Tips and pearls
The 2022 Scottish Orthodontic Conference featured a range of excellent presentations; here’s one, plus a preview of 2023
During the Scottish Orthodontic Conference in January this year, I had the privilege of sharing some of my orthodontic tips and pearls with my colleagues. I am delighted to share some of them again in this article.
Firstly, I would like to disclose that I do not have a financial interest/arrangement or affiliation with any organisations which could be perceived as having an actual or apparent conflict of interest in the context of the subject of this article.
One of the record-taking tips was using an LED panel to optimise the quality of extra-oral photos (Figure 1). Many sources, including Amazon, supply this LED panel; it costs around £50 plus £40 for the frame. I recommend 600mmx1200mm panel size with a power of 4500 watts. For convenience, the panel can be connected to a smart plug to be voice-controlled by Alexa!
During my presentation, I also discussed using the Demistifier for intraoral photography. It allows two-handed photography, eliminates fogging, and provides excellent lighting for pictures. Again, many brands like the Demistifier are supplied by many sources for £50. Regarding bonding and banding, I talked about the benefits of the orange box and drawers (Figure 2); the AO company supplies these.
The orange box allows the dental nurses to preload the brackets with bonding adhesive and stores them in the orange drawers; this allows for a smooth bonding procedure and reduces the stress of chair-side loading of the brackets unless the clinicians opt to use the expensive pre-loaded one! Additionally, I recommend using chromatic bonding adhesive (CBA) such as 3M Transbond plus. Transbond Plus is pink in the non-cured form but becomes transparent after curing; this allows visualisation of the exccess of adhesive after seating the brackets, which can be easily removed. Subsequently, this might reduce plaque accumulation and white spot lesions (WSLs).
The other benefit of the CBA is that you and your staff can monitor the premature setting of the adhesive during storage in case light leaks into the orange boxes. Some claim that preloaded brackets can be stored in orange drawers for up to 14 days without compromising the bonding strength. Ideally, a small note should be left on the orange drawer stating the date of adhesive application. The same principle can be applied to preload the clear aligner attachment templates to allow quick bonding. I recommend spraying the template with some isolating spray such as cooking oil to reduce attachment adherence to the template upon removal.
Another tip for banding an auxiliary appliance such as transpalatal arch (TPA) or rapid maxillary expander (RME) is to apply a small piece of flat wax underneath each band to act as a carrier for the luting cement (Figure 3). I use a light cure chromatic resin-modified glass ionomer cement (RMGIC Band-Lock) as its colour can be recognised from the tooth structure upon removal. RMGIC is a good fluoride reservoir against WSLs, as per the latest Cochrane review.
Another tip that I shared was about bracket variations. While I was writing this article, my paper – The hybrid setup of the labial fixed orthodontic appliance – was published by the American Journal of Orthodontics and Dentofacial Orthopaedic (February 2022)1. I highly recommend that the reader refers to this paper for in-depth information. However, I would like to share this line from a published article: “Moving brackets across the occlusal line reverses tip and torque, crossing the midline reverses tip, whereas flipping the bracket reverses the intended torque expression.” Moreover, I would like to stress the influence of changing the vertical positions of the upper incisors’ brackets, as shown in Figure 4.
In summary, placing the bracket gingival to the middle third of the crown reduces the palatal root torque (PRT). While incisal positioning increases PRT, both have an additional influence on the second-order bend due to the wagon wheel effect and the vertical height.
During the conference, I shared a tip that I call “needle tubes (NT)”; an alternative to second molar tubes. Using NT, a stopper or even a small piece of 20G blunt needle can be cut, sandblasted and bonded to lower second molars (Figure 5). As the NT has a very low profile compared to the molar tube, I find its bonding failure low. However, it is essential to remember that the NT doesn’t allow torque expression. Therefore, it should be replaced, if needed, with a proper molar tube when the occlusion allows.
Another tip was about cutting thick working archwires in fixed appliance therapy. I recommend an oblique cutting of the thick working archwire using a distal end cutter, as shown in Figure 6, to allow easy threading through the molar tube and minimise the need for “green-stonning”. The Wiper Auxiliary Wire (WAW) is another tip used to upright the root at the implant site, optimising the inter-radicular spaces (Figure 7-8). Regarding space management, I shared a suggestion of using an extracted tooth after amputation of its root to temporally restore an extraction space in adults (Figure 9).
Do you know that orthodontic elastics can also be used for enhancing the extraction and exfoliation of multiple stubborn primary teeth? We have published an article titled “A-Z management of Infraoccluded teeth”, with the DentalTown/UK mentioning this technique (Figure 10). I recommend using 1/8”, 4.5 Oz elastic for this purpose. If you are using a chain retainer-like OrthoFlex, one of my tips is to use dental floss to measure the labial distance between right and left 2-3 embrasures; after adding 2mm, the obtained length would represent the length of the required bonded retainer. This is a handy tip that I learnt from Dr Neal Kravitz, and it minimises the waste of the expensive OrthoFlex.
Moving to my favourite part, the temporary anchorage device (TAD), I shared TAD-supported Burstone mechanics, as shown in Figure 11. Please note that this system requires a comprehension of biomechanics to avoid anticlockwise rotation of the occlusal plane counteracts the anticlockwise movement that flares upper incisors; however, this discussion is beyond the scope of this article.
For those using clear aligner therapy, I have a few recommendations: 1) Invest in building your in-house lab; this will not only save substantial lab fees but will give you control of your cases. I should admit, it is a very steep learning curve, but it is worth it; 2) Use fluorescent composite like BracePaste from AO company for attachments. When a UV light is directly projected on the cured BracePaste attachments, any extra composite beyond the required shape of the attachment can be easily visualised; this means less food accumulation around attachments’ access and less staining, but most importantly, a better seating of the aligner around the attachment with potentially predictable biomechanics.
Dr Mo Almuzian is Specialist Orthodontist at Sunrise Dental Clinic: www.sunrisedental.co.uk
Looking to 2023
Now in its seventh year, the first Scottish Orthodontic Conference, in January 2015, was organised by Peter McCallum (specialist orthodontist in practice and previous chair of the British Orthodontic Society) and Iain Buchanan (consultant in orthodontics at Glasgow Dental Hospital).
The idea was to bring together hospital and high-street based orthodontists and their teams for a day of education, networking and social interaction (the cheese and wine reception remains one of the highlights of the day!).
There has been a wide and varied array of speakers and topics from across Europe covering topics such as orthognathic surgery, hypodontia, aligner treatment, practice marketing, temporary anchorage devices, digital orthodontics, mental wellbeing and dozens of clinical ‘pearls’.
As the conference has evolved, increasingly more dentists with a specialist interest in orthodontics, orthodontic nurses and orthodontic therapists have attended, bringing together the wider dental community around Scotland. This has also been reflected in the presenters over the years, which frequently includes non-specialists bringing a different perspective to the audience.
Current organisers, Laura Short (consultant, Glasgow Dental Hospital), Andrew McGregor (specialist in practice) and the team at the Royal College of Surgeons and Physicians, Glasgow have begun the process of organising the 8th conference on 27 January 2023 which promises to be the first face to face meeting following the global pandemic.
Look out for details later this year and if you’d like to participate, please contact Andrew directly to discuss further: firstname.lastname@example.org