, it is disconcerting to see a child of ten or eleven with an anterior
crossbite that has been uncorrected; yet the child visits the dentist every six months. Certain types of
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orthodontic treatment are feasible, but not comprehensive treatment.

DR. PERRY Yes.
DR. RIEDEL Yes, to the level of an individual's ability to perform such treatment.
DR. BRANDT If orthodontic specialists could satisfy all orthodontic treatment needs, would that
not be a better service and more in the public interest?
DR. GREWE Yes, absolutely. As a matter of fact, a number of states have statutes in dental law
that indicate just that. This is by virtue of specialty licensure.
DR. PERRY Yes. If they could, if the patients so desired, if the general practitioner so referred. If,
if, if.
DR. RIEDEL I suppose so, but the additional question is, can they and will they?
DR. GRABER It is better to have the specialist satisfy all comprehensive orthodontic demands.
Problems arise in setting the guidelines for preventive, interceptive and comprehensive orthodontic
therapy. It is impossible and unwise to arrogate to ourselves all orthodontic considerations.
DR. BRANDT Would you favor revamping dental curricula to provide dentists with greater
expertise in what are now specialized areas? Would this be in order to increase delivery of
orthodontic services to more patients?
DR. PERRY Yes.
DR. RIEDEL Certainly dental curricula must be constantly revamped to provide the graduating
dentist with greater expertise in dentistry. The educational, social and economic levels of our
population are every bit as important in relation to the delivery of orthodontic services as a
development of expertise in orthodontics in our predoctoral students.
DR. DOUGHERTY Most specialties in dentistry are extensions of genera! practice and are taught
well depending on departmental strengths. General dentists are usually competent in operative,
restorative, minor surgical procedures, endodontics and periodontics. To make them experts in
orthodontics and oral surgery would add another five years to the curriculum.
DR. GRABER I would urge revamping the predoctoral training to permit better diagnosis of
orthodontic problems and simple orthodontic treatment. Greater emphasis should be placed upon
teamwork, with the orthodontist working closely with the pedodontist and generalist. If this is done,
it will emulate what is done in medicine effectively. Such steps are being taken right now, under the
aegis of the AAO and the ADA.
DR. GREWE Probably not. The best way of increasing the amount of service is to expand the
effective utilization of auxiliaries, with educated specialists and general dentists.
DR. BRANDT What does the term "Pediatric Dentistry" mean to each of you?
DR. RIEDEL The term means providing for all the dental needs of children.
DR. DOUGHERTY The general practice of dentistry for children.
DR. GRABER Dental procedures on children, but it is a leaky semantic umbrella.
DR. GREWE It is the 1960-70's term for childrens dentistry. It does not imply any special type of
dentistry or dentist, but does imply a specific patient age group.
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DR. PERRY Childrens' dental health care.
DR. BRANDT Can a dentist be completely competent in more than one specialty?
DR. DOUGHERTY Yes, intellectually; but not clinically, where changes in the total procedural,
schematic and philosophical gears must be made on a patient to patient basis.
DR. GRABER I definitely feel a dentist can be competent in more than one specialty. In medicine
there are men who are qualified and board eligible in more than one specialty. In dentistry, which is
more circumscribed and specialized in the beginning (actually only a specialty of medicine in some
countries), this is surely possible. When a specialty designation is sub-marginal, as I consider
pedodontics to be, I feel it is possible for the dentist to be qualified in both orthodontics and
pedodontics.
DR. GREWE It would be difficult, particularly if one specialty is not pursued. For example, would
you want your child to undergo neurosurgery by a physician who is both a pediatrician and surgeon,
but practices as a pediatrician 75% of the time? There are advantages to being board eligible in more
than one specialty to utilize the knowledge to improve patient care.
DR. PERRY I would think so.
DR. RIEDEL It depends upon the "scope" of that given specialty. If the term "pediatric dentistry"
means one who is competent to understand all the needs of a child patient, then I can see the
specialization of pediatric dentistry as possible. If one expects that specialized individual to provide
all the services for the child patient, then such specialization may not be possible.
DR. BRANDT What are the advantages of a combined orthodontic-pedodontic post-doctoral

training program?
DR. PERRY At this time, there is one area of advantage— academic.
DR. RIEDEL We must get away from the concept of training a specialist in the traditional sense in
orthodontics and pedodontics. Then, perhaps, we can identify advantages. The pediatric dentistry
program was developed with the objective of educating an individual competent to understand all
the needs of a child patient. That individual might function in education or research to direct
instruction for the handling of the child patient. Such an individual would have a broader view,
wider scope, a better background relative to the needs of children. Perhaps both orthodontics and
pedodontics have become too narrow in their concepts. The child is a whole person, growing and
developing with both physical and emotional problems and needs.
DR. DOUGHERTY I see no advantages. It just adds one or two years before being able to practice
orthodontics.
DR. GRABER There are several advantages. Those guiding the orthodontic-pedodontic programs
will be better qualified in both specialties; pedodontists doing orthodontics will have adequate
training; pedodontists' complaints they cannot take orthodontic courses will not be valid;
orthodontists will be less critical of such graduates, since they will have good training.
DR. GREWE Any graduate program has an objective to educate a student to perform specific tasks,
i.e. a program may be designed to produce orthodontic practitioners, orthodontic teachers, hospital
dentists, etc. The student oriented toward education would benefit from a combined
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orthodontic-pedodontic program. I don't think the individual who is going to do hospital dentistry or
orthodontics will benefit-from such a program.
DR. BRANDT Is the orthodontic-pedodontic program designed to produce teachers or clinicians?

DR. RIEDEL We expect to produce teachers with a research background.
We intend to require specific courses in instructional techniques and will emphasize those aspects of
orthodontics that apply primarily to the needs of children.
DR. DOUGHERTY The pedodontists hope to get teachers, but the students hope to become
orthodontic clinicians.
DR. GRABER Our orthodontic-pedodontic program is a pilot project, starting one student per year.
It is our stated objective to produce career teachers and researchers. Clinical training is complete,
but the major thrust is to train full-time cadres for our dental schools.
DR. GREWE The main purpose is to produce teachers for the undergraduate dental program.
DR. PERRY Our present efforts are directed toward producing teachers.
DR. BRANDT By making one specialty out of two, would the educational process that has
produced consistent advances be disrupted and cause a slowdown in progress?
DR. GRABER I do not believe we should make one specialty out of two. Quite the contrary. If this
were done, there is no question there would be a disruption in both specialties. We feel we
adequately train our students in the three-year combined program for both specialties.
DR. GREWE No. However, the public should know the skills and educational requirements of a
particular specialty.
DR. PERRY It could conceivably cause a slowdown.
DR. RIEDEL I cannot see that the production of a widely educated, broad-based individual would
be likely to produce a slowdown in progress. I would expect the greater educational opportunity
applied to a carefully selected few would likely increase progress.
DR. DOUGHERTY There would be no slowdown if the same high standards are utilized in student
selection.
DR. BRANDT What are the differences and similarities in the education of orthodontists and
pedodontists in growth and development, and cephalometrics?
DR. GREWE At the University of Maryland, the present programs in pedodontics and orthodontics
take basic courses in growth and development and cephalometrics together. These courses are more
theoretical than applied. The clinical application of these subjects is taught to orthodontic students
in more depth and separately from the pedodontic students.
DR. PERRY Again, this depends upon the particular program and its strengths and weaknesses.
DR. RIEDEL In the specific areas, the program differs from institution to institution. Course
materials may be similar, but utilization may be at different levels between orthodontists and
pedodontists. I know some orthodontists who never trace a headfilm and I know pedodontists who
do. So, I fail to see how it helps anyone to know the differences and similarities in the education of
the orthodontist and pedodontist in growth and development and cephalometrics; it may be
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important how such education is applied.

DR. DOUGHERTY The differences are in depth, application and performance. To read a book on
golf is a lot different than playing the game successfully and predictably.
DR. GRABER The education of the orthodontist and pedodontist in growth and development and
in cephalometrics differs from school to school. In general, I believe both specialties are equally
well grounded in growth and development. In cephalometrics there are various levels of
sophistication, particularly in diagnosis and clinical application. The level of sophistication required
by the orthodontist in cephalometrics is considerably more involved and above that required for
pedodontics. The level is identical for the combined pedodontist-orthodontist.
DR. BRANDT Would everyone agree that, at present, most pedodontists are not as well trained in
sophisticated mechanotherapy as the orthodontists?
DR. PERRY True, but I have also seen some poor work done by orthodontists.
DR. RIEDEL If one evaluated all the pedodontic and orthodontic programs in this country, I am
sure we would have general agreement that most pedodontists are not as well trained in
sophisticated mechanotherapy and should not be expected to be so trained .
DR. DOUGHERTY The statement is correct.
DR. GRABER It is obvious almost all pedodontists are not as well trained in orthodontic
mechanotherapy as orthodontists. There is a marked difference in the levels of training and
experience.
DR. GREWE I doubt the present practicing pedodontists as a group would ever attain the same
level of competence as the present practicing orthodontists. For future practitioners, it would take a
comparable education to produce comparable skills.
DR. BRANDT How are consumers to be protected from practitioners under-trained in orthodontics
who offer comprehensive orthodontic treatment that cannot be of the highest standard?
DR. DOUGHERTY By the courts.
DR. GRABER Public education is the answer for better patient understanding of the merits of
specialty service. Peer review is the essential professional prerequisite.
DR. GREWE We must teach the public the differences in orthodontic and pedodontic training. It
may have to happen through the courts. State licensing is a good method to prevent ill-trained and
unscrupulous pedodontists from doing comprehensive orthodontic treatment. West Virginia and
Oregon have such laws now.
DR. PERRY How are we protected now from shabby treatment by the generalist or orthodontist? In
the end, all concerned will be aware of malpractice implications of such practitioners.
DR. RIEDEL Some type of peer review should be instituted, and that type of program should be
started by orthodontists themselves. There are forms of peer review already. The American Board of
Orthodontics, Tweed Foundation, Angle Society all require presentation of case records. This type
of requirement should be more universal, on a regular periodic basis. We should retain as well
educational minimum requirements for belonging to our respective societies.
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DR. BRANDT Which field would you guess the orthodontist-pedodontist will concentrate on?
DR. GREWE If one contacted all who have completed formal graduate courses in pedodontics and
orthodontics in the United States, I would guess that over 90% would be practicing orthodontics
exclusively.
DR. PERRY Orthodontics.
DR. RIEDEL We seem to be looking at the pediatric dentist solely as a clinician and that's not the
intent of the pediatric dentistry program. The pediatric dentist would concentrate on teaching and
research and, if he decided to direct his efforts towards clinical activities, he would provide
comprehensive care for the child patient. What do most children need most frequently? Some
restorative dentistry? Treatment of malocclusions?
DR. DOUGHERTY He will do orthodontics unless he must do pedodontics to survive.
DR. GRABER Based upon past experience, economics, and practice and prestige factors, most
graduates would do orthodontics primarily.
DR. BRANDT Those who recommend a merger of orthodontics and pedodontics often mention
"overlap" of interest between the two fields. Are there not overlaps with other specialty areas? There
is a large amount of surgical-orthodontics being done. Why not merge with the oral surgeons?
DR. DOUGHERTY Why not? This is often a team effort.
DR. GRABER Our major concern, leading to the question of merger, is that so many pedodontists
are doing orthodontic procedures already, to the exclusion of the traditional pedodontic operations.
Many of these men are orthodontic specialists by their own designation. This does not have a
parallel as far as the question of a merger with oral surgery is concerned.
DR. GREWE There is as much rationale to merge with pedodontists as with oral surgeons. There
might be just as many reasons to merge with periodontists. However, I am convinced that the
profession and the public would suffer in terms of quality.
DR. PERRY This may be the next move. I have had several applications for orthodontic graduate
training from several well qualified oral surgeons in the past six years.
DR. RIEDEL I have never exactly recommended the merger of orthodontics and pedodontics. As to
overlap with other specialized areas, neither the oral surgeon nor the orthodontist in the average
setting would find it necessary or desirable to spend all his time in surgical-orthodontics. They have
many other interests and, while uniting to serve the patient as a team, it would seem that merger is
not the proper direction or term to use.
DR. BRANDT Would each of you comment on the recent action by the Oklahoma Board of
Governors of Registered Dentists (as reported in the Academy of General Dentistry Newsletter, May
1975) which said, in effect, pedodontists shall not treat major malocclusions, skeletal distocclusions,
skeletal mesiocclusions and major arch length discrepancy problems?
DR. GRABER I am in accord with the Board's action. This is the crux of our problem now. Too
many generalists and pedodontists are treating major malocclusions, with no peer review and with
inadequate training and experience. For the public it must be "caveat emptor".
DR. GREWE The public will no doubt be better served by this action.
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DR. RIEDEL To attempt to legislatively define major malocclusion is fraught with difficulty.
Furthermore, when one talks about treatment, the question is whether the removal of teeth is
considered treatment, or whether mechanotherapy is the only method of treatment. Define, if you
will, a major malocclusion. What is a handicapping malocclusion?
DR. DOUGHERTY I think the Oklahoma Board has become enlightened through the action of the
courts, liability insurance carriers and patient complaints.
DR. BRANDT Is it proper for a pedodontist to initiate serial extraction procedures?

DR. GREWE As a general rule, serial extraction procedures are best dealt with by individuals who
have the ultimate responsibility of the orthodontic care. The public and the profession should be
educated to this philosophy.
DR. PERRY The orthodontist who is expected to finish the patient should be in on the original
diagnosis for permanent tooth extraction.
DR. RIEDEL This is an area in which a great deal of further evaluation and study should be
performed. I do feel the initiation of a serial extraction procedure should be coordinated by the
individual who would eventually be responsible for its completion. A cooperative effort by the
pedodontist, generalist and/or the orthodontist would be a far better approach to the problem .
DR. DOUGHERTY No, the pedodontist should not initiate serial extraction procedures.
DR. GRABER I feel that all serial extraction decisions should be made in concert with the
orthodontist, and the orthodontist should be guiding the procedure, since he is the one to do the
active treatment.
DR. BRANDT It has been said, "The designation of pedodontics was one of the worst organized
blunders ever made. Pedodontics is the general practice of dentistry at a child age level." Is that
correct?
DR. PERRY This statement has been taken from context and I do not know the basis for it. There
are many competent, dedicated and qualified pedodontists whose existence refutes that quote. There
are also thousands of children who refute the remark. There are many university and hospital-based
pedodontic programs which bear witness to the folly of the statement.
DR. RIEDEL The question of whether pedodontics should have a specialty designation would be
dependent upon how much pedodontics is taught at the undergraduate level; then modest amounts of
additional specialized information might be left for a graduate or specialized designation. This
question relates to the overall philosophy of undergraduate dental education.
DR. DOUGHERTY I agree with the statement with reference to present practice .
DR. GRABER I am more or less in agreement with the comment. Pedodontics did serve a useful
purpose, but now has outlived its usefulness. Limitation of practice is one thing. Specialty status for
general practice on children is another. How about a new specialty, geriatric dentistry, also
delineated by a special age group with special problems?
DR. GREWE Perhaps it is correct.
DR. BRANDT Dental insurance is the "hottest" item in the insurance market, and national health
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insurance seems imminent. How do you think orthodontics and the individual orthodontist will be
affected by these programs?
DR. RIEDEL Comprehensive insurance plans will increase the demand for dental services. The
complications are those which will develop with the degree of control and possible interference
which insurance carriers bring to the patient-doctor relationship. Somebody still pays and, in dental
insurance, somebody has to pay for the establishment and administration of the insurance program
itself — the people who pay will be those indemnified and, likely, those who provide the service.
DR. GRABER Adult orthodontics will particularly benefit. It will ease the economic stringencies
for the future.
DR. GREWE No doubt there will be many more orthodontic patients in the future covered by
insurance. This will result in more paperwork, controls, external review of some form.
DR. PERRY We will be suffocated in an avalanche and blizzard of insurance forms and other
paper work.
DR. BRANDT Would you prefer governmental programs or those controlled by private enterprise?
DR. DOUGHERTY It makes little difference to the private practice of orthodontics. However, it
may affect income and conditions of practice. I doubt that private insurance would welcome the
intrusion of government into such a lucrative area for themselves .
DR. GRABER Private enterprise, emphatically. The patient will benefit servicewise and costwise.
Just look at the British system.
DR. GREWE Private enterprise.
DR. PERRY Private enterprise.
DR. RIEDEL There is no question in my mind that private enterprise system is more economical
and efficient.
DR. BRANDT Would you favor payment on a per capita basis or on a fee-for-service basis?
DR. GRABER I am not too sure, but the fee-for-service seems to be fairer to the patients.
DR. GREWE Fee-for-service, with appropriate peer review.
DR. PERRY Fee-for-service, I think orthodontists could have trouble on a capitation basis.
DR. DOUGHERTY Each has merit, but I favor fee-for-service as more equitable for patients and
orthodontists alike.
DR. BRANDT Will a socialized program be beneficial for patients and the orthodontist?
DR. GREWE In 1972, under the auspices of the World Health Organization, I traveled through a
number of European countries evaluating the interactions between orthodontic and dental
educational programs, the system of health care delivery, and actual care. Patients receiving
orthodontic care in the various countries varied from excellent to inferior and inadequate. The
orthodontists do relatively well. Practicing is difficult, restrictive. Taxes supporting the systems
were enormous. Having viewed other systems, I am convinced that private orthodontic practice in
the U.S.A. is the most efficient and provides the best care.
DR. PERRY It is not entirely beneficial to either. Perhaps it's more beneficial to the patient than to
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the orthodontist, when compared to today's system of private enterprise. My conclusion is based
upon first hand knowledge of several governmental schemes overseas. Quality will suffer and the
patient will pay for it in taxes.
DR. RIEDEL The only advantage to a socialized program is the potential to provide services to
some who might not otherwise be able to receive such service. Costs will be higher and more widely
assessed. Quality controls must be included and they will add to cost and decrease efficiency.
DR. DOUGHERTY Probably it will be beneficial to both. More people will be served who need
orthodontics and orthodontists will be busier.
DR. GRABER Only if mixed with liberal private practice. Socialized orthodontics alone is
mediocrity at its best.
DR. BRANDT Can you mention any country that has a socialized program of orthodontics that is
popular with the practitioners?
DR. DOUGHERTY At present there is no country which has socialized orthodontics. There exists
socialized tooth movement for a minimum fee with minimum results. I would hope that, if socialism
comes to orthodontics, the high standards will be allowed to prevail.
DR. GRABER None that I know of. Certainly not Great Britain or Sweden.
DR. GREWE There are some orthodontists in Great Britain who are satisfied with the system, and
some who are dissatisfied. It is interesting that the migration of orthodontists generally is from
countries with socialized health systems to countries with non-socialized systems.
DR. BRANDT Increased third party participation will probably mean increased numbers of
orthodontic patients. Will this mean reduced fees and a greater strain on productivity?
DR. PERRY Not necessarily. It depends on how competitive orthodontists become.
DR. RIEDEL Somebody has to pay, and it won't be the third party. The answer includes either
higher costs to the patient or reduced fees to the orthodontist. Who knows how productivity will be
affected?
DR. DOUGHERTY Many of these patients are being syphoned off at the GP and pedodontic level
at the present time. Since most plans require patient participation, I have noted that the fees charged
by the GP and pedodontist have increased over that of the orthodontist in the same community. I
doubt that reduced fees will come once the pseudospecialist gets out.
DR. GRABER There should be no problem with orthodontic productivity. With constant inflation,
fees are not likely to be reduced. Increased use of auxiliary personnel could change this picture,
however.
DR. GREWE I don't look for reduced fees or strains on productivity.
DR. BRANDT The ADA recently amended its code of ethics to delete two clauses relating to third
parties. It now cannot be considered unethical for a dentist to participate in a closed panel whose
names are advertised to the public. In light of this, do dentists need a union or guild? Or, do
orthodontists need a union or a guild?
DR. DOUGHERTY Hardly. We have the AAO through which we act. Let me say that the AAGP
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has a tighter "union" than does the ADA and it does promote its members in orthodontics.
DR. GRABER The orthodontist is a private businessman, very often a corporation. Do
manufacturers need a union? Lawyers? Setting their own working conditions, hours, fees, type of
service does not qualify for a union type organization. In my opinion, they would be giving up a lot.
DR. GREWE I don't think the orthodontists need a union. The AAO is a professional association
which serves orthodontists in many ways.
DR. PERRY No. Not yet.
DR. RIEDEL Unions and guilds have been tremendously helpful to the economic welfare of the
people whom they represent. Will society continue to recognize differences between crafts and
professions? The answer may depend upon the image that professionals provide to the public. If
orthodontics unionize, it will be viewed as a craft, not a profession.
DR. BRANDT What qualifications should be required for one to be selected to serve on a peer
review committee?
DR. GRABER I am a strong advocate of peer review. The qualifications of those who serve on this
committee is that they be Board certified, in less competitive status and, if possible, older men. At
least half the Board should be taken from schools and hospitals to provide the expertise that is
necessary to determine the candidates' ability and performance.
DR. GREWE A candidate should be a diplomate of the American Board of Orthodontics, member
of the ADA and AAO, and respected by his profession for both his skills and his honesty.
DR. PERRY The members of the Board should be selected and elected by their local
contemporaries and friends that have a sound basis for support.
DR. RIEDEL Peer review can best be organized and conducted by groups, not individuals. The
most qualified individuals should have identified their competence through course presentations,
lectures, demonstrations, Board certification, etc.
DR. DOUGHERTY Education, clinical experience, and selection by peers.
DR. BRANDT Could such a board be relied upon to operate without political overtones?
DR. GREWE Yes, I think so.
DR. PERRY It had better be or the men should resign. Their mettle should be such that moral and
professional obligation comes before political payoff.
DR. RIEDEL Politics are present everywhere, but in union there is strength. The sheer weight of
numbers should allow for a democratic process.
DR. DOUGHERTY It can be relied on, if not subverted by cronyism and favoritism .
DR. GRABER No board in medicine or dentistry is completely free of political overtones.
DR. BRANDT What suggestions would you make to insure fair and equitable operation of a peer
review board ?
DR. PERRY It's dentistry's responsibility to implement that care which is needed. Otherwise, Big
Brother will.
DR. RIEDEL Provide numbers of the highest qualified people to conduct peer review and provide
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those people first from the orthodontic profession, before third parties and consumers demand it.
DR. DOUGHERTY The selection of knowledgeable, educated, fair and equitable peers.
DR. GRABER Dentistry should appoint its own representatives. By having several organizations
contribute to the overall board, having schools rotate orthodontic department heads, extraneous
influences could be kept to a minimum. The names of the peer review board could be taken from a
list submitted by the entire membership of a particular area, then submitted to the membership for a
vote by written ballot.
DR. GREWE One rule that could be helpful would be to limit the terms of the board to several
years and then hold new elections.
DR. BRANDT How do you feel about the concept of school and hospital based dental programs?
DR. RIEDEL Dental delivery system improvement is not as simple as hospital and school based
projects suggest. Problems still exist relative to public awareness and stimulation of public demand.
Some answers to that lie in public education and motivation.
DR. DOUGHERTY These programs are fine. But, who will man the pumps? Nobody is against
motherhood, the flag, and welfare of children. It's great pie-in-the-sky. The question is, are we
willing to pay for it?
DR. GRABER School and hospital-based projects would be of advantage in the inner city and in
areas where economic status is low. This could provide the best possible dental care for young
Americans.
DR. GREWE I question that such projects will significantly improve the system. Public health
measures such as dental health education in elementary schools, water fluoridation, promoting
utilization of proven dental aids would be beneficial.
DR. PERRY I would have to see it in action and see its results to assess it objectively.
DR. BRANDT In these types of delivery systems, the auxiliary would play a more important role.
How much would you permit them to do in the oral cavity?
DR. DOUGHERTY The present hygienist, with a college education, is overeducated and
underused in her duties. I see her role as the true para-dental personnel who could take impressions,
remove archwires, select bands, clean teeth, supervise plaque control, educate in nutrition, take
cephalograms and make tracings.
DR. GRABER I am in favor of extensive work by auxiliaries in the oral cavity, providing there is
adequate training, an orthodontist is always present, and that peer review is operative.
DR. GREWE In some states, auxiliaries can now do almost any procedure that is reversible. They
cannot cut hard or soft tissue or activate archwires. This seems proper. Students and practitioners
must realize that they are responsible for the acts of an auxiliary.
DR. PERRY What is her training, competence, and who is overseeing her work?
DR. RIEDEL Dental auxiliaries should be permitted to operate within the boundaries of their
training and competencies for which they are certified.
DR. BRANDT Are you satisfied that these types of dental clinics would be more efficient, produce
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better dentistry, and elevate the dental profession?

DR. GRABER This type of clinic in a depressed area would likely be efficient, but not necessarily
produce better dentistry. Such service would be adequate, but not outstanding.
DR. GREWE No.
DR. PERRY Not for certain. It would be the individuals involved who would make or break it.
DR. RIEDEL No.
DR. DOUGHERTY Not in all situations.
DR. BRANDT When a new orthodontist opens a practice, the usual location is in a well-to-do
suburb, or in an affluent area in a city. If this is so, who will provide orthodontic services to the
underprivileged who reside in the poorer sections of town?
DR. GREWE Orthodontists will establish practices in low income areas as the demand for
orthodontic care increases in these sections.
DR. PERRY I believe third party support, group practice, supply and demand will level this
inequity in care availability. We'd better face it and not say that our generalist brothers or pedodontic
colleagues can handle those cases.
DR. RIEDEL University dental school clinics provide orthodontic treatment at a reduced fee for
those unable to afford customary fees. I am sure if an orthodontist does not provide service, then
others will attempt to do so.
DR. DOUGHERTY Who indeed will supply good nutrition, housing, education, etc.? We always
have those socio-economic arguments which come disguised in humanitarian intent by those who
say some treatment is better than none; as if half a filling, half an extraction, half a root canal filling
were better than nothing.
DR. GRABER A new orthodontist is thinking of income when deciding upon a location. With third
party payment he may now go to poorer sections of town and do well. The best opportunities for
recent graduates are in the inner city.
DR. BRANDT Would it be advisable to limit the scope of orthodontic courses taught to general
practitioners within specific parameters — minor tooth movement, jumping lingually locked
incisors, space maintainers, etc. ?
DR. PERRY This may be a logical start, but with increased sophistication and interest, the scope
will have to be broadened.
DR. RIEDEL Here we go again with the question of a course teaching things to do, moving teeth
here and there, etc. Concepts are the important thing.
DR. DOUGHERTY It has been tried.
DR. GRABER Ideally, it would be best to limit the scope to minor tooth movements. Practically, it
will not work. The alternative will be sequential courses, each more complex than the preceding
one. Complex orthodontics is being taught to periodontists, pedodontists, and generalists, outside
the specialty domain and there is no peer review. It is a matter of concern. Such courses should be
given in dental schools where proper accreditation exists.
DR. GREWE Yes and no. If there are orthodontists available geographically, yes. However, if
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patients have to travel extensively, the general practitioners should be encouraged to involve
themselves in various educational programs.
DR. BRANDT At what point should general practitioners and pedodontists be taught involved
multiband techniques?
DR. DOUGHERTY Upon graduation, when they can devote their total time and energy to the
discipline of orthodontics.
DR. GRABER Pedodontists and generalists should have the same training as the orthodontic
specialist. Nothing less is acceptable to protect patients. If it takes two years to train an orthodontist,
how can a self-designated dentist, with part-time effort, without comparable faculty, do the same?
Learning by short courses and apprenticeship is difficult.
DR. PERRY It must be available, or there will be more "quickie" courses outside the universities,
and outside the control of organized dentistry. It depends upon the interest, needs, and professional
conscience.
DR. BRANDT Should generalists be invited to all orthodontic courses, regardless of the
sophistication of the material taught?
DR. GRABER There should be sequential courses, starting with the simple and working up to the
complex. It is probably wise to expose the dentist to the real depths of orthodontic doctrine, to teach
him the justification of orthodontics as a specialty.
DR. GREWE If the applicant has the prerequisites, he should be accepted. In many instances,
admission is not handled by the department of orthodontics, but by the continuing education people,
which is not too good.
DR. PERRY Yes, we must now do this. Those in attendance, regardless of their level of
achievement, must recognize and know when not to treat, as well as how to treat.
DR. RIEDEL Certain orthodontic courses may require a prerequisite level of knowledge. If the
applicant qualifies, let him in.
DR. DOUGHERTY No. It is a waste of time for the teacher and the knowledgeable participant.
DR. BRANDT How is the public's interest better protected, by opening all courses to all dentists or
only to those qualified?
DR. GREWE Perhaps the best way to protect the public's interest is to keep orthodontists current,
productive, most efficient, and to utilize peer review.
DR. PERRY You have to change the law before you arbitrarily rule on that one.
DR. RIEDEL I don't know how the public's interest can be better protected. I doubt it has to do
with allowing certain people to take courses and others not to take courses. Peer review evaluating
the results of treatment procedures would be helpful. Another way is to include evaluation of
postgraduate courses. Dentistry seems to have a peculiar attitude. Once a dentist has graduated from
dental school, he no longer feels he should be evaluated. Some peer review must be instituted .
DR. DOUGHERTY Courses should be limited to those qualified. However, I see no public
protection in this, since the charlatan does what he pleases anyway .
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Article Text 19
DR. GRABER The question of protecting the public is time linked, circumstance linked, training
linked, and inclination linked. The public's best interest is served by rendering the best possible
orthodontic guidance to those who demand it. The orthodontic specialty can take care of the entire
demand for orthodontics in the United States. In a Utopian world, the public is best served by those
best qualified to render the service. There is less chance for damage when treatment is performed by
the qualified. This is the message to get across.
DR. BRANDT Orthodontics has built strong specialty programs in dental schools on the
post-doctoral level. Is it a valid criticism that it never really did the same at the predoctoral level?
DR. PERRY Dental schools would not give Angle the time needed for his curriculum. The
pendulum has swung and now the postdoctoral people are invited to use some of the time in the
predoctoral program that was spent carving teeth, doing prosthetic setups, etc.
DR. RIEDEL I suppose the criticism is valid. We have tried to do too much with too little time.
There are so many things to learn about dentistry. The predoctoral program should be increased
rather than decreased. The part orthodontics has to play in an undergraduate curriculum must stem
from agreement regarding the objectives for our graduating students.
DR. DOUGHERTY It is no criticism. It is an acknowledgement of the fact that orthodontics is a
totality as a discipline and quite foreign in concept to most undergraduate disciplines in dentistry.
Curriculum II at the University of California was a total undergraduate discipline in orthodontics
which existed for thirty years and was successful.
DR. GRABER Since orthodontics is, by its nature, one of the most justified of all dental specialties,
it is only right that it built a strong postgraduate program. The lack of emphasis on orthodontics at
the undergraduate level may be due to the reluctance of the traditionally strong prosthetic and
operative departments to give up enough hours to allow development of adequate orthodontic
indoctrination. Dentistry can blame itself for the inadequate orthodontic training the predoctoral
students get, just as much as for the primary postdoctoral emphasis that exists today.
DR. GREWE Yes, the criticism is valid.
DR. BRANDT Are the dental schools in the U.S.A. now devoting a larger percentage of their
program to teaching preventive and interceptive orthodontics?
DR. RIEDEL The emphasis at the University of Washington is toward increased sophistication and
development of diagnostic acumen. What do we really know about intercepting a malocclusion?
What is meant by intercepting a malocclusion? Can we truly perform the act of intercepting a
malocclusion?
DR. DOUGHERTY Some schools are bending to these pressures. Unfortunately, many programs
are not under the guidance of the orthodontic department.
DR. GRABER At the orthodontic teachers conference in Chicago in 1974, a resolution was passed
asking that a minimum of 100 hours of orthodontics be incorporated in all dental curricula.
DR. GREWE There is now a greater percentage of total clinical teaching programs devoted to
various forms of preventive and interceptive orthodontics. I believe this is a good direction to be
moving in.
687
Article Text 20
There has been a significant increase and this is proper. We do need a definition of
"preventive" and "interception".
DR. BRANDT What is taught in preventive and interceptive orthodontics?

DR. DOUGHERTY Some cephalometrics, serial extraction, habit prevention, space maintenance,
and some diagnosis and treatment planning.
DR. GRABER There are lectures on growth and development, etiology, diagnosis and treatment of
simple malocclusions. Laboratory courses in appliance fabrication are now part of the predoctoral
course.
DR. GREWE The materials presented in textbooks by Graber, Moyers, Hitchcock and Sassouni are
basically what is taught in orthodontics in the undergraduate curriculum.
DR. PERRY Space maintenance, simple crossbite corrections, tooth guidance. Honor students treat
some cases with appliances under the supervision of graduate faculty and graduate students.
DR. RIEDEL Serial extraction falls into this category, but what do we orthodontists really know
about serial extraction? We have so few documented records on the effects of serial extraction. How
then do we teach this kind of procedure at an undergraduate level? If we suggest a cautious
approach with specialist consultation, we are accused of talking down to the dental students.
DR. BRANDT Do dental colleges stress growth and development sufficiently?

DR. GRABER Some do. However, this subject has extensive coverage in orthodontic texts and is
probably covered better than any other facet of orthodontics.
DR. GREWE At present, the University of Maryland does not adequately cover growth and
development and the development of occlusion. The subject matter has to compete with other
subjects equally important in the dental curriculum.
DR. PERRY The students probably think these subjects are overtaught, but in reality it is
insufficient. However, there is increasing emphasis on these topics.
DR. RIEDEL In a curriculum with emphasis on doing something with one's hands, it is difficult to
identify the relevance of growth and development to the educational needs of the undergraduate
student. The attitude usually is, "Don't give me all that growth and development stuff. Show me how
to straighten teeth." This attitude prevails on the practitioner level as well.
DR. DOUGHERTY The subject is not taught to a good level of competence.
DR. BRANDT What changes would you recommend in dental school curricula that would affect
orthodontists?
DR. GREWE There are four suggestions: 1) Eliminate the three-year dental school programs, 2)
give serious consideration to lengthening the course to five years, coupled with a decrease in
enrollment, 3) involve students in clinical activities during all the dental school years, 4) continue
and implant in the curricula auxiliary utilization with expanded functions.
DR. PERRY More extensive first and second year courses in embryology, genetics, growth and
development. In the third and fourth years, lectures, laboratory and clinic for honor students, where
extensive orthodontic diagnosis and treatment procedures would be taught.
688
Article Text 21
DR. RIEDEL At the University of Washington, we have attempted to involve our dental students
with a continuing and comprehensive care for child patients. Students are assigned children in the
second year and provide dental care for the next two years, under the supervision of an instructor.
The objective is to develop diagnostic skills. If any procedure is too complicated, it is referred to
proper personnel. This program develops a good patient-student-instructor relationship. After the
student graduates, the instructor reassigns the patient.
DR. GRABER The greatest change would be a much greater number of hours devoted to
orthodontics. It would permit more coverage of etiology, diagnosis, selective clinical experience,
and more time for observing graduate orthodontic students and staff.
DR. BRANDT Are most faculties in touch with the realities of dental practice and the
socio-economic atmosphere?
DR. PERRY Yes, I believe they are.
DR. RIEDEL Most of the members of the faculty at the University of Washington do have an
involvement with part-time practice, usually in the area they teach. As a result of inter-faculty
contact, they are at least generally acquainted with the problems confronted in various fields of
dentistry. It is possible that the non-practicing faculty member may lead a more sheltered life
relative to the realities of dental practice. However, he may be able to spend his time gathering
educational information, where others spend time in private practice.
DR. DOUGHERTY I believe they are in touch.
DR. GRABER Most faculties have kept in touch with the realities of dental practice and
socio-economic concerns. Some schools have done a better job than others. My own feeling is that
dentistry has been living in the past, with a certain degree of protectionism, as evidenced by the
fight against denturism.
DR. GREWE Most faculties have been in touch with realities. However, I am not too sure that
universities and deans have.
DR. BRANDT How do you see the future of orthodontics in the United States— bright or dismal?
Would you encourage someone to study orthodontics today?
DR. GRABER Any projection is speculative. Much depends on our social and economic future.
From an economic return point of view, the future may not be as bright as the past thirty years have
been. From the point of view of service to the patient, with improved techniques and diagnostic
tools, more people will have better orthodontics than ever before. If I were to choose between
orthodontics and pedodontics-orthodontics, I would choose orthodontics. Almost everyone going
into either group will be doing orthodontics primarily in any event.
DR. GREWE The future is bright. I would encourage students into orthodontics. If they are
interested in dental education, I might encourage them to study, concurrently with orthodontics, oral
surgery, pedodontics, or periodontics, but only if they have the necessary interests and skills.
DR. PERRY Bright. If the dental graduate were interested in orthodontics, I'd encourage him to
pursue it.
DR. RIEDEL Malocclusion is probably the most prevalent dental problem in the American
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Article Text 22
population today. The need for orthodontic service is tremendous. To satisfy that need should be the
objective of orthodontists. In 1976, I would suggest a rewarding future will result from the study of
orthodontics. In 1980, however, I might opt for a different kind of discipline— pediatric dentistry
— or whatever comprehensive care for children will be called.
DR. DOUGHERTY I see the future as bright, prosperous, and stimulating from the academic,
research, and clinical points of view. I would encourage most able and seriously interested students
to pursue orthodontics and to take pedo-ortho if they have to, to accomplish their goal.
DR. BRANDT The objective of this discussion was to evaluate the future of orthodontics in areas
in which you gentlemen are expert. I believe that the thoughtfulness and frankness of your
discussion will provide useful insights in those areas. Let me express sincere appreciation and
thanks to each of you on behalf of our readers and the Editorial Board of JCO.
HARRY L. DOUGHERTY
Chairman, Orthodontic
Department, University of Southern California Graduate
Orthodontic Department. Dr. Dougherty is a Fellow, Institute of
Experimental Biology; Dentofacial Consultant, Children's
Hospital of Los Angeles, Orthopaedic Hospital, County Hospital
of Los Angeles; Member, OKU, Sigma Zi; Member, ADA, AAO,
Pacific Coast Society of Orthodontists; Fellow, American
College of Dentists, International College of Dentists;
Diplomate, American Board of Orthodontics.
T. M. GRABER
690
Footnotes 23
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume Sep
Department, University of Chicago. Internationally known
teacher, lecturer, author, and practitioner. Recipient of the AAO
Albert H. Ketcham Award, Distinguished Service Award.
Member, ADA, AAO, Angle Society, European Orthodontic
Society, International Association of Dental Research,
American Anthropology Association, OKU, Craniofacial Biology
Society; Diplomate, American Board of Orthodontics. The
textbooks authored and co-authored by Dr. Graber are widely
used by Students and practitioners .
JOHN M. GREWE
Department, University of Maryland. Dr. Grewe's career in
dentistry has included a variety of research and teaching
assignments, including travel abroad as a consultant for the
World Health Organization. He has published numerous
articles on a variety of subjects. Member, ADA, AAO, Academy
of Oral Pathology, International Association for Dental
Research, International Society for Craniofacial Biology,
American Society of Dentistry for Children, American
Association for the Advancement of Science, FDI, American
Cleft Palate Association.
691
Footnotes 24
HAROLD T. PERRY
Department, Northwestern University. An orthodontic
practitioner, teacher, lecturer and writer of numerous published
articles, Dr. Perry has been a faculty member of the
Orthodontic Department at Northwestern since 1954 and
Chairman of the department since 1964. He has lectured
extensively in many parts of the world. Member, ADA, AAO,
Angle Society. fellow, American College of Dentists,
International College of Dentists.
RICHARD A. RIEDEL
Department, University of Washington. Dr. Riedel is one of the
best known authors, researchers, teachers and lecturers in the
world. His full curriculum vitae is vast. Some of his
memberships are: ADA, AAO, Angle Society, Tweed
Foundation, International Association for Dental Research,
International Society of Craniofacial Biology; Fellow, American
College of Dentists; Diplomate and Director, American Board of
Orthodontics .
SIDNEY BRANDT
692
Footnotes 25
Sidney Brandt, DDS —

JCO Interviews Editor. Dr. Brandt is himself a teacher of
international reputation and an outstanding clinical
orthodontist. He has enriched the orthodontic literature in a
number of ways, not the least of which has been his searching
interviews with outstanding orthodontists, asking the questions
that you would ask if you were there. ED.
693
Footnotes 26
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Sep(692 - 697): The Bioplast Positioner
THE BIOPLAST POSITIONER

a new production method
CARL ERIK ANDERSEN, DDS
ELSE SCHRAMM, DDS
Some years ago machines for heatforming of thermoplastic material under pressure or vacuum
were developed for dental purposes. In 1969 an elastic material for use in these machines became
available under the trade name of Bioplast (ethyl-vinyl-acetate).This material possessed nearly all
the desired characteristics of a positioner material.
Construction
In the following text, step-by-step construction of a tooth positioner using the Biostar moulding
machine (Fig. 1) is described.
When orthodontic treatment has reached the stage where treatment with a positioner is indicated,
impressions and bite records are taken, if convenient with fixed appliances in place, and models are
poured. It is advisable to make study models at this stage for future reference, construction and
treatment evaluation. All orthodontic band contours in the plaster working model are carefully
removed, so that tooth surfaces and gingival margins are clearly defined.
The next step is to produce a set of models in which the plaster teeth are placed in wax, making it
possible in an easy way and by very little consumption of time for the orthodontist, to produce the
desired setup for the final construction of the positioner. Over the trimmed model a Bioplast plate is
moulded (2mm thickness and 4-5 atm. pressure) using the Biostar moulding machine. The mould
thus obtained (Fig. 2) serves for the production of the setup models. The Bioplast moulds are filled
with hard plaster to 6-8mm above the gingival border. When the plaster has set, the "dental arches"
are carefully removed from the moulds and the teeth to be moved are numbered. With a plaster saw,
cut between individual teeth to within 2-3mm of tooth contacts and break apart to prevent damage to
contact areas (Fig. 3). The root base areas are ground and furnished with "apical" retention grooves.
It is important that these "roots" be sufficiently narrow in the mesiodistal direction to allow easy
positioning during the setting up.
Those parts of the dental arches where the position of the teeth is to remain unchanged are
furnished with retention holes for the subsequent joining to base plaster (Fig. 4). Replace all teeth in
the mould. Melt sticky wax into apical grooves to increase retention of modelling wax, which is then
poured over the "roots" in a layer 3-4mm thick. The wax should stick to the mould in order to
prevent base plaster from penetrating to crowns. Before pouring base, another strip of sticky wax is
added to increase adhesion between wax and plaster (Fig. 5).
When the poured plaster base has set, the Bioplast mould is cut away with an "electric knife"
(Fig. 6). The models are ground flat on the basal surface and, with the aid of the bite record
692
Article Text 1
previously taken, mounted in a Galetti articulator (Fig. 7). The "setup" models are ready for
corrective positioning, i.e. the alignment of the plaster teeth into optimal occlusion. While forming
optimal occlusion, compare shape and size of arches with study models previously made. In order
not to create excessive tooth movements, mark original tooth position in relation to the base in
advance (Fig. 8). An electric oven (60-300° C) is suitable to soften wax evenly prior to performing
tooth movements. Use the electric knife to arrange one arch at a time and start with the mandibular
arch. When optimal occlusion is achieved, gingival borders should be contoured to reproduce
gingival volume of the study models.
As it is impossible to use these finished models with the teeth mounted in wax because the
moulding of the hot Bioplast would melt the wax, another set of working models has to be made for
the final procedures.
Finished setup models are saturated with water, alginate impressions taken, and working models
poured in stone. The stone models are coated with a release medium, such as Cold Mould Seal, and
a 3mm Bioplast sheet is moulded over each at 3-4 atm. pressure. The two halves of the positioner
are cut from their models with the electric knife 4-5mm above the gingival border (Fig. 9). Margins,
particularly the vestibular ones, are reduced in thickness with a vulcanite trimmer.
To establish proper seating of the positioner in the mouth, place steel stabilizing springs ( Fig. 10)
between maxillary premolar and molar. Additional stabilizing springs may be placed in the
mandibular arch when greater corrections have been made.
The springs are formed from 1mm hard steel wire (Fig. 11), heated and pushed through the
Bioplast plate into vertical holes drilled in the plaster mesial to the first molars. Note that the
vestibular arms are a little longer than the palatal ones.
Mount working models in an articulator (Fig. 12) with the bite locked opened 2mm beyond
freeway space.
The two positioner halves are placed on the articulated models and heated under the Biostar
heating element for 45-60 seconds (Fig. 13). The articulator is then immediately closed to the locked
position causing the two positioner halves to adhere. Four pins of about 2½mm diameter (for
example handpiece burs) are inserted between the two halves to create air vents (Fig. 16).
To provide the positioner with a smooth finish, a 1.5mm Bioplast plate is moulded over the
vestibular surface. Grinding the models, as shown in Fig. 16, prevents the thin plate from being
overstretched with subsequent local failure and incomplete adhesion. Simultaneous heating of base
and vestibular plates is performed with a special heating device (Fig. 1 and 14) (obtainable from
Danoterm-Electric, Naesbyvej 20, DK-2610 Rodovre, Denmark). To mould the vestibular plate, use
45 seconds of preheating and 5-6 atm. pressure.
Excess material is cut away with electric knife and edges reduced slightly at the mucogingival
693
Article Text 2
junction. Vents are drilled and smoothed by passing heated shaft of a drill from vestibular to lingual
side. The procedure will, in addition, close any gaps between base and vestibular plate. In second
molar area union is secured and edges smoothed with electric knife (Fig. 15). The completed
positioner is shown in Fig. 16.
Ideally, a more accurate mounting technique should be employed because of the large distance
between condylar axis and occlusal table of the Galetti articulator. Increased precision is achieved
with the following procedure. Facebow registration is performed and setup models are mounted in
an articulator of the Hanau type. After setup, the distance between arches is set to freeway space
+2mm and a bite registration is made with Optosil. With assistance of bite registration, models can
be mounted in Galetti articulator and positioner completed in manner described above.
Discussion
Production of a positioner is time-consuming. However, after having used the described

construction methods over a period of four years in more than 300 cases, the authors believe that its
advantages outweigh drawbacks of construction procedures.
The following disadvantages of the Bioplast material and method should be noted:
1. The relatively rigid material requires an exact fitting of the margins to avoid decubital ulcers.
2. The relatively high elasticity module of the material causes considerable pressure on teeth when
positioner is inserted.
3. The method requires care during union of parts, otherwise they may separate.
The advantages of Bioplast are:
1. It is transparent, and thus exact seating of positioner in the mouth can be observed. Motivation
and instruction of patient are simplified, since a direct demonstration shows how teeth should bite
into appliance.
2. It has sufficient rigidity to enable the positioner to be of small bulk but have good form stability.
3. Taste is less objectionable.
4. It is resistant to salivation effects.
5. It can be trimmed easily with a vulcanite bur.
6. Pressure moulding provides detailed tooth adaptation.
Bioplast
Portions of this article are printed with permission of the

Danish Dental Journal.
Biostar
694
Footnotes 3

Mould Seal

Optosil

FIGURES
Fig. 1
Fig.1 Biostar moulding machine with auxiliary heating element.
695
Figures 4
Fig. 2
Fig. 2 Duplicating mould for preparation of setup model.
Fig. 3
Fig. 3 Sawing the individual teeth free.
696
Figures 5
Fig. 4
Fig. 4 Teeth in position in duplicating mould. Note retention grooves for sticky wax and retention holes for plaster in
anterior segment.
Fig. 5
Fig. 5 Three layers of wax— sticky wax, modelling wax, sticky wax— shown on an upper arch in which all teeth have
been separated.
697
Figures 6
Fig. 6
Fig. 6 Electric knife.
Fig. 7
Fig. 7 Setup models in Galetti articulator.
698
Figures 7
Fig. 8
Fig. 8 Before teeth are set in desired position, original position is marked on base of model.
Fig. 9
Fig. 9 Cutting free upper half of positioner with electric knife.
699
Figures 8
Fig. 10
Fig. 10 Stabilizing springs.
Fig. 11
Fig. 11 Stabilizing springs installed in upper model. Note vestibular arms are a little longer than palatal ones.
700
Figures 9
Fig. 12
Fig. 12 Working models mounted in articulator.
Fig. 13
Fig. 13 Positioner halves being heated before union.
701
Figures 10
Fig. 14
Fig. 14 Simultaneous heating of front and base plates.
Fig. 15
Fig. 15 Union is strengthened in second molar region.
702
Figures 11
Fig. 16
Fig. 16 Completed appliance in position on ground working models. Note air vents.
703
Figures 12
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Oct(713 -): 714 THE EDITOR'S CORNER
the editor's corner

The economic threat to the survival of private orthodontic practice should not be allowed to
obscure the fact that our greatest jeopardy may lie in a takeover of the specialty by third parties,
private and government. There is a very real threat that orthodontists, faced with a decreasing
demand for their services, may feel unable to increase fees to accommodate to increased costs and
inflation, and willing to take a decrease in their living standard; and that they may increasingly be
willing to surrender control of both their professional prerogatives and fee structure to third parties
who may gain control of a major portion of the patient source.
Third parties add a cost factor of administration and profit to orthodontic fees. Inevitably, they
must control costs and control the orthodontist if they are going to succeed as a profit or non-profit
organization. There are many ways they can accomplish this end, but two easy ones to visualize are
for them to sell coverages which include participating dentists and fixed fees or coverages which
pay for a percentage of the orthodontist's fee. With either method, they wind up in control of us.
Either because the diminishing number of new patients makes us timid and/or because the third
parties become involved with a major number of our patients, the third party will be able to adjust
the fixed fee schedule or call to question and control fees of which they pay a percentage.
The individual practicing orthodontist cannot stand up against the insurance company or union or
government. It may begin with orthodontists willingly accepting lower fees to fill their free time. In
the end, third parties can destroy both the fee structure and the professionalism, taking over the
decisions about what treatment is done, when it is done, by whom it is done, for how long it is done,
and at what fee it is done. Given the economic conditions we face, we cannot surrender control of
fees, because it is one of the very few controls we have over our economic destiny and survival.
After all, what are the alternatives in a declining economy? You can raise fees, lower costs, practice
build to try to find new patients, or accept a lower standard of living. It is true that third parties have
the potential to increase the number of patients under orthodontic care. However, the number that is
reasonably possible through these programs may not be so great that we could hold our economic
ground if fees were held at their present level or reduced. In addition, third party commercial
insurance programs tend to encourage an increase in the number of cases treated by
non-orthodontists.
So, we have the prospect of vulnerability of orthodontists by reason of declining income potential
and the aggressive growth of third party programs. If this is a major hazard, it would be wise to
consider what orthodontists ought to be doing, while there yet may be time, to change the premise
on which this forecast is based, namely that we have an adversary position with the individual
orthodontist on one side and the large insurance company, the larger insurance industry, the
potentially much larger government agency programs on the other.
An agency is needed to stand between the individual practitioner and the third parties. It would be
the purpose of this intermediary to establish principles and guidelines for third party programs
713
Article Text 1
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Oct(713 -): 714 THE EDITOR'S CORNER
which would preserve the high quality of orthodontic care and protect the interests of the consumer
and the practitioner in matters that relate to the professional aspects of the third party programs; and
act as fiscal intermediary so that there is no financial relationship directly between the third party
and the individual practitioner; as well as to promote increased utilization of orthodontic service.
A separate agency is needed to stand in the middle among the consumer, the third party and the
orthodontist to monitor performance and quality, including a peer review mechanism.
These agencies will only find credibility and acceptance if they are not under the complete
control of the specialty, but have a shared input and control from a cross section of those whose
concern is the delivery of high quality orthodontic treatment. It should be the initiative of the State
orthodontic societies to create these two agencies on a State basis. It would be wise to establish a
national agency to coordinate the efforts of the State orthodontic societies, and to maintain liaison
among them.
714
Article Text 2
OCTOBER 1976, VOL. 10 / ISSUE 10

The Modular Self-Locking Appliance System Part 2: A Variation in the
Combination Technique
728
Round Table Discussion Third Party Programs 744
The Twenty-Minute Strapup 764
Technique Clinic: A Direct Bond Stabilizing Splint 769
Third Party Interference in Orthodontic Practice 770
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Oct(728 - 741): The Modular Self-Locking Appliance System Part 2: A Variation in the Combinatio
THE MODULAR SELF-LOCKING

APPLIANCE SYSTEM
Part 2
JACK M. MAGILL, DDS
To review, the Modular Self-Locking Appliance System features a receptacle with three vertical
slots to receive the unique insert brackets into which the archwires are snapped with finger pressure
(Fig. 16).
We shall describe the practical application of these modular components by discussing one of the
most demanding and challenging treatment procedures— the Class II Division 1 bimaxillary
protrusion. The typical clinical picture— procumbent incisors and arch length deficiencies due to
excessive tooth material, together with poor facial balance as a result of unfavorable skeletal and
soft tissue qualities and deep overbite characteristics— demands the most careful attention for
anchorage preservation and establishment of proper incisor positions. Although finishing problems
are relatively routine, correcting axial positions of maxillary incisors (lingual root torque) and
uprighting cuspids and bicuspids calls for the utmost in disciplined treatment. Mastering of
malocclusions in this class enables the operator to deal more easily with less difficult situations. To
expedite treatment, a series of three stages has been arranged.
STAGE 1 (TIPPING)
While the insert bracket can be placed in any of three positions in the first stage of light wire
treatment, positions of choice are the mesial slot of the receptacle on the upper and lower four
incisors and in the distal slot on the upper and lower cuspids (Fig. 17). Centering the insert bracket
in the first stage requires removing it to place the inserts in the mesial and distal slots for the next
stage. This is time-consuming and we try to avoid such repetition. Also, with the insert bracket in
the mesial position, there appears to be less unfavorable rotation of upper and lower incisors during
early treatment stages; and definitely less distolingual rotation on cuspids when the insert bracket is
placed in their distal slot.
Of course, exceptions may be made for specific tooth malpositions and the initial insert brackets
can be placed wherever they will be most effective. Where tooth malpositions are not too severe, it
is strongly recommended that double insert brackets be considered from the start of the first stage .
Special Consideration
728
Article Text 1
When the malocclusion is characterized by a deep overbite, the first stage usually includes the
incisal coverage bite plate (Fig. 18).
This bite plate is exceedingly effective in initiating bite opening, which is mandatory in order to
achieve our treatment goals expeditiously. It is inserted before anterior band placement and it,
1. accomplishes a preliminary bite opening,
2. eliminates occlusal interference and helps avoid anchorage loss,
3. prevents bracket shearing, band destruction, or bonding failure on lower incisors and cuspids, and
4. provides an opportunity for repositioning the mandible, when the tendency for this phenomenon
exists.
In unyielding and stubborn steep overbite cases, where bite opening presents a problem, light
round archwires with strong molar tip-back bends may be used in conjunction with the bite plate to
assist in this correction. Of course, elastics are not used at this time, nor are the appliances activated
for any tooth movement other than intrusion of incisor teeth together with extrusion of teeth in the
buccal segments.
Placing Bands and Archwires
When preliminary bite opening has been established sufficiently, banding and placement of
archwires constitutes the first stage of treatment.
It is advisable to place the initial self-locking insert brackets into the slotted receptacles prior to
band cementation (but not prior to bonding). This is a simple, time-saving step. As soon as the
cement or bond has set, archwires can be snap-locked in less than one minute for each archwire, and
treatment is started immediately, using Class II mechanics.
We call attention to the wide receptacles on both anterior and posterior teeth. This extra width
certainly furnishes a greater purchase for correction of rotated and tipped teeth. Although the wide
receptacles decrease interbracket width, which should diminish the flexibility and activity of the
archwire, this is not the case with the pivotal free-sliding snap-in technique, as compared to the
horizontal binding slot with the tightly ligated archwire. The archwire is freely engaged in the insert
bracket chamber, creating a one-point pivotal contact between wire and bracket. Since it is virtually
impossible to attain a completely non binding wire-bracket relation, realistically we think in terms of
reduced or low frictional wire-bracket activity. Tooth movement occurs gently, rapidly, and easily.
Almost any tooth malposition can be accommodated by the self-locking bracket. However, there
are severe cases where a single tooth must be ligated temporarily until the wire can be locked into
the insert chamber.
Uncrowding through action of vertical loops (Fig. 19) flows easily and quickly. As soon as
possible, we discard the multiple-loop archwire for a plain two-looped archwire (Fig. 20), while
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continuing Class II mechanics until a Class 1 molar and cuspid relation is achieved. The two-looped
archwires can be preformed and easily adjusted for cuspid-to-cuspid contact, to avoid recrowding.
The loops can also continue to move the cuspids distally, if necessary.
In critical anchorage cases, the reality of limited space provided by the extraction of four
premolars, and the need to locate mandibular incisors ideally in harmony with their basal supporting
bone and facial framework, require reliable avenues for incisor retraction, which minimize loss of
posterior anchorage. In this technique, anchorage considerations are routine via anchor bends mesial
to molars, with strategically placed resistance springs.
Class 111 Mechanics
It may be recalled that the remarkable facial changes attained by Tweed and others were achieved
through the use of Class 111 mechanics with the establishment of ideal mandibular incisor position.
We, too, found marked improvement in facial profile following preparation of mandibular
anchorage with Class 111 elastics and, in the treatment of Class 111 cases by means of the light wire
technique, we observed that mandibular incisors moved backward easily and quickly, with less
undesirable lingualization, so that mandibular protrusions were rapidly eliminated.
It followed that a similar strategy could be employed to retract mandibular incisors in critical
anchorage cases requiring the use of the entire extraction space. We employ the maxillary posterior
teeth as our anchorage unit for light elastic forces, while leaving the mandibular posterior teeth free
from extraneous pressures which influence their mesial migration into the premolar extraction
space. Further stability of the maxillary molar teeth is assured by placing a transverse palatal bar
from upper molar to upper molar, together with cervical headgear.
The rationale for Class 111 mechanics includes:

1. Improved movement of lower incisors over basal bone.
2. Avoiding stress on lower molars and preventing excessive forward movement into extraction
space.
3. Less lingualization of lower incisors than with the use of lower horizontal elastics.
4. Compensation for tipping of occlusal plane caused by Class II mechanics. We, and others, have
observed the tipped occlusal plane returning to its original position after Class 111 mechanics.
5. It is often desirable to overcorrect lingual positions of lower incisors, to compensate for the
forward movement of the lower dentition as a result of leveling and uprighting.
Transpalatal Bar
The transpalatal bar is a maxillary resistance unit which is made of a single .036 semi-soft round
wire, which fits into lingual .036 horizontal tubes on the maxillary molars. The appliance is bent
back behind the tubes, cinching slightly, creating a fixed/removable resistance appliance (Fig. 21).
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This appliance can be made in the mouth quickly and easily.
With this additional anchorage reinforcement providing bracing support to resist forward
movement in the upper arch during Class 111 mechanics, we can use intramaxillary elastics in the
upper arch in addition to the intermaxillary elastics. In this manner, maxillary incisors move
lingually and distally at the same time as the mandibular teeth are being retracted. This strategy
proves most rewarding in the attainment of optimum incisor position and subsequent improved
facial esthetics.
Another interesting and added benefit of the palatal bar appliance is its contribution to resistance
to forward and lateral displacement of molars during torquing, because torquing incisors encourages
expansion and forward movement of molars. We have found it beneficial to keep the palatal bar in
place until the end of treatment. It assists in maintaining a Class 1 molar relationship and, in
addition, it prevents unwanted movements and rotations of upper molars as a result of elastic and
spring traction.
So, the classical setup during Class III mechanics is plain .016 upper and lower archwires, a
palatal bar, cervical headgear, upper horizontal elastics and Class III elastics (Fig. 22).
Anchorage loss during Class II or Class III mechanics occurs not only because of lack of bracing
support for molars, but also because of cuspal interferences, especially upper and lower cuspids. It is
of utmost importance to watch cuspid relationships constantly, keeping upper cuspids moving in a
position distal to lower cuspids by activating the vertical loops to exert constant distal pressure.
We must watch for all oral habits and tooth interferences which may retard the simultaneous
movement of both upper and lower anterior segments lingually.
End of First Stage
The first stage of treatment generally brings about a compelling biologic response in which
reduction of protrusion, bite opening, uncrowding, and correction of jaw relationships take place
simultaneously and without excessive tipping. Excessive tipping is to be avoided because it
significantly extends treatment time and may cause root resorption. Adequate, but not overly
exaggerated tipping is permitted, because the insert bracket and archwire chamber are slightly
higher than the wings of the receptacle. When basic tooth positions have been achieved at the end of
Class III mechanics (Fig. 23), we are ready for leveling (Stage II).
STAGE II (LEVELING)
The objectives of the second stage are:

1. Leveling (alignment).
2. Preliminary uprighting of cuspids and bicuspids.
3. Correction of rotations and labiolingual malpositions.
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4. Continued bite opening.

5. Improved arch relations.
6. Improved arch form.
7. Closure of all remaining extraction spaces .
The second stage of treatment sets forth the modular aspect of the Modified Combination
Technique in the conversion to a double bracket insert. The second bracket insert is placed in the
unoccupied mesial or distal vertical slot of the receptacle, opposite to the insert bracket used in the
first stage, creating a double bracket (Fig. 24). These bracket inserts are widely spaced for more
effective tooth movement during the leveling and finishing stages. It becomes quite obvious that, by
placing another insert bracket at the other extremity of the receptacle, the twin inserts offer a
synergistic action with one effort complementing another. This arrangement is precisely what we
have in mind with the Modified Combination Technique, where two or more low frictional
components are used to blend for the production of physiologic tooth movement.
The upper and lower second bicuspids are banded at this time, using mesial and distal bracket
inserts. With severely irregular tooth positions, an .012 or .014 highly tempered round steel archwire
can be used to start the task of tooth alignment and changed to an .016 archwire after a few visits.
During this stage, the ease and rapidity with which the combination leveling and space closing
appliances can be inserted is most satisfying. Simple finger pressure will click the archwire into the
insert brackets in a minute or less (Fig. 25). For difficult tooth malpositions, an ordinary wire
director is helpful in plugging the archwire into the insert slot (Fig. 26). Following archwire
insertion, the insert beaks are gently closed with a How plier (Fig. 27).
During the leveling process, as a result of the floating and relatively frictionless arrangement of
wire and bracket, the high degree of biologic performance causes the teeth to flow into proper
positions. It appears that axial inclinations and rotations are corrected effortlessly. Because of the
lessened friction and increased freedom of movement, the teeth exhibit a "settle in as you go"
response. With the pivotal low friction bracket attachment, it is apparent that cuspal inclined plane
surface contacts, and other forces of occlusion, play a major role in effecting tooth alignment, even
while round wire appliances are in place. Once tooth movement is initiated and gently guided,
natural biomechanical forces, free from all restrictions, produce spectacular and positive physiologic
reactions; molding the dental arches into more favorable positions.
Leveling and Space-Closing Appliance
This appliance is made of .014 or .016 wire, having a space-closing helical loop (Fig. 28). This
imparts flexibility to engage tipped teeth, and begins uprighting teeth adjacent to the extraction
spaces. All conventional adjustments can be incorporated into this appliance. Once snapped and
locked into position, it will translate most gentle forces to the teeth, arranging the dentition
according to plan.
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While the use of auxiliaries is not a regular procedure, in individual instances they should be
applied. Placement of an uprighting spring or rotation auxiliary is amazingly simple (Fig. 29). There
is no need to disengage the archwire. The auxiliary spring works with complete appliance control.
An important molar control feature is the lasso tie to inhibit molar rotations during space closure
(Fig. 30).
A cardinal requirement of this technique is to permit the archwires to function for long periods
without interference or unnecessary adjustments. It is definitely a mistake to change archwires too
frequently. A good high grade, fully tempered steel wire is recommended.
When Stage II is completed, the accomplishments should include a generalized alignment of all
teeth, with rotations and overbite corrected, and all anterior and extraction spaces closed (Fig. 31).
The teeth adjacent to the extraction sites should demonstrate improved axial positions, with final
movements taking place during the next stage.
STAGE III (FINISHING)
This final step in treatment deals with correction of axial inclinations of anterior and posterior
teeth, with special emphasis on lingual root torque and labial crown torque of maxillary incisors.
Closure of small spaces, maintenance of overbite correction, and ideal arch form are vital functions
of this stage.
Final movements occur by means of an .016 or .018 dual helical spring archwire (Fig. 32), which
has proven to be exceedingly effective for uprighting and aligning teeth. These archwires, plus a
superimposed torquing appliance (Fig. 33), impart a gentle though positive action to complete
correction of axial inclinations of cuspids and bicuspids in the extraction area, as well as satisfactory
axial inclinations of upper incisor teeth. Molars are uprighted, satisfactory arch form is achieved,
overbite correction is continued, and remaining spaces are closed (Fig. 34). This final appliance
embodies the ideal modifications which have always been routine requirements such as: upper
lateral incisor and molar offsets, ideal arch form, gable bends and molar tipback adjustments.
It is imperative that cuspids and bicuspids be tied together to prevent reopening of extraction
spaces. Very fine ligature wire (.006) can be snapped into the cuspid and bicuspid insert brackets
and tied.
The Role of Bracket Modularity in Incisor Torquing
The simplicity of initiating the upper incisor torquing process highlights the modular aspect of the
Modified Combination Technique. When the double helix finishing appliance has been in place for
about 6 to 8 weeks, and the remaining small spaces are closed, the torquing procedure may begin.
Insert brackets are placed in the center slots of the upper central and lateral incisor receptacles.
The .016 torquing auxiliary is snapped into place in these added inserts, without disturbing the
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existing finishing appliance which serves as a base wire. The torquing wire lies alongside the
finishing appliance and both wires enter the oval buccal tubes (Fig. 35).
While the torquing appliance effectively and freely moves the upper incisor roots palatally, the
transpalatal bar is maintained to prevent expansion of buccal segments and to resist forward
movement. Torquing of incisors and uprighting the buccal segments can be achieved at the same
time.
Light Class II elastics are continued. Up and down elastics are worn for a relatively short period
of 6 to 8 weeks prior to appliance removal to help integrate the buccal segments and improve
intercuspation (Fig. 36). These elastics also assist in uprighting cuspids and bicuspids in extraction
cases. In open bite cases the upper and lower incisors react very favorably to anterior box elastics
(Fig. 37).
The horizontal slot still enables one to ligate archwires, if desired (Fig. 38).
SUMMARY OF THE MODIFIED
COMBINATION TECHNIQUE
FEATURES
• No special skills required to insert archwires.
• No special ties.
• Reduced number of chairside assistants needed.
• Lessened chair time.
• Minimal unwanted tooth movements.
• Easy, rapid, uncomplicated torque for incisor teeth.
• No unpredictable reactions to
torque.
• Low frictional relation between wire and bracket chamber makes elastic cord more applicable for
rotations, uprighting, and space closing. This procedure is simplified because no wire
disengagement is necessary and teeth flow along wire into correct positions.
• Fewer archwire changes.
• Treatment time moderately reduced.
• A lesser number of auxiliary springs in the third stage of treatment.
• Smaller gauge wires and larger archwire chamber permit greater flexibility and increased biologic
response, via natural forces of occlusion.
• Archwires designed and tempered for long range of action, making frequent visits unnecessary.
• No heavy base wires required for special tooth movements.
• The modularity of the system enables the operator to "plug into treatment".
• The self-locking system is a natural for bonding, because of less pressure and tension on bonded
attachment. Plastic brackets are more compatible with self-locking inserts, since ligature stresses are
eliminated.
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Article Text 7
Conclusions
A free flowing, low frictional appliance system delivers a high degree of controlled biologic
performance. Our system uniquely combines techniques which we already know with modifications
designed to simplify and uncomplicate many time-consuming procedures. It is because we are
concerned with rendering quality orthodontic care with increased accessibility to treatment for more
patients at moderate costs, that we have steadily attempted to modify, simplify, and improve
procedures.
Further progress is steadily being made. For example the Low Profile Receptacle has recently
been created to offer less bulk in height and width (Fig. 39). The horizontal slot and tie wings have
been completely eliminated. When bonding, this slim attachment has positive benefits with regard to
space requirements and interferences with anterior bite relationships.
A significant factor in the development of the Modified Combination Technique was a need that
we identified in our practice to attract and be able to treat larger numbers of patients at somewhat
lower fees. Our practice, located in a typical inner city of a large metropolitan area began to
experience a decline in new patients, which has become typical of these locations in which the
population has largely changed to one which includes large numbers of indigent people who have a
need for orthodontic treatment, but an inability to afford normal fees and with little or no third party
support for orthodontics. It occurred to US that if we wanted to stay in our long-standing location
and continue to deliver high quality orthodontic care, we were going to have to develop treatment
procedures which would enable us to maintain our high standards for treatment and to reduce fees at
the same time, to enable larger numbers of these patients to afford our treatment. Actually the fee
reductions are on the order of about 25-30% below an average fee, but low enough to enable us to
conduct a very busy, professionally and financially rewarding practice. We feel that the Modular
Self-Locking Appliance in the Modified Combination Technique has made this possible.
In succeeding installments, we will demonstrate the system on a variety of cases.
ACKNOWLEDGEMENTS
Grateful appreciation is extended to Miss Fredricka Sattinger for her artistic drawings of the various
attachments; to Mr. Morton Savar and Mr. Harry Reiser for their technical contributions in
photography; to Miss Ethel Lobell for her typing and editing. We thank Mr. Bay Brunson of Rocky
Mountain/Orthodontics for his help in developing the various attachments.
FIGURES
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Article Text 8
Fig. 16
Fig. 16 The modularity and mechanics of the single and twin insert brackets demonstrate the versatility and simplicity of
the Self-Locking System.
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Figures 9
Fig. 17
Fig. 17 Receptacles on upper centrals and all cuspids are wide; on upper laterals and lower incisors— narrow or
medium. Recommended placement of insert brackets in first stage is shown.
737
Figures 10
Fig. 18
Fig. 18 Incisal coverage bite plate for initial bite opening avoids shearing of brackets, tearing of bands, and occlusal
interferences .
738
Figures 11
Fig. 19
Fig. 19 Multilooped first stage archwires to uncrowd and align teeth.
Fig. 20
Fig. 20 Change to plain 2-looped archwires as soon as possible.
739
Figures 12
Fig. 21
Fig. 21 Transpalatal bar appliance.
Fig. 22
Fig. 22 Class III and horizontal elastics are worn until lower incisors are in desired positions.
740
Figures 13
Fig. 23
Fig. 23 End of first stage of treatment.
Fig. 24
Fig. 24 Second stage. Attachments in anterior and posterior segments are prepared for leveling and uprighting by
placing additional insert brackets in opposite vertical slots.
741
Figures 14
Fig. 25
Fig. 25 In most cases, the archwire clicks into the insert bracket with simple finger pressure.
Fig. 26
Fig. 26 A wire director may be used to assist Insertion of archwire.
742
Figures 15
Fig. 27
Fig. 27 Careful gentle closure with a How plier encloses archwire, but does not bind it in the chamber.
743
Figures 16
Fig. 28
Fig. 28 Leveling and space-closing archwire (.014 or .016); modifications for bite opening and uprighting are built in.
744
Figures 17
Fig. 29
Fig. 29 Auxiliary springs for uprighting and rotating may be applied while main archwire is fully engaged in the insert
brackets .
Fig. 30
Fig. 30 Lasso tie to maintain molar positions throughout treatment.
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Figures 18
Fig. 31
Fig. 31 End of second stage of treatment.
Fig. 32
Fig. 32 Dual helical spring finishing archwire .
746
Figures 19
Fig. 33
Fig. 33 Torquing appliance for central incisors.
Fig. 34
Fig. 34 Toward the end of the third stage of treatment.
747
Figures 20
Fig. 35
Fig. 35 Torquing wire lies alongside the dual helical finishing archwire and both wires enter oval buccal tubes.
Fig. 36
Fig. 36 Up and down posterior elastics to improve posterior intercuspation.
Fig. 37
Fig. 37 Anterior box elastic frequent/y used in open bite cases.
748
Figures 21
Fig. 38
Fig. 38 Optional use of receptacle as a regular edgewise bracket.
Fig. 39
Fig. 39 Low profile receptacle.
References
1. Fogel, M.S., and Magill, J.M.: The Combination Technique, Am. J. Orthodontics 49:801-825, 1963.
749
References 22
2. Tweed, Charles H.: The Application of the Principles of the Edgewise Arch in the Treatment of Malocclusions. Parts
I and II, Angle Orthodontist 11:5-11, 12-67, 1941.
3. Tweed, C.H.: Frankfort-Mandibular Plane Angle in Orthodontic Diagnosis, Classification, Treatment Planning and
Prognosis, Am. J. Orthodontics and Oral Surg. 32: 175-221, 1946.
4. Begg, P.R.: Differential Force in Orthodontic Treatment, Am. J. Orthodontics 42-481-510, 1956.
5. Begg, P.R.: Light Archwire Technique, Am. J. Orthodontics 47:30-48, 1961.
6. Margolis, H.I.: Axial Inclination of Mandibular Incisors, Am. J. Orthodontics and Oral Surg. 28:571-594, 1943.
7. Holdaway, Reed A.: Changes in Relationship of points A and B During Orthodontic Treatment, Am. J. Orthodontics
42: 176-193, 1956.
8. Williams, Raleigh: The Diagnostic Line, Am. J. Orthodontics 55: 458-476, 1969.
9. Brandt, S.: Personal conversation:
10. Garcia, F. G.: Oval Tubes for First Molar Anchorage, J. Clin. Ortho., Vol. Vl #5, 1972.
750
References 23
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Oct(744 - 763): Round Table Discussion Third Party Programs
round table
THIRD PARTY PROGRAMS
Dr. David C. Hamilton
Dr. B. Holly Broadbent
Dr. Don E. Lahrman
Dr. Eric Luks
JCO It is important for orthodontists to understand third party programs and to develop principles,
guidelines and procedures for dealing with them, because precedents that are set in these programs
now are likely to be the guiding influence in how programs will be set up in the future. The Great
Lakes Society of Orthodontists has recognized this need and has developed the best Prepayment
Manual on Group Funded Orthodontic Care Programs that I have seen. It establishes a posture for
the Great Lakes Society and for its individual members in dealing with third party programs. You
gentlemen, who are members of the Committee which was most instrumental in formulating that
Manual, are among the most experienced and knowledgeable orthodontists in the country on this
subject and I would like to explore with you the rationale of the policies and procedures set forth in
the Manual. Let us make clear at the start that all third party programs are not the same.
DR. HAMILTON There are government programs and commercial insurance programs, although
at this point there is no Federal program which provides orthodontic care in every state, with the
exception of what is left of Champus. There are programs under which different states have used
Federal funds to treat cases, but these are initiated by the states. Then there are state programs—
crippled children and cleft palate programs— which do include some orthodontic treatment.
JCO What types of commercial insurance programs are there?

DR. HAMILTON Basically four. Self insured trust funds which, in my opinion, are the most
economical way for groups to provide payment for dental care; programs by private commercial
insurance companies; programs by so-called non-profit service corporations such as Blue Shield and
Delta; and closed panel or HMO type programs.
JCO Let's explain what Delta is.

DR. HAMILTON Delta Dental Plans is the name of a national organization that was formed to
amalgamate the efforts of dental service corporations which had been set up in many states and to
encourage the remaining states to form such corporations. The dental service corporations are not a
part of organized dentistry, but they certainly are creatures of the State dental associations. They
were formed by dentists and in most cases initially funded by dentists, supposedly in recognition of
a need to assure the public of properly oriented dental care programs. These are non-profit service
corporations and, in the guise of being the dentists' own plan, have violated many principles on
which dentistry should stand. Any other plan operating on the same basis would be found
unacceptable.
DR. LAHRMAN Eleven years ago in Indiana we made an in-depth study of the service corporation
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Article Text 1
concept and concluded that the risk in marketing service corporation type plans appeared to ride
with the participating dentist.
Actually, all dental insurance is different than other types of insurance. In a dental insurance plan,
the utilization is much higher. Up to 95% of the population has some form of dental disease. Since
the utilization cannot be controlled, it leaves actuaries two other areas where they can exert pressure
to control costs— the dentist's fee and the treatment delivered.
In dentistry, there may be a choice regarding treatment. Third parties have tried to solve this by
using the "least expensive adequate treatment" or "optional course of treatment" concept, and in all
cases they reserve the right to make such a determination. Indiana dentists believe that diagnostic
judgment belongs entirely to the attending dentist.
Actually, dental insurance shouldn't be called insurance at all, but prepayment.

DR. HAMILTON That's right. It's prepayment. There was an editorial in the ADA journal a few
years ago entitled "Dental Prepayment — A Mystery Story". It asked how you can get more dental
care for less money by having dental insurance. The answer was that you obviously don't, because
there is now introduced between the dentist and his patient a whole group of clerks, salesmen,
administrative personnel and facilities. The cost to the consumer has to be higher if our fee remains
the same.
DR. LAHRMAN It makes no difference whether it is a profit or non-profit group, the claims cannot
be higher than the premium.
DR. LUKS In Canada, the dental benefit is paid for with pre-tax dollars. So, to the recipient, the
prepayment plan is likely to be less expensive than paying for his dental services with after-tax
dollars. The government encourages health care in this way. This might offset the administrative
costs of a plan.
JCO They have broadened the base.

DR. HAMILTON We would like to see an increase in the base of people seeking orthodontic
treatment. In my opinion, the best way to accomplish this goal is through the AAO with a good
public relations program. Contracts written like the recent Steel Workers contract would also benefit
orthodontics. 100% of the initial fee for orthodontics consultation is paid separately and not
deducted from any lifetime maximum for orthodontic treatment. In the United Auto Workers
contract, on the other hand, they only get paid 50% of that initial fee and it is included in the lifetime
maximum. The total cost difference to the company has to be minimal, but to the patient it means
that they can seek an orthodontic consultation almost without cost and from the finest orthodontist
they can find. We should strive to have that kind of clause included in every dental program .
We object to the discriminatory way that most dental contracts have treated orthodontists. They
have limited orthodontic benefits to a $500 lifetime maximum and that is not true of any other area
of dentistry. Most programs have $750 a year for dental benefits every year. If a dentist plans his
program right, he can put in $750 of dentistry a year, year after year.
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Article Text 2
JCO Do all dental programs have the same limit?

DR. HAMILTON No, but a majority of them do. Occasionally you see a little larger maximum, but
most are based on the principle of a lifetime maximum. We see some programs now at the $800
level and a few at $1,000. I haven't seen any above that and very few pay 100% of the cost. These
are usually the self-insured trusts, which have their own program and decide how they are going to
spend their money.
The lifetime maximum for orthodontics also usually includes any oral surgery and x-ray fees
associated with orthodontic treatment. Most contracts provide a 50% limit for orthodontics and
crown and bridge and then for orthodontics they set a $500 lifetime maximum. Including other fees,
a four bicuspid extraction case provides only about 32% of the average fee actually charged by the
orthodontists.
JCO It isn't really discriminatory against the orthodontist. It is the patient who has the problem, as
long as it is an indemnification program.
DR. HAMILTON If a patient is getting reimbursed 85% for something rather than 32%, they are
more likely to have the treatment done.
DR. LUKS Looking at it from another point of view, if you have a maximum allowance for
orthodontics, then the insurance company is not motivated to be overly concerned with the total fee.
DR. LAHRMAN Ontario Blue Cross may not be interested at this time in total fees, but there are
companies that are. A letter received by a patient from one insurance company stated that the
orthodontic treatment plan had been reviewed and a total fee of $1200 had been accepted for the full
course of planned treatment. In that case, the orthodontist's fee was $1500. The company was only
going to pay $500. Yet, the company told the patient that it had accepted a total fee of $1200. This is
a direct interference in the dentist-patient relationship.
JCO Was anything done about that?

DR. LAHRMAN Yes. We met with the insurance commissioner in our state to discuss this and he
wrote a letter to the insurance company saying, "In no case should you allow the patient to pay any
amount other than the net differences between what your policy pays and the total charges of the
dentist. Any further violation in this matter will give rise to this department citing your company for
unfair claim practices." So, there are some checks and balances.
DR. HAMILTON The point Eric is making is very important because, in spite of what I said about
discriminatory practices, what Eric said is in line with our policy— "Copayment with provision for
substantial patient participation is strongly supported." This is one of the basic disagreements
between the profession and labor unions. Labor wants 100% of everything paid for. The professions
have said that patients will use more discretion both in their choice of treatment and in their
selection of a doctor if they have a part of the fee to pay themselves. This keeps the cost of care and
programs down and will do so in future years if the free enterprise system is permitted to operate.
One of the things that creates inflation in health care delivery is that third party programs do away
with the operation of the law of supply and demand in a free enterprise system.
JCO What opportunities do you have to influence programs?
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Article Text 3
DR. HAMILTON It is a very frustrating problem. Does the ADA consider adequately the
orthodontic aspects of the programs and the orthodontic rider? The answer would have to be "No." i
think we have to go in every direction that we can. First, attempt to get the ADA to represent us.
But, even if an orthodontist happens by chance to be involved in negotiations he is not necessarily
oriented along the lines of AAO policy. At times, he may not even be aware of what the AAO has
been doing. The AAO Council has taken recent steps to correct this breach of communication and
ADA Staff has been attending our council meetings. This should have some positive results.
DR. LAHRMAN Before we can hope to influence these programs, we have to get one foot in the
door. Generally, when a plan is going to be offered, we hear about it, but frequently too late. In
Indiana, we heard about two plans. We offered our services to them in the formulation of a good
dental plan. Our offer was never even acknowledged.
DR. HAMILTON It should be clear on that point that you are referring to the dental association
and not the orthodontic association. Of the few cases in which the help of the dental association is
requested, specialties are not given an opportunity to participate. Because of some circumstances
peculiar to orthodontics, we think they ought to discuss these matters with us. We have every right
to negotiate any items that are under the orthodontic rider. The fact that there is an orthodontic rider
in most programs is evidence that there is a difference. Every state orthodontic association should
have a good orthodontic health care committee and attempt to negotiate the orthodontic rider on any
plan they hear about.
DR. LAHRMAN They never come to us first. We are a small part of the total picture. Because of
that, we have to work with our local, state and regional dental societies, who may hear about a plan
first.
JCO As a practical matter, do you have this relationship with general dental political units?
DR. BROADBENT We do in Ohio. We have our committee and guidelines set up, and we have
80-90% of the factors involved in the insurance mechanism down in writing. The remaining 10-20%
is still a gray area and we are working on it. I want to emphasize the fact that indemnification is the
approach that dentistry should be stressing. It makes it simple for the purchaser, the administrator,
and the dentist and it keeps all people responsible. A big problem is dentistry's bipartite approach.
The dental service corporation is ostensibly our spokesman in the area of prepayment, but
unfortunately they work on a service benefit concept in which the service is the benefit and the
dentist is paid on a basis of usual, customary and reasonable fees, rather than an indemnification
program. Delta may be contacted for their input, but the dental community itself to my knowledge
has not been given the opportunity to explain the benefits of an indemnification type program .
DR. HAMILTON In one national contract, the insurance was contracted in part with the dental
service corporation and in part with private commercial insurance companies, under the terms of the
very same contract. The same premiums were paid to both. Yet, the service corporation, which
claims to be non-profit, asks a 5% withhold from dentists. There must be administrative costs there
that are out of proportion. The 5% withhold is a fee that the doctor never gets and yet his overhead
is the same. It becomes much more than 5%, because it is not off his cost end, but his profit.
DR. BROADBENT More like 10%.
DR. LAHRMAN We feel that a table of allowances or an indemnification type of program is the
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Article Text 4
only way. It doesn't really matter to us how much is paid by the carrier. We feel we have enough
credibility with the patient to prove to them the necessity of the service and that they will pay the
difference. This keeps the dentist-patient relationship intact. Another approach advocated by the
Indiana Dental Association is the Bill Payer concept.
The Bill Payer concept is a simple, painless way of providing the most effective dental health
care at less cost than dental insurance programs. Basically, the Bill Payer is a self-insurance or direct
payment plan with the employer company putting the agreed upon dental care benefit monies into a
trust fund instead of an insurance package. The trust fund allots each employee the same number of
dollars, which he can spend on the dental care of his choice. The Indiana Dental Association
advocates the Bill Payer approach because it surmounts many of the problems inherent in the usual
dental health programs— costly administration, preauthorization delays, slow payment of claims,
control over treatment plans, determination of benefits, confusion over coverage terms.
DR. HAMILTON One program operating in New York, New Jersey, Maryland and other states
tells subscribers they must have the fee approved. You must send in diagnostic records if you accept
the patient. The company, on the basis of the records, grades the case on a scale of 1 to 8, which
determines the fee they are going to pay. Participating dentists in this program agree to accept this
payment as their total fee. Non-participating dentists can charge any fee they like, but the company
will only pay the patient the given amount, and they inform the patient where they can go to get the
orthodontic treatment with the insurance payment as the full fee. They send letters and list names of
those they term "cooperating dentists". Since it is a self-insured union program, it is not required to
adhere to rules of the insurance commissioner and we have not been able to stop it. We've gone
through several channels, including the state attorney general's office.
JCO Is the best attempt to influence programs to be made on a regional level or on a state level?
DR. HAMILTON It is more important on a state level because of the differences in insurance laws.
The most positive method of affecting these programs is through the democratic process of electing
state dental officials who represent the grassroots and having the total dental profession united
behind an established set of principles.
DR. LUKS Most insurance companies have consultants, including orthodontic consultants. I think
the orthodontic consultant to an insurance company should be approved by the provincial or state
orthodontic body. You can have an orthodontist who is not approved guiding a program which is not
in accordance with the wishes of organized orthodontics. Of course, we have guidelines about how
consultants ought to be chosen, but the companies don't have to abide by them.
JCO Your manual says, "A specialist should supply specialty service". That is contrary to the real
world. How do you promote that principle in the dental community?
DR. HAMILTON Someplace we had to simply state what we believe which is that, for the best
interest of the patient, specialty care should be provided by a specialist. Otherwise, there is no need
for a specialty. There is no question that there is an occasional nonspecialist who can do a competent
job, but our statement must be in the interest of groups of patients. The results of two recent surveys
indicate that many general dentists believe that too much orthodontics is being done by general
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practitioners, and they do not condone it.

DR. LAHRMAN All dentists must realize that they will ultimately be judged at the same level as
the specialist in a court of law, if they perform the same work.
DR. LUKS This is another reason why we need a one-level peer review mechanism .
JCO Is a program that limits specialty work to specialists legal?

DR. HAMILTON There are several programs like that and it would appear that it is legal. In one
New York case it was said that the purchaser has the right to determine who shall provide the
services. In the Teamster's program in California, after some years of problems in the orthodontic
sector, they decided that orthodontics shall be done only by men who limit their practices to
orthodontics.
Figures being publicized with respect to the amount of orthodontic treatment being provided by
specialists as opposed to general practitioners may be misleading. In Michigan, we were told that
40% of all orthodontic treatment being done under Michigan Delta Plan is being done by general
dentists, but, they didn't differentiate between comprehensive orthodontic treatment and minor tooth
movement. The GLSO is currently engaged in a manpower study which should provide more
accurate information with regard to the actual provision of orthodontic services at all levels.
JCO The key question that sustains the argument that nonspecialists should do orthodontics is not
the question of whether there are enough orthodontists in the country to fulfill all the orthodontic
desire. It is the additional question of whether there are enough to fill the need and whether, if we
are able, are we willing? Are orthodontists going to go into the ghetto areas and provide orthodontic
treatment to that portion of the population that has not been receiving care? The government is
impressed so far with indications that orthodontists settle in affluent portions of cities, in wealthy
suburbs, and in well-to-do towns; and that they don't service the lowest economic group. While
there is an argument that they may attract orthodontists if the economic shift is to that portion of the
population, there is no assurance that it will.
DR. HAMILTON I believe that if the fees paid by the program are fair, competent orthodontists
will go into those areas. Two levels of fees or two qualifications will create two levels of
orthodontic care.
JCO There is an effort now to define what quality is and to formulate methods to control quality.
DR. HAMILTON Just because you are an orthodontist doesn't mean you are producing quality
work. A real task for the specialty is to clean up its own house and police itself. If we don't do this, I
think someone is going to do it for us. The answer is for the profession to provide a mechanism to
identify and to attempt to do something about those practitioners who are either incompetent or
dishonest. This is what third parties are concerned about and rightfully so. I don't think we should in
any way cover up or hide the inadequacies of that small percentage of our members or anyone else.
We believe there should be a single level of review. When general practitioners use the word "peer
review" they may insist that they be reviewed by their peers, which to them means general dentists
reviewing general dentists and orthodontists reviewing orthodontists. We say that the service
rendered and not the individual who performed it should be the factor which decides how it is
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reviewed.
DR. LAHRMAN If we don't set up a review mechanism, we can be sure that it will be done for
us. I might cite an HEW administrative manual that suggests seven control mechanisms—
predetermination, case review, posttreatment clinical evaluation, utilization review, peer review,
office audit, and professional standards review. These are not mandatory yet. They are
recommendations.
JCO How does the association stand on these mechanisms?

DR. HAMILTON A simple statement of policy is that "Any and all review procedures should
remain the prerogative of the dental profession and its appropriate, properly appointed committees.
Review procedures involving the mediation of a grievance, disputed fee, or procedure referred by a
dissatisfied consumer, third party, or dentist either during or following treatment must be carefully
differentiated from review procedures requested for the purpose of assessment of the quality of the
service." Peer review committees set up to handle grievances should not attempt to do quality
assessment. If a third party were to request, for example, a random review of 15% of all their cases,
the standard peer review committee could not physically handle quality assessment. It should be a
paid committee. We think that dentists should do this and not consultants hired by the third party.
Third parties should not attempt to review our treatment.
In most states, if a grievance originates with the patient, it goes to the Patient Relations
Committee and not to the Peer Review Committee. If the Patient Relations Committee is unable to
resolve the case, it might then go to the Peer Review Committee. Differences in opinion or disputes
between the dentist and a third party would likewise go to peer review. We think that volunteer
committees can handle grievances and that the profession should be willing to provide that service
on a volunteer basis. However, in Pennsylvania for example, the insurance commissioner has said
he is going to require that every insurance company in the state providing dental service have some
ongoing method of checking the quality of the service. If a percentage of cases are going to be
checked to satisfy such an order or to sell insurance programs, then this must be paid for by industry
as any quality check procedure is.
JCO Dentists are going to have to form an intermediary organization such as the dental service
corporations should have been — a fourth party if you will— to deal with the insurance companies
and possibly others. The company should pay this corporation and this corporation should pay the
reviewers. When the company pays the reviewers, the company is hiring them and they become the
creatures of the company.
DR. HAMILTON In Pennsylvania, the dental association is studying the concept of an independent
corporation to review dental care. We already have Professional Standards Review Organizations in
this country for medicine. It is only a matter of time until dentistry becomes a part of these.
DR. LUKS It is true if the company hired orthodontists, they could be said to be biased in the
company's favor. It would not be as credible as if they were to deal with a fourth party or hire
orthodontists elected by or approved by the orthodontic society to review orthodontics.
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JCO Of course, if anything, the trend is in the opposite direction with more and more consumer
representation. Do you know anywhere where orthodontists are reviewing orthodontists?
DR. HAMILTON We have states with a special committee of the state orthodontic society to
handle orthodontic cases. The procedure is that the case goes to the dental peer review committee. If
it is an orthodontic case, there is the option of going before the special committee. The real problem
is that a general dentist may feel that the committee would treat him differently than it would a
specialist.
I think that the final decision should come from the dental peer review committee with the advice
of the specialty committee. Also, we are not looking to create complex and costly review. We ought
to follow the bank commercial on TV that says: "One man can approve a loan, but it takes three to
turn it down." If the acceptability of treatment is seriously questioned, more than one person should
be involved in the decision.
DR. LAHRMAN The review decision can be appealed to the State level or even the national level
by the patient, the doctor, or the third party. In some states, they have lay people on the peer review
board.
DR. LUKS In Ontario, we now have lay people representing consumers on our professional peer
review committees. I am not entirely certain how they are chosen, but this is an answer to consumer
demand and I don't think it is a bad thing.
JCO One problem that could occur if you have general dental peer review and orthodontic peer
review both for orthodontics is that, if orthodontists were harder on orthodontists than GP's were on
GP's, you might give the public the impression that GP's were doing fine and orthodontists were not.
DR. HAMILTON Another good reason why it should be done by one committee with one standard.
We have an interesting document which is a memo that shows the handling of one month's dental
claims by one major insurance company. It shows what happened to 5000 claims reviewed by the
company. They approved all but about 900 with no question at all. The 900 went for further review
to a clerk who supposedly had additional training in reading x-rays. Of these about 250 or 5% went
to a dental consultant, and of these, 3 cases got to peer review.
One problem that dental consultants have is that they see only the 5% of claims that are problems.
In time they tend to become pessimistic about dental care. If they saw all 5000, they might be
impressed with how many dentists are doing a good job.
JCO Are there professional audits going on in dentistry?
DR. HAMILTON To my knowledge, only in a few closed panel type programs and perhaps on an
experimental level by the ADA.
JCO Will PSRO involve audit?

DR. HAMILTON Very definitely. That's what PSRO is all about. One of our purposes in
establishing a review corporation in Pennsylvania is that we might anticipate the establishment of a
PSRO in Pennsylvania which would contract with this review corporation to do the work. It would
maintain review within the profession, although we have considered the possibility of including
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consumers on the Board.

JCO How can State orthodontic societies function in relation to third parties?
DR. LAHRMAN The State orthodontic societies provide one way of getting together as a group,
discussing the key issues before a state meeting, and having the prepayment care committee of that
particular state society act as a direct liaison with the regional society— in our case, the Great Lakes
Society of Orthodontists.
JCO How many component societies have guidelines like yours?

DR. HAMILTON Many state associations have them.
JCO Does the AAO have guidelines?

DR. HAMILTON They have established principles. They have minimal guidelines.
DR. LAHRMAN They have a small manual on orthodontic health care programs which includes
guidelines on interrelationships.
DR. LUKS Ontario made some small modifications to apply to our local conditions, but adopted the
Great Lakes policy just about completely. In Ontario, we live amicably with these guidelines and we
don't have any real problems with prepayment. Our biggest problem is with those who render the
service.
DR. HAMILTON Until recently, many areas have not had the impact of third party payment and
had no real motivation to do anything about it. The Great Lakes area was one of the first hit. You
have to understand what happened to dental offices and orthodontic offices in Michigan and Indiana
where the auto workers were. For some eighteen months prior to initiation of the Auto Workers
Contract, practices went down to nothing. No one was having dental work done except what was
absolutely necessary, because they all knew that the program was coming in. Then on October 1,
1974, when the program came into effect, there were offices that worked sixteen hours a day for
those three months attempting to get enough income in that year and to take care of the mass of
patients.
JCO What should the relationship be among the dentist, the patient, and the third party?
DR. HAMILTON The relationship of the third party and the dentist should remain independent. It
is our opinion that no orthodontist should commit himself to being a participating dentist in any
program. His participation can only benefit the third party at the expense of the dental profession.
This is a mechanism of non-profit service corporations. It is interesting that profit making
commercial insurance companies can provide the same coverage to patients without that
arrangement. You have to question the need for participating dentist agreements.
DR. LUKS Non-profit companies with the service benefit concept had to guarantee that they had
dentists who would produce these services at the fees they had precalculated.
DR. HAMILTON Most men do not understand the differences between a dental service
corporation and an insurance company. In a service corporation you give up your rights as far as the
patient is concerned. The service corporation can change its rules and regulations at any given
meeting of the organization and you are part of whatever they do. You have a contract with them.
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JCO You do have the right to resign under those circumstances.

DR. HAMILTON But, in orthodontics when you have already started a case, your responsibility for
that case continues.
JCO This is a general problem as far as insurance for orthodontic care is concerned, because
insurance contracts are written on an annual basis and they can be terminated or changed when the
renegotiation occurs.
DR. LUKS We overcome that by dealing with the patient only.
DR. HAMILTON The AAO council has been striving to get the Health Insurance Council and the
labor unions to agree that once an orthodontic case is approved, they will insure the funding to
complete the financial obligation for the case. It would require something like a 5% premium
increase to cover it.
JCO That is an important concept, because it may have been the existance of insurance that caused
the patient and the orthodontist to get involved in the first place. When the third party steps out, it
leaves two innocent bystanders not knowing what to do about it.
DR. HAMILTON Another problem is that many times an otherwise highly objectionable program
offers an attractive fee. Frequently, the practitioner will accept fixed fee schedules, closed panels,
and interference with diagnostic decisions, and every repressive measure you can think of in order to
get the patient and the fee. Such programs are financially irresponsible and will ultimately cost the
consumer far more money. They eventually fail, but only after some financial intermediary has
feathered his nest.
DR. LUKS In the province of Ontario, Delta was not well received and they just weren't selling
many policies. They eventually withdrew the participating clause and some other bad features. I
don't want to leave a false impression about Blue Cross in Ontario, for whom I am consultant. Blue
Cross doesn't operate in Ontario in the manner they operate elsewhere. They don't have participating
agreements, prefiling of fees, etc. None of these.
DR. HAMILTON Delta just couldn't compete with a large insurance company that was willing to
lose some money to get the early business. An insurance company can bid low on a contract,
knowing that they can write it off against their other programs in the first few years, and then when
they come in to renegotiate the contract, they can prove they are operating at a loss.
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Office Policy Form Letter

JCO What should the orthodontist know about prior authorization?
DR. HAMILTON Prior authorization for certain purposes is a good thing. It
is good because the patient should know ahead of time whether they have coverage and what the
coverage consists of. To confirm eligibility and coverage, preauthorization is a good thing. When it
goes beyond that to preauthorizing the fee or requiring diagnostic records sent to the company, we
should absolutely refuse.
We originally utilized a Confirmation of Eligibility Form which we believe had value,
particularly for orthodontic patients; however, some companies refused to cooperate with filling it
out and it is not used extensively.
DR. LAHRMAN Even though the insurance companies are not cooperating with us in filling out
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the Confirmation of Eligibility Form, I still think it is a good form, because it asks the patient right
at the first appointment whether they are really covered or not. They go home and find out.
JCO At what point do you inquire about insurance coverage?

DR. HAMILTON With the volume of third party cases that we have in our practice, it is much
more practical to ask the patient at the initial visit. The 26-year old wife of a steel worker will come
in thinking that she has $500 toward orthodontic treatment, only to find she is not covered at all,
because the contract only covers dependent children up to age 19.
DR. LAHRMAN In our office, after the examination, we give the patient two forms, one stating
our office policy and the other is the Confirmation of Eligibility form.
DR. LUKS There is sometimes a problem if you start a case without prior authorization. Some
companies will not pay anything unless there has been preauthorization. If you don't ask, you can
occasionally have a problem by starting treatment and then find out that your patient has dental
insurance.
DR
HAMILTON We have printed our policy statement on a county dental society basis. We have these
in tablet form. We sign it and give it to the patient. They know that if they go to another dentist in
the county, they are likely to have the same office policy.
The most complex and difficult area in preauthorization is the submission of diagnostic records.
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This is the one area in which we have the most problems. You could get dentists to agree on all
other principles, but many general dentists are very willing to send in x-rays. To have a policy that
says that you won't and to have them send them in is a bad thing. Someplace along the line, the
ADA must come up with some absolute guidelines on this. Never before in medical insurance has
anyone required this or even assumed that it was either necessary or advisable. Why then in
dentistry?
New AAO Overlay Form
JCO In orthodontics, this has been going on for a long time in welfare programs.
DR. HAMILTON The last principle in our guidelines states that special consideration may be
necessary in programs designed to provide care for indigent patients, to establish a priority basis for
seriously handicapping malocclusions. This means that we would not object to sending records to
programs like this, because we understand that Federal and state funds are limited and they have to
define what patients can or cannot be treated.
DR. LAHRMAN We won't do that for anybody. We feel you can't say that a patient can be
diagnosed in that way for one agency and not for another.
DR. HAMILTON It's a severity judgment and, actually, in Pennsylvania we don't send in records.
We send a Salzmann Index or Handicapping Malocclusion Assessment Record (HMAR). If we feel
that the case has extenuating circumstances beyond the HMAR, these will be considered if we send
in the records. It works well in spite of the deficiencies of the Index.
DR. LUKS It may create problems to send records to one body and not to another. In Ontario, we
won't send in records for indigent cases. The Ontario welfare agency has its own consultant who
screens the actual patients.
DR. HAMILTON There are different ways of handling the screening. The reason we did what we
did was to try to open some doors and make sure that we could provide care to indigent people and
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welfare programs. I believe it is important not to confuse programs where the patient or his
employer or union are actually purchasing an indemnification or prepaid service type program with
public health or welfare type programs. They differ in principle and practice. The Great Lakes
Society recognized these differences clearly when it included policy Item No. 19, which states
"Special consideration may be necessary in programs designed to provide care for indigent patients.
More serious handicapping malocclusions or facial deformities should be treated on a priority
basis." The AAO policy further states: "Special consideration of the above policies may be
necessary in publicly funded programs designed to provide care for indigent patients and may
necessitate treatment on a priority basis." We hope to encourage orthodontists to cooperate with
special programs, even if the fees are less than their usual fee. Only in this way will we accomplish
the things we want to in health care delivery. It is important to change the attitude of the public and
many professionals that the benefit of orthodontics are strictly cosmetic.
JCO There are two entirely different programs. One is orthodontic treatment and the other is a
physically handicapping child program. The problem for me with Salzmann's Index is that it
provides a secretarial method of limiting orthodontic diagnosis, because you are saying this is or is
not treatable under this program. You are eliminating value judgments on the part of the
orthodontist. You are cutting into his prerogatives in a way that only satisfies the financial portion of
the program. They can argue all they want that it makes a welfare program feasible. You create a
precedent of a restrictive mechanism which then can be applied to a more general program.
DR. HAMILTON The AAO committees as well as orthodontic graduate departments should
constantly be seeking better methods for assessing malocclusion. While recognizing the deficiencies
in the HMAR (it is of no value in mixed dentition or primary dentition cases) to date no better
method has been devised. An interesting article on assessment was published in the June 1975 AJO.
JCO What success are you having with regard to influencing the mechanics of third party care? The
ADA universal claim form is generally accepted. You have an overlay for that. Is the overlay
generally accepted?
DR. LAHRMAN Yes. We believe in a universal claim form, but in Indiana, we can't even accept
the recently revised form. There are certain explanations on the back of our form that state our
position that we feel are necessary.
DR. LUKS Insurance companies cross the border, and we have problems with the ADA form and
with its coding. The orthodontists in Ontario don't like the ADA orthodontic code. I gather that the
orthodontists in the States don't like the ADA classification of orthodontic services either. There are
so many classifications, numerical systems and claim forms, it is a real problem to put aside
differences and unify a claim form. A company's clerks may only be equipped to handle their code,
their form and their system of information.
JCO Can you get away with the AAO overlay in any part of our country with any insurance
company?
DR. LAHRMAN Yes.
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JCO And there are two AAO overlays, one having a set of code numbers?
DR. HAMILTON Not exactly. The new AAO overlay replaces the older one. The new one does
not have the code numbers on it, but rather a column for the code numbers. Men who object totally
to the coding mechanisms have pointed out that the existence of the column might encourage men to
utilize it or suggest that it is appropriate. Current guidelines of the GLSO discourage any use of
guide numbers.
DR. LUKS We are using the old overlay form.
JCO If an orthodontist uses the new AAO overlay and does not want to fill in the numbers, can he
get away without doing that?
DR. LAHRMAN He'd get away with that. Yes.
DR. HAMILTON Yes. Great Lakes members will use the form, but not the numbers.
JCO Now suppose the company asks for diagnostic records and the orthodontist refuses. Does he
get away with that?
DR. LUKS They do in Ontario. No records are sent.
DR. HAMILTON That would depend on the circumstances and the third party being dealt with.
JCO But in Pennsylvania, it is my understanding that some third parties will say, "If we don't get
your records, this patient is not going to get his full benefits".
DR. HAMILTON That is exactly right.
JCO Supposing you say to that patient, "Go to your group. If the company is trying to deny you
benefits, have your group go to bat for you"?
DR. HAMILTON That is the smartest approach to it.
DR. LAHRMAN And you can tell the patient to write to the insurance commissioner.
DR. HAMILTON This points to the importance of sticking together, establishing some principles
and standing together on them. This is what was done in Indiana and, whether you agree with
everything they say or not, this group was able to make itself effective by a semblance of unity.
DR. LAHRMAN I can't overemphasize the importance of cohesiveness.
DR. HAMILTON The chances of success on this score seem to be inversely proportional to the
population. The areas where most trouble is encountered are the most populated areas. It is the
element of competition.
DR. LAHRMAN It is difficult to get a cohesive group because you may only get 35-40% of the
members to dental meetings where you can explain yourself. Men are notorious for not reading what
you send them. It almost has to be face-to-face, person-to-person contact .
JCO It says in the Great Lakes Manual that you fill out a form just once and that is the last form you
fill out. is that generally acceptable?
DR. LUKS It is not always the last form. Some companies have Continuing Treatment
Confirmation Forms.
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DR. LAHRMAN In Indiana, we are not filling those out and advise dentists not to. The reason is
that it establishes a precedent that you are willing to fill out a number of forms, which we do not feel
are necessary. One form explaining the situation is all that we feel is
necessary. The patient has his paid receipts. We tell the patient and the company that the receipt and
a statement from the patient should suffice.
DR. HAMILTON We have the secretary initial the form that says the patient is still under
treatment. We recognize the right of the company to know that they are still under treatment. If they
ask for anything other than initialing the form, we reject it. We send back a lot of forms that request
data about appointments, when the appointment was, how long, service rendered, etc.
DR. LUKS Insurance companies want to cut off fees when the treatment has ended. That's one
reason they want the continuation form. If you sign the form that treatment is completed and you
still have retention care, the patient ceases to receive benefits. In our office, we consider them to be
under treatment while they are in retention .
DR. LAHRMAN In our office policy on insurance we say, "No additional forms, progress reports
or details of appointments will be completed by our office" .
DR. LUKS We have a problem in that the orthodontists have taken a hard line as Great Lakes has,
but general dentists have conceded many areas to the insurance companies, including acceding to
requests for information, forwarding x-rays and models.
JCO If there is one thing in your manual with which I do not agree, it is the principle that it's all
right to invite a consultant of the insurance company to come into your office and evaluate a case
with you.
DR. HAMILTON We're not saying the third party should come in and do this, but that some
mechanism of in-office review should be set up. We feel if we do this by having licensed dentists in
our own state doing consultant review according to guidelines that protect the patient, the doctor,
and the third party that we can cover cases of possible fraud. We believe it is time we stopped
protecting those few in the profession who are guilty of fraud and/or inept treatment. Only by actual
review of the patient can these cases be determined with accuracy, and we prefer the review in our
own offices rather than having our patients examined in some other office or clinic.
DR. LUKS It tells the insurance company that we think our treatment is beyond reproach. We are
willing to have a dental consultant come in and discuss it.
DR. HAMILTON It has been said in Michigan that the company is entitled to review the total files
of participating dentists to establish that his fee is indeed the routine fee he charges all his other
patients. We're not advocating that. We are saying, " If you want to see a specific patient and his
records in our office, you may make an appointment with us and you can see them under established
guidelines."
JCO Is it being used?

DR. LAHRMAN It is being used in our area, but I haven't heard of it being used in orthodontics.
Our rationale for it is that we say you can't evaluate a case on the basis of x-rays. You have to see
the patient.
DR. HAMILTON If we don't come up with some method of self-policing, somebody is going to
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come up with something worse.
JCO I agree, but setting up a Review Corporation, as we said before, might be what we should be
working for instead of each little guy opening his office to deal with review. Cooperating 100%
with a peer review group is a better way to go.
DR. LAHRMAN In Indiana, our insurance commissioner sits with legal counsel from the dental
society and legal counsel from the insurance industry. At such times, we have to occasionally
compromise on points such as consultant review.
JCO Has it been established what an adequate diagnosis is and what adequate diagnostic records
are?
DR. HAMILTON Here is the recently approved AAO statement on pretreatment diagnostic
records: "Adequate records vary with the complexity of the case and must be sufficient to document
the type and severity of the original malocclusion or orthodontic problem and to develop an
acceptable course of treatment. They might include . . . " The Council has listed what might be
included but does not attempt to insist on a specific list because there might be, for example, an
extremely competent orthodontist who doesn't believe in cephalometrics and has never used it.
JCO It is a good question whether you can just look at an anterior crossbite and focus your attention
on that little circle without investigating what else is involved. Many a GP has used up a patient's
orthodontic money and time treating some minor aspect of a major malocclusion.
DR. LUKS It is a problem when a non-specialist uses up all of the insurance allowance for
orthodontics on some minor appliance therapy.
JCO Do insurance companies authorize mixed dentition and two-stage treatment?

DR. LAHRMAN We have had no problems with that.
JCO Guidelines written by general dentists will say that limitation of payment to those qualified in a
specialty is improper. Your Great Lakes Manual says— " ... orthodontic treatment under prepaid
programs should be rendered, whenever and wherever possible, by those having the qualifications
necessary for announcement of limitation of practice approved by the House of Delegates of the
American Dental Association." Do you conflict with the general dental community on this point?
DR. HAMILTON Great Lakes' guideline is now more severe than that of AAO. AAO changed
theirs to read— " . . . orthodontic treatment under prepaid programs should be rendered, whenever
and wherever possible, by those having the qualifications necessary."
JCO Which means every general dentist.

DR. HAMILTON It means that a general dentist could qualify. In the case of comprehensive
treatment, we believe he should have additional training, education, and experience.
JCO How many insurance companies write dental insurance with orthodontic benefits?
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DR. HAMILTON About 60.
JCO Is it known how many patients are covered by those 60?

DR. HAMILTON I don't know.
JCO What is your position on fee profiles?

DR. HAMILTON The company does not need fee profiles. They have everything they need to
know, on the basis of fees already submitted to them for cases under treatment in their programs.
Fee profiles are a handle on dentists to control fees. With the volume of dental care actuarial
statistics available and increased computerization, fee profiles and prefiling of fees is obsolete,
unnecessary and abusive.
JCO What is a usual, customary and reasonable fee?

DR. HAMILTON A usual fee is your fee— the fee you wouId usually charge in your practice for
the service. A customary fee is the range of fees charged for a comparable service by comparable
practitioners in your community. Generally, a plan will set a limit within that range. For example,
customary may be set at the 90th percentile. The company will pay fees up to the highest fee
submitted by 90% of the dentists.
There may be extenuating circumstances in a case and even though your fee may usually be $500
and the customary fee in your area may be $600, you want to charge $700. That fee may be
approved if the company or a peer review committee determine that it is a reasonable fee under the
circumstances.
JCO Many practitioners accept direct payment from the insurance company. Your manual states—
"The orthodontist should have the right to accept or refuse the assignment of payment by the third
party." and also "The acceptance of the assignment of fee is strongly discouraged." You even
suggest that if direct payment is received, it should be forwarded to the patient. I suppose the chief
reason for accepting direct payments is that it is assured. What is the objection to it?
DR. LUKS Our basic premise is that we deal only with the patient. If we accept direct payment
from the third party, we have some financial obligation to the third party and could be liable for all
kinds of requests.
DR. HAMILTON In addition, it requires maintaining a double bookkeeping system, constant
communication with third parties, and increased problems with tax accounting. There are problem
decisions, such as the case of divorce where the mother tells you that if the husband gets his hands
on the insurance check, that's the last she'll see of it, and won't we help her out by accepting the
check. These problems must be decided with discretion on an individual basis.
JCO Some companies insist on direct payment. What then?

DR. HAMILTON Usually, the dental service corporations will not pay the patient in the case of
participating dentists. Interestingly enough, they refuse to pay the non-participating dentist directly,
which is to our advantage. With the participating dentists, it is part of the company's method of
761
Article Text 18
controlling the fee and also it is much easier for them to send out one check a month for all services
performed in that month than to send checks to a number of different patients. We refuse to accept
direct payment.
JCO There have been evidences, even in the case of non-participating dentists, that companies have
tried to control fees.
DR. HAMILTON That is true. In Michigan, in one bulletin handed out to auto workers said, "If
you go to a non participating dentist and he charges you a fee that is higher than you think is
reasonable, then you should contact our group and we'll attempt to work this out. "
JCO Does the orthodontist protect himself or serve his patients better, or possibly get into trouble, if
he tries to get copies of all the contract agreements in his area and digest what they say so that he
will be aware of a patient's coverage and be able to describe their benefits to them?
DR. LAHRMAN It might be good knowlege for an individual dentist to have, but he should not
become responsible for having it. One of the functions of the state prepayment council is to know
the terms of the agreements in their state and plan for future bargaining agreements concerning
dentistry.
DR. HAMILTON The minute you attempt to interpret a contract or advise a patient based on your
knowledge of a contract, you have violated our first principle, which is the independent relationship
between the dentist and the third party. If you misinterpret their contract, you may be liable. It is best
to refer the patient to their group or insurance company for explanations of their contract, even if
you think you know the answer.
Our most important principle is the independence of the dentist in relation to the third party and
our most important stand is against the participating dentist concept. The second most important is
our stand on preauthorization, particularly the opposition to submission of diagnostic records to a
third party. The ADA has said they are against routine submission. That's as far as they'll go and
they don't define routine. They could say 10% of orthodontic cases is routine.
DR. LAHRMAN The participating dentist category creates a closed panel. We want to be sure that
free choice of dentist by the patient is always maintained. I will quote from an analysis of an
unpublished survey conducted for HEW by the National Opinion Center in Chicago in late 1972.
"When the public is asked whether they would use a group dental practice if they could choose their
own dentist and have him do all their work, 91% said they would be willing to get their dental care
from such a group. On the other hand, if going to a group means being treated by whichever dentist
is available at the time the patient is treated, only 47% say they would be willing to get their dental
services from a group. In other words, the public want to continue having their own dentist, even if
new financing arrangements are made."
JCO Of course, in the general dental community, free choice is free choice of dentist. There is no
specialty category in third party work.
DR. HAMILTON I don't think we ought to spend our time waging a battle about who treats cases.
We should state the facts as we see them and fight for a single standard of review. If a general
762
Article Text 19
dentist treats an orthodontic case, he should be ready to be judged by the same standards and for the
same level of competence as an orthodontist for the same case.
JCO But that is not acceptable to them.

DR. HAMILTON I say they can't have their cake and eat it too. If they want to treat cases, they
should be willing to be judged by the same standards. It is interesting to note that, if an orthodontist
for whatever reason, returned to practice operative dentistry, he would expect to be judged by the
same standards as any other dentist.
JCO Before concluding our interview, are there any other comments you wish to make?
DR. HAMILTON Only one. Probably the most misunderstood and potentially harmful issue is the
interpretation that those who support principles and policies such as those of the Great Lakes
Society of Orthodontists are simply "anti-Delta". This is not true. We are basing our stand on
principles which we believe should be applied equally and without discrimination to all third parties
without compromise. Delta has elected not to adopt these principles or to agree that they are
important. Because Delta supposedly is organized dentistry's voice in the third party market, the
issue is vital and we must speak out firmly against Delta's position. It is interesting to note that the
Academy of General Dentistry policies (with the exception of those pertaining to specialty
treatment) are almost identical to ours.
It is always difficult to influence the apathetic or those who are interested only in their immediate
economic gain that these ideals and principles are important and worth some inconvenience and
even sacrifice. It will require the united efforts of all dentists to achieve the goals we promote. The
hope for the future practice of dentistry may depend on our measure of success.
JCO I think that if individual orthodontists and orthodontic groups obtain your Great Lakes Society
Prepayment Manual (from the Great Lakes Society of Orthodontists, 88 East Broad Street,
Columbus, Ohio 43215) the information in it will give them a sound set of principles and guidelines
for understanding and dealing with third party programs; and it will not be necessary for each one to
rediscover for himself all the experience and wisdom that is incorporated in your Manual. I want to
thank you gentlemen, on behalf of our readers, for illuminating what has become one of the most
important developments in dentistry.
David C. Hamilton
New Castle, Pa., Chairman.
B. Holly Broadbent
Jr., Beachwood, Ohio.
763
Footnotes 20
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume Oct
Don E. Lahrman
Fort Wayne, Indiana.
Eric Luks
Toronto, Ontario, Canada.
764
Footnotes 21
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Oct(764 - 768): The Twenty-Minute Strapup
THE TWENTY- MINUTE FULL STRAPUP

ELLIOTT SILVERMAN , DDS
MORTON COHEN, DDS
In three previous articles, the authors described in detail a revolutionary indirect bonding
technique. In each succeeding paper, major advances were presented. Despite a high rate of success,
our goal has been to develop a system utilizing fewer steps in the procedure and one that will do
away with the need for an ultraviolet lamp.
New Bonding Agent
Striving for the ideal in indirect bonding and working with the Research Division of the L.D.
Caulk Company, Milford, Delaware, we have helped clinically to develop a new bonding agent
named Auto-Tach. This new and important product eliminates two steps of the previous indirect
technique. Due to its fluid consistency and adequate working time, Auto-Tach can be loaded into the
Bracket-Tray without undue haste. After the tray is inserted into the mouth, no ultraviolet light is
needed to set the material, since it is a thermoset and self polymerizes rapidly in the warm environs
of the oral cavity. In short, the fewer steps involved, the faster the technique. The faster the
technique, the easier to maintain dryness. The better the dryness, the surer the procedure, since
moisture is the greatest deterrent to success in any bonding technique.
Only the following simple steps are now needed to assure success in indirect bonding:
1. Prophy, rinse and dry the teeth.
2. Etch the teeth from molar to molar for one minute, then rinse and dry thoroughly.
3. Mix the bonding material, load the Bracket-Tray and insert in the mouth.
4. Hold the tray in position for approximately three minutes.
5. Proceed to the next arch.
6. Remove both trays.
It should take no longer than twenty minutes to complete a full strapup in the mouth in both
arches, including second molars if desired.
New Technique in Detail

1a. The teeth in both arches are prophied with a simple pumice or cleansing agent, using a prophy
brush or rubber cup in a handpiece (A).
1b. The patient is then allowed to rinse or is spray-rinsed by the operator. An evacuator system must
be used at this point, since conventional saliva ejection is too weak. A portable evacuator works
well, except for the noise it emits. Central evacuation, of course, is ideal.
1c. The McSpreader, an efficient cheek retractor is inserted in the patient's mouth (B). Developed by
the authors for this purpose, it completely prevents any parts of the oral mucosa from touching the
buccal surfaces of the teeth as far back as the second molars. At this time, this appears to be the best
764
Article Text 1
device available for indirect or direct bonding technique.

Triangular shaped Dri-Angles are placed over the Stenson duct openings (C), absorbant side
against the cheek mucosa. The McSpreader and Dri-Angles complement each other perfectly.
1d. The teeth are air-dried thoroughly (D) making certain that there are no oil or water droplets in
the air lines. One simply has to project air from the air syringe onto a mouth mirror. If oil or water
droplets are present, a simple inexpensive filter unit is easily installed on the air line where it leaves
the compressor.
2a. A 50% solution of buffered phosphoric acid is soaked on a cotton pellet and quickly applied to
the buccal and labial surfaces of all the teeth in the maxillary arch. When the last tooth in the arch is
reached, the operator then lightly spreads the etchant on each tooth while constantly dipping the
pellet into the liquid in order to cover every surface. Do not rub the phosphoric acid, but use a
spreading motion. The pellet moves over the entire arch for one minute (E).
2b. The teeth are washed again (F). One must be certain that all of the etchant is washed clean from
every tooth. The evacuator will insure rapid elimination of the water sprayed into the mouth. (It is
recommended that combination air-water syringes not be used because of obvious contamination
problems.) Plastic squeeze-type water bottles do nicely for this washing phase.
2c. The soaked Dri-Angles are then replaced with two fresh Dri-Angles while leaving the
McSpreader in place. The teeth are then dried until all of the treated teeth appear frosted, a sign of
successful etching (G).
3a. The catalyst paste of the adhesive (refrigerated when not in use) is mixed in equal amounts with
the base paste on a cold thick glass slab for 10 seconds. The slabs should be kept under refrigeration
until ready for mixing. When first removed from the refrigerator, the slab is wiped only once to
eliminate the condensation. Further condensation need not be removed. The lower temperature
allows the operator to mix the two portions of the Auto-Tach material and load the Bracket-Tray
without undue haste, since the setting time is over three minutes. The brackets in the tray have
Nuva-Tach on their backings, as this material is still used in the laboratory procedure for affixing
the brackets to the stone models. The Nuva-Tach, conforming exactly to the surfaces of each tooth,
provides a tailor-made backing for every bracket. The Auto-Tach forms a chemical bond with the
previously set Nuva-Tach. Only a small amount of Auto-Tach is needed on each bracket, since the
fit of the Nuva-Tach is almost airtight (H).
3b. While the operator is drying the teeth, an assistant mixes the two parts of the adhesive and loads
the tray. The operator continuously air-dries all of the teeth in the arch until the tray is ready to be
inserted into the maxillary arch.
765
Article Text 2
4. The tray is firmly inserted and held under mild pressure in the mouth (I). In approximately three
minutes, the material should be set. The tray is maintained in the mouth with the McSpreader in
position and the same procedure is begun for the lower arch.
5. The lower arch is done in the same manner as the upper, with one exception. When placing the
Dri-Angles, an extra set is placed on either side of the tongue, deep in the lingual vestibule (J). This
acts as a tent for the tongue, preventing it from touching the teeth during the operation and giving
the tongue a positive location. This keeps the tongue in place and allows full attention to be given to
the teeth.
6. After allowing three minutes for the lower material to set, the maxillary tray is peeled off first
(K). Then the mandibular tray is removed (L), completing the entire procedure in approximately
twenty minutes (M), varying with the speed and experience of the operator. Waxed dental floss is
passed through all contact areas. If bridging occurs, this is easily removed with metal lightning
strips.
766
Article Text 3
Properties of Auto-Tach
Auto-Tach is a self-cured, hydrophilic resin cement formulated for maximum penetration

coefficient and desirable physical properties. It consists of a Bisphenol A- based comonomer blend,
filled with micronized vitreous fillers and pigments, and cured by Redox-generated free radicals.
Following activation of the catalyst paste by homogenization of the activator provided, and mixing
in equal portions with the base paste, it is used in conjunction with Nuva-Tach for bonding plastic or
perforated metal brackets to etched tooth enamel, using a Bracket-Tray. It meets the ADA
recommended standard practices for biologic and clinical evaluations.
Clinical tests performed both at the manufacturer's laboratory and by the orthodontic department
of a leading university, indicated that Auto-Tach resists displacement from tensile forces on the
teeth approximately four times greater than Nuva-Tach can. This lowers the failure rate dramatically
767
Article Text 4
and has been verified by the authors' observations on their private patients.
A similar bonding material, Solo-Tach, possessing the same chemical properties but slightly
thicker in consistency and faster setting to prevent bracket gravitational slide, has also been
developed by the L.D. Caulk Division for those wishing to bond brackets directly to teeth. Of
course, the Bracket-Tray prevents bracket slide in the indirect method of bonding.
768
Article Text 5
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Oct(769 - 769): Technique Clinic: A Direct Bond Stabilizing Splint
technique clinic
A DIRECT BOND STABILIZING SPLINT
DR. GARY P. HUSSION
A patient who had fractured the roots of both maxillary central incisors in a bicycle accident was
referred to me for splinting.
An .030" round wire was contoured to the labial surface of the teeth to be splinted and short .020"
spurs were soldered to it to give additional stability. The appliance was bonded using standard tooth
conditioning and brush-on technique with the Directon bonding system.
The degree of stability achieved with this method was, in my estimation, far superior to wire
splints, gutta percha, acrylic, or any other of the traditional methods, including bands and an
archwire. The "play" between archwire and bracket slot does not allow for good stabilization as
evidenced by the mobility of teeth at debanding.
This method achieved a remarkable degree of stabilization and offers the added advantage of
cleanliness and comfort that other methods lack for long term stabilization. The wire was later cut
distal to the centrals to remove interference with the labially erupting lateral incisors.
GARY P. HUSSION
DR. GARY P. HUSSION 1300 Thornton Street

Fredericksburg, Va. 22401
769
Footnotes 1
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Oct(770 - 773): Third Party Interference in Orthodontic Practice
Third Party Interference in Orthodontic

Practice
LLOYD E. PEARSON, DDS
MARTIN L. SCHULMAN
Mr. Martin L. Schulman

Chairman of the Board
Dental Corporation of America
P.O. Box 1011
Washington, D.C. 20013
Dear Bud,
During the past year to year and one-half, a situation with insurance carriers has arisen that is of
concern. While we do not accept assignments, we are being asked at each appointment to sign a
sheet verifying that the patient is still undergoing orthodontic care. It appears that if a payment
schedule is set up for 24 months and the treatment is finished and retainers are placed in 20 months,
then the insurance carrier no longer helps the patient pay the last four payments. They do not then
allow for the cost of construction of retainers, final records, or the one year of full retention that is
covered by the case fee. It appears to me that what is occurring is an attack on our case fee principle
which informs the patients of the financial obligation at the start of treatment. Perhaps the carriers
are attempting to get us to itemize our treatment program and break it down for their analysis, or
they may be doing this to limit their liability. In any event, I consider it unfair to the patient and
something that is very difficult for the practitioner to deal with.
As you pursue this further, would you please keep me informed.
Sincerely,
Lloyd E. Pearson, D.D.S.

Dr. Lloyd E. Pearson
644 Southdale Medical Building
Minneapolis, Minnesota 55435
Dear Lloyd:
In my travels through the country, I find that the carriers who deal with orthodontists are doing so
on an increasingly independent basis. This is disturbing to me because it is an indication of
something I have feared for many years. I have felt that whoever controlled the third party position
would control orthodontic fees, at least insofar as it relates to supplementary payment orthodontics.
Apparently, this is happening now through the various carriers.
770
Article Text 1
This is manifesting itself in several ways. The way you point out in your letter is perhaps the most
insidious and far-reaching philosophically of those I have encountered. I more commonly see
situations where the carrier charges the doctor a management fee from the amount contributed to the
doctor to pay for the carrier's cost of operation.
There is a question about the legality of such an amount being withheld from the payment due the
orthodontist. Ironically, this amount can be passed on to the patient by a non-participating doctor but
must be absorbed by a participating doctor. This is a good example of the inequities that have been
developed by this program. It's rather sad, isn't it? . . . especially for the patient, who must pay this
fee— at times in the form of a higher total fee than that quoted to a non-insured patient with the
same problem to be corrected.
In some cases, third party carriers are making the orthodontist wait three to six months for
payment.
I am aware of an area where the slightest alteration from a normal "paper" pattern results in the
papers being "pulled" from the processing flow. The papers are then held for further action. The
carrier will never again process them for action until the doctor takes action to reinstitute the
payment procedures.
In other cases, they are beginning to define and require advance approval on the amount of fee
and treatment time involved for different malocclusions.
These seem to be the beginning of even more far-reaching controls that strike at the very core of
the professional independence of our medical specialty.
This reminds me in so many ways of principles that are established and defended that are really
based upon considerations not based upon principle at all, but are related to money. I find, Lloyd,
that many people look for and establish "principles" that most benefit their own monetary interests.
Unfortunately the profession is composed of a great many individualistic professionals who do

not work well together. They will not agree uniformally on any single principle of action. The
carriers recognize this lack of uniform action and make the most of it. They seek lower fees and
higher levels of performance, an unlikely combination to achieve.
I would like to compare what has happened to third party fees to the evolution of orthodontic fee
structures over a long period of years. For many years, orthodontists used an open fee, believing that
it was fair for the patient and fair for themselves. Although there is great equity in that position, the
one reason that overwhelmingly changed the open-fee principle to a fixed fee was the patients'
attitude towards open fees in later stages of treatment.
The patient had difficulty relating to correction of a posterior malocclusion. The patient believed
that from the time the anterior teeth were straight the case was finished and the doctor was
continuing treatment only to collect additional fees. The profession of orthodontics, in its desire to
771
Article Text 2
complete treatment in a proper fashion, including the treatment of posterior malocclusions, finally
settled on using a fixed fee for treatment. This resulted in accepting the continuation of treatment
beyond the estimated time of treatment probably in more cases than completing treatment in less
than the estimated time of treatment. The basis for the present commonly used fixed fee is a valid
basis in my judgment. The orthodontist now treats for the best results he can secure without regard
to fee beyond the agreed amount. This seems to give equal satisfaction to both doctor and patients.
Now we have third party carriers trying to recreate a basis that combines the fixed fee for a
maximum dollar commitment with the open fee for a minimum. It isn't an equitable basis, and yet,
the carriers may prevail because there are enough orthodontists who are seeking work, both
qualified and unqualified, who are willing to go along with the carriers' standards.
Although the present payment basis of 90% of usual and customary fees in most cases precludes
any difference in fees because of this ploy you are experiencing, the carriers foresee the day when
they shall, indeed, have a great deal more to say and do to control fee levels. They are really still
"feeling their way" in the handling of dental fees and their even newer entry into orthodontics.
Insurance companies and prepaid carriers are both similar in my judgment. They want to MAKE
MONEY as insurance companies, and they want to DEVELOP POWER as prepaid carriers. In both
instances, the level of overhead costs keeps growing and SOMEONE must pay for them. Ultimately
it must be the consumers, although there is absolutely no reluctance on the carrier's part to collect
what they can from the orthodontist.
Many union and corporate plans provide for corporate funding of these programs. These tend to
lower the level of economic ability of people to secure orthodontics for their children. This is a great
blessing. It enables many youngsters to be treated for their malocclusions who otherwise would
enter maturity untreated. The benefit should not be confused with the related problems of payment.
Perhaps the unfair controls indicated above are really just an insidious indication that as the years
go by, there will be an even more pervasive and damaging entry by the insurance industry into the
orthodontic profession to establish the level of fees for treating different malocclusions.
I am aware of a condition in one state where one carrier requires the orthodontist to submit his
diagnostic records and his treatment plan for review and approval. Upon investigation it turned out
that a "little old lady", with no professional background made these reviews.
Shades of years ago when the profession objected so strongly and properly about the retainer
makers who would design a retainer from a stone cast to move teeth. There was no reference to paid
level, personality, profile, or people— obviously wrong, and the situation above is just as wrong.
This is a difficult situation to deal with. It seems unlikely that the carriers will ever adopt a more
reasonable approach to fees for services. The carriers seem to accept the theory that all orthodontic
services are equal— only the fees vary. They place no credence in postgraduate training, or
772
Article Text 3
awareness of diplomate status by the American Board of Orthodontics, or even a complete lack of
formal orthodontic specialty training. Fee seems to be the carriers' sole consideration.
Perhaps, the basis for improvements in this area lies with having the Dental Specialty Acts more
widely adopted by the states. Many states have these specialty licenses. More effort is needed to
expand these laws.
I am reminded of an insurance plan that publishes a list of what they call "the 90th percentile of
fees" for different orthodontic problems. Upon examination of the published list, I found it to be
substantially below what I know the average fees to be for these malocclusions in most orthodontic
practices for that area. I questioned an insurance company representative as to their source of
information. The carrier had made a survey of the orthodontic community in their state. They
received replies from less than half of the orthodontists to whom they mailed the questionnaire. The
insurance executive agreed that the replies most likely came from low-end and probably low-quality
orthodontists who were seeking cases to be supported by the insurance company. I tried to pursuade
the insurance company that they were embarked on a self defeating scheme, that they were fostering
"price" orthodontics that had to be less than ideal in treatment results and thus were really
higher-fee. The insurance executive agreed with me, but felt that the more qualified orthodontists
were not interested in working with them or they would have filed their fee schedules. I replied that
that was probably true based upon the fee schedules the insurance survey indicated.
I recently heard of a similar situation in another dental specialty. The doctor completed his
procedure, submitted his bill and was rebuffed by the carrier with the reply that they would pay only
90% of the "usual" fee for his specialty in his area. The amount offered for payment was several
hundred dollars lower than the formula, properly applied, would have covered. The doctor asked
how the "usual" fee was established by the carrier. He was told that it was done by a mail survey.
The doctor replied that he had not submitted his fee schedule. The carrier responded that that was
correct, they had not received his fee schedule. The doctor then announced that he questioned the
legitimacy of the 90% published "usual" fee schedule because . . . HE WAS THE ONLY
SPECIALIST IN THE COUNTY IN THE SPECIALTY AREA UNDER REVIEW.
The question remains. If he had submitted his fee schedule when it was requested, would that
schedule have been adopted? The answer is, MAYBE. It probably would have had some influence
on the level of customary fees published by the insurance carrier.
Perhaps we can conclude from these two "usual and customary fee" situations that it is wrong to
ignore a survey of fees by insurance carriers. Ignoring this problem will not make it disappear. It
must be met with unity, understanding and action.
The whole problem seems insoluble unless the carriers develop some sense of responsibility
toward their insured patients' needs relative to quality of services to be rendered.
Perhaps Peer Review will enable the profession to establish a basis that will encourage the third
773
Article Text 4
party carriers to recognize more than a state license to practice dentistry. The orthodontic specialty
itself must accept some measure of responsibility, or perhaps irresponsibility for not providing
recognizable standards of proficiency. Efforts to date for Peer Review cannot presently be nationally
used for that purpose. The standards are not uniform. Systems vary from excellent in some states to
nonexistent in others.
This is a complicated problem. It is not black or white, but all shades of gray. It is a different
problem in different areas. Perhaps it should be dealt with differently in different places.
Obviously, third party orthodontics is an increasing segment of the orthodontic market. There is
at present a struggle going on that involves patients, third party carriers, and the profession. It is
evolving differently in different areas. I don't know that it will ever become one single system of
procedure.
In conclusion, Lloyd, I wish I could offer a magic formula that would answer everyone's
dilemma, but I can't. I can only try to be persuasive to the program carriers to realize their position
and not take advantage of it beyond the point of equity. I would hope to pursuade the orthodontic
profession to work together to establish an equitable basis for measuring professional competence.
Sincerely,
Martin L. Schulman
774
Article Text 5
OCTOBER 1976, VOL. 10 / ISSUE 10

728
Round Table Discussion Third Party Programs 744
The Twenty-Minute Strapup 764
Technique Clinic: A Direct Bond Stabilizing Splint 769
Third Party Interference in Orthodontic Practice 770
NOVEMBER 1976, VOL. 10 / ISSUE 11

The Effect of Antero-Postero Incisor Repositioning on the Palatal Cortex as
Studied with Laminagraphy
804
Time-Saving Band Driving Technique 823
826
Five-Year Clinical Evaluation of the Andrews Straight-Wire Appliance 836
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Nov(789 -): 790 THE EDITOR'S CORNER
the editor's corner

Orthodontic treatment has lacked a correlation between the mechanics of most techniques and the
anatomical environment within which these techniques operate. We tend to have a diagrammatic
concept of bone remodeling accompanying tooth movement in a uniform environment without
consideration of the difference that density of bone may make, specifically cortical bone.
We have established treatment goals disregarding or without being aware of serious limitations
resulting from individual bone anatomy and we have used treatment methods to achieve these goals
which were hampered or frustrated by the anatomical limitations.
JCO is presenting a series of three papers by Drs. Ten Hoeve and Mulie (with Dr. Brandt of our
staff) which address themselves to movement of the anterior teeth in relation to the cortical bone of
the palate and of the symphysis. The maxillary problem is covered in this issue and the symphysis
will be covered in the next issue. In a third paper, changes in mechanotherapy to resolve some of the
lack of correlation of mechanics to anatomy will be suggested.
Using unique methods, the authors demonstrate new understanding of the anatomy of these areas
in relation to what orthodontists are trying to accomplish in them.
Edwards has recently pointed out the need to evaluate the width of the alveolus through which
orthodontists set out to move teeth bodily and with torque. Ricketts has recognized and taken
advantage of intrusion of anterior teeth in his treatment mechanics. Ten Hoeve and Mulie seem to
confirm this and suggest some general thoughts about some standard, conventional approaches to
orthodontic correction.
They suggest that indiscriminate leveling of the curve of Spee, disregarding the bony
environment of the mandibular incisor teeth, may produce variable relative extrusion of the posterior
teeth and intrusion of the anterior teeth, and the relative amounts of each may be more important
than most of us have realized to obtain a stable result. After reading the work of Ten Hoeve and
Mulie, we cannot indiscriminately apply a step-by-step treatment system to an individual without
first having a better understanding of his individual anatomic tooth environment within which we
propose to change his tooth positions.
Orthodontists will have to be more discriminating about extraction which is followed by

excessive lingualization of upper incisors, and more discriminating about torque. We have been
under the impression that all that is required is to place a torquing appliance and wait, monitoring
the amount of torque cephalometrically and stopping when we arrive at the desired amount. Up to
now, we haven't had a good interpretation of why some took longer, why some didn't fully achieve
the desired position, why some relapsed, and why some showed resorption. Now we have, and it
may revolutionize our thinking and procedures in these important regards. Gung-ho torque to
produce a certain interincisal angle, or an esthetic result, or a certain angle of upper incisor to SN or
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Nov(789 -): 790 THE EDITOR'S CORNER
lower incisor to mandibular plane must be reevaluated.
A significant thought that comes to mind is that disregard for the juxtaposition of anterior tooth
roots and palatal cortical plate may cause anchorage to be set up in the anterior and result in arch
length loss by mesial movement of the posterior teeth. When this thought is combined with their
demonstration of root resorption, with their indictment of excessive lingualization, and with their
questioning of excessive tipping as instrumental in extruding upper incisors, we look forward to
their third article on suggested changes in mechanotherapy to improve on some of the deficiencies
they are alluding to. The movements that they refer to in treatment of Begg cases are common to
most other techniques, and the considerations apply equally to any technique that levels
indiscriminately, that retracts indiscriminately, and that torques indiscriminately.
It seems to me that we ought to take a closer look, from this point of view, at the philosophy and
treatment techniques of Ricketts. They seem to be closer to this understanding of the relationship of
tooth position and tooth movement to bony environment than other techniques.
We are also going to have to recognize more often those cases in which the anatomical
limitations are too great to overcome with tooth movement alone and for which
surgical-orthodontics is necessary. Also, what applies in the anterior region must apply to the
remainder of the alveolar trough. This kind of investigation should be extended into the cuspid area
and into the posterior segments. For the present, most importantly, we must acknowledge the
observations of Ten Hoeve and Mulie and encourage the commercial development of equipment to
permit us to make use of their methods to evaluate the position of each of the anterior teeth with
relation to cortical bone before we set out to move teeth in its direction.
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Nov(804 - 822): The Effect of Antero-Postero Incisor Repositioning on the Palatal Cortex as Studied
The Effect of Antero-Postero Incisor

Repositioning on the Palatal Cortex as
studied with laminagraphy
DR. ANE TEN HOEVE
DR. ROBERT M. MULIE
This is the first of a series of three papers. It is restricted to findings within the maxillary arch. The
paper to be published next month will be confined to a study of the mandibular dentition. These two
papers were presented before the European Begg Society in Timmerdorfer Strand, Germany in May
1976. Your editor has rewritten these papers for publication here.
the near future, a joint paper by Drs. Ten Hoeve, Mulie and myself, describing recommended
modifications in mechanotherapy, will be published in the Journal of Clinical Orthodontics.
SIDNEY BRANDT, DDS, Associate Editor
Many orthodontists have accepted the "pressure/tension" theory as an explanation of the
biological mechanism of orthodontic tooth movement. Sandstedt is credited with initiating this
belief with his observation in 1904 of "undermining resorption". Over the years, the pressure/tension
theory underwent modification, influenced by extensive research. 1 As an example, DeAngelis2
wrote that mechanotherapy causes a bending of the alveolar process, resulting in piezoelectric
changes, which evolve a cellular response throughout the alveolar process. It is evident that
orthodontic tooth movement takes place within the alveolar process.
With constantly increasing sophistication in fixed appliance mechanotherapy, techniques have

evolved which, in theory, make it possible for the orthodontist to effect tooth movement in any
direction and to any extent desired. Such versatility has resulted in several commonly accepted
treatment objectives, among which are:
1. an edge-to-edge incisal relationship,
2. elimination of the curve of Spee, and
3. a favorable interincisal angle.
There are many cephalometric analyses suggesting a positioning of the incisors in relation to
anatomical landmarks.
Limits of Cephalometric Evaluation
Recently, some investigators have warned that orthodontists should not overemphasize
cephalometric evaluation at the expense of understanding that anatomy would place limitations upon
tooth movements in certain specialized instances. Duterloo 5 observed a definite shortening of the
marginal aspect of the palatal cortex following orthodontic treatment. There did not seem to be any
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Article Text 1
repair or remodeling, even several years after treatment. This elicits a natural question— When does
orthodontic treatment cause a loss of alveolar bone to the extent that irreversible damage results?
Edwards6 has also questioned the limitations of tooth movements based upon his studies of the
anterior portion of the palate. These observations of Duterloo and Edwards were verified by the
authors on cephalograms of their treated cases, demonstrating the aspect of the palatal cortex visible
on cephalometric headplates (Fig. 1). However, since cephalometric headplates are midsagittal
projections of several structures, there is no certainty of obtaining from them a perfectly clear x-ray
view of the bony structures palatal to the maxillary incisors. In an effort to clarify this anatomical
area, the authors utilized laminagraphy.
Use of Laminagraphy
The laminagraph used at the Institute of Radiology at the University Hospital, Groningen,
Holland is a Philips Horizontal Polytoom XD 4005-SPX 68 8E (Fig. 2).
This machine makes a hypocycloidal motion. The midsagittal plane of the patient's face is
positioned parallel to the table on which the patient is lying. The distance from the table to the long
axis of one of the maxillary central incisors is measured and the sagittal plane of this incisor is
adjusted to the x-ray beam by moving the table up or down.
When the post-treatment cephalogram of the patient in Figure 1 was compared to his laminagram
(Fig. 3), the laminagram demonstrated newly formed cortex all the way to the cemento-enamel
junction and indicated that a significant amount of remodeling of the palatal cortex occurred after
extensive bodily movement.
Two possible reasons why the palatal cortex is visible on a laminagram and not on a
cephalometric x-ray are:
1. With laminagraphy, only a thin area is x-rayed and there is no overlapping of the various
structures which occurs on a cephalogram.
2. The laminagram is exposed with 45KV, compared to 90KV for cephalograms. The higher KV
level may "burn" out the thinner palatal structures. The importance of the KV level can be
demonstrated with two laminagrams of the same patient taken at two different KV levels ( Fig. 4).
The film exposed with 75KV presents essentially the same image that the cephalogram does. The
film exposed with 45KV shows a thin layer of palatal cortex.
At the orthodontic department of the University of Groningen, 23 patients were studied with
laminagraphs. All these patients were treated or in treatment with the Begg Technique. They were
divided into groups, in accordance with when the laminagraphs were taken:
A. At the start of Stage III
B. Immediately after treatment
C. Six months after treatment
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D. 12-24 months after treatment

E. 2-5 years after treatment
Of the 23 patients, 19 ranged in age from 11-15 when treatment was initiated and the remaining
four were 17-24 years of age. The majority were Class II division 1 malocclusions, but three were
Class II division 2. The ANB angles ranged from 4 to 10 degrees.
Case Observations
There are several interesting cases in Group C (six months posttreatment). Case F.B. was a
female, aged 11 years 7 months when treatment was begun. The malocclusion was a Class II
division 1 with a deep anterior overbite and a severe protrusion (14mm). The four first bicuspids
were extracted and treatment lasted 28 months. In examining the visible aspect of the palatal cortex
in the different stages of treatment as traced from cephalometric films (Fig. 5), note the relative
position of the maxillary incisor to the palatal cortex, particularly at the beginning of Stage III and at
the end of treatment, and the details of overall tooth movement. Ideal torquing had not been
attained. The crown was moved forward and it extruded. Its root sheared downward along the
remaining border of the palatal cortex. At the end of treatment, the axial inclination of the maxillary
incisor to SN measured 101°, indicating that torquing was not overdone.
The cephalometric tracing shows some shortening of the palatal cortex, but the laminagram (Fig.
6) reveals a thin sliver of cortical bone that can be tracked downward along the lingual of the tooth.
The laminagram also reveals a peculiar root resorption, beginning at the apex and extending along
the lingual surface. It is unlikely that a routine cephalogram would show this type of detail.
Case R.W., 20 years old at the start of treatment, presented a Class II division 1 malocclusion
complicated by a marked maxillary protrusion (16mm). The four first bicuspids were removed and
active treatment lasted 28 months. The cephalograms demonstrate the visible aspect of the palatal
cortex and the superimposition again reveals a lack of true lingual root torque of the incisors (Fig. 7).
Here too, there was a downward and forward translation of the crowns. The usual objective in
torquing is to place the long axis of the maxillary central incisors to SN at 105°, plus or minus 5°. In
this instance, the long axis was only at 76° and hence the teeth were in unfavorable positions in
relation to the remaining palatal cortex. In spite of its rather peculiar position, the palatal cortex was
able to remodel to this tooth movement. The laminagram (Fig. 8) reveals a thin line of cortical bone
dropping down in an unusual angle to the original cortex.
Also noted was a characteristic kind of root resorption, a reduction in the root end on the labial
apical border. This might have been caused by the tipping action, which thrusts the root ends against
the labial plate. Similar responses were seen in other cases in which significant amounts of tipping
of incisor crowns had been accomplished.
Case HB was a male aged 13 years 8 months when treatment started. It was a Class II division 1
malocclusion with a deep anterior overbite and a maxillary protrusion (10mm). The four first
bicuspids were removed and treatment lasted 28 months. The cephalometric tracings reveal the
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Article Text 3
position of the maxillary incisor relative to the palatal cortex and the various completed tooth
movements (Fig. 9).
The long axis of the maxillary central incisor was placed at 103° to SN. The shortening of the
visible aspect of the palatal cortex was apparent. However, a laminagram ( Fig. 10), demonstrated
the existence of a thin layer of palatal cortex bone, as well as the type and amount of root resorption.
Case MP was a female aged 24 years 6 months at the start of treatment. The malocclusion was a
Class II division 1, with an overjet of 12mm. The four first bicuspids were extracted and treatment
took 24 months to complete. The unfavorable position of the maxillary incisor to begin torquing is
clearly evident in the cephalometric tracing (Fig. 11). The remaining palatal cortex was practically
on top of the incisor apex. Here too, there was the anticipated downward and forward crown
movement and very little, if any, real torque. On the cephalogram it appears that the palatal cortex is
continuous with the labial cortical plate. However, the axial inclination of the maxillary incisor to
SN is 90° and it is apparent that the objectives of treatment were not attained. A dramatic story is
seen in the laminagram (Fig. 12).
There is a significant notch on the lingual root surface. The palatal cortex attempts to follow the
notched configuration. The area of the notch probably represents the contact point of the root and
the cortical plate prior to torquing. If one examines the laminagram carefully, some root resorption
can also be seen on the labial aspect of the apex.
Conclusions
After a study of the laminagrams and cephalograms used in this investigation, three important
conclusions were arrived at:
1. There seems to be a characteristic type of root resorption, extending from the apex of the root,
along the lingual root surface, sometimes accompanied by notching and scalloping.
2. It has been assumed that Stage III mechanics routinely produce "true" lingual root torque. This
study makes this assumption questionable.
3. There is evidence that a palatal cortex will establish itself approximately six months after
treatment, no matter how extensive the tooth movement had been in a lingual direction.
Let us examine each of these conclusions.
Root Resorption
Root resorption is and has been a major complication and problem in orthodontics. In spite of
extensive research and investigation 15 the exact etiology remains obscure. Gaudet 7 and Reitan8
conducted some interesting experiments on tissue reaction following light wire root torque. Gaudet
found, in a project on monkeys using Begg torquing mechanics, there were numerous areas of root
resorption on the pressure side. The deeper areas of resorption were found in the apical two-thirds of
the root. Reitan, using a light wire torquing arrangement on dogs, found a significant root resorption
on the pressure side, halfway from the alveolar crest to the apex. Both Reitan and Gaudet concluded
that a force level exerted at the peak of the torque loop amounting to less than four ounces, or below
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Article Text 4
70 grams, caused little or no root resorption. It might seem logical to conclude from these studies
that excessive force can be a causative factor for root resorption.
However, at the Orthodontic Department of the University of Groningen, every torquing auxiliary
is custom-fitted. Commercial products are never used. The amount of pressure incorporated into the
torquing loops or spurs is dependent on the extent of the lingual inclination of the incisors. The
forces exerted are kept within the range suggested by Gaudet and Reitan, whose findings correlate
well with the mechanical typodont experiments of Connelly and Kahler. 9 Since much care is taken
to minimize and control pressures in Stage III, it would be improper and illogical to blame excessive
torque forces for the amount of root resorption seen in the laminagrams. There is reason to believe
that root resorption may be dependent upon the position of the maxillary incisors and their relation
to anatomical structures prior to torquing .
Monitoring Root Torque in Stage III
While observing the progress in Case MP, a decison was made to monitor root torquing in Stage
III with cephalograms. For this purpose, a lead shield was constructed, 4mm thick and coated on
both sides with aluminum. It was connected to the cephalostat and the patient seated behind it, with
his face positioned within an opening in the lead shield (Fig 13).
If only the maxilla and mandible are to be radiographed and greater precision is desired, a smaller
lead shield is connected to the larger one and held with magnets. It can be moved in all directions. If
it is necessary to identify smaller, thinner bony areas such as the palatal cortex, the KV level is
reduced from 90 to 70.
Prior to taking any of these x-rays, the authors sought assurance from the Institute of Radiology at
the University of Groningen of the safety of exposure of patients to this radiation. It was discovered
that a standard headplate, with 90 KV and 320 mAs at 12 feet, gives an exposure of 120 mR. The
partial headplates, with 70 KV and 100 mAs at 12 feet, creates an exposure of only 20 mR. Another
interesting comparison is with the periapical radiograph, which has an exposure of 600mR. This
investigation indicated that the patient was well protected when the lead shield was used. There was
also less scatter radiation. It was deemed safe to make a partial headplate once a month (Fig. 14).
With this type of "partial headplate" it is not complicated to superimpose the maxilla on the
palatal plane and the mandible on the symphisis. Thus, a methodology for following tooth
movement on a regular, serialized basis was instituted.
This system of monitoring is demonstrated on Case RK (Fig. 15). The four first molars had been
extracted because of decay. There was an extreme maxillary protrusion (20mm). Stage III was
reached after 8 months of treatment. Note the position of the lingually inclined maxillary incisor in
its relation to the remaining cortical plate at that time, and see the change in its position during
torquing at intervals of 5, 7 and 6 additional weeks (Fig. 16).
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It appears to the authors that the apex first approximates the dense cortical plate after 5 weeks;
then the incisor slides downward and forward on a fulcrum closer to the apical region. When
torquing was discontinued, the apex of the tooth was on the cortical plate. The overall tooth
movement (Fig. 17) indicates there was little or no true lingual root torque. The laminagram (Fig.
18), completed six months after discontinuing lingual root torque, shows a scalloped area in the
apical region. A thin palatal cortex can also be seen. Treatment for this case lasted 17 months.
Additional cases, monitored in this fashion, displayed similar responses. In another case (Fig. 19)
the maxillary incisors responded favorably to the initial torque force, then remained at a standstill
for several months, and finally finished with a downward and forward movement.
The information obtained from the series of partial headplates, tracings, and laminagrams raises
questions about torquing and tooth movements prior to torquing. These are:
1. Does excessive tipping of the maxillary incisors create an unfavorable relation to the palatal
cortex, perhaps caused by incisal extrusion, which in turn may be aggravated by continued Class II
elastic traction?
2. How much true lingual root torque can be expected when the palatal cortex is close to the apical
region of the incisors?
Reitan8 stresses the importance of the density of bone. Lamellated bone is more difficult to resorb
with orthodontic pressure than bundle bone. It must be remembered that Reitan and Gaudet did their
research on teeth which were in normal relation with the dental arch. They did not torque within a
treatment program that would first lingualize, then upright incisors.
Excessive Lingualization of Maxillary Incisors
The authors believe that excessive lingualization of maxillary incisors may be a questionable
procedure. Translating Reitan's findings to such situations, it appears that torque forces create a zone
of hyalinization in the area where the remaining dense cortical plate meets the lingual root surface.
This hyalinization zone acts as a fulcrum and, as the torquing auxiliary dissipates its action, a
forward and extruding crown movement results. This hyalinized area will become reorganized and
cause root resorption. Then there will be another hyalinized zone immediately formed, because of
the angular relation of the incisor against the dense laminated palatal cortical plate. This reaction
will keep repeating itself and, as a consequence, there will be a shearing downward and forward of
the incisor along the dense cortical plate, resulting in a typical root resorption. As Reitan states 8,
"Once root resorption is started, even pressures exerted by fibrous tissue against the resorbed root
surface tends to maintain or increase the resorption process."
Continuous studies of laminagrams indicate the density of bone may be a causative factor for root
resorption. It may be totally unfavorable to reposition an incisor against the cortical plate, as this
position would cause hyalinization in an area where, under normal conditions, hyalinization will
occur during torquing.
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In an investigation to record the incidence and degree of root resorption in cases treated with the
Begg technique, Goldson and Henrikson 11 found a high frequency and more severe root resorption
on the maxillary central incisors that were torqued for lingual root positioning. Their studies were
done with intraoral periapical films taken in a labiolingual direction. Therefore, the amount and kind
of resorption that occurred could only be identified in the mesiodistal plane. The laminagrams
presented in this report show significant root resorption on the apicolingual surface.
The assumption that the fulcrum during torquing with Begg auxiliaries is within the bracket may
be correct. However, the authors believe that this can be significantly altered by anatomical
relationships. During treatment, teeth may be positioned against anatomical barriers prior to
torquing. In such instances, as determined with laminagrams, an "anatomical fulcrum" is
established. This fulcrum does not have a fixed position, but seems to glide apically as the incisors
elongate. Close inspection of Figures 13 and 19 reveals an anatomical fulcrum in the deep scalloped
resorbed areas. In a recently published paper on Begg technique 12 one of the causes mentioned for a
deepening of the bite and the reappearance of an overjet was excessive torque force. However, in
the same paper, the contention was made that insufficient torque may be due to too little force being
applied.
The cases described indicate that the main cause of the problems was lingualization of the
incisors into unfavorable positions; and that the mechanotherapy is limited and somewhat controlled
by the anatomy. The Begg technique has many attractive features for the treatment of malocclusions,
but the requirement to tip the maxillary incisors lingually to an excessive degree is a questionable
one.
Remodeling of Palatal Cortex
A remarkable fact revealed by the laminagrams is the presence of a palatal cortex, despite
extensive tooth movement in a lingual direction. This is a gratifying discovery, since orthodontists
have been asked if they are moving teeth through the lingual plate. 6 In patients six months
post-treatment, where no palatal cortex could be seen on cephalograms and the tracings indicated
that the incisors were through or outside the visible cortex, laminagrams revealed the presence of a
thin layer of new cortex.
In the group of four cases where laminagrams were made at the beginning of Stage III and the
central incisor is against the dense cortical plate, even where incisors were tipped markedly lingually
there is a sliver of bone extending to the cemento-enamel junction (Fig. 20).
In the group of seven patients where laminagrams were made immediately after treatment, no
palatal cortex could be detected (Fig. 21).
The tracing showed extensive tooth movement to attain treatment objectives. In all probability,
the bone present prior to torquing was resorbed and therefore, at this point in treatment, a palatal
cortex does not exist. However, there will be osteogenesis. Otherwise, there would be severe
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mucogingival retraction on the palatal surface. Perhaps the laminagrams of this group could be
correlated with the histological findings of Wainwright 13 when he deliberately moved the roots of
premolars through the buccal cortical plate in monkeys. He observed that in the perforation sites, the
periodontal ligament and the periosteum merged to become continuous and lay between the root
surface and the overlying buccal soft tissue. In this zone, many osteoblasts became visible. There is
reason to believe that, in our cases, immediately after treatment there is such a merged zone with
osteoblasts which form a new palatal cortex in approximately six months.
The new palatal cortex is not comparable to the original cortex. It is a thin, irregular sliver of
bone. It will take several more years of observation to learn what happens later on. However, all six
cases in Group D (one to two years post-treatment) showed a well-developed, curved, dense cortical
plate (Fig. 22). When treatment was completed, it is likely there was no cortex. However, within two
years, a new one was formed. The laminagrams reveal an area of repaired resorption in the apical
region.
Relapse of Torque
In the group six months posttreatment, 6 of 8 cases demonstrated slight relapse of torquing
movement on the tracings of the partial headplates. In the cases one to two years post-treatment, 4 of
6 demonstrated relapse of torquing movement. We now have two cases four years out of retention.
In both there had been extensive tooth movement, but now there is a well-defined, dense, curved
cortical plate. Both of these cases show a relapse of the torquing procedures (Fig. 23).
Observations
When laminagraphy is combined with tracings of cephalograms, some interesting lessons can be
learned. In cases in which cephalograms and laminagrams show teeth moved through the palatal
cortex immediately after active treatment, laminagrams taken six months later reveal a newly
formed palatal cortex. Hence, there is no reason to suspect that there will be an irreversible reaction
causing damage to the alveolar bone, nor should it be of concern that the newly formed bone is of
inferior quality.
The laminagrams have proven that there is no anatomical limit to tooth movement in the marginal
area of the alveolar process. However, there is a very definite limit to tooth movement of the apex
against the palatal cortex. This is clearly demonstrated on a patient (Fig. 24) for whom, in retrospect,
treatment with orthodontics alone was not the best procedure. Even though there was extensive
tooth movement within the marginal alveolar process, when efforts were made to move root apices,
all that was accomplished was considerable root resorption.
It seems that after 12 months or thereabouts, a well-curved, dense cortical plate resembling the
original one reappears. There is strong evidence that this is associated with relapse of previously
attained torquing tooth movements. Might this suggest a physiologic limit to tooth movement
determined by function, speech, tongue, etc, as contrasted to the anatomical limits?
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While the cases used in this study were all treated with Begg technique, which is taught at the
Graduate Department of Orthodontics at the University of Groningen, the authors feel that their
observations apply to all systems of treatment. It is possible, however, that some of the
complications noted were the result of special mechanotherapy requirements of certain fixed
appliance systems. In the Begg technique, it appears from the laminagrams and tracings that when
the maxillary incisors are tipped lingually so their root apices are close to the cortical plate,
additional problems will be encountered in Stage III. The patients who were monitored regularly
with partial headplates during Stage III displayed a shearing downward of the root along the dense
cortical plate, root resorption and elongation of the crowns. Preliminary investigation of a few cases
being treated with the edgewise mechanism indicate some similarity in response. Bodily movement
and root torque were questionable as soon as the incisor roots approximated the lingual cortex.
Our studies indicate that the major cause of these complications is that orthodontists seem to limit
tooth movement within the marginal area of the alveolar process (Fig. 25).
Is Intrusion the Answer?
Why not take advantage of all the alveolar bone up to the palate? This can be accomplished by
intruding the maxillary incisors so that the dense cortical plate will approximate the lingual root
surface near the cementoenamel junction (Fig. 26).
In such a favorable relationship, torquing forces can function in an optimum fashion. Reports in
the literature indicate that it is difficult to intrude maxillary incisors with Begg mechanotherapy. The
authors have discovered that, with minor changes in the Begg technique, a significant amount of
intrusion of maxillary incisors can be obtained and a favorable relationship of the incisors for root
torquing (Fig. 27).
At the Orthodontic Department of the University of Groningen, a group of patients are under
treatment, utilizing the Begg technique with the modifications to intrude the maxillary anteriors.
Preliminary observations reveal some interesting facts:
1. Active intrusion of the maxillary incisors can be accomplished.
2. As the intrusion becomes significant, the overjet is decreased, with resultant soft tissue
improvement.
3. The eventual root torque requirements will be lessoned.
To validate and document these preliminary observations, this group of patients is being
monitored carefully with partial headplates with precision lead shield, which seem to be ideal for
this study.
The authors also believe that there may be validity and advantages to correct or partially correct
severe discrepancies at a younger age, which may negate more extensive tooth movement at a later
age.
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Summary
A group of 23 patients were monitored and studied. 27 laminagrams taken on this group revealed:
1. Immediately after orthodontic treatment, a palatal cortex could not be detected.
2. Approximately six months after orthodontic treatment, a palatal cortex could be detected,
although in most cases it was a thin irregular sliver of bone.
3. From 1-5 years post-treatment, the palatal cortex seems to have remodeled and reshaped to
resemble a normal cortex.
4. Relapse of the incisor roots seems to be associated with the reshaping of the cortex.
The development of the lead shield and partial headplate helped in studying the relationship of
the maxillary incisors to their surrounding anatomical structures, and this knowledge should help in
the development of more efficient mechanotherapy for torquing procedures.
It becomes essential to recognize that routine orthodontic tooth movement may have anatomical
and physiological limitations. If the objectives of treatment are beyond these limitations, surgical
intervention may be required to attain these goals.
Excessive lingual tipping of the maxillary incisors may create future treatment problems. Greater
emphasis should be placed on intruding maxillary incisors.
ACKNOWLEDGEMENT — The authors wish to thank the following people for their generous
assistance in the preparation of this paper:
R.L. Dijkstra, P. Hartevelt, K.J. Poel, Photography Department, University of Groningen.
Prof. J.R. Blickman, H. van der Zwaag, Institute of Radiology, University of Groningen.
Mr. van der Pol, Institute of Instrument Fabrication, University of Groningen.
Els-Marjan Groenman, Jan Boersma, Department of Orthodontics, University of Groningen .
The authors are especially indebted to Dr. Sidney Brandt, Morristown, N.J. for his counsel and
guidance in the preparation of this manuscript.
FIGURES
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Article Text 10
Fig. 1
Fig. 1 Patient GH. Cephalograms before (left) and after (right) treatment.
Fig. 2
Fig. 2 Laminagraph, Institute of Radiology, University Hospital, Groningen.
814
Figures 11
Fig. 3
Fig. 3 Patient GH. Post-treatment laminagram.
Fig. 4
Fig. 4 Laminagram of same patient with 75KV (left) and 45KV (right).
815
Figures 12
Fig. 5
Fig. 5 Patient FB. Tracings indicate palatal cortex visible on cephalometric films and its relationship to maxillary incisor.
Fig. 6
Fig. 6 Patient FB. Post-treatment laminagram (left) and laminagram and schematic drawing 18 months after treatment
(right).
Fig. 7
Fig. 7 Patient RW. Tracings indicate palatal cortex visible on cephalometric films and its relationship to maxillary incisor.
816
Figures 13
Fig. 8
Fig. 8 Patient RW. Post-treatment laminagram and schematic drawing.
Fig. 9
Fig. 9 Patient HB. Tracings indicate palatal cortex visible on cephalometric films and its relationship to maxillary incisor.
817
Figures 14
Fig. 10
Fig. 10 Patient HB. Post-treatment laminagram and schematic drawing.
Fig. 11
Fig. 11 Patient MP. Tracings indicate palatal cortex visible on cephalometric films and its relationship to maxillary
incisor.
818
Figures 15
Fig. 12
Fig. 12 Patient MP. Post-treatment laminagram and schematic drawing.
Fig. 13
Fig. 13 Lead shield with precision opening.
819
Figures 16
Fig. 14
Fig. 14 Example of x-ray taken with partial headplate apparatus.
820
Figures 17
Fig. 15
Fig. 15 Patient RK. Profile and cephalometric data before (above) and after (below) orthodontic treatment.
821
Figures 18
Fig. 16
Fig. 16 Patient RK. Progressive root movement of maxillary incisors (left to right) at start of Stage III and at intervals of
5, 7, and 6 weeks.
Fig. 17
Fig. 17 Patient RK. Overall superimposed root movement of maxillary incisor.
822
Figures 19
Fig. 18
Fig. 18 Patient RK. Laminagram 6 months after end of Stage III.
Fig. 19
Fig. 19 Patient RP. Progressive root movement of maxillary incisors.
823
Figures 20
Fig. 20
Fig. 20 Laminagram. Beginning of Stage III.
824
Figures 21
Fig. 21
Fig. 21 Laminagram. Immediately after treatment.
Fig. 22
Fig. 22 Patient HS. Schematic drawing of performed tooth movement, and post-treatment laminagram .
825
Figures 22
Fig. 23
Fig. 23 Patient MSo. Demonstrating relapse of root torque.
Fig. 24
Fig. 24 Laminagram showing limitation of apical movement.
826
Figures 23
Fig. 25
Fig. 25 Tooth movement within the marginal area of the alveolar process.
Fig. 26
Fig. 26 Hypothetical tooth movement including intrusion of incisors.
827
Figures 24
Fig. 27
Fig. 27 Schematic diagram and partial headplate of patient treated with intrusion of maxillary incisors.
References
1. Baumrind, S.: A reconsideration of the propriety of the "pressure tension" hypothesis. Am. J. Ortho. 55:12, 1969.
2. DeAngelis, V.: Observations on the response of alveolar bone to orthodontic force. Am. J. Ortho. 58:284, 1970.
3. Barrer, H.: Limitations in orthodontics. Am. J. Ortho. 65:612, 1974.
4. Schudy, F.: JCO Interview. JCO 9:495, 1975.
5. Duterloo, H.S.: The impact of orthodontic treatment procedures on the remodeling of alveolar bone. In Studieweek
1975, p. 5-21.
6. Edwards, J.C.: A study of the anterior portion of the palate as it relates to orthodontic therapy. Am. J. Ortho. 69:249,
1976.
7. Gaudet, E.J. Jr.: Tissue changes in the monkey following root torque with the Begg technique. Am. J. Ortho. 58:164,
1970.
8. Reitan, K.: Effects of force magnitude and direction of tooth movement on different alveolar bone types. Angle O.
34:244, 1964.
9. Connelly, H. and Kahler, J.: Static analysis of the face— Angle relationship of auxiliaries in torquing and uprighting
with light wire procedures. Thesis, Columbia University, 1967.
10. Kustra, S.: Personal communication.
11. Goldson, L. and Henrikson, C.: Root resorption during Begg treatment: A longitudinal roentgenologic study. Am. J.
Ortho. 68:55, 1975.
828
References 25
12. Cadman, G.: A Vademecum for the Begg technique: Technique principles. Am. J. Ortho. 67:601, 1975.
13. Wainwright, M.: Faciolingual tooth movement: Its influence on the root and cortical plate. Am. J. Ortho. 64:278,
1973.
14. Swain, B. and Ackerman, J.: An evaluation of the Begg technique. Am. J. Ortho. 55:668, 1969.
15. Newman, W.: Possible etiologic factors in external root resorption. Am. J. Ortho. 67:522, 1975.
829
References 26
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Nov(823 - 825): Time-Saving Band Driving Technique
Time-Saving Band Driving Technique

LEO M. LAMPROS, DDS
The instruments most frequently used for seating bands are the mallet and band seater, used
manually, and the semiautomatic Eby band driver. Shortly after I entered practice in 1965, it became
apparent that, if I could combine the advantages of these two techniques, it would allow me to
produce a better strapup in less time and with less discomfort to the patient. Therefore, I started
experimenting with a pneumatic compressor to provide the necessary air pressure to run a handpiece
that would duplicate the force of the Eby band driver and the rapidity of strokes provided by an
assistant tapping a band seater with a mallet.
A contra-angle handpiece was selected that could be adjusted for intensity and rapidity of action
of the seating point. These adjustments accommodate for varying patient discomfort thresholds and
for different force intensities needed to seat anterior and posterior bands. Additional advantages of
the contra-angle over the straight handpiece are that it permits access to the most distal tooth in the
mouth and it allows maximum utilization of seating lugs on anterior teeth.
Over the years, seating points of various designs and thicknesses have been tried. The point that
is now used is a Baird #4 RA. Although this point has a relatively small diameter, its serrated
surface prevents slippage and there Is little, if any, marginal creasing of the bands when pressure is
applied. This point also allows marginal adaptation and burnishing in areas that are difficult to reach.
The Band Driver
The pneumatic Band Driver (Fig. 1 ) is extremely simple to use, even by auxiliary personnel (in
states which allow them to fit bands). The Band Driver available today has been markedly refined.
The noise level is negligible and causes no apprehension in the patient. A foot control switch is
available. The new handpieces have disposable coverings which allow easy cement removal and
increase point retention of the chuck.
TECHNIQUE
Incisors
The maxillary and mandibular central incisor bands are usually seated first. They are relatively
simple to fit and allow the operator to get the feel of the instrument. Once the proper band size
selection has been made, the seating point is used against the middle of the bracket base on the
labial surface of the band (Fig. 2A). If it is judged that the bracket level will be acceptable, the point
is used against the mesial and distal marginal corners (Fig. 2B) and finally against the lingual
seating lug (Fig. 2C). The point can be used to burnish the lingual surface into the lingual concavity
of the anterior teeth (Fig. 2D).
When these bands are cemented, they will not overseat, because the operator will be using the
823
Article Text 1
same constant pressure that was used to fit them; and there will be minimal marginal cement.
Bicuspids
Bicuspid bands are seated in much the same manner. Starting with the seating point against the
middle of the bracket base on the buccal surface, the band is test-seated for accuracy of fit. The
point is then placed on the lingual seating lug to produce proper lingual position. The point is then
returned to the original point of contact and the band is seated to its proper bracket level. Margins
are easily burnished by holding the seating point at a forty-five degree angle to the occlusal surface.
This procedure pulls the band tightly against the tooth surface eliminating rough, cement-filled
margins.
Cuspids and Molars
The most difficult teeth to fit and seat are the cuspids and molars. These bands are best seated by
starting from the lingual surface and then moving the seating point to the middle of the bracket base
on the labial, or on the buccal tube. In most instances, the margins of these bands have to be
contoured with the seating point to adapt to the labial surface of the cuspids and into the buccal and
lingual grooves of the molars (Fig. 3).
Final seating of molar bands may be carried out using a band biter. The bands are removed,
washed, and prepared for cementation. The number of bands cemented at one time will vary with
each individual operator. However, little difficulty has been encountered in cementing an entire arch
with one cement mix.
Conclusion
This technique has been used exclusively for seating and cementing bands in my office for over
ten years. To date, I have not experienced any clinically evident adverse side effects to any teeth or
supporting structures. I feel the success of the technique is evident in my exceptionally low
incidence of band replacement.
Baird #4 RA
Available from Clev-Dent Division of Cavitron Corp., 3307

Scranton Rd., Cleveland, OH 44109
Band Driver
Available from Clev-Dent Division of Cavitron Corp., 3307

Scranton Rd., Cleveland, OH 44109
824
Footnotes 2
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume Nov
FIGURES
Fig. 1
Fig. 1 The Band Driver (Photo courtesy Clev-dent Division of Cavitron Corp., Cleveland, Ohio.)
825
Figures 3
Fig. 2
Fig. 2 Use of seating point on maxillary incisor. A. Against middle of bracket base. B. Against mesial marginal corner of
band. C. Against lingual seating lug. D. Burnishing lingual concavity.
826
Figures 4
Fig. 3
Fig. 3 Adapting band into lingual groove of mandibular molar.
827
Figures 5
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Nov(826 - 835): The Modular Self-Locking Appliance System Part 3: A Variation in the Combinatio
THE MODULAR SELF-LOCKING APPLIANCE

SYSTEM
Part 3
MAXWELL S. FOGEL, DDS JACK M. MAGILL, DDS
This is the third installment in this series in which Drs. Fogel and Magill are presenting the
appliance system and the treatment procedures of the Modular Self-Locking Appliance. Parts 1 and
2 appeared in the September and October issues of JCO.
NOTE— The receptacles used in the clinicaI cases in this and succeeding installments are
triple-slotted Siamese attachments, since the one-piece receptacle described in the first installment
was not available at the time these cases were treated. However, they are currently obtainable
(Rocky Mountain/Orthodontics) and are being used. Principles of archwire insertion in treatment
remain exactly the same.
CASE 1
Patient G.D., age 17.
The case presented a marked bimaxillary protrusion with incisor crowding and marked forward
displacement of the lower cuspids with severe mesial axial inclination.
Premolar extraction and strong measures to deal with the anchorage problem are indicated in
order to attain proper tooth alignment and satisfactory facial change.
Treatment
The four first premolars were

extracted and the Modular Self-Locking Appliance was placed in a usual manner. The single insert
bracket phase was begun with the insert brackets in the mesial vertical slots on the incisor teeth and
in the distal vertical slots on the cuspids.
826
Article Text 1
As the teeth uncrowded under

the influence of the multiple vertical loops and Class II elastics, as soon as possible the upper arch
was replaced with a plain looped archwire. The elastic mechanics were changed to Class III to
upright the lower incisors.
To support the Class III mechanics and the upper intramaxillary elastics,
maxillary anchorage was reinforced with a cervical headgear and a palatal bar. (The double palatal
bar has now been replaced with a single fixed/removable type.)
When the lower incisors were upright,

we were now ready for the leveling and uprighting stage. To prepare for this step, the second insert
bracket is placed, in a minute or less, and new archwires snapped into place. Since very little space
closure was necessary, due to the severe arch length discrepancy and the amount of incisor
retraction needed, we went directly to the final double helix finishing appliance. Class II elastic
traction was resumed.
The archwires were made with carefully shaped arch form; modifications to upright cuspids,
bicuspids and molars; and lateral incisor and molar offsets. This appliance very effectively levels
and uprights and, in most instances, corrects all necessary rotations.
After 14 months of treatment, appliances were removed. Small band spaces

were closed with a light anterior elastic, followed by a tooth positioner.
Post-treatment records show improved tooth positions and improved facial esthetics.
827
Article Text 2
Comments
In this case, we can see the benefits of the most significant principle of the insert bracket light
wire technique— that functional, non-restrictive attachments are great aids in appliance
mechanics— and also the alignment of teeth via the widely spaced bracket assemblage. Alignment
is almost automatic, requiring no special auxiliaries. The unique functional and biologic response to
the forces of occlusion help the teeth to assume favorable and natural positions.
Upper incisor torque was not required for this patient. It has been our experience that, since the
insert bracket is positioned slightly more gingivally, less tipping occurs than with other techniques.
In a percentage of cases, little or no incisor root torque is necessary.
CASE 2
Patient S.D., age 15.
Pretreatment records demonstrate a moderately deep overbite and a borderline Class II division 1
malocclusion. There was a slight fullness of the facial profile. The upper arch form was good with
slightly displaced left central and right cuspid. The lower arch showed marked mesial axial
inclination, a forward position of lower cuspids, and generalized crowding of lower incisors.
Treatment
The four first premolars were

extracted and the Modular Self-Locking Appliance was placed with the insert brackets in the
preferred positions— in the distal vertical slots on the cuspids and in the mesial vertical slots on the
incisors.
The upper and lower archwires were designed to uncrowd the incisor teeth and open the bite.
Since the upper arch had almost no displacement of teeth, a plain 2-looped, slightly activated
archwire was used. The lower arch was treated with a 4-looped, 2-hook archwire, more strongly
activated with moderate anchorage bends to assist in opening the bite. Class II mechanics were
applied to establish jaw relations and reduce the maxillary protrusion. Note the favorable effect on
tooth movement of the suggested placement of the insert brackets.
828
Article Text 3
As soon as possible, we went to Class III

mechanics to upright the lower incisors. At the same time, it is expedient to coordinate treatment by
moving upper incisors lingually, using horizontal elastics.
Effective resistance measures are taken,

employing a transpalatal bar and cervical headgear, when moving lower incisors upright over basal
bone.
The next step is leveling. Insert brackets are added to create the widely spaced double insert
brackets which efficiently align upper and lower teeth and also begin uprighting the teeth adjacent to
the extraction spaces.
Space-closing and leveling archwires,

coordinated to maintain equal treatment progress in both archwires, are simply snap-locked into the
archwire chamber of the insert brackets.
Leveling, rotating and uprighting respond effectively to the transmission of forces via the
archwire freely engaged in the insert brackets. Loops impart flexibility and gentleness to the buccal
segments, assisting in the correction of axial inclinations of cuspids and bicuspids. Each arm of the
helical loop operates to correct cuspid and bicuspid positions, as well as to effect closure of small
spaces.
Leveling and uprighting is continued during the finishing phase using the double helix finishing
appliance with "V" bend modifications and lateral incisor and molar offsets.
The aim is to establish ideal tooth

positions during this last phase of — treatment. The double helical springs, together with the
829
Article Text 4
free-sliding archwire, yields very favorable activity in the buccal segments. In most cases, this is the
last appliance needed to finish treatment.
The torquing auxiliary, superimposed on

the main finishing archwire, very adequately corrects axial positions of the maxillary incisors.
The compelling aspect of torquing is its simplicity and gentleness, with the security of a
controlled performance. Lateral expansion and forward movement of the buccal segments is a
natural reaction to the torquing procedure. To counteract this, the palatal bar is kept in place
throughout. Very light Class II mechanics are continued during this period.
Following appliance removal, 18 months after the start of treatment, a positioner was prescribed
and worn for approximately three months.
The post-treatment records show the results of routine treatment with the Modular Self-Locking
Appliance.
FIGURES
830
Article Text 5
Case 1a
Case 1 Post-treatment records
831
Figures 6
Case 1b
Case 1 Pretreatment records
832
Figures 7
Case 2a
833
Figures 8
Case 2b
834
Figures 9
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Nov(836 - 850): Five-Year Clinical Evaluation of the Andrews Straight-Wire Appliance
Five Year Clinical Evaluation of the

ANDREWS STRAIGHT-WIRE APPLIANCE
RONALD H. ROTH, DDS, MS
Introduction
Those who have read my previous publication, or attended the International Congress for
Orthodontists in Munich in 1973, are aware that my basic area of interest has been in the
relationship of gnathological concepts to orthodontics. Over a period of the last eleven years, I have
devoted much of my time and effort into determining what the posterior occlusal relationships
should be for the natural dentition so as to achieve a good functional occlusion on a more routine
basis after completion of orthodontic mechanotherapy.
Approximately eight years ago I was invited to present a paper entitled Case Detailing and
Control of Axial Inclinations at the Loyola-Jarabak Orthodontic Foundation in Chicago, Illinois. I
have somewhere in the neighborhood of 300,000 intra-oral slides of orthodontic cases at every stage
of treatment on most all cases that have been treated in my office. In preparing for the above
mentioned paper, I studied the slides of treatment mechanics of a great number of cases to determine
which type of treatment mechanics seemed most efficient and effective to accomplish the desired
treatment results. While studying the slides, it became readily apparent to me that part of the
difficulty encountered in achieving the finalized detailed tooth positions desired was in overcoming
the inherent error built into the standard edgewise appliance.
As I continued to study gnathology and began to evolve a concept of detailed tooth positioning of
natural teeth for better functional occlusion, the difficulty became one of placing the teeth into more
exacting positions. With the passage of time, I found that it was much easier to accomplish the
desired tooth positions by placing more of the desired angulations into my appliance by tipping or
torquing the brackets than it was to accomplish these ends by bending the arch wires. To achieve
some of these desired tooth positions, it became necessary to go into the use of auxiliary springs and
attachments to overcome the disadvantages of the standard edgewise appliance. Changing the
angulations and torque of various brackets seemed to yield a better and more consistent treatment
result than had been obtainable before, and although I was able to more closely approach ideal tooth
positions, much time and effort was spent in bending and replacing many arch wires.
In 1968, I was introduced to Dr. Lawrence F. Andrews of San Diego, California, who had
developed a "Straight-Wire Appliance" in which all the ingredients for an ideal result had been built
into the brackets and in which there was a specific bracket designed for each tooth. The Andrews
concept was built on his study of a collection of 120 non-orthodontic normals selected on the basis
of occlusions that could not be anatomically improved upon with orthodontic therapy. None of the
non-orthodontic normals had received prior orthodontic treatment.
After an intensive study of these non-orthodontic normal samples, Andrews selected six
836
Article Text 1
components common to all occlusions in this sample. He published a paper entitled The Six Keys to
Normal Occlusion, American Journal of Orthodontics, September, 1972. Andrews also compared
the sample of 120 non-orthodontic normals with 1150 orthodontically treated cases that had been on
display at national meetings in the United States between the years 1965 to 1969. He noticed certain
consistent differences between tooth positions on the non-orthodontic normals and the treated
orthodontic sample, and concluded that either the orthodontists were not fully aware of the detailed
positions for each tooth that they desired, or that there was something in our appliances that was
making it extremely difficult for us to achieve the desired end results.
The Andrews Straight-Wire Appliance was developed by measurement of crown angulations

from average measurements taken from the 120 non-orthodontic normal samples.
Crown angulation was used rather than the angulation of the long axes of the teeth since long axis
measurement of all teeth is not feasible. The average measurements from the non-orthodontic
normal sample were used to construct a hybrid edgewise appliance in which all three dimensions for
tooth positioning for each tooth was built directly into each bracket. In other words, the proper tip,
torque and in/out for each tooth type is built into these specialized edgewise brackets (Fig. 1). He
postulated, that due to the similarities between the measurements of the non-orthodontic normals, it
should be possible to construct an appliance that would be 0° in error and that unbent (other than
arch form) rectangular wires could be used in treatment.
It was also discovered by Andrews that to include all three dimensions into the bracket, required
a contoured bracket base into which the torque and in/out were incorporated (Fig. 2). The tip
angulations were provided by machining the bracket slots at specified angles to the bracket. These
brackets proved impractical to machine and so a precision casting method for manufacture was
developed .
Andrews' occlusion study was based purely upon anatomical measurements of tooth positions on
untreated normals. However, there was almost an exact similarity between where Andrews felt teeth
should be positioned from an anatomical standpoint, and where this author felt natural teeth should
be positioned from a gnathological standpoint. It is always comforting to a clinician to have his
conclusions backed up by another individual who has assessed the problem from a slightly different
viewpoint.
After having pantographically recorded and mounted a large number of post-treatment

orthodontic cases on the Stuart articulator, my concept of idealized tooth positions to achieve centric
relation closure, mutually protected occlusion and elimination of excursive interferences, came very
close indeed to Andrews' concept based on his anatomical study (Fig. 3).
As a result of my study, the development of the Straight-Wire Appliance was an exciting event to
this author, for here was a means to accomplish my treatment objectives with greater ease and better
consistency in a shorter treatment period.
837
Article Text 2
After using some of the earlier prototype Straight-Wire brackets on approximately 30 cases, I
switched my entire practice over to the Straight-Wire Appliance, when the appliance became
commercially available, nearly five years ago.
This paper will present what I feel are some of the advantages of the Straight-Wire Appliance in
achieving good functional and anatomical orthodontic treatment results.
Controversy
Since the introduction of the Straight-Wire concept to orthodontists in the United States, a great
deal of controversy has come about for it seems that it is much easier to discredit something new
than it is to make the necessary change to progress. Despite the controversy, every major
orthodontic company in the United States has come up with a "so-called Straight-Wire Appliance"!
It would perhaps be best before going any further to discuss some of the controversies.
One of the statements that has always been made is "It is difficult, if not impossible, to place
brackets so exacting that the desired or built-in angulations of the brackets will be properly
expressed with unbent arch wires" At the heart of every excellent treatment result lies a well-placed
appliance regardless of the appliance that is used. One cannot achieve a routine degree of excellence
with a poorly placed appliance. This is particularly true of the edgewise appliance. I would submit
that it is far easier and possible to control tooth positions with bracket placement than by bending
wire. If one were to take a perfectly positioned set of teeth and place a standard edgewise appliance
on these teeth with all brackets ideally positioned and then bend an upper and lower full size set of
rectangular wires including first, second and third order bends, how many orthodontists would be
able to place these wires and leave them in position for two or three months without moving some
of the teeth or all of the teeth from their ideal position? On the other hand, if we were to place an
appliance on this same perfect dentition in which the brackets themselves had a very minimal
amount of error and then place an upper and lower unbent (other than arch forms) set of full-sized
rectangular wires, we could be reasonably secure that very little if any untoward movement of these
teeth would occur. The question then is not: "Is the Straight-Wire Appliance perfect for all cases?"
The question should be: "Isn't it ridiculous to place standard edgewise brackets that are inherently
and grossly in error in all three planes of space on teeth and then proceed to bend the wire to not
only move the teeth but to overcome the inherent error built into the attachments?"
Although the Straight-Wire Appliance is by no means perfect, the minimal amount of error built
into the attachments for almost any case is minor enough to almost be overlooked in terms of the
clinical end-product.
To build into an appliance the desired tooth position for each tooth in all three planes of space
requires building of torque and in/out into specialized bracket bases of varying thicknesses that are
specifically contoured to fit the bracket site area (middle of the clinical crown) on each tooth crown.
This cannot be accomplished with the standard edgewise brackets regardless of how one tips the
bracket and torques the slot, for no matter what one does to the standard edgewise brackets, he can
838
Article Text 3
only incorporate two of the necessary dimensions, rather than all three. Although a standard
edgewise appliance can be constructed to include less error by the addition of tip of the brackets and
torque of the bracket slots, one is still required to place definite bends in the arch wires to
accomplish idealized tooth positioning. Although addition of tip and torque to standard edgewise
brackets may make treatment somewhat easier and results more consistent than what can be done
with an untorqued and unangulated edgewise appliance, it still places an unnecessary burden of
chair time on the orthodontist. Being able to treat most cases, if not all, with arch wires that are
unbent, other than arch-form, reverse curve and compensating curve of the edgewise wires, gives
the orthodontist a tremendous saving in chair time and clinical treatment time required to achieve a
better and more consistent end result (Fig. 4).
The Advantages of the Straight-Wire Appliance
After exclusively using the Straight-Wire Appliance for a period of almost four years, certain
orthodontic advantages of the appliance become dramatically recognizable.
1. Ease of arch wire construction. Since there is no need for bends of the arch wire other than
arch form or reverse or compensating curves, bending of arch wires becomes rather simple and
quick regardless of wire size.
2. No need for inter-bracket span. Since there are no bends in the arch wire, an inter-bracket span
of any great magnitude is unnecessary to reduce the force level; therefore, wide siamese brackets
can be employed to control rotations.
3. Ease of arch wire placement. When the teeth are properly aligned into ideal positions, all the
bracket slots lie parallel to the occlusal plane. Therefore, during leveling, the placement of the next
arch wire size can be done without torquing the rectangular wire to get it to slide into the posterior
tubes. The torquing key never has to be used to place the wire into the anterior or posterior brackets.
4. Less "round-tripping." Since the teeth move in more direct vector lines from their maloccluded
positions to their individualized positions, there is less "round-tripping" of the teeth.
5. Better control of tooth positions. Since all requirements for idealized tooth positions are built
into the brackets rather than the arch wires, tooth positioning is better controlled and self limiting.
Missed appointments usually result in no untoward tooth movement. In fact, the actual result is
improved tooth positions, which leads one to wonder whether many times arch wires are changed
too soon and too often.
6. Better and more consistent results with shorter treatment time. The movement of teeth in direct
vector lines to their final positions, limited by what is engineered into the appliance, results in
shorter treatment time for the patient and less chair time for the orthodontist .
7. Patient comfort. Placing of large rectangular arch wires is easier for both the patient and the
orthodontist with less jiggling of the teeth and therefore much less discomfort.
839
Article Text 4
8. Complete space closure in both extraction and non-extraction cases can be accomplished with
one set of arch wires since there are no bends in the arch wires to interfere with the brackets
themselves during space closure.
9. Ease of Ligation. The gingival wings of the brackets are constructed so that they stand away
from the gingiva labially and buccally (Fig. 5).
10. Bracket Identification. Easy bracket identification due to the identifying markings that are
cast into the brackets (Fig. 6).
11. Easier, more accurate bracket placement. Specific bracket base compound curvature insures
consistent, reliable fit. Tip within bracket and torque in base permits bracket-to-crown referencing
for consistent bracket placement and level slot lineup (Fig. 7).
12. Advantage in surgical cases. The Straight-Wire Appliance offers a great advantage in surgical
cases where the jaw relationship discrepancy is such that occlusal forces are working against the
ultimately desired tooth positions prior to surgical correction of the jaws.
CASE 1
Pre-treatment photos of a
bimaxillary protrusion case, CI II Div 1, where the maxillary anterior teeth were retracted utilizing
an anterior maxillary osteotomy.
Initual archwires.
840
Article Text 5
Lower anteriors retracted orthodontically.

Rectangular archwires in place and ready for surgery.
Extraction of maxillary first bicuspids. Stripping of palatal soft tissue. Completion of palatal bone
removal.
Three weeks later, ready for labial surgery approach.
Bone cut to nasal aperture. Freeing the maxilla. Retraction of premaxilla by pulling archwire
distally out of maxillary second molar tube.
Note root position and root approximation adjacent to extraction site. Six weeks after surgery. New
archwires in place.
Rectangular archwire in place 3 months after surgery.
841
Article Text 6
Finished result post-treatment photos.

Case 2
Skeletal CI III pre-treatment photos.
Placement of archwires.
842
Article Text 7
Intermaxillary fixation.
Levelling wires 2 months after surgery.
Post-treatment photos 4 weeks after debanding.

Gnathological Applications
As stated in my previous article, if I were to define very simply the requirements of an ideal
occlusion, both anatomically and functionally, for the natural dentition, I would have to say: "It
would incorporate The Six Keys to Normal Occlusion with mandible in gnathologic centric relation."
That is, the rearmost, uppermost and midmost relationship of the mandible to the cranium (after
Stuart). This seems to satisfy both orthodontic and gnathologic requirements in the overwhelming
majority of cases.
Treatment Technique
Since the Straight-Wire Appliance is nothing more than a hybrid edgewise appliance, any
treatment technique that is presently being used with an edgewise appliance is readily adaptable for
use with the Straight-Wire Appliance. Cases need not be treated with only straight wires. For
instance, this author routinely uses a combination of Jarabak helical loops, Ricketts utility arches
and buccal sectional mechanics. In the later stages of treatment, double keyhole loop arches and
eventually straight ideal rectangular wires are utilized (Fig. 8).
There are different series of Straight-Wire brackets ( Fig. 9) for specific types of malocclusions
that require counter-tip and counter-rotation on the teeth adjacent to the extraction sites, or extra
torque for the maxillary central and lateral incisors, or double and triple molar tubes (Fig. 10) for
those who prefer sectional mechanics such as used in the Ricketts technique or the Burstone
technique. The mandibular six-year molar bracket is also available in a double tube for use with lip
bumper or facebow as used in the Jarabak technique.
Functional Requirements for Finished Cases
One of the difficulties in achieving a good functional occlusion in patients with a steep
mandibular plane angle is that of providing the patient with sufficient overbite to disclude the
843
Article Text 8
posterior teeth upon movement in any direction out of centric closure. Providing the necessary
overbite requires sufficient tip of the maxillary incisors and cuspids and sufficient torque of the
maxillary centrals and laterals so that these teeth occupy sufficient space to completely contain the
lower arch upon closure into occlusion, and yet provide complete space closure in the maxillary
arch. The angulation and inclination built into the Straight-Wire Appliance allows this to be
achieved with ease. To provide maximum interdigitation of posterior teeth when the mandible is
closed in centric relation requires sufficient antero-posterior correction of the jaw relationship and
correct arch width coordination when the mandible is in the terminal-hinge position, but most
importantly, it requires proper bucco-lingual axial inclinations of bicuspids and molars. Control of
these axial inclinations is at best difficult with a standard edgewise appliance but can be
accomplished with ease with the Straight-Wire Appliance because the torque control of posterior
teeth is built into the brackets rather than bent into the wire (Fig. 11).
Of course, normal care and assessment for diagnosis and treatment planning must be included in
the clinician's approach to treatment. Too much "thinking" should not be expected from the
appliance! The same holds true in selection of mechanics to accomplish the desired jaw relationship
correction and tooth movement. The appliance does, however, do a beautiful job of positioning teeth
into occlusion if properly placed. I would say that the use of the Straight-Wire Appliance has
routinely subtracted six to ten months of treatment time from my cases and has drastically reduced
the chairtime spent placing and replacing arch wires.
The Straight Wire appliance is available in direct bond in metal brackets and the author would
suggest the use of Caulk Nuva-Tach system with the direct bond brackets. The contour of the
bracket base makes these brackets easy to place with direct bonding (Fig. 12).
Conclusions
Clinical use of the Andrews Straight-Wire Appliance over the last five years has convinced this
author that there are many advantages to the use of the Straight-Wire Appliance. It truly does create
better and more consistent results with shorter treatment time for the patient and less chair time for
the orthodontist. The appliance is adaptable to any mechanics system used with a standard edgewise
appliance. This author can find no clinical disadvantages to the use of the Straight-Wire Appliance.
As with anything new, one must take the time and effort to familiarize himself with the appliance
and its proper placement on the teeth. One must also spend sufficient time evaluating his mechanics
in light of the advantages inherent in the Straight-Wire Appliance. I have found that many of my
more complex mechanics, that were used to overcome the inadequacies of the standard edgewise
appliance, were no longer necessary when using the Straight-Wire Appliance. Thus, my treatment
mechanics are somewhat more simplified than they were five years ago. A discussion of the
advantages and disadvantages of certain mechanics systems as applied to the Straight-Wire
Appliance is well beyond the scope of this paper. Although one may use any mechanics with the
Straight-Wire Appliance that he so desires, it would be we'll to evaluate whether certain mechanics
systems that one may be using are counterproductive, or unnecessary, or not taking full advantage of
844
Article Text 9
the mechanics engineered into the Straight-Wire Appliance.
FIGURES
Fig. 1a
Fig. 1A Average tip measurements of crown angulations from non-orthodontic normal study.
845
Figures 10
Fig. 1b
Fig. 1B Average torque measurements of lower teeth from non-orthodontic normal study. Note the contour of
Straight-Wire Appliance bases on lower diagram so that bracket slots are parallel to the occlusal plane.
846
Figures 11
Fig. 2
Fig. 2 A. Compound contour provides torque with occluso-gingival contour while bracket slot remains level to occlusal
plane. B. Compound contour mesio-distally provides rotation while varying bracket thickness provides in-out. C. Slot
machined at the appropriate angle provides tip.
847
Figures 12
Fig. 3
Fig. 3 A. Verifying centric relation occlusion of mounted case. Facebow transfer of maxillary cast to Stuart Articulator.
B. Crown angulations of ideal functional occlusion similar to Andrews' measurements of non-orthodontic normals.
848
Figures 13
Fig. 4
Fig. 4 A. Case treated to this point with a standard edgewise appliance. B. Maxillary arch rebanded with the Straight-
Wire Appliance and levelling archwire placed. C. One month later. Note improvement in tooth positions. D. Heavier
round wire (2 mos.). E. Rectangular wire and CI II elastics (3 mos.). F. CI II corrected (4 mos.). G: At debanding. H.
One month after debanding.
849
Figures 14
Fig. 5
Fig. 5 Comparison of edgewise and Straight-Wire tie-wings.
Fig. 6
Fig. 6 Bracket identification marks. Dot — disto-gingival wing of upper. Dash— disto-gingival wing of lower. Groove —
second bicuspid.
850
Figures 15
Fig. 7
Fig. 7 A. Ease of placement because tip is in angulated slot rather than in tipping of bracket. B. Ease of placement for
correct height since torque is in the base rather than in the slot.
851
Figures 16
Fig. 8
Fig. 8 Routine auxiliaries.
852
Figures 17
Fig. 9
Fig. 9 Variety of Straight-Wire bracket series.
853
Figures 18
Fig. 10
Fig. 10 Upper triple tube, lower double tube, lip bumper tube.
Fig. 11a
Fig. 11A Standard edgewise appliance on extracted teeth with full size rectangular archwire in place (no bends other
than arch form) showing inherent tip and torque errors.
Fig. 11b
Fig. 11B Straight-Wire Appliance on extracted teeth with full size rectangular archwire in place (no bends other than
arch form) showing inherent appliance positioning of maxillary teeth.
854
Figures 19
Fig. 12
Fig. 12 Direct bond Straight-Wire brackets.
References
1. Andrews, L. F.: The Straight-Wire Appliance, AAO Film Library.
2. Andrews, L.F.: The Straight-Wire Appliance, PCSO Bulletin, 1970.
3. Andrews, L. F.. The Six Keys to Normal Occlusion, Sept. 1972, AJO.
4. Roth, R. H.: Gnathological Concepts and Orthodontic Treatment Goals. Technique and Treatment with the Light
Wire Appliances (2nd Ed.) Jarabak, J. R. and Fizzell, J. A., The C. V. Mosby Co., St. Louis, 1972.
5. Roth, R. H.: Temporomandibular Pain-Dystunction and Occlusal Relationships, The Angle Orthodontist, April 1973.
855
References 20
DECEMBER 1976, VOL. 10 / ISSUE 12

The Limitations of Tooth Movement Within the Symphysis Studied with
Laminagraphy and Standardized Occlusal Films
882
Fighting Inflation Through Productivity Sharing 900
906
The High-Pull Timing Headgear 918
It's Time For the Timing Headgear 919
Management of Impacted Cuspids 922
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Dec(865 -): 866 THE EDITOR'S CORNER
the editor's corner

In the past, when there were more children and fewer orthodontists, it was possible to increase
gross income while increasing fees minimally, if at all. Orthodontists preferred to increase their
productivity through the use of expanded duty auxiliary personnel and other efficiencies.
It had the disadvantage of increasing costs because it required more personnel, more chairs, more
supplies, more office space to treat more patients.
The combination of increasing costs and continuing inflation has to catch up with you eventually
if you do not respond with fee increases adequate to balance them. The day of reckoning speeds up
when the number of available patients declines and the applicability of the orthodontist's
productivity declines or disappears. This is what has happened in orthodontics and this is the crux of
the economic problem to which we have to respond.
There are four areas of response for orthodontists — increase the number of patients, increase
fees, decrease costs, nullify the effect of inflation.
The effect of inflation can be nullified in large measure either by receiving the fee in advance or
by tying the fee to the inflation rate. To receive the fee in advance is a rarity, but can be made the
mode by instituting a bank plan arrangement for all fees. Failing that, the fee can be arranged so that
the remainder will be adjusted annually for the inflation rate. This is imperfect because it occurs
after the fact, and especially imperfect in a rising inflation, but it is better than doing nothing and
can be improved if the first year fee were to include an adjustment for the estimated inflation in the
coming year.
Increasing fees is a must if the orthodontist is to have a chance to keep up with the other factors
— declining number of patients, increased costs, and inflation. How much to increase fees can be
determined by constructing an economic model of your practice according to the method shown in
the two articles — Orthodontic Economic Indicators and Blueprint for Economic Survival in
Orthodontics — which appeared in the April and May issues of JCO. The decision about fee
increases must be tempered by the amount of patient resistance to present fees. However, if an
analysis of your practice indicates that a certain amount of fee increase is indicated as a survival
factor, because it has become your only balancing factor, you don't have much choice except to do it
and to consider alternate locations to obtain a proper balance of number of patients and size of fees.
Increasing the number of patient starts is the most potent way to increase gross income and,
hopefully, net income, but this is becoming more difficult as the child population decreases and the
number of orthodontists increases. It means paying more attention to practice building, competing
harder for referrals, seeking more adult patients, efficiently compressing your time in one location in
order to open a satellite office in another location, and treating more patients with third party
insurance benefits.
865
Article Text 1
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Dec(865 -): 866 THE EDITOR'S CORNER
Third party programs are a growing influence over patient supply in orthodontics. They are a
potential source of additional orthodontic patients by virtue of encouraging increased utilization and
at the same time they are a potential hazard to orthodontics by reason of their need to control the
program with regard to costs, performance and quality. That control is not compatible with the
needs of the profession to maintain fees at levels which will provide an adequate standard of living
and to itself control the professional aspects of the program.
Controlling costs is a difficult area because costs keep rising and controlling costs too much can
be counterproductive. However, since salaries are usually the area of highest cost in a practice, we
should consider what Robert Schulhof describes in an article in this issue as Productivity Sharing.
One might think of productivity sharing as applicable chiefly in a climate of increasing numbers of
patients. However, in a situation of decreasing numbers of patients it may also have an application.
Essentially, it is a method of motivating employees to greater effort with the incentive of a share in
the profits. Whereas we have been thinking of increasing the productivity of the orthodontist by
adding the hands of expanded duty auxiliary personnel, we now must think of increasing the
productivity of each employee and being able to reduce the number of employees, while maintaining
efficiency and increasing the salaries of those who remain.
The problem that a system of productivity sharing may have in orthodontics is the reticence on
the part of most or all of us to open our books to employees and to reveal the gross income of our
practice and our own salary. Without such information, the system of productivity sharing could still
be a formula that you can use to determine periodic bonuses. It would not give the employee a
feeling of proprietary interest, but could still be an effective incentive mechanism.
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Article Text 2
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Dec(882 - 899): The Limitations of Tooth Movement Within the Symphysis Studied with Laminagra
The Limitations of Tooth Movement Within

the Symphysis
studied with laminagraphy and standardized
occlusal films
DR. ROBERT M. MULIE
DR. ANE TEN HOEVE
In the November issue of the Journal of Clinical Orthodontics, the authors presented a paper
involving the maxillary arch entitled "The Effect of Antero-Postero Incisor Repositioning on the
Palatal Cortex". This is a companion article on the mandibular arch. Both papers were presented
before the European Begg Society in Timmendorfer Strand, Germany in May 1976. Your editor has
rewritten these papers for publication.
In the near future, a joint paper by Drs. Ten Hoeve, Mulie, and myself describing modifications in
mechanotherapy will be published in the Journal of Clinical Orthodontics.
SIDNEY BRANDT, DDS, Associate Editor
One of the main objectives in treating Class II malocclusions successfully is the elimination of
the curve of Spee. There are various techniques and mechanical procedures to level the dentition. In
most instances, the teeth will be leveled by: 1
a. intrusion of the mandibular incisors,
b. elevation of the mandibular buccal segments, or
c. a combination of these.
Intrusion of the mandibular incisors is frequently associated with some labial flaring of these
teeth.
The entire question of intrusion of mandibular incisors is controversial. Some authors and
teachers2,3 regard such tooth movement as unstable and unwarranted. Their mechanotherapy might
be directed towards that objective, perhaps with the aid of Class III mechanics, when extrusion of
premolars and molars might be considered physically improbable as, for example, in adults.
Proponents of mandibular incisor intrusion, Sims 4 and Ricketts5, are not in favor of extruding the
buccal segments, because of the negative rotation factor on the mandible. Both of these authors have
reported extensive amounts of anterior intrusion and claim stability has been maintained for years.
Ricketts recommends a "utility" arch which, in addition to an intrusive force, adds labial root torque
to the mandibular incisors, which provides directional guidance of the roots into the alveolar process.
Tipping of the occlusal cant when the mandibular incisors are depressed is regarded as a transient
882
Article Text 1
change by Williams , who claims that this will revert to its original position in the posttreatment
period.
It is apparent that some operators prefer to intrude mandibular incisors for leveling the curve of
Spee and some only do it when there is no other method possible. What has sometimes been
overlooked is the anatomy of each individual patient to determine if there is room within the
alveolar process to permit that type of movement.
Symphysis Study
A project was undertaken at the Orthodontic Department at the University of Groningen to study
the symphysis on patients in the Orthodontic Clinic who were being treated with the Begg
technique. Three types of symphyses were detected, and tracings and headplates showed how the
mechanotherapy applied on the mandibular incisors worked in each type.
(The dots and arrows on the tracings show where the apex will be after leveling; or up to which
level the lingual cortical plate could be traced on the headplate, prior to leveling.)
TYPE 1 — the mandibular incisors are in the center of a relatively wide symphysis (Fig. 1A). A
significant intrusion was attained with proper mechanotherapy (Fig. 1B). The roots are not on the
lingual cortical plate at the beginning of Stage III (Fig. 1C).
TYPE 2 — the symphysis is narrower (Fig. 2A). In treatment, bite opening was proceeding
normally, with depression of the incisors, but then it stopped abruptly. In all likelihood, this was
when the apex moved lingually and ran into the dense cortical plate (Fig. 2B). Note the lingual
relationship of the mandibular incisor roots at the beginning of Stage III (Fig. 2C).
TYPE 3 — the cross-section of the alveolar process reveals that there is hardly enough space to
contain the incisor roots (Fig. 3A). When routine mechanotherapy for leveling the curve of Spee
was initiated, for some time the incisors maintained themselves above the occlusal plane and
nothing seemed to happen. Then, suddenly, within a four-week period, the teeth leveled off and the
bite opened. The cephalogram and tracings (Figs. 3B and C) reveal what happened. The mandibular
incisors "fell off the symphysis". A close inspection of Fig. 3C shows where the apex was formerly
positioned on the symphysis.
These x-rays seem to indicate quite clearly that the shape and width of the symphysis will be
determining factors in the response of the mandibular incisors to applied mechanics.
Laminagraphy of the Symphysis
In these cases, it is essential to evolve a proper interpretation of the cephalograms. The

cephalogram is a midsagittal projection of several structures. Studying Fig. 3C would suggest that
there may be an actual perforation of the lingual cortical plate.
It was thought that perhaps laminagraphy could supply a more definite answer. Laminagrams
were taken at the Institute of Radiology of the University of Groningen of the symphyses of eight
883
Article Text 2
treated cases that suggested special conditions on the headplates, and/or that had extensive
movement of the mandibular incisors. Two of the more interesting cases will be demonstrated and
discussed, and their laminagrams explained.
Figs. 4A and B show cephalograms of a malocclusion before and after treatment. Fig. 4C
demonstrates the movement of the mandibular incisors during treatment. The headplate and tracings
after treatment do not provide a clear, definite position of the incisor roots. The laminagraph ( Fig.
4D) taken in the axis of the right central incisor does not show a lingual cortical plate. It may be
very thin or consist of immature bone. The laminagram does show that the apex of the right central
incisor has perforated through the dense cortical plate and is now lingual to this bony structure.
There is an area of root resorption on the lingual and the apex appears blunted. If bone is to be
found in this area, extensive remodeling will be required to keep up with this lingual movement of
the apex.
The remodeling capacity within the symphysis, following extensive tooth movement, is shown in
Fig. 5. The tracing (Fig. 5C) shows massive lingualization of the incisors and, with this type of tooth
movement, it is unavoidable to have the apices run into the lingual plate. The laminagram (Fig. 5D),
in the axis of the right central incisor, reveals a thick lingual plate, which covers the entire lingual
root surface. There does appear to be some blunting of the root apex, probably caused by the
penetration of the original cortical plate.
Laminagraphy of the alveolar processes is a difficult and timeconsuming procedure, especially

for the anterior portion of the mandibular alveolar process. Just to get the long axis of one of the
central incisors parallel to the film is quite hard because, usually, the anterior portion narrows and
curves from right to left. A properly executed laminagram will clarify the lingual view of one
central incisor. However, because of the anatomy of the cross-section of the anterior portion, the
lingual relationships of the various incisors might be quite different, especially in those
malocclusions that present with crowded or lingually malposed incisors prior to treatment. For these
reasons, an effort was made to devise a roentgenographic technique to record all four incisors, at
one time, in a transverse plane.
The laminagram in Fig. 4D led us to the proper solution. A dental periapical film was placed
along the edges of the mandibular incisors and the x-rays were directed along the lingual root
surfaces in an apicoincisal line perpendicular to the film (Fig. 6).
X-Ray Modifications and Experimental Technique
The cone of a Philips Oralix x-ray machine was modified by adding two parallel posts. One of
these posts had a holder for a periapical film (3 × 4cm) which could be moved up and down as
required. The film was oriented perpendicular to the x-ray beam at all times.
In the experimental setup, a dry mandible was fixed to the horizontal rods with cold-cure acrylic
(Fig. 7). The dry mandible and rods could be rotated in the fixed x-ray beam, as well as raised or
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Article Text 3
lowered by adjusting the screws. The angulation could be varied by adjusting the horizontal rods
and the degree of rotation could be read with a protractor. In this setup, films could be taken of the
mandibular incisors in an apicoincisal direction.
A long series of experimental films were completed prior to doing them on patients, to determine
how to expose the film properly along the lingual root surface to provide the information sought. In
the method used (Fig. 8), the right central incisor was removed from the dry mandible and a straight
piece of wire was fixed along the lingual wall of the socket. The mandible was now rotated and
occlusal films were taken at intervals of several degrees. When the wire appeared as only a dot (Fig.
8B), this indicated that the x-ray beam was in fact along the lingual root surface. The position of the
mandible was noted on the protractor. The right central incisor was replaced in the socket and
another film taken (Fig. 8C). In the x-ray image, looking down on the incisor cingulum, a small
portion of the curvature of the lingual root surface should be seen, and the root canal should lie
lingual to the incisal edge. The direction of the x-ray beam is not extremely critical. There can be a
discrepancy of a few degrees and the film will still provide an accurate reproduction of the area
involved.
On a routine cephalogram, it is quite difficult to determine with accuracy the distance of the
mandibular incisor roots from the lingual cortical plate. This is probably caused by cuspid (and
sometimes bicuspid) overlap on the midsagittal projection, which may blur the details of the x-ray.
The distance of the roots of the mandibular incisors to the lingual cortical plate should be of
clinical importance, since there are different types of symphyses (Figs. 1, 2, 3). To establish whether
it is reliable to measure this distance on a standardized film taken in an apicoincisal direction, a
piece of wire 2.5mm long was placed through the cortical plate perpendicular to the lingual root
surface of one of the central incisors (Fig. 9).
The occlusal film shot along the lingual root surface of that incisor reveals that the piece of wire
also measured 2.5mm on the film. This definitely establishes that the distance between the root and
the lingual plate, measured on such a standard film, does represent the true distance of the root from
the lingual plate. This also defines the distance that the greatest curvature of the root is away from
the lingual cortical plate.
Clinical Technique
This technique was made available for clinical use. A simple device, resembling the experimental
setup was adapted to the Philips Oralix x-ray machine. It consisted of a holder for the x-ray film
added to the unit and adjusted so that the film would be perpendicular to the beam. (Fig. 10).
It is a problem to utilize the inclination of the mandibular incisor to help direct the x-ray beam.
For this purpose, using a small tray, a compound impression is made over the incisal edge of an
incisor on the patient's plaster model in such a manner that a director attached to the tray is placed
alongside the lingual root surface. The cephalogram can be used to help determine the line for the
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Article Text 4
director. The tray and the director are transferred to the patient's teeth and the inclination of the
director is fixed to the patient's skin with a strip of red tape (Fig. 11).
The red tape simulates the lingual surface of the incisor and indicates the direction for the x-ray
beam. The holder with the film is then placed on the incisal edges of the teeth.
Observations on Patients
The first case is one in which the final positions of the mandibular incisors were questionable and
the laminagram (Fig. 4D) provoked additional questions. From the standardized occlusal film shot
along the right central incisor (Fig. 12A), it is apparent that there are distinct differences in the axial
inclinations of the four incisors. Clinically, and by examining the patient's models ( Fig. 12B), there
is no hint that such variation exists. It is also obvious from the film, that the lingual cortical plate has
become curved, to conform to the different axial inclinations of the incisors.
When the occlusal film and the laminagram are examined in concert, it becomes evident that
three incisors are lingual to the thick symphysis, although the laminagram shows this lingualization
for the right central incisor only. On the laminagram, bone could not be detected lingual to the root
surface, while the occlusal film does show a non-continuous lingual cortical plate behind the right
central incisor. This contrasts with the left central incisor, which has a very thin, continuous bony
covering. It is apparent that the left central and lateral incisors are very close to perforating the
lingual plate. So, the actual bony condition lingual to the mandibular incisors is not as seen in the
laminagram (Fig. 4D), because that applies to one tooth only. The occlusal film provides the
necessary information of the tooth-to-bone relationships of all the incisors.
Fig. 13 is of a malocclusion in which an exaggerated curve of Spee was eliminated by extruding

the buccal segments and intruding the incisors. An occlusal film, taken after leveling (Fig. 13A) and
shot along the right central incisor, reveals a significant difference in the axial inclinations among
the incisors. In fact, three of the incisors are close to perforating the lingual cortical plate. This
difference in angulations could not readily be detected on a cephalogram, because of the
overlapping on the midsagittal projection. Nor would the plaster models (Fig. 13B) have been of any
help in showing the true root positioning. The original condition had crowded mandibular incisors,
and the unraveling and depressing tooth movements may have contributed to the differences in axial
inclination.
Our experiments with the occlusal films also taught us that variation in the axial inclinations
means that within the symphysis there could be a distance of 4-5mm between the root apices in a
labiolingual direction. This is important, because treatment planning and evaluation of treatment
results are frequently based on measuring the position of one mandibular incisor in the midsagittal
plane on a cephalogram.
Clinical Problems
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Article Text 5
The case shown in Fig. 14 appears to have attained the objectives of treatment and to be a
reasonable result. The mandibular incisor is on the APo line, an accepted cephalometric reference
measurement. The tracings and headplate (Figs. 14C and D) indicate a possibility that the incisors
are completely behind the symphysis and may have perforated the lingual cortical plate. Does this
apply to all the incisors, or just one or two? Is what is seen on the cephalogram an artifact?
The lingual surface of the alveolar process was carefully palpated; then an occlusal film was shot
along the lingual root surface of the right central incisor (Fig. 15A). This film reveals an unusual
situation. The root of the right central incisor is bulging lingually behind the symphysis. It appears
as if the lingual cortical plate adapted its shape to the tooth movement, but that the root with the
largest circumference eventually broke through the plate. This phenomenon seems to correlate with
Wainwright's 7 histological findings when he moved the roots of premolars (in monkeys) through the
buccal plate. Wainwright concluded that the bone immediately adjacent to the perforated site had
proliferated in the direction of the tooth apex movement, as if to "follow" the path of the apex.
The occlusal film (Fig. 15A) indicates that there is a thin cortical plate behind the left central
incisor and that both lateral roots have a more labial relation. Nevertheless, the incisal edges appear
to be well aligned as seen on the model (Fig. 15B).
If an occlusal film were taken more from the labial (Fig. 15C), it would be along the lingual root
surface of the lateral incisors and would show the apical region of the right central incisor (Fig.
15D). This film indicates that the apex of the right central incisor is displaced lingually to a
significant degree.
If the objective of treatment is to have the incisal edge of lower incisor on the APo line, 8
regardless of their inclination, perhaps such an objective would be more meaningful and valid if all
the incisors were aligned within the symphysis and had the same angulations. The occlusal film in
this case provide additional valuable information that could not have been gleaned from a headplate
or a laminagram.
In the case shown in Fig. 16, the tracing (Fig. 16A) shows considerable lingualization of the
incisors. The original malocclusion was a bimaxillary protrusion. The after-treatment cephalogram
did not show any cortical plate behind the incisors. The laminagram (Fig. 16B) does demonstrate a
thin sliver of cortical bone behind one central incisor. The occlusal film ( Fig. 16C) indicated there is
bone behind all the incisors. Furthermore, they have the same inclination with the incisal edges in
line (Fig. 16D).
Discussion and Conclusions
An effort has been made to prove that the dimensions of the symphysis may interfere with
intrusive movements of the mandibular incisors. The cases demonstrated in this paper were treated
with the Begg Technique, in which leveling the curve of Spee is usually associated with a resilient
.016 round wire and a crisp anchorage bend placed mesial to the molar sheaths. The usual result is a
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Article Text 6
depression of the incisors along with lingual displacement of the apices. This type of root movement
may cause some of the complications described in this paper, by placing incisor roots too close to
the lingual cortical plate. If the objective in leveling the curve of Spee is the extrusion of the
mandibular posterior segments, the operator must be conscious of the action-reaction syndrome
when placing archwires. Even so, this might not insure avoidance of these situations.
For more than one year, the Orthodontic Department at the University of Groningen has been
taking standardized occlusal films of the mandibular incisors with the technique described. It is a
most useful x-ray to locate the relative positions of all four incisors to the lingual cortical plate and
of the individual axial inclinations of these teeth. One of the remarkable observations is the apparent
enormous adaptability of the lingual aspect of the mandibular alveolar process in many cases, while
leveling procedures are being accomplished.
Ricketts' concept of the "utility" arch, which has for its objective labial root torque of the
mandibular incisors while leveling the arch, seems to be a valid procedure, based upon the findings
in this paper.
There appears to be some correlation between post-treatment differences in axial inclinations of

mandibular incisors and pretreatment crowding. Perhaps the variation that we are not aware of in
pretreatment crowding contribute to relapse. It is surmised that too rapid alignment of crowded
anteriors while they are being intruded may cause some unfavorable reactions. This does not imply
that a lingually malposed lateral incisor is more likely to perforate the lingual plate, but it may be
prudent to take an occlusal film prior to intruding incisors to determine if an incisor has an apex
farther lingual than its neighbors and, if it has, to correct it with proper torquing mechanics.
Most fixed appliance systems seem to have some "automatic" means of leveling the curve of
Spee. It might be wise to investigate the size and shape of the symphysis before undertaking any
major tooth movement in this area, whether you are placing the incisal edges along the APo line or
torquing mandibular anteriors lingually to gain a predetermined interincisal angle. 9
As a result of extensive experience with the Begg technique at the University of Groningen, some
conclusions about this system of mechanotherapy have been crystallized. The perforations and near
perforations of the lingual plate and the variations in mandibular incisor inclination may be caused
by the rapid unraveling of crowded incisors accompanied by intrusive force in Stage I along with
anchorage loss in Stage III when torquing and Class II mechanics are applied. A methodology was
developed to handle these types of complications. This will be described on several cases.
Fig. 17A demonstrates depression and lingual apical root movement. Any further lingual root
movement would not be indicated. Anchorage loss due to Stage III mechanics should also be
discouraged. Therefore, the lower reverse torquing complex devised by Brandt 10 (Fig. 18) was
placed. This applies labial root torque to the mandibular incisors. Within one month ( Fig. 17B),
there was new bone formed behind the central incisors and the area resembling a "wake" indicates
where the central incisors were moved from. It was also obvious that the lateral roots were still close
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to the lingual cortical plate and seemed to lag behind in movement. An occlusal film shot along the
lateral incisors five months later (Fig. 17C) showed all four incisors well away from the lingual
cortical plate with a "wake" which represents new bone formation. The lateral incisors still appear to
need more labial root torque. The partial headplate (Fig. 17D) shows where the apices came from
and a distinct cortical plate. There probably would have been a perforation if the reverse torquing
auxiliary had not been utilized.
In another instance (Fig. 19), the mandibular incisors were brought from minus 7mm directly up
to the APo line. This was associated with a change in the axial inclinations of these teeth and any
further lingual movement of their apices would be most undesirable and unfavorable. Fig. 19A
shows how close the right central incisor was to perforation. A lower reverse torque assemblage was
inserted and after four months (Fig. 19B) the centrals showed a nice "wake" and are well away from
the lingual cortical plate. In this case, too, the laterals seemed to lag behind in their root response. It
appeared that there was progressively diminished torque on the distal spurs. Consequently, these
were activated with more force and four months later (Fig. 19C) all four incisors had the same
angulation and were away from the cortical plate, although the centrals did have a slight relapse
toward the lingual. The partial headplate (Fig. 19D) revealed a distinct lingual bony plate on the
mandible. If a lower reverse torque assemblage had not been used, the apices of the incisor roots
would not have been as favorably placed; in fact, they might have been in a most unfavorable
position.
Thus, another advantage of this roentgenographic technique is apparent. It becomes possible to

determine if the mechanotherapy has achieved the objectives on all the incisors equally. These
x-rays will also inform the operator if it is essential to apply labial root torque at the beginning of
orthodontic therapy and, when these forces have been used, whether they have worked evenly on all
the incisors.
Another interesting detail can be seen in Fig. 20A. This was a nonextraction case. Lower reverse
torque mechanics were applied and accomplished 25° of labial root torque. The x-ray shows that the
bone immediately lingual to the incisors is not yet organized, but in the area closer to the lingual
cortical plate a trabecular pattern is visible. The white lines extending from the interproximal spaces
of the incisors to the lingual cortical plate represent the original mesial and distal socket walls of
these teeth, extending in an apicoincisal direction.
This case emphasizes that with an occlusal film the "wake is no fake". The authors take occlusal
films along the lingual root surface no matter what type of tooth movement was attempted or
accomplished. Thus, the incisor is regarded as a "reference object" on which superimposition can be
done (Fig. 20C). It is also possible to see the new bone that is formed as a reaction to uprighting
lateral roots on an occlusal film.
One of the items demonstrated is that the symphysis may have sufficient room in the initial stages
of treatment for intrusion of the incisors. After some time, the root apices may contact the dense
cortical plate, resulting in a standstill of tooth movement. Eventually, if greater forces are applied, a
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Article Text 8
perforation results.
In the treatment of the malocclusion in Fig. 21, there has been a significant amount of mandibular
incisor intrusion, but an overbite of 4mm was still present. The occlusal film at that time (Fig. 21A)
revealed that the root apices were right against the dense cortical plate, inhibiting further bite
opening. A lower reverse torque complex was inserted and, within two months, the incisors were
well depressed and the bite opened properly. Fig. 21B shows the roots gliding away from the lingual
plate into more cancellous bone, permitting intrusive action. Note that proper adjustment of the
auxiliary spurs can even the angulations of all the roots. Fig. 21C shows progress and the
reorganization of the bone into a trabecular pattern.
The Brandt lower reverse torquing auxiliary has the versatility of being able to vary the force on
each of the torquing spurs so that individual tooth movement can be better controlled. This is
advantageous, particularly since the occlusal films reveal there may be differences in the angulations
of the roots. These variations in the torque spur adjustments are important when dealing with
different types and shapes of symphyses. The operator should also know if the mandibular incisors
are well positioned within the symphysis and, if so, make every effort to keep them that way. If the
root positions are not favorable, then critical judgment is required to determine what treatment
objectives are to be attempted and what mechanotherapy procedures are to be used.
All patients at the University of Groningen who are monitored with headplates are also closely
supervised for the position of the mandibular incisors within the symphysis.
Standard Begg mechanics were used for leveling the curve of Spee in Fig. 22. There should be
adequate intrusion of the incisors, since the roots were well forward of the lingual plate. In the
malocclusion in Fig. 23, there will not be any effort to increase the anchorage bends for depression
of the incisors, because the roots have no where to go. If more bite opening is required, a lower
reverse torque assemblage might be inserted to bring the apices into more cancellous bone, where
intrusion is more likely to occur. The Brandt type of lower reverse torque auxiliary can be utilized in
the early stages of treatment for this purpose. Then an occlusal film is taken to be sure that all the
roots have moved into cancellous bone.
Summary
The various incisal movements within the symphysis have been studied with cephalometrics and
laminagrams. These include perforations and near perforations of the lingual plate. A
roentgenographic technique has been developed to record the position of the mandibular incisors in
a transverse plane. The perforations and differences in axial inclination are not readily discernible
by other types of x-rays. Orthodontists are cautioned to take careful note of the size, shape and
dimensions of the symphysis, as well as the positions of the incisors within this region, prior to
initiating tooth movement.
The text of this paper should not be interpreted as an indictment of the Begg technique. By
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Article Text 9
continuing to clarify and learn the details of actual tooth movements with precision, more problems
encountered in treatment can be corrected and controlled. If these complications are understood,
modifications in the mechanotherapy can then be incorporated. The basic principles of the Begg
technique need not be violated. Tipping and uprighting of teeth are still considered by the authors to
be a superior means of treating malocclusions. However, in light of the findings in these studies,
adjustments in the technique seem to be necessary and justified.
ACKNOWLEDGEMENT — The authors wish to thank the following people for their generous
assistance in the preparation of this paper:
R.L. Dijkstra, P. Hartevelt, K.J. Poel, Photography Department, University of Groningen.
Prof. J.R. Blickman, H. van der Zwaag, Institute of Radiology, University of Groningen.
Mr. van der Pol, Institute of Instrument Fabrication, University of Groningen.
Els-Marjan Groenman, Jan Boersma, Department of Orthodontics, University of Groningen.
The authors are especially indebted to Dr. Sidney Brandt, Morristown, N.J. for his counsel and
guidance in the preparation of this manuscript.
FIGURES
Fig. 1
Fig 1 A. Cephalogram before treatment. B. Superimposition C. Cephalogram at beginning of Stage III
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Figures 10
Fig. 2
Fig. 2 A. Cephalogram before treatment. B. Superimposition. C. Cephalogram at beginning of Stage III.
Fig. 3
Fig. 3 A. Cephalogram before treatment. B. Superimposition. C. Cephalogram at beginning of Stage III.
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Figures 11
Fig. 4
Fig. 4 A. Cephalogram before treatment. B. Cephalogram after treatment. C. Superimposition. D. Laminagram,

mandibular incisor.
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Figures 12
Fig. 5
Fig. 5 A. Cephalogram before treatment. B. Cephalogram after treatment. C. Superimposition. D. Laminagram,

mandibular incisor.
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Figures 13
Fig. 6
Fig. 6 Direction of beam for apicoincisal x-ray.
Fig. 7
Fig. 7 Experimental setup, using dry mandible.
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Figures 14
Fig. 8
Fig. 8 Experiment using a piece of wire to determine proper image in an apicoincisal direction.
Fig. 9
Fig. 9 Experiment using wire to determine distance to lingual plate.
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Figures 15
Fig. 10
Fig. 10 Device for taking intraoral x-ray.
Fig. 11
Fig. 11 Intraoral x-ray device in use on patient.
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Figures 16
Fig. 12
Fig. 12 A. Occlusal film after treatment (taken along right central incisor). B. Model after treatment.
Fig. 13
Fig. 13 A. Occlusal film after leveling arch (taken along right central incisor). B. Model immediately after treatment.
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Figures 17
Fig. 14
Fig. 14 Case H.S. After treatment.
899
Figures 18
Fig. 15
Fig. 15 Case H.S. A. Occlusal film after treatment (taken along right central incisor). B. Model after treatment. C.
Changed x-ray angulation. D. Occlusal film (taken at changed angulation).
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Figures 19
Fig. 16
Fig. 16 Case H.B. A. Superimposition. B. Laminagram after treatment. C. Occlusal film after treatment. D. Model after
treatment.
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Figures 20
Fig. 17
Fig. 17 Case A.W. A. Superimposition. B. Occlusal film one month later. C. Occlusal film five months later. D. Partial
headplate showing distinct lingual cortical plate.
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Figures 21
Fig. 18
Fig. 18 Brandt lower reverse torquing auxiliary.
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Figures 22
Fig. 19
Fig. 19 A. Occlusal him, beginning of Stage III. B. Occlusal film after four months. C. Occlusal film after reactivating
spurs on the lateral incisors. D. Partial headplate showing distinct lingual cortical plate.
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Figures 23
Fig. 20
Fig . 20 Case R. H. A . Occlusal film at end of treatment. B. Tracing showing total tooth movement. C. Using the incisor
as a "reference object" for superimposition.
Fig. 21
Fig. 21 A. Occlusal film after intrusion of incisors had ceased. B. Occlusal film with incisors in cancellous bone and axial
inclinations relatively even. C. Occlusal film showing further progress and trabeculation of bone.
905
Figures 24
Fig. 22
Fig. 22 A symphysis favorable for incisor intrusion.
Fig. 23
Fig. 23 A symphysis unfavorable for incisor intrusion.
References
1. Mitchell, D.L. and Stewart, W.L.: Documented leveling of the lower arch using metallic implants for reference. Am.
J. Ortho. 63:526, 1973.
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References 25
2. Root, T.L.: JCO Interviews Terrell L. Root on Headgear. JCO 9:20, 1975.
3. Schudy, F.F.: Sound biologic concepts in orthodontics. Am. J. Ortho. 63:376, 1973.
4. Sims, M.R.: Anchorage variation with the light wire technique. Am. J. Ortho. 59:456, 1971.
5. Ricketts, R.M.: JCO Interviews Robert M. Ricketts on Growth Prediction. JCO 9:420, 1975.
6. Williams, R.: The cant of the occlusal and mandibular planes with and without the pure Begg technique. JCO 2:596,
1968.
7. Wainwright, M.W.: Faciolingual tooth movement: Its influence on the root and cortical plates. Am. J. Ortho. 64:278,
1973.
8. Williams, R.: The diagnostic line. Am. J. Ortho. 55:458, 1969.
9. Schudy, F.F.: JCO Interviews Dr. Fred F. Schudy, JCO 9:495, 1975.
10. Brandt, S.: Begg Technique Course, University of Groningen, Groningen, Holland, April 1971.
907
References 26
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Dec(900 - 905): Fighting Inflation Through Productivity Sharing
Fighting Inflation through Productivity

Sharing
R. J. SCHULHOF
Is it ever possible to make everybody happy? Can you simultaneously increase your profits, your
employee morale, and your patient satisfaction? Can you reduce your percentage overhead and pay
higher salaries at the same time? Can you increase productivity while actually improving quality?
Sounds impossible?
Because of a new management philosophy which we refer to as "Productivity Sharing", we have

accomplished these things at Rocky Mountain Data Systems. And the same philosophy just might
work for you in your orthodontic office.
Productivity Sharing
The concept behind productivity sharing is simple. If we increase the total wealth produced per
person, we can pay each worker more and take home more ourselves. Increased productivity is thus
shared by the worker, the management, and the public. On the other hand, if we find that we
produce less per person working in our organization, we must either raise prices, decrease profits, or
lower wages. Since the general trend is that wages always increase, we are therefore actually left
with one of the first two alternatives.
We might think that sharing productivity only works in a growing market. However, it can also
be used in a stable or declining market to eliminate unnecessary salaries and costs, making sure that
each dollar spent for salaries is being spent well. If productivity sharing can cause better service for
the patient you might even find your practice expanding while others decline.
Although Rocky Mountain Data Systems is not an orthodontic practice, but rather a service
company of approximately 20 employees, we are dealing with basically the same labor pool as the
orthodontist. Our system is applicable to motivating the employees of an orthodontic practice in that
we are also hiring untrained females, sometimes giving them their first job, and must train them
from the ground up to do a highly skilled manual task.
To explain the rationale behind productivity sharing, it is necessary to understand how and why it
started. As you may know, Rocky Mountain Data Systems is a service corporation offering
cephalometric analyses to the orthodontic profession. The first 5 years of its history saw tremendous
and steady growth — but no profit. The problem centered around the amount of training required
for each employee. It takes 6 months for a new trainee to become a cephalometric analyst capable of
earning a day's pay. I am sure your experience in hiring untrained females will vouch for the fact
that a turnover rate of between 15 and 30% per year is not atypical. Even if the average employee
stays with you for 3 years (which doesn't sound too bad), you will replace one-third of your work
force each year. Since it takes a year to develop a really good employee, actually only two-thirds of
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their stay is profitable to you.
I thought our workers were fairly productive. We had a merit review system which rewarded each
worker according to her own total production and the quality of her work. Every six months, her
work was reviewed and she received a raise proportionate to her quantity and quality. Certainly we
were doing all we could.
The end of 1973 had seen a break-even year. Although we were please with this, inflation was
rampant. Our average production salary was $145 a week plus benefits; but if each employee were
to keep up with the cost of living, salaries would have to be raised 10%. There was just no way to do
it. Since the company was breaking even, the workers were getting every dollar we could afford to
pay them. I myself had not had a raise in four years.
Who were the hardest workers? Well, myself and Jack Chew, our Data Systems man. What was
the difference between us and everyone else? Was it that we were men with family responsibilities,
and they were women? Or was it because we were part-owners of the company, knowing that we
would benefit directly if the company was a success? The sky was the limit for us. We had no
established maximum salary, no limitations — just the knowledge that if we made good, we would
be rewarded. And, more importantly, we felt we owned the business.
It is true of almost every successful business that the owner is the one who works hardest. He has
the most to gain and the most to lose. Perhaps this was the answer. If we could somehow restructure
our setup so each worker would have the same zeal we did.
What To Do?
How about stock ownership? No. Our stock wasn't traded on any exchange, and hence had no
immediate value. Possibly in five or ten years it might, but to expect our employees to work for such
an abstract goal was not too realistic.
How about a profit sharing and pension program? There was no profit to share, and the pension
requires that you either leave the company to get it or wait many years. Also, because of new
government regulations, pension funds are associated with more and more headaches, paperwork,
and risk.
In addition, our experience had shown that our 6-month merit reviews had the problem of being
every 6 months. Ever notice how hard an employee works two weeks before the review? No, the
carrot was not close enough to the nose. Hence, if 6 months is too long a period to motivate,
retirement has even less attraction for the particular group we are dealing with. Men and women in
their 40's and 50's are interested in retirement; people in their 20's and 30's are not.
How about piece-work? Certainly that is a simple way of paying directly for work done. We had
tried that, and it resulted in lower quality and a total disappearance of teamwork. It was every
woman for herself.
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How about job-enrichment and shared decision-making to get the employees involved? After
years of experimentation with every new management fad published, we have found that the
principle that each worker should make as many decisions as possible about her work is quite
feasible. Management should not try to do all the thinking. However, involving the employees
"democratically" in the decision-making process tends to waste time and cause divisive factional
splits. Running a business must be autocratic in a sense. Decisions cannot be made by committee;
they must be made by the person who has the most information and is best qualified to make the
decision. When that person is the worker, that is fine. But when it is the boss, democracy won't work.
So we had to do something new. We accepted the objective to pay everyone working for us as
much as we could. After much experimentation, we hit on the following formula:
1) TAKE A BASE YEAR (OR YEARS) WHICH YOU CONSIDER TO BE ADEQUATE IN

TERMS OF PROFITS— NOT SO HIGH THAT IT WAS ACHIEVED UNDER FORTUITOUS
CIRCUMSTANCES, BUT NOT SO LOW THAT YOU COULDN'T EXIST IF YOU COULD
NOT BETTER IT.
For us, that amounted to the 12 months, July 1973 to July 1974. At that time, we were basically
scraping by with a 5% return on invested capital.
2) YOU WILL NEED TO CALCULATE TWO FIGURES:
A) YOUR TOTAL GROSS RECEIPTS
B) THE TOTAL SALARY FIGURES (ALL EMPLOYEES)
If you are the sole proprietor, you should probably not count your own pay as a salary.
3) DIVIDE YOUR GROSS SALES OR RECEIPTS BY THE SALARIES PAID IN THE PAST
YEAR. THIS GIVES YOUR PRODUCTIVITY BASE.
4) EACH MONTH, DIVIDE THE SALES BY THE SALARIES PAID TO CALCULATE THE
PRODUCTIVITY RATIO FOR THE MONTH. IF THE MONTH'S PRODUCTIVITY RATIO IS
GREATER THAN THE PRODUCTIVITY BASE, PAY A BONUS THAT MONTH TO EACH
EMPLOYEE EQUAL TO ONE-HALF OF THE INCREASE; THEREFORE SHARING THE
PRODUCTIVITY GAIN BETWEEN MANAGEMENT AND LABOR.
For example, if you are the average orthodontic practice, your salaries paid equal 20% of your
gross; therefore, your productivity base is 5. If, in a given month, the productivity ratio went to 6,
which is a 20% increase over the base, you would give each one of your employees a separate check
at the end of the month for 10% of their salary equal to one-half the productivity increase. The
productivity bonus has the following advantages over other methods of incentive:
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Article Text 3
1 ) You can afford to pay it. The people make more as you make more.
2) It is paid monthly. The carrot is on a very short stick, maximizing motivation. In addition, it has
an advantage over straight salary in that you cannot rest on your laurels. You must perform each
month to get your money.
3) It is easy to calculate. You do not need to do a complete accounting, or open up the company
books for inspection, in order to pay it. All you need to know are gross receipts and gross salaries.
4) It is an incentive geared to the success of the whole team, not just one individual trying to look
like a hero. It develops a positive attitude toward the company.
5) It solves the problem of employees who have reached the maximum salary in their category . They
have new hope to make more.
In addition, we offered a quarterly cash bonus equal to 10% of the profits. This was done so that
profit became a dollar you put in your pocket. The profit-sharing bonus had the (one) disadvantage
of requiring an extensive calculation .
We are willing to show our official profit statement to any of our employees as a matter of
record. As an orthodontist, you may not wish to do this. However, if you are a corporation, paying
yourself a salary that you consider to be reasonable, you might use what is left over as a real profit,
which can then be an incentive.
We continued our merit review program as before. It is necessary to reward individual

performance and to make sure that your salary system pays the best employees the most money.
Your merit review system ranks your employees and gives them their proportionate share of the
wealth. Your productivity bonus determines how much wealth there is to share.
How Did It Work?
What was the result of all this? The immediate result was, of course, an enthusiastic reaction.
Everyone seemed to respond well to the goal that we shall all try to get rich together. After all, if we
didn't want to become wealthier, why were we working?
I am sure you are aware of the cyclic nature of orthodontic case starts, with the lows in January
and June, and the highs when it is time to get back to school. This pattern was doing us in, as during
the bad months we had too many people, and during the good months we didn't have enough (and
deliveries would lag).
Our new system was started in August, which is usually a fairly good month, but not a peak. We
noticed immediately that the cases began going out faster. People were not only working harder, but
smarter; since it was now their business, they wanted to make their customers happy. Even though
business hadn't increased, backlog decreased, and service and quality improved. In addition,
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discussions changed from, "Why haven't you repainted the bathrooms?" to "Is there money in the
budget to repaint the bathrooms, or should we wait? We certainly don't want to cut into profits."
The result was a real cash bonus the first month of about $20 green money per employee. This
really excited them, and was likely a key element in the success of the program. We hadn't set the
goal too high, and had shown them we were serious about paying them real money. That lump sum
of $20 meant a lot more than a raise of $5 a week, which would have been dribbled away.
In succeeding months, some strange things happened. The marginal workers who were, in fact,
"ripping off the company" were now "ripping off the workers." A few found it difficult to accept,
subsequently quitting, as it was no longer socially acceptable not to work to capacity.
Who were these people replaced by? Well, as each vacancy occurred, there was a discussion as to
whether the gap could be filled by current employees. The employees were allowed to decide
whether they could find a way to take over the heavier load and thereby increase productivity (and
their take-home pay), or whether they needed help. In every case, they elected to bear the burden.
When is the last time that happened in your office?
After the marginal employees left, another phenomenon ensued. The real performers, who had
been holding back, became more highly motivated than ever! Under the previous policy, they
apparently had held the attitude, "If they don't care, why should I?" Equality is a myth. People are
very unequal, and the key to success is to have the most unequal people you can find.
Productivity Sharing in a Recession
Enter the great recession of 1974. For the first time in our history, business actually declined. We
had grown to the point where we could not add enough new customers to compensate for the lower
case starts of our old customers. This was a real test of the system. What would happen in a
declining market?
Previously, our employees had us over a barrel. They knew that anyone with a year's experience
was worth a fortune, and they could get away with quite a bit before we would be upset enough to
fire them. Now, suddenly (with our increased productivity), the under-achievers had become
expendable. The recession allowed us to get rid of them, and the efficient people were motivated to
learn additional skills and take over the burden of the vacated jobs.
THE RECESSION YEAR OF 1975 ACTUALLY SAW EQUAL OR REDUCED SALES IN

SOME MONTHS— YET SALARIES AND EARNINGS CONTINUED TO GROW— AS ONE
BY ONE THE WEAK EMPLOYEES WERE BEING WEEDED OUT AND THE STRONG
WORKERS WERE MOTIVATED TO TAKE OVER FOR THEM. The workers were willing to
take over new tasks, because there was something in it for them. The result was no loss of profits,
even during a recession year. In fact, during 1975 profits grew to 7% of sales. And each employee
was making additional money through bonuses. By the end of 1975, the bonuses were equaling 10%
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Article Text 5
of salaries. That is, an employee earning $600 a month would receive a lump-sum check of $60
actual spendable income each month (less payroll taxes) .
Enter the recovery of 1976. Normally, a recovery would mean hiring new, inexperienced people,
throwing them on the production line, and hoping quality wouldn't suffer too much. Because our
bonus system had resulted in increased profits in 1974 and 1975, we could now afford some new
equipment in order to automate. Every previous attempt at automation had met with considerable
resistance. People are more comfortable with old problems than new solutions. They tend to be
afraid of — and resist — change. How often have you brought back a new technique from a
meeting, only to find its implementation resisted every step of the way? When I would implement a
new system, I would immediately receive a barrage of reasons why it wouldn't work. Or, once the
system was implemented, I would have a whole lot of problems "that it had caused" dumped in my
lap.
Productivity Sharing Today
In 1976, we changed our production methods significantly, using new equipment which we felt
would improve production and cut labor, provided it was used properly. The system was presented
as a means of increasing business by producing a better product and distributing it with the same
number of people. Since this would result in increased productivity, it would result in increased
salaries as well. Instead of the usual, "It can't be done," the reaction was, "Great. We'll make it
work."
Business is now up 50% over last year, with no increase in personnel. Turnover is negligible —
5% compared to our previous 30% — with only one person in 20 having been replaced during the
last 12 months. Most importantly, the customers are reporting improved quality and faster service.
This has actually built the business.
The productivity snowball continues to increase. The more productivity increases, the more
money our employees are paid, and the more highly motivated they are to do better work. As people
receive higher compensation and enjoy their work more, they tend to stay longer— producing more
and better work, and receiving even more money. Average compensation has risen from $145 to
$216 per week in two years— an increase of over 50%. Productivity is up 70%, and profits have
reached an all-time high of 10% of sales. The company has continued its policy of no price
increases; therefore, as inflation increases, the product becomes an even better buy. Sharing the
wealth has created wealth to share, and we don't have a union at Rocky Mountain Data Systems.
Those who don't believe in the system point to the fact that surveys in some orthodontic offices
show that recognition, and not money, is the primary motivating factor. First you must ask yourself
the obvious: If money were the primary motivating factor, would that person have been working in
that orthodontic office in the first place? Recognition in dollars, and pointing to the team's progress
(as compared to their goal), is a very communicative form of recognition for a job well-done.
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People would rather work to make themselves rich than to make you rich. This is human nature.
However, if making themselves rich also aids in making you rich, you have teamwork cooperation
to achieve your mutual objective.
Summary
1) Define the productivity ratio as dollar sales per dollar salary. This will protect you if you increase
salaries by merit reviews or promotions.
2) Choose a goal low enough so that the system will pay money soon, even if you have to prime the
pump a bit.
3)Never change the goal. This undermines confidence in the system.
4) Resist the temptation to become greedy. You may begin to feel that your people are overpaid
when you add up the total salary at the end of the year. But remember, for every extra dollar they
took home, you earned an extra dollar, too. What they received, they earned.
I am sure you will find seeing the distinctions between labor and management erased as exciting
as we have. The economic system of our country could likely be increased 30% if labor would stop
fighting management, and vice versa. Management attempts to get the workers to do as much as
possible for as little pay as possible. Labor retaliates by trying to do as little work as possible for the
highest salaries they can get.
Compare this to a football team in which the line and the backfield are playing two different
games. Teams that don't work together never win the Super Bowl. Does your team work together?
R. J. SCHULHOF
President, Rocky Mountain Data Systems, 15125 Ventura

Blvd., Sherman Oaks, Calif. 91403.
BONUS
Our policy is that the employee must have at least 6 months'

service to be eligible for the bonus.
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Footnotes 7
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Dec(906 - 917): The Modular Self-Locking Appliance System Part 4: A Variation in the Combinati
THE MODULAR SELF-LOCKING APPLIANCE

SYSTEM
Part 4
JACK M. MAGILL, DDS
This is the fourth installment in this series in which Drs. Fogel and Magill are presenting the
appliance system and treatment procedures of the Modular Self-Locking Appliance. Parts 1, 2, and 3
appeared in the September, October and November issues of JCO.
NOTE— The receptacles used in the clinical cases in this series are triple-slotted Siamese
attachments, since the one-piece receptacle described in the first installment was not available at the
time these cases were treated. However, they are currently obtainable (Rocky
Mountain/Orthodontics) and are being used. Principles of archwire insertion in treatment remain
exactly the same.
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CASE 3
Patient M.T., age 22.
The case presented fullness of the lower third of the face masked to some extent by the generous
soft tissue. The maxillary incisors were markedly protrusive and irregular; lower incisors were
crowded in spite of the fact that one lower incisor was missing. Overbite was shallow.
Treatment
The four first premolars were extracted and the Modular Self-Locking Appliance was placed with
the insert brackets in the usual first stage position — in the mesial vertical slots on the incisors and
in the distal vertical slots on the cuspids. Multiple-loop .016 archwires were placed and Class II
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mechanics were started.
The anterior teeth in both arches were quickly unravelled, at which time plain 2-looped archwires
were placed and Class II mechanics continued.
With the lower incisors in good position, Class III mechanics were not necessary. The overbite is
moderately corrected and will continue to improve during the leveling stage. Preparatory to the
leveling stage, the second insert brackets are placed to create the twin self-locking insert brackets.
The space-closing and leveling archwires are then freely engaged in the insert brackets. Leveling
and uprighting now becomes an automatic operation.
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Article Text 3

These archwires should be left in place for six weeks and allowed to expend their forces
completely.
The double-helix finishing appliance and light Class II mechanics, together with natural
physiologic settling while wearing these final appliances, brought this case to a rapid conclusion.
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Treatment took 17 months using four round archwires only. Following appliance removal, the
positioner was worn for a few months. Posttreatment records demonstrate an excellent dental and
facial improvement.
CASE 4
Patient J.W., age 15.
The case presented a Class II division 1 bimaxillary protrusion with marked procumbency and
mild crowding of the upper and lower anterior segments. The upper right cuspid was blocked out of
the arch.
Treatment
Following the extraction of the four first premolars, the Modular Self-Locking Appliance was
placed in the usual manner and treatment was started with 2-looped .016 archwires and Class II
elastics.
The elastic action was changed to Class III to upright the lower incisors and when that action was
successfully completed, the second insert brackets were added to create the twin self-locking insert
brackets and the leveling and space-closing archwires were placed.
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It is interesting to examine tooth positions during the initial stages to observe the favorable
behavior of the incisor teeth as a result of insert bracket placement. In the second stage, the
space-closing and leveling archwires authoritatively control tooth positions, while arch relationships
are maintained with Class II mechanics.
911
Article Text 6
The final double-helix finishing appliance continues the leveling, uprighting and alignment.
The torquing auxiliary is added to the final finishing archwire, to effectively produce the desired
axial inclinations of the maxillary incisors.
The palatal bar which was used as a resistance unit during Class III mechanics, is also maintained
in position during the torquing phase to inhibit widening of the buccal segments during torquing.
912
Article Text 7
Treatment time was 30 months. Following appliance removal, a positioner was used for a few
months. Post-treatment records demonstrating the marked improvement in tooth position and facial
profile are the routine type of result that we expect.
913
Article Text 8
Comments
The response of the teeth to the low frictional attachments of the Modular Self-Locking
Appliance System are tremendously interesting. It is an effortless reaction to suitably adjusted
simple archwires placed in the insert brackets.
CASE 5
Patient E.M., age 14.
The case presented a Class II malocclusion with a deep overbite and severe crowding in the
anterior segments.
Treatment
Following the extraction of the four first premolars, the Modular Self-Locking Appliance was
placed. At the end of Stage 1, after 10 weeks, the bite had opened and all anterior teeth had been
adequately aligned.
914
Article Text 9

Note that in this case the insert brackets were centrally positioned in Stage 1. There appears to be
little difference in the type of tooth movement, compared to cases in which the insert brackets are
placed in the mesial slot on the incisors. Usually, the mesial slot is used and it is time-saving when
the second insert bracket is added for the second stage.
915
Article Text 10
The single insert brackets were exchanged, therefore, for the double insert brackets at the
beginning of Stage 2 and the .018 leveling and space-closing archwires were placed. Space-closing
and leveling were smoothly accomplished.
For the final phase, the double-helix finishing appliance is placed.
916
Article Text 11
The torquing auxiliary is placed over the double-helix finishing appliance.
Each stage should take approximately three to four months, depending on the severity of the
malocclusion. Following 14 months of treatment, appliances were removed and a tooth positioner
was used for three months. Post-treatment results show favorable tooth positioner and facial profile.
(TO BE CONTINUED)
917
Article Text 12
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Dec(918 - 919): The High-Pull Timing Headgear
THE HIGH-PULL TIMING HEADGEAR

MICHAEL E. NORTHCUTT, DDS
In two previous articles in JCO— The Timing Headgear (June 1974) and Updating the Timing
Headgear (November 1975)— I have shown the design and use of the timing headgear. For those
not already acquainted with this appliance, it is a headgear which contains a timing module to record
the time that the headgear is actually used. The accumulated time appears as a digital readout on a
readout unit in the office.
The cervical timing headgear.
Closeup of timing headgear unit.
Orthoband harness.
Cervical timing headgear combined with Orthoband harness.

High-Pull Timing Headgear
918
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JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Dec(918 - 919): The High-Pull Timing Headgear
The high-pull version presented some unique problems not

found in the cervical version, and took longer to develop. Its final form is the result of a long
evolution of test and rebuild and solving such problems as variable head size and shape. It is
comprised of a harness into which the standard cervical timing headgear is inserted.
The advantages of this design are:

1. The cervical headgear timer can now be integrated into the high-pull form to reduce inventory.
2. All strapping is removable, so that it is replaceable and so that the timing headgear unit may be
reused on multiple patients.
3. The high-pull timing headgear harness is flexible to accommodate variations in head size and pull
angles.
The timing headgear unit has been shortened and considerably modified from its original form.
There is a new spring-loaded probe receiver on the module, and the internal electronics have been
vastly improved.
headgear
Aledyne Corporation, Box 652, Los Altos, Calif. 94022.
919
Footnotes 2
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Dec(919 - 920): It's Time For the Timing Headgear
It's time for the TIMING HEADGEAR

JOE I. MITCHELL, DDS
One of the products that we have been evaluating in our graduate orthodontic clinic at Ohio State
University is the new Timing Headgear. We presently have 22 units that have been in use on our
clinic patients for up to eight months, and they have been very well received by both the students
and our patients.
At first we tried this new product on patients with a history of poor cooperation and saw
improvements in a great majority of the cases. All of a sudden, cases that were going nowhere
started making progress. In addition to using the Timing Headgear on these "problem" patients, we
now also use them with new patients to help us evaluate potential cooperation. In cases where we
would like to use some type of headgear, we try the Timing Headgear first and monitor the amount
of wear for four or five weeks. This gives us an indication of the potential cooperation. We find this
to be very helpful in treatment planning.
The Timing Headgear has been very enlightening to us from a number of standpoints. We are
now seeing the effect of good headgear wear on treatment. We were also able to see just how little
the patients were actually wearing the headgear before. Where before we would question our
mechanics in the slow moving cases, now we can point with more certainty to lack of cooperation as
the problem in many instances. We can also explain to the parents why treatment was progressing so
slowly.
It was not uncommon at all to get readings showing an average of four hours wear per day from
patients who had been asked for eighteen or more hours per day. Readings like this from even some
of our best patients made us question the accuracy of the device itself. This prompted us to do a
controlled study of the Timing Headgear. We found it to be accurate to within one hour in one
hundred and twenty. Some of our patients who diligently record the amount of wear they get have
shown it to be accurate to within one hour in as many as four hundred and sixty. The durability and
reliability of both the headgears and the digital readout device have been excellent. With the
exception of one unit worn in the shower, we have had no malfunctions to date.
Perhaps even more enlightening is the response of the patients to the Timing Headgear or "Bionic
Nite Brace" as one of them calls it. While some of them still squirm and fidget and make excuses
why they haven't worn the headgear, many others very proudly write their prediction on a slip of
paper to see how closely their total matches the digital counter.
Some patients undergo quite a change after a few months with the Timing Headgear. We have all
had patients who would swear up and down that they were wearing their headgear just as instructed
in spite of a lack of clinical signs. Many of these patients who would defy you to suggest that they
were not getting the proper amount of wear did a complete turn about when confronted with the
Timing Headgear. Since the number of hours that the headgear has been worn is no longer a point of
contention, the patients now turn their determination into wearing the headgear and trying to predict
919
Article Text 1
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Dec(919 - 920): It's Time For the Timing Headgear
the total hours that the counter will show.
Of course, there are still a few patients who just will not cooperate regardless of the situation.
The Timing Headgear can single these out for us very quickly and we can adjust our treatment
accordingly. In general, the patients like the new headgear because they realize that they are making
progress and this means that they will be completing treatment sooner.
As a result of the universal favorable response from the students and the patients, we have asked
that the Timing Headgear be included as part of the regular treatment regime in the clinic. I am sure
that many of us will also find the Timing Headgear to be a continued valuable aid in our own offices.
Timing Headgear
AIedyne Corporation, Box 652, Los Altos, Calif. 94022.
920
Footnotes 2
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Dec(922 - 923): Management of Impacted Cuspids
MANAGEMENT OF IMPACTED CUSPIDS

ROBERT M. RUBIN, DMD
The history of the management of impacted cuspids includes an array of devices including
castings, circumferential wires, swaged crowns, threaded pins, black copper cement and carboxylate
cement. Direct bonding as a predictably successful technique has largely replaced all the other
methods. The one remaining problem has been maintaining a dry field, which is essential for
successful direct bonding. The development of a bonding material with extremely rapid initial
setting (Bond-Eze, Unitek) has greatly facilitated successful bonding of impacted cuspids in my
office.
No ultraviolet light is necessary which would require additional time for initial polymerization
and increase the likelihood of contamination by moisture.
The Technique Using Bond-Eze

1. Request the surgeon to expose several square millimeters of the cuspid enamel by the most direct
route possible. Several x-rays should be used to locate the cuspid crown and a cephalometric x-ray is
frequently helpful. Palpation is also an important aid. Most impacted upper cuspids require a palatal
approach. The surgeon is asked to place a plastic crown form filled with a non-eugenol dressing to
maintain the opening. It is not essential that the crown form be placed over the incisal edge of the
tooth. Its purpose is to prevent inflammatory tissue from forming over the opening to the crown. A
celluloid or plastic crown form reduces the amount of inflammation so that, when it is removed,
there is little or no bleeding.
2. The patient is scheduled for the bonding procedure 7-10 days after the surgery. The crown form is
carefully removed with an explorer. No anesthesia is necessary. Essentially, a healing fistula has
formed that is free of bleeding.
3. It is rarely possible to pumice the enamel as is usually done in direct bonding procedures.
However, a scaler should be used to remove any organic film from the crown. Care should be taken
not to contact the soft tissue in order to avoid bleeding.
4. Cotton pledgets with epinephrine or other hemostatic agent can be used to stop slight bleeding.
Plain cotton is used to wipe the enamel.
5. An etching gel is carefully introduced onto the exposed enamel. Contact with the soft tissue
should be avoided, although this is not absolutely critical.
6. After the prescribed etching period (usually one minute), a gentle air/water spray is used to
remove the gel. Central evacuation is helpful for this procedure. Gentle blasts of air are used to dry
the enamel, being careful not to provoke bleeding. A frosted white appearance of the enamel
confirms proper etching.
7. A small brush is moistened with the adhesive liquid and introduced into the powder to create a
bead of the mix. This bead is carefully placed on the prepared enamel surface and gently spread,
being certain that it doesn't touch soft tissue or any exudate present. After 15 seconds, the initial
polymerization is complete and it is no longer necessary to be concerned about moisture. The
enamel-adhesive bond is secure, and the subsequent bond between additional adhesive and the
922
Article Text 1
JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume 1976 Dec(922 - 923): Management of Impacted Cuspids
previously placed material can occur in the presence of contamination.

8. A bead of adhesive mix is placed on the back of a plastic attachment (half a Siamese bracket is
excellent) and the attachment is joined to the adhesive on the tooth. The two materials will join
instantly.
9. In five minutes, an elastic ligature can be tied from the plastic attachment to the main archwire. A
section of open coil spring on the archwire is helpful to keep the elastic ligature from sliding on the
archwire.
10. The patient should be seen at approximately three-week intervals. As the crown moves into
position, it may be necessary to rebond the tooth to gain mechanical advantage. Sometimes, soft
tissue surgery is necessary to reduce the buildup of soft tissue that can accompany rapid movement.
This technique has been used successfully in over 100 cases over the past two years. It minimizes
the surgical procedure and greatly reduces the possibility of damage to adjacent teeth that
accompanied procedures that employed pins or circum-coronal wiring.
923
Article Text 2

Jco 1976

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JANUARY 1976, VOL.

THE EDITOR'S CORNER 9

the editor's corner

Patient Master Record.

In my practice, Orthomatic prepares a statement if one of two situation exists. If there is a

Doctor's lnvolvement With Reports

children of referring dentists.

Need to Know Information

Practice Management Systems, Inc. 7280 North Irving

Fig. 3 Treatment slip.

Fig. 4 Preprinted check.

Fig. 5 Sample statement.

DR. BRANDT Can you describe just how that occurs?

DR. BRANDT What cephalometric measurements do you use?

DR. BRANDT Please describe how you use these analyses.

Fig. 3 Result of excellent treatment of Class I malocclusion including serial extraction.

Fig. 12 The Tweed Analysis.

Fig. 13 Class I. Maxillary-mandibular prognathism.

Fig. 14 Class I. Maxillary-mandibular retrognathism.

Fig. 15 Class I. Maxillary-mandibular alveolar dental protrusion.

Fig. 16 Class I. Maxillary-mandibular alveolar dental retrusion.

Fig. 17 Class II. Maxillary prognathism.

Fig. 18 Class II. Mandibular retrognathism.

Fig. 19 Class II. Maxillary alveolar dental protrusion.

Fig. 20 Class II. Mandibular alveolar dental retrusion.

Fig. 21 Class III. Mandibular prognathism.

Fig. 22 Class III. Maxillary retrognathism.

Fig. 23 Class III. Mandibular alveolar dental protrusion.

Fig. 24 Class III. Maxillary alveolar dental retrusion.

Fig. 25 High angle facial pattern.

Fig. 26 Low angle facial pattern.

Full-Scale Color Transparencies of

Fig. 2 Cropped sample of actual transparency.

THE EDITOR'S CORNER 81

the editor's corner

THE STRAIGHT-WIRE APPLIANCE

4. SWA bases are contoured vertically as well as horizontally, resulting in a good

Straight-Wire approach, and it is sustained by an explicit rationale. Final slot location no

The "NONs" Again

SIX KEYS TO NORMAL OCCLUSION

KEY II— Crown angulation, the mesiodistal

KEY III— Crown inclination, the labiolingual or bucco-lingual

(B) Upper posterior crowns (cuspids through

KEY IV— Rotations. Teeth should be free of

KEY Vl— Curve of Spee. A flat occlusal plane should be a treatment

The Other Reasons

Now we can tie static and functional goals together.

An experienced clinician, examining a meaningful innovation, may reasonably ponder whether a

THE SNOWFLAKE PROBLEM

short of them when they are attainable may be unacceptable.")

Clinical Common Sense

This is the first in a series of articles in which Dr. Andrews

That axiom could be interpreted wrongly, as well as rightly.

general dentists (and educators and many others) to change

11. Roth. R. H.: personal communication, 1975.

An Approach to Incisor Retreatment

Incisor relapse overcorrected

"Little Dicktators" should be made up in advance in three sizes so as to be available when

assessed by the Bolton analysis.

A. INITIAL PERIOD OF INTERCEPTIVE TREATMENT. Quite often in Class II division 2 I will

be unwise to proceed with serial extraction in such cases.

DR. BRANDT Is that the way you present it to parents?

Fig. 30 Interproximal reduction of primary cuspid.