How many types and styles of archwires do you use?
This can be an inventory/stocking/overhead nightmare! So my strategy is to both reduce supply overhead and increase treatment and office efficiency by reducing the types and styles of archwires I use.
Again, here's my 2 cents:
Upper/Lower Nitinol archforms:
Don't order both. Just order and use either upper or lower. I've always used just one type here. I just don't think it makes a difference with something as flexible as nitinol. Some may say that if you don't use both upper and lower that the teeth won't interdigitate or perhaps you can end up with a wider mandibular arch causing antererior/posterior crossbites, but I just haven't seen it clinically. Ever.
Ovoid/narrow/euro, etc.,:
Again only one shape used here. The alternative can be a real headache if you are trying to match each patient's natural arch form with your current stock. I always use a rounded, ovoid arch form. For everyone. Once we're into steel wires, if needed they can be reshaped to customize the arch better. But in nitinol for me, its ony one shape.
Sizes:
Of course this depends on your prescription so I'll just list my typical sequence (.018 Roth):
.012 Nitinol (Love this wire!)
.016 Nitinol
16x22 Thermal Nitinol or 17x25 Thermal Nitinol
16x22 SS (if needed)
Often nonextraction cases are debonded with U/L 17x25 Thermal Nitinols.
The goal is to use a prescription and treatment mechanics that utilize only a few wires. Some times I venture from this (I use .018 nitinol that I put my own reverse curve in, etc.), but again for the 70% of patients this is the norm.
Consider the effect on overhead: the bulk of my wire orders are 4 wires. Contrast this with someone who typically uses 6 wires x U/L x 2 or 3 arch forms and all of the sudden you are stocking 24 different wire types and sizes rather than 4. That alone is an overhead burner and labor/charting/inventory intensive.
Bonding vs. Bending
I typically don't bend wires. I have several rebonds during treatment, so once the brackets are exactly where I want them the wires usually don't need any bends. Now, if I have a patient scheduled for a debond the next appointment and #8 is tipped slightly lingual then I will put a quick bend if for something like that.
This strategy can be a tricky one in an effort to control overhead. I will definitely go through more brackets and thus more overhead with bonding instead of bending. However I feel that my clinical efficiency is improved and treatment time reduced such that it makes up for it. Also, since the brackets are now so inexpensive (blatant commercial see www.cxorthosupply.com), I feel the impact on overhead isn't as great.
Well that's it for archwires!
As always, comments are welcome!
Dr C
Monday, November 28, 2011
Monday, November 14, 2011
BT's: what are they good for?
So are there any of you that consistently use BT's on patients? If you already are very familiar with them this blog may not be too useful but I hope you enjoy it anyway. As always, comments are welcome!
At our office, BT is an alternate label for Bite Turbo. I'm not sure if that name is trademarked, so we've always just called them BT's.
BT's are additional amounts of bonding material we apply to selected areas to open the bite and guard against tooth bracket contact.
Here's the scoop:
Since I bond ALL TEETH, it's super important for us to limit broken brackets in order to, 1: reduce treatment time, 2: save chair time, 3: keep down emergencies, all resulting in 4: REDUCED overhead!
Although the obvious use is to guard against broken brackets, perhaps just as valuable (and possibly more so) is the desirable effects BT's can have on treating certain malocclusions. For example, if I have a 14yo patient with 100% overbite, I place BT's on the lingual of #8 and #9. If the laterals are lingually displaced (as in Class 2 Div 2) I'll place them lingual of #7 and #10.
By opening the bite, the occlusion and muscles of mastication are "disengaged" and extrusion of the premolars and molars occurs extremely fast. As you may know this very thing has been accomplished with Bite plane (or bite plate) retainers for years, however it's faster to apply and more predictable with BT's.
Alternatively, on a high-angle or open bite patient I generously apply BT's to the lower 1st molars. This of course opens their bite even more, but the added bite pressure on the lower molars is an intrusive force and can help you with your bite closing mechanics.
Here a few things to remember when using BT's:
1. Don't forget about them! If you are using class II elastics BT's that are still hanging around can interfere with your class II A-P correction. Also, they look pretty silly on retainer models or in hygienist's chairs! Some practitioners use a different color adhesive so that it easily identifiable during treatment and at debond.
2. Be careful to use bonding adhesive which does not have too heavy of filler that it can wear down opposing enamel!
3. Inform the patient and parent, especially adult patients, that their back teeth aren't going to touch for the first part of their treatment! I make sure adults know this is going to significantly reduce their time in appliances (which it does), because it's definitely not a comfortable bite for them in the beginning.
One final thing on BT's. Several companies sell instruments to help form and apply BT's. Also, metal BT's (official "Bite Turbos") are available also. I've just found adding the adhesive myself is the easiest, most inexpensive way to go. I usually just use extra adhesive flash from the brackets when I place them at the Full bonding appointment.
Well that's it for BT's! Another critical element I use in my practice to increase efficiency and reduce overhead!
At our office, BT is an alternate label for Bite Turbo. I'm not sure if that name is trademarked, so we've always just called them BT's.
BT's are additional amounts of bonding material we apply to selected areas to open the bite and guard against tooth bracket contact.
Here's the scoop:
Since I bond ALL TEETH, it's super important for us to limit broken brackets in order to, 1: reduce treatment time, 2: save chair time, 3: keep down emergencies, all resulting in 4: REDUCED overhead!
Although the obvious use is to guard against broken brackets, perhaps just as valuable (and possibly more so) is the desirable effects BT's can have on treating certain malocclusions. For example, if I have a 14yo patient with 100% overbite, I place BT's on the lingual of #8 and #9. If the laterals are lingually displaced (as in Class 2 Div 2) I'll place them lingual of #7 and #10.
By opening the bite, the occlusion and muscles of mastication are "disengaged" and extrusion of the premolars and molars occurs extremely fast. As you may know this very thing has been accomplished with Bite plane (or bite plate) retainers for years, however it's faster to apply and more predictable with BT's.
Alternatively, on a high-angle or open bite patient I generously apply BT's to the lower 1st molars. This of course opens their bite even more, but the added bite pressure on the lower molars is an intrusive force and can help you with your bite closing mechanics.
Here a few things to remember when using BT's:
1. Don't forget about them! If you are using class II elastics BT's that are still hanging around can interfere with your class II A-P correction. Also, they look pretty silly on retainer models or in hygienist's chairs! Some practitioners use a different color adhesive so that it easily identifiable during treatment and at debond.
2. Be careful to use bonding adhesive which does not have too heavy of filler that it can wear down opposing enamel!
3. Inform the patient and parent, especially adult patients, that their back teeth aren't going to touch for the first part of their treatment! I make sure adults know this is going to significantly reduce their time in appliances (which it does), because it's definitely not a comfortable bite for them in the beginning.
One final thing on BT's. Several companies sell instruments to help form and apply BT's. Also, metal BT's (official "Bite Turbos") are available also. I've just found adding the adhesive myself is the easiest, most inexpensive way to go. I usually just use extra adhesive flash from the brackets when I place them at the Full bonding appointment.
Well that's it for BT's! Another critical element I use in my practice to increase efficiency and reduce overhead!
Thursday, November 3, 2011
Molar Bands vs. Molar Tubes
In my practice I will do almost anything to avoid banding a molar. Ok so if it's a gold crown I'll try a bracket once (believe me I've used metal primers, diamond burs, cyanoacrylate, everything!) and if it comes off it gets a band. But any other time molars get molar tubes. And don't even get me started on bicuspids. I think I've banded 2 in 18 years! Here's why to me molar tubes are far superior:
Placement- Nothing speeds up treatment (or complicates it) more than precise positioning of brackets and tubes. It can be the number one overhead reducer in a practice in the form of reducing treatment time. Bands just aren't as accurate.
Hygiene/Caries- Besides being very difficult to clean around, if the band cement gets contaminated or washed out, the risk of caries is super high. Often you don't know they are loose until it's too late.
Inventory- I don't want to have a jillion (yes jillion) sizes and brands of bands all over the place. It's a huge cost to stock them, and then when you change companies you don't know what sizes are compatible, etc. Plus they're expensive per band!
Chair time/patient experience- Separators take time and can be an emergency appointment. The assistant has to fit all the bands so when you finally come to the chair there are like 22 of them scattered around with spit all over them. It's gross! Plus, it's too old school. It doesn't project an image of an efficient, streamlined practice. I have parents and adult patients say all the time "this is too easy, when I was young they had to fit these huge metal rings around my teeth!" and I say "yes, we don't use bands here unless we absolutely have to." (I use them for RPE's)
Spaces after Debond- There's not much getting around it. With bands, after the braces are off there are going to be food traps. Most may go away over time and I guess you can close them with a Hawley (does anyone use Hawleys anymore?), but a stubborn food trap is a B*** to close post Ortho and the General Dentists/Hygenists tend to frown on them....
Okay this post is getting long I could add a few more things but those are the most important to me.
Now of course molar tubes have some issues too. Like they come off! And whatever you do don't bond them lower to keep them out of occlusion! (See "precise bracket placement"). So you need to use BT's (additional 'glue spots' on selected teeth- to be discussed in future blogs) if you are going to use molar tubes. And yes there is a cost if they come off (replacement tube, chair time, emergency appt) but if you pay $1 tube (see Cxorthosupply.com- blatant commercial) and do some things to minimize breakage the benefits still BY FAR outweigh the disadvantages!
So bond those molars for fast, accurate, hygenic treatment!
Placement- Nothing speeds up treatment (or complicates it) more than precise positioning of brackets and tubes. It can be the number one overhead reducer in a practice in the form of reducing treatment time. Bands just aren't as accurate.
Hygiene/Caries- Besides being very difficult to clean around, if the band cement gets contaminated or washed out, the risk of caries is super high. Often you don't know they are loose until it's too late.
Inventory- I don't want to have a jillion (yes jillion) sizes and brands of bands all over the place. It's a huge cost to stock them, and then when you change companies you don't know what sizes are compatible, etc. Plus they're expensive per band!
Chair time/patient experience- Separators take time and can be an emergency appointment. The assistant has to fit all the bands so when you finally come to the chair there are like 22 of them scattered around with spit all over them. It's gross! Plus, it's too old school. It doesn't project an image of an efficient, streamlined practice. I have parents and adult patients say all the time "this is too easy, when I was young they had to fit these huge metal rings around my teeth!" and I say "yes, we don't use bands here unless we absolutely have to." (I use them for RPE's)
Spaces after Debond- There's not much getting around it. With bands, after the braces are off there are going to be food traps. Most may go away over time and I guess you can close them with a Hawley (does anyone use Hawleys anymore?), but a stubborn food trap is a B*** to close post Ortho and the General Dentists/Hygenists tend to frown on them....
Okay this post is getting long I could add a few more things but those are the most important to me.
Now of course molar tubes have some issues too. Like they come off! And whatever you do don't bond them lower to keep them out of occlusion! (See "precise bracket placement"). So you need to use BT's (additional 'glue spots' on selected teeth- to be discussed in future blogs) if you are going to use molar tubes. And yes there is a cost if they come off (replacement tube, chair time, emergency appt) but if you pay $1 tube (see Cxorthosupply.com- blatant commercial) and do some things to minimize breakage the benefits still BY FAR outweigh the disadvantages!
So bond those molars for fast, accurate, hygenic treatment!
012 Nitinol- God's Gift to Orthodontists!
*NO RELIGIOUS OFFENSE INTENDED*
Well this is the first blog entry for a subject near and dear to my heart. Especially in the recent economic climate and with increased numbers of orthodontic competitors, it's becoming more and more important to maintain a manageable overhead in your Orthodontic Business. I'll try to update this blog each week or so on tips and tricks I've learned over 18 yrs to keep my overhead low, mechanics efficient, and the number one cost-saver, minimizing treatment time.
COMMENTS ARE ENCOURAGED
So here we go...
.012 Nitinol
I don't know about any of you, but in our Orthodontic Residency we used modern techniques, straight wire appliances, and all kinds of nitinol wires, but before I started my private practice I had never used .012 nitinol. Starting wire was .014 (for an .018 slot) or.016 (for a .022 slot). These wires worked well. But I have to give credit to my brother (thanks Larry!) for introducing me to the .012. Nothing has sped up my initial aligning phase like .012 nitinol. It has truly shaved months off of my average treatment time! In fact the main reason I don't use expensive self-ligation brackets is that I just don't need them for quick alignment. I have the .012!
With the .012 you can get immediate engagement in 95% of the brackets, and you get a super light, gentle force that often results in limited or no pain for the patient after the full bonding appointment. I rarely ligature tie rotated teeth at the first appointment, but that's an option for me at the next visit with some of the stubborn rotations. Usually after the 2nd visit alignment is complete.
Now, if you are using the .012 you need to be careful of certain things. No gum! I tell patients that possibly later in treatment they can chew sugarless gum but not in the initial phases. Also, if I don't need the molars right away I still bond them but I only place the wire U/L 5-5. That way if the patient does bite something hard I don't have to worry about an emergency appointment where the wire has come out of the 6's. Also if they happen to break off the tube on the 6's (I rarely use bands- future blog subject) there isn't a long wire poking them.
So if you haven't already tried it, use .012 nitinol!
www.cxorthosupply.com
Future blog subjects: bonding vs. banding, BT's, efficient use of chairtime.
Well this is the first blog entry for a subject near and dear to my heart. Especially in the recent economic climate and with increased numbers of orthodontic competitors, it's becoming more and more important to maintain a manageable overhead in your Orthodontic Business. I'll try to update this blog each week or so on tips and tricks I've learned over 18 yrs to keep my overhead low, mechanics efficient, and the number one cost-saver, minimizing treatment time.
COMMENTS ARE ENCOURAGED
So here we go...
.012 Nitinol
I don't know about any of you, but in our Orthodontic Residency we used modern techniques, straight wire appliances, and all kinds of nitinol wires, but before I started my private practice I had never used .012 nitinol. Starting wire was .014 (for an .018 slot) or.016 (for a .022 slot). These wires worked well. But I have to give credit to my brother (thanks Larry!) for introducing me to the .012. Nothing has sped up my initial aligning phase like .012 nitinol. It has truly shaved months off of my average treatment time! In fact the main reason I don't use expensive self-ligation brackets is that I just don't need them for quick alignment. I have the .012!
With the .012 you can get immediate engagement in 95% of the brackets, and you get a super light, gentle force that often results in limited or no pain for the patient after the full bonding appointment. I rarely ligature tie rotated teeth at the first appointment, but that's an option for me at the next visit with some of the stubborn rotations. Usually after the 2nd visit alignment is complete.
Now, if you are using the .012 you need to be careful of certain things. No gum! I tell patients that possibly later in treatment they can chew sugarless gum but not in the initial phases. Also, if I don't need the molars right away I still bond them but I only place the wire U/L 5-5. That way if the patient does bite something hard I don't have to worry about an emergency appointment where the wire has come out of the 6's. Also if they happen to break off the tube on the 6's (I rarely use bands- future blog subject) there isn't a long wire poking them.
So if you haven't already tried it, use .012 nitinol!
www.cxorthosupply.com
Future blog subjects: bonding vs. banding, BT's, efficient use of chairtime.
05/02/2022 UPDATE
Crazy this was over 10 yrs ago...
So I'm going back over these blog posts and commenting about anything I may have changed my mind on since posting.
In this particular Blog even though it's been 10 years I really haven't changed much, but I've added a few things:
* Still use .012 NITI in 99% of cases as starting wire
* Still only initially engage wire U/L 5-5 to reduce emergencies
Things I've added
* Sometimes I even use .012 THERMAL NITI to get initial full engagement with severely crowded teeth.. Now this is a very flexible, super light force wire that does not fully rebound so don't expect severe rotations to fully correct.
* I've added small and large eyelets as KEY in my starting regimen. They work excellent for engaging lingually displaced teeth without the need for coil springs in many cases!
Here's a typical case where initial eyelets were used:
Day of Initial Placement
2nd Adjustment
Let me know your thoughts! I'll update a couple of these blogs each month to show what things have stood the test of time in my office!
Subscribe to:
Posts (Atom)