Paige Humphries

Orthodontic Specialty Office Visit

For this specialty office observation assignment, I observed an orthodontic office. The

office I visited was Chvatal Orthodontics at the Valley River location. Dr. Chvatal has three

locations in which he practices. Two of these offices are located in Eugene and the other is

located in Cottage Grove. I spent four hours moving from chair to chair and observing several

procedures. The office I visited had eight orthodontic assistants that the doctor moved between

frequently to check the work of the assistants and to make final adjustments.

Debonding Procedure

The first procedure I witnessed was a debonding procedure. The time allotted for this

appointment was one hour. The orthodontic assistant sat and reclined the patient as the first

steps of this procedure. No medical history was reviewed by the orthodontic assistant. The

assistant explained that they were going to be removing the patient's braces, and then placed

cheek retractors into the patient's mouth to increase visibility, keep the field dry, and provide

retraction. The assistant utilized stainless steel bracket removing pliers to remove the metal

brackets. To remove the brackets, the bracket is placed between the pliers and squeezed gently

until the bracket comes loose from the tooth. This was done for each tooth with a bracket, and

when they were all loose, the bracket and archwire came off as one piece. This left behind the

composite resin that was used to hold the bracket to the tooth. Following this, the assistant

utilized a slow-speed handpiece with a tungsten carbide football bur to remove the composite left

on the tooth surface. This process was time-consuming and involved meticulous, overlapping,

and intermittent strokes. Care was taken not to touch the bur to the gingival tissue and to not

“slip” from the tooth surface. Both arches were completed, and then the assistant utilized a small

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ultraviolet light, that made any remaining deposits of composite resin glow, so they could be

easily identified and removed. The assistant then went back and removed any remaining

deposits of composite resin and gave the patient a final rinse.

Following this procedure, the assistant confirmed the need for post-treatment imaging.

This office utilized a cone-beam computed tomography (CBCT) device that scanned the patient's

head and teeth, producing a three-dimensional image. This scan showed the hard and soft tissues

and appeared to be a similar procedure to a typical panoramic imagining machine. They were

able to utilize a form of software to create a panoramic image from the product of the CBCT

scan. This office did not have any other x-ray machines or the capability of taking periapical

images or bite-wing images. Upon completion of the x-rays, the assistant took extraoral photos

of the patient with a traditional digital camera. The patient was asked to face to the left, face to

the front, smile in a front facing position, and then face to the right. These photos are used to

assess overall facial changes/symmetry and to compare to the photos taken before treatment.

After the completion of x-rays and extraoral imaging, the assistant utilized an iTero

scanner for the production of intraoral photos and the creation of retainers. The assistant

retrieved the device, selected the correct patient, and began scanning. The scanner had a

sterilizable cover that went over the lens, and the assistant began methodically moving the device

intraorally to capture all aspects of the dentition and gingival tissue. The device displays the

dentition and oral anatomy/structures digitally. Upon completion of this scan, the assistant

began discussing the plan in place for dental retainers with the patient. For this patient, the

treatment plan included a Hawley removable retainer for the maxillary arch and a fixed

mandibular anterior lingual retainer. The Hawley removable retainer has a metal framework

with an acrylic plate. The Hawley retainers are often manufactured digitally upon the model

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printed from the iTero scan. This office sends the scan to an outsource lab that makes these

appliances and then ships them back to the office. Following this, the dental assistant began

preparing for the orthodontist to place the mandibular fixed lingual bar. The bar used in this

procedure was made from beta titanium and came in a long rod that was cut down into small

pieces for use. The assistant began by adjusting the wire to the right length (canine to canine), as

well as adapting the wire to the natural position of the teeth using an Aderer three-prong wire

bending orthodontic pliers. The assistant then prepared the etch, primer, and bonding agent for

the placement of the lingual bar. The etch used was 37% orthophosphoric acid.

Following this, the orthodontist went over to the patient and began examining the lingual

bar and adjusting the appliance to improve the fit. The orthodontist then dried the mandibular

anterior teeth and etched both mandibular canines on their lingual surfaces. Then with the help

of the assistant and after 20 seconds, the orthodontist rinsed away the etch material and then

dried the teeth again. Following this, the primer was placed and cured for 10 seconds. Then, the

wire was held against the tooth in its appropriate location and the orthodontist applied composite

resin to the canine teeth, covering the wire. The orthodontist used a micro applicator brush to

spread the composite resin over the wire to create a tight seal. Lastly, the composite resin was

cured for 30 seconds. Upon the completion of the mandibular appliance, the patient was advised

to schedule at the front desk and was dismissed from the appointment. Finally, the assistant

began cleaning her space and completing the brief note on what treatment was performed.

Overall, the procedures included explaining the process to the patient, placing cheek retractors,

removing the brackets, removing the composite resin used to hold the brackets to the teeth, and

other post-treatment procedures.

Bonding Procedure

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 The second procedure I got to witness was a bonding procedure. This included only the

placement of brackets from canine to canine on the maxillary arch due to the presence of

remaining primary teeth. The first step in this appointment included explaining the procedures to

the patient and their caregiver. Upon the start of treatment, the patient was reclined, and a cheek

retractor was placed that held the tongue away from the teeth. This type of retractor was utilized

due to the importance of keeping the dentition dry during bonding procedures. Next, the

assistant tried many metallic bands on the patient maxillary molars. Metallic bands are often

placed on the most posterior tooth during the bonding procedure for braces. For this patient, the

purpose of these bands was to allow for the utilization of headgear. The assistant found the band

that fit tightly around the tooth, and then removed the bands and prepared them for the

orthodontist. The assistant then cleaned the buccal surface of the dentition with a dry toothbrush,

followed by a cotton swab. Once the surface was cleared of debris and moisture, the assistant

applied the etch to the teeth (37% orthophosphoric acid) and allowed this to remain on the teeth

for 10 seconds before rinsing the etch off with water and the HVE. After drying the surface

again, the assistant placed a primer onto each tooth and light-cured this for 10-20 seconds. After

this, the assistant selected the brackets that were tooth-specific and placed a small amount of

composite resin onto the mesh framework on the back of each bracket. The brackets utilized by

this office were Azdent Metal Brackets. The assistant used the tip of the composite applicator to

push the material into this framework. Finally, the braces were placed onto the facial surface of

the teeth and moved to their appropriate positioning.

Following this, the orthodontist arrived and utilized a metallic bracket height gauge

instrument to place the brackets in their final position. He also removed any composite that

came out from underneath the bracket with a scaler. Once this was complete, the dentist cured

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the composite resin with a dental LED curing light. Once the brackets were placed, the

orthodontist tried the bands onto the most posterior maxillary molar to confirm the appropriate

fit. With cement placed on the inner aspect of the band, the orthodontist sat the band with the

help of the patient biting them into place with the use of a bite stick. Once the bands were placed

appropriately on the teeth, they were light-cured. The dentist emphasized that the longevity of

the bands had more to do with the fit than the cement used to hold them in place. After the bands

were placed, the dentist moved to a different patient and the assistant began inserting the

archwire. The initial wires are very flexible and thin. The use of self-ligating brackets makes

the insertion of the metal wire into the bracket easier.

Once the bonding procedure was completed, the assistant began discussing home care

with the patient. The assistant walked the patient through the concept of “dry brushing” to

remove the gross debris before brushing with toothpaste and water. The patient was then shown

how to floss around the braces and how to apply wax for comfort as the tissue gets used to the

metal brackets. The orthodontist then returned to try in the face bow of the cervical pull

headgear, which is used to correct class II occlusion (overbite/overjet). This bow inserts into the

holes located on the buccal surface of the bands that were placed on the most posterior maxillary

teeth. Once the orthodontist determined the fit, the assistant demonstrated to the patient how to

use the headgear and the strap. The patient was advised to place the headgear herself, and upon

completion of this, the assistant explained the guidelines to follow for wearing the appliance.

The guidelines included wearing the headgear while sleeping every night and tightening the strap

when it begins to feel loose. Overall, this procedure included the placement of cheek retractors,

brackets, bands, etching, priming, bonding, the placement of the archwire, and home care

instructions.

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Team Members

The team members of this practice included the orthodontist, orthodontic assistants, a

lead orthodontic assistant, a lab technician, a treatment plan coordinator, and front office staff.

The orthodontic assistants work independently for the majority of the appointments. They

complete bonding procedures, debonding procedures, and archwire changes. The orthodontist

oversees the assistants and provides care by finalizing and adjusting the work of the dental

assistant. He makes the decisions for the treatment and then allows the assistants to execute this

for the most part. The lead assistant helps to oversee the other orthodontic assistants and

sometimes works more closely with the orthodontist to provide treatment. This person is usually

more senior to the office or has many years of experience. The lab technician works in a

separate area of the office to create oral appliances in-house for the patients. This includes

utilizing the scans from the iTero device and creating oral appliances on 3-D printed models of

the dentition. The treatment plan coordinator works hand in hand with the orthodontist to come

up with the best course of treatment for the patients. They consider factors such as needed

treatment, finances of the patient, expected outcomes, and ensuring the patient has a full

understanding of the process. Lastly, the front office had two receptionists staffed. These

receptionists work to answer phone calls, schedule patients, check patients in for their

appointments, provide patients with the necessary forms to fill out, and bring patients back to the

operatory. These individuals complete many tasks that keep the office functioning smoothly and

they are often the main point of communication for the patient. Overall, each team member plays

a critical role in the flow of this office.

Employment of a Dental Hygienist

When asking the orthodontist and the dental assistant why they didn’t have a dental

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hygienist in the office, they all mentioned that the idea sounded great, but they simply had never

had one. The assistant mentioned that several times per day, patients come into the office to get

their archwire removed and then go to a different dental office to receive prophylactic care.

These patients then return to the orthodontist on that same day to have the wire put back in. This

may be exhausting for the patient and the assistant staff. An in-office dental hygienist could

benefit the orthodontist staff as well as the patients. Braces make plaque control challenging,

especially when younger children have these appliances and are responsible for maintaining their

oral health. Frequent deplaquing and debriding would be extremely beneficial to these patients,

as well as frequent homecare education. The orthodontic assistant seemed to focus on brushing

and home care during the bonding procedures, but this was not revisited for any other procedures

that I witnessed. I could see a major benefit in having a dental hygienist as well as a general

dentist in the office. This would allow for collaboration and well-rounded patient care.

Record Keeping

This office had a very brief and simple format for their charting. The assistants would

select a pre-typed note consisting of a few sentences of information. They reviewed this pre-

made note and then adjusted it to ensure that it accurately depicted the treatment provided. The

note for the treatment provided (debonding, bonding, wire change, etc.) only included what was

completed during the appointment that day. It did not include progress made, evaluation of the

dentition, bite analysis, or even aesthetic perspectives. The software used for dental charting was

Cloud 9 Software. Based on a conversation with the orthodontic assistants, I learned that their

charting at initial appointments (consultation) usually focuses on items such as bite/occlusion,

the position of the teeth, and aesthetic goals. The focus in this orthodontic office was not on

dental disease, carious lesions, or other factors that are considered and evaluated by a general

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dentist.

Sterilization and Infection Control

The sterilization room of this office was set up very similar to the sterilization room at

LCC. It was in a location that patients were not frequently walking past. It exhibited a clearly

defined “dirty” side and a “clean” side. This office had one large ultrasonic, with two sterilizers

which were the same “Midmark Ultraclave” that we use at LCC. They utilized CaviWipes to

clean their operatories and equipment between patients. One major difference in infection control

that I noted was the fact that they utilize barriers less frequently than LCC does, leave

unpackaged instruments in their unit drawers, and the fact that they handle sterilized packaged

instruments with ungloved hands. Although we do not do these things at LCC, I have heard this

may be a common practice within the “real world”. Overall, I think LCC has an extremely

effective and thorough method for infection control and sterilization, and seeing an office use

similar processes was a positive.

Rationale for Referral

Patients may be referred to an orthodontist by their general dentist. This referral is often

prescribed to children, yet the need for orthodontic treatment may not become prevalent until

later in life for some individuals. Individuals are referred to an orthodontist for reasons such as

crowding of the dentition, to align bite/occlusion issues, and TMJ problems. One of the most

prominent reasons for a referral to an orthodontist is for aesthetic reasons, the straightening and

aligning of the teeth. Orthodontics works to correct malocclusion, overjet, overbite, open bite,

excessive spacing between the teeth, and many other conditions. The patient first schedules an

appointment with the orthodontist and then works with the treatment plan coordinator to

determine how the patient's goals will be met.

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Unique Observations

Overall, I enjoyed this office visit far more than the clinical restorative rotation. In

general offices, it seems as if the dentist and assistant are almost always working together as a

pair, whereas the orthodontic assistants functioned extremely independently. They understood

and were trained to complete nearly all of the procedures, and the orthodontist would examine

the work they did, complete the finalization aspects of treatment, and then move along to the

next patient. I prefer independent work, and that is part of the reason I enjoy dental hygiene so

much. We get to work with many other individuals, but we also have an abundance of

independence. Dr. Chvatal’s office overall ran very smoothly. The staff were kind, good with

the patients, and seemed happy to be there. It is exciting to be a part of a school that allows and

encourages us students to try new things and explore other areas of the dental world. I enjoyed

and learned a lot from this experience.

Contact

Chvatal Orthodontics- Valley River Center (Dr. Chvatal)

Date of office visit: 11/01/2023 9am-1pm

https://www.eugenebraces.com

(541) 683-8490