Paige Humphries

11/02/2023
Orthodontic Specialty Visit
For this specialty office observation assignment, I observed an orthodontic office. I spent 4 hours moving
from chair to chair and observing several procedures. The office I visited had 8 orthodontist assistants that the
doctor would move between frequently to check the work of the assistants and make final adjustments.

Debonding
The first procedure I got to witness was a debonding procedure. The appointment time/ length allotted for this
procedure was one hour. The orthodontal assistant sat and reclined the patient as the first steps to the
procedure. No medical history was reviewed by the orthodontist assistant. The assistant asked if the patient had
any questions, and when there were none, the assistant began by first explaining that they were going to be
removing the patient braces. Cheek retractor were utilized to increase visibility, keep the field dry, and to
provide retraction. The assistant utilized stainless steel bracket removing pliers to remove the metal brackets.
To remove the brackets, they place the bracket between the pliers and squeezed gently until the bracket came
loose from the tooth. This was completed for each tooth with a bracket, and when they were all loose, the
bracket and arch wire came off as one piece, leaving behind 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. Upon the completion of an arch, the assistant provided water and suction to
remove the particles of the composite. Both arches were completed, and then the assistant utilized a small
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 the composite resin, and
then gave the patient a final rinse.

Upon the patient return from brushing their teeth, the assistant confirmed the need for post treatment imaging.
The office utilized a Cone-beam Computed Tomography device that scanned the patients head and teeth and
produced a three-dimensional depiction of the patient. This scan showed the hard and soft tissues and
appeared to be a similar procedure to a typical panoramic imagining machine. They could utilize the imaging
to create a panoramic image from the product of the CT 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 asked the patient to stand Infront of a bright screen attached to the wall to take extraoral photos. The
patient was asked to face to the left, face to the front, smile in front facing position, and then face to the right.
This is used to assess overall facial changes / symmetry and to compare to the photos taken prior to treatment.

After the completion of x-rays and extraoral imaging, the assistant utilized an iTero scanner for the production
of intraoral photos and for the creation of retainers. The assistant retrieved the device, selected the correct
patient, and began scanning. The scanner has 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. For this patient they were to complete a
Hawley removable dental 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 printed from the itero scan. This office sends the scan to an out- source
that makes these appliances. Following this, the dental assistant began preparing for the orthodontist to place
the mandibular fixed lingual bar. The bar is made from beta titanium and comes in a long rod that is cut down
into small pieces for use. The assistant began by trying in the wire and adjusting into the right length (canine
to canine), as well as adapting the wire to the natural tooth positioning by using a Aderer Plier Three Prong
wire bending orthodontic device. The assistant then prepared an etch, primer, and bonding agent for the
placement of the lingual bar. The etch used was 37% orthophosphoric acid.

Following this, the orthodontist came over to the patient and began checking the fit of the lingual bar and

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making finalization adjustments to the appliance. The orthodontist then dried the dentition, and etched both
mandibular canines on their lingual surface. Then with the help of the assistant and after about 20 seconds the
orthodontist rinsed away the etch material and then dried to tooth well. Following this the primer way placed
and cured for 10 seconds. Lastly the wire was held against the tooth in its appropriate location and the dentist
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 activities.

Bonding Procedure
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 dentition. The
first step in this procedure included explaining the procedures to the patient and their care giver. Upon the
start of treatment, the patient was reclined, and a cheek retractor was placed that held the tongue back. This
type of retractor was utilized due to the importance of keeping the field dry during bonding procedures. The
assistant 1st tried in many metallic bands that are often placed on the most posterior molar tooth. For this
patient, these bands were placed to allow for the utilization of head gear. The assistant found the band that fit
the best to the tooth, and then removed the bands and prepared them for the doctor. 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 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. Upon drying the
surface again, the assistant placed a primer onto the tooth surface and light cured this for 10-20 seconds. After
this the assistant selected the brackets that are tooth specific and placed a small amount of composite resin onto
the mesh framework on the back of the 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 braced were set onto the dentition and moved to their appropriate positioning. At this point the
assistant called the orthodontist over the evaluate the brackets. He utilized a metallic bracket height gauge
instrument to place the brackets in their final position and removed any composite than came out from under
the bracket with a scaler. Once this was complete the dentist cured the composite resin with a dental LED
curing light. Once the brackets were placed the orthodontist tried on the bands that the assistant had selected
to confirmed appropriate fit, and then with cement placed on the inner aspect of the band, the orthodontist sat
the band with the help of the patient biting it into place with the use of a bite stick. Once the bands were sat
appropriately on the tooth, 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 wire. 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. The
patient was sat up and asked if anything felt uncomfortable or sharp and then the assistant began going over
homecare. The assistant walked the patient though the concept of “dry brushing” to remove the gross debris
prior to brushing with tooth paste 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. Th 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 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 head gear and the strap. The patient was advised to place the head gear on in the mirror and to then show
the assistant. Upon completion of this the assistant explained the guidelines to follow for wearing the
appliance such as wearing it every night to bed and tightening the strap when it begins to feel loose. The
patient was then dismissed and told to schedule their next appointment in 8 weeks. Overall, this procedure
included the placement of cheek retractors, brackets, bands, etching, priming, bonding, the placement of the
arch wire, and homecare instruction.

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Team Members
The team members of this practice included the orthodontist, orthodontic assistants, a lead orthodontic
assistant, lab technician, treatment plan coordinator, and front office staff. The orthodontic assistants work
independently for the majority of the appointment. They remove brackets, place braces, and complete wire
changes. The orthodontist oversees all of the assistants and provides care by finalizing and adjusting the work
of the dental assistant to make it the best it can be. He makes the decisions for the treatment that is to be had
and allows his assistants to execute this for the most part. The lead assistant helps to oversee the other
orthodontist 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 appliance in house for the patients. This includes utilizing the scans
from the iTero device and creating devices 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 factor 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 receptionist work to answer phone calls, schedule patients, check patients in for their
appointment, provide patients with the necessary forms to fill out, and to bring patients back to the operatory.
These individuals complete many tasks that keep the office functioning smoothly and they are 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 hygienist in
office, they all mentioned that the idea sounded great, but they simply did not have one. The assistant
mentioned that several times per day, people come in to get the arch wire removed, go get a cleaning at a
different dental office, and then return back to the orthodontist on that same day to have the wire put back in.
This may be exhausting on the patient and the assistant staff. An in-office hygienist could benefit the
orthodontist staff as well as the patient. Braces make plaque control challenging, especially when younger
children have them and are responsible to maintain their own oral health. Frequent deplaqueing and debriding
would be extremely beneficial to these patients, as well as frequent education about home care. The
orthodontic assistant seemed to focus on brushing and home care upon the bonding procedures, but this was
not touched on again for any other procedures that I witnessed. I could see an emmense benefit in having a
hygienist and as well as a general dentist in office. This would allow for collaboration and well-rounded
patient care.

Record Keeping
This office has a very brief and simple format to their charting. The assistants would select a pre-
typed note consisting of a few sentences of information. They review this pre-made note and adjust make sure
it accurately depicted the treatment provided. The note for all treatment provided (debonding, bonding, wire
change, etc.) only included what was completed during treatment 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 conversation with the orthodontic assistants, I learned that their charting at
initial appointments (consultation) usually involves focus on items such as bite, position of the teeth, and
esthetic goals. The focus is not on dental disease, carious lesions or other factors that are considered and
evaluated by a general dentist.

Sterilization and Infection Control

The sterilization of this office was set up very similar to the sterilization room at LCC. It was in a
location that patients would not be walking past it frequently. It exhibited a clearly defined “dirty” side and
“clean” side. This office had one large ultrasonic, with two sterilizers which were the same “Midmark
Ultraclave” that we have at LCC. They did not have a method in place to label whether what was in the
sterilizer was clean or dirty, and stated that the outside of the sterilizer was to be managed with clean hands.
One major difference in infection control that I noted was the fact that they utilize barriers much less
frequently, leave unpackaged “clean” instruments in their unit drawers, and the fact that they handled
sterilized, packaged instruments with ungloved hands.

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Rationale for referral
Patients are often referred to an orthodontist from their general dentist and they are often referred as
children but sometimes may not receive or need orthodontic care until they are older. Individuals are referred
to orthodontist for crowding of the dentition, bite/ occlusal issues, TMJ problems, aesthetic reasons

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 go hand in hand and come as a pair. Whereas the orthodontist assistants
functioned extremely independently. They understood and were trained to complete the procedures, and the
orthodontist would examine the work they did and then move along. I prefer the independent work, and that is
part of the reason I enjoy dental hygiene so much. We get to work with many other individuals, but from a
distance sometimes and with an independent role. Dr. Chavatals office ran very smoothly, the staff was kind,
good with the patients, and hard working.

Contact
Chavatal Orthodontics (Dr. Chavatal)
Date: 11/01/2023
https://www.eugenebraces.com
(541) 683-8490

Specialty Office Observation Report

1. Describe, in detail, the treatment procedures you observed the specialist provide. Include instruments
and specific dental materials used, and post-operative instructions if applicable.
2. In addition to the procedures you observed, list the other services typically provided by this specialty
office.
3. List all of the office team members and briefly describe their roles and responsibilities.
4. If the office employs a dental hygienist, describe the scope and extent of his/her role in the specialty
practice.
5. Briefly describe the components of the patient record that are specific to the specialty practice and
explain their use. Describe specific practice management software, if applicable and if it is specialized
for the specialty practice.
6. Describe sterilization, disinfection and infection control procedures used in the specialty practice.
Describe any techniques, materials, products, or protocols that differ from those used in the LCC dental
clinic. Include your opinion and rationale as to whether or not LCC should adopt these techniques,
materials, products, or protocols.
7. Describe the rationale for referral from a general dentist to this type of specialist.
8. Include your unique, personal observations and reflections regarding your visit.
9. Submit the typewritten formal report using professional language, with correct sentence structure,
grammar, spelling, and punctuation. No larger than 12 pt. font should be used for this report.
10. Include a website and/or contact person with a phone number.