This lecture was not about the appearance of the well-finished case, but rather, the various processes needed to consistently turn out well-finished cases in a timely fashion. Dr. Earl Johnson gave a well thought out presentation of the finishing techniques used in his office.

Dr. Johnson has maintained a private practice in Mill Valley, California since 1967. He teaches in the orthodontic departments at UCSF and UOP. He has also authored "Earl’s Pearls" in this publication for a number of years, a feature with which many of the readers are well acquainted. We are thankful for his contributions to this publication.

Complete orthopedic corrections early

The decisions made at the start of treatment have a great deal to do with the ease of finishing the case. These include the timing of orthopedic correction and orthodontic treatment. In Dr. Johnson’s practice, orthopedic problems are assessed and appliances are placed to correct these problems either in Phase I or in the first portion of Phase II. He will deal with alignment, space closure, and detailing in the later part of the treatment period. Dr. Johnson starts headgear wear, if needed, at the initial banding when the enthusiasm and compliance of the child patient is highest.

Orthodontic corrections: Important factors affecting treatment time and end result

Bracket position

Factors critical to a case that finishes well include the triad of bracket position, arch wire selection, and a case specific bracket prescription. Bracket position is at the crux of this triad. Bracket position is responsible for correcting the marginal ridge relationship, rotations, and root positions.

Dr. Johnson corrects errant bracket positions after initial alignment, usually within four months after the appliances are placed. He will use both a visual and radiographic review (Special Pas or a panogram) to plan the corrections. Once the visual inspection is done and the progress films are checked, repositioning of all incorrectly placed brackets is completed in one appointment.

Treatment timing

In order to finish cases in a timely fashion, full appliances are placed at the beginning of treatment, including the second molars. He takes this goal seriously enough to remove any remaining distal operculums using an electro-surgery unit. Sequential bonding protocols simply require longer overall treatment time, so avoid starting cases unless all teeth are available for appliances. Sectional mechanics are OK but having banded teeth wait for unbanded teeth to erupt is not OK.

Archwire sequence

Archwire selection, tie-in protocols, and adjustments all affect total treatment time. Every wire change, every adjustment, must move a case to completion efficiently.
It shouldn’t have to be said, but don’t use two separate visits to do what is possible in one visit. Additionally, all wires must be fully seated for a least a month before moving onto a new wire. For very severely rotated or displaced teeth, Dr. Johnson suggests using a super soft coaxial nitinol wire called ‘Supercable,’ manufactured by Orec (the company that makes the Speed bracket).

Goals

Wherever possible, Dr. Johnson accomplishes two objectives at the same time. Vertical problems can often be corrected during the initial alignment stage of treatment. Vertical problems require an accurate diagnosis and a goal specific treatment plan that considers facial and dental esthetics.

Total treatment time

Dr. Johnson is able to accomplish his core treatment protocols in 12-14 months. Beyond that, special treatment needs will necessitate an additional treatment time. These most commonly include upper arch expansion or recovery of impacted teeth. He will achieve these additional goals before proceeding with the basic core treatment protocols.

Orthognathic surgery will add some treatment time (for the actual surgery and recovery period). He will assess any extra treatment protocols or phases and add their required time to the 12-14 month core treatment time. Then he can present a realistic estimation of treatment time to the patient family.

Extended finish date

How often have you looked at your chart wondering why a case seems to be taking forever to finish only to find you’ve done your job, but the chart is replete with notes about poor patient compliance? This is probably the biggest barrier to an on-time finish. When it comes to the length of treatment time, patients tenaciously remember the initial target date you presented, with no regard for their failures during treatment.

The patient family may not remember those problems with breakage, missed appointments, lack of complete headgear or elastic cooperation, the insurance company delaying coverage for orthognathic surgery, etc., all of which add to the treatment time. Keep the patient posted on the revised finish date and why it has been extended.

Compliance

He gave some suggestions that could reduce problems with patient compliance.

• Remind patients to wear elastics or headgear etc. at every visit, don’t assume they remember or are following your instructions. Have them leave with all elastics in place even if they are to be worn only at night.
  
  
• Remind them to get those progress films taken so treatment can progress. No film = no treatment = extended time wearing braces.
  
  
• Remind the poorer brushers at every visit that poor oral hygiene will result in increased treatment time. Point out what has been missed and what hints you see. Don’t start any procedures until the patient has produced very clean teeth. If this takes up the whole appointment, treatment time is extended.
  
  
• When you see a patient who missed their previous appointment, show them how much the missed appointment has extended the treatment time.
  
  
• Inform the patient, every time, when the estimated completion date is moved further into the future because of a problem on their part. Ask them to initial your notes in the chart that the estimated completion date is extended, and make parents aware of this too.

The key here is consistent repetitive communication about the finish date. Make on-time completion of treatment a high priority. Convince your patients that they are in control of their own destiny. They will figure out the rest.

Some clinical tips to facilitate tooth movement

• Create space to correct rotations – use open coil super-elastic springs (Sentinol) between overlapped teeth from the onset of treatment. Soft initial archwires will correct rotations only when there is room; they will not alone make additional room for alignment.
  
  
• Use bonded bite planes and/or bite blocks (light cure composite build ups, or Turbo bite blocks) to correct crossbites, open the bite and to aid in Class II correction. Place these posteriorly for open bite cases (don’t want posterior extrusion) and anteriorly for deep bites (when posterior extrusion is OK).
  
  
• Use auxiliary forces to correct molar rotations (lingual arches or headgear bows)
  
  
• Leave wires in until they can be fully seated. Remember, wires are far more efficient at rotating teeth than AlastiKs, which quickly lose a significant amount of force.
  
  
• Drop down to a smaller wire if the existing wire cannot be tied completely to the bottom of the bracket slot.
  
  
• Second bicuspids are often initially bonded too occlusally because of high gingival levels. If this happens, place your initial flexible arch wire under the bracket (gingival side) to extrude the bicuspid. Reposition the bracket at the very next appointment.
  
  
• If there is an open bite, check out for a newly developed tongue thrust, or an occlusal prematurity.
  
  
• Use a straight wire appliance (pre-adjusted brackets), but remember, many teeth are not average. Customize your prescription to match the existing tooth malposition problems.
  
  
• Try GAC’s eyeleted closed coil springs (Sentinol), for sliding mechanics when closing extraction sites. These coils work deliver a non-declining constant force and really speed up this treatment step.

Taking controlof the settling process

For 15 years, Dr. Johnson used positioners in all cases. Today, and for the last 10 years, he uses none. He states that positioners only allow passive settling of the teeth. He prefers to manage the settling process in a ‘proactive’ way.

Once Dr. Johnson has done all that is possible by adjusting his fixed appliances, he removes the portions of the archwires sequentially. For "proactive settling", he removes the posterior segments of the archwires leaving in place an upper anterior wire segment from lateral to lateral, and a lower anterior wire segment from canine to canine. The posterior teeth are extruded settling them into a tighter occlusion by using finishing elastics worn 24 hours per day, for one week.

These continuous finishing elastics are looped over the gingival the brackets where the wires have been removed, in a zigzag up and down fashion. This, combined with spot equilibration, increases the number of posterior occlusal contacts. Any teeth hitting on inclined planes will extrude and move laterally away from each other as the teeth settle.

During this proactive settling process he will equilibrate the teeth reducing high marginal ridges and deepening pits and grooves. The object is to increase the number of centric contacts on each and every tooth. Dr. Johnson suggests that those interested in learning equilibration techniques should first learn how to consistently find centric relation.

Two good techniques are the two-handed Peter Dawson technique and the one-handed "Earl Johnson" technique. In Dr. Johnson’s technique his thumb is placed on the chin, depressing the mandible slightly downward making it difficult for the patient to close. Then the patient is asked to try to close, in so doing, the loaded closing muscles, masseter et al, will drive the condylar heads upwards and forwards seating them in centric relation. With the condyles seated, the patient closes, onto articulating ribbon marking all centric relation contacts.

High spots are removed so the two teeth can move towards each other more, tightening the centric and producing even more centric contacts. This is done several times during the finishing process both before and after wire segmentation and removal. After achieving a solid centric bite with no CR-CO shift, one can remove balancing interferences while preserving centric contacts.

Closing band space

Johnson addressed the problem of band space. Dr. Johnson uses bands on the posterior teeth (better control of bracket position) and band spaces are present at band removal. He has found that passively allowing the spaces to close does not work for him. He closes these spaces by using Class I elastics. After all buccal segment bands but the most distal are removed, he has the patient wear a light ¾" elastic from molar to molar. The Class I elastics are worn full time for two weeks. If flossing shows that all the contacts are tight, the remaining anterior brackets and the most posterior bands are removed.

Bond removal

He removes bonding adhesive with an 1171 carbide bur running at 80,000 rpm in a low speed contra-angle. Dr. Johnson has a special 4X speed multiplying contrangle that he uses on the slow speed handpiece to increase the maximum RPM from 20,000 to 80,000. You can contact him for more information about this contra-angle if you wish (415) 388-2970. The facial surfaces are then buffed with black and then tan rubber points using the same contra-angle. Finally, the incisal edges are manicured and polished edges are manicured with a diamond bur and polished.

Conclusion

Many factors must be taken into consideration in building a practice that consistently produces well-finished cases in a timely manner. These are listed above. There is no time like the present to review the treatment protocols you follow to see if improvements can be made. Consistent time treatment producing consistent excellence should be your first priority.

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