In-Ovation L MTM No Trace Bracket Systemtimockfamilyortho.com/wp-content/uploads/2015/08/... · 7....

MTM No Trace Bracket System

Brandon Owen DDS, MS

Disclosure

• I am a paid consultant and paid lecturer for GAC

• All the cases shown today are my own, and none of the photographs have been altered (aside from cropping and contrast adjustment)

• I am so excited to be here

• PLEASE FEEL FREE TO INTERJECT WITH QUESTIONS AT ANY TIME!!!!!

Why Use Lingual

• Professionally rewarding

• Personally rewarding

• Financially rewarding

Why Use Lingual

• Professionally Rewarding:

– Sets you apart from others in your area

– Gives people the impression that you are state of the art and progressive with the newest techniques

– Allows development of new referrals

Why Use Lingual

• Personally Rewarding:

– This is my happiest group of patients

– They are excited to start treatment

– They find the treatment to be easier than they thought

– I get more referrals from these patients

– It is fun to use (quick results)

Why Use Lingual

• Financially rewarding:

– High cost/visit treatment

– Practice differentiation

– Opens up an untapped patient market

– Low cost for supplies

– These patients tend to have higher discretionary income

Course Outline

• Background of lingual orthodontics

• Case selection for MTM In-L No Trace

• Bonding Protocols (direct vs. indirect vs. lab vs. digital)

• Wire selection and shaping

• Treatment progression

• Cases

• Summary

• Hands on demonstrations

My background

• Grew up in Montana• University - Montana State University (BS-2000)• Dental School – University of Minnesota (DDS-2004)• Orthodontic Residency – U. of Minnesota (MS-2006)• Purchased a practice in 2006 with heavy TMJ emphasis

in Fort Collins, Colorado• Diplomate of the American Board of Orthodontics• Member of Midwest Angle Society• Member of CDABO, AAO• Officer of the CDA, LCDS• Asked by the Pankey Institute to join their faculty

My Practice

My Practice

• 6 clinic chairs, 2 exam rooms• 3 front desk/exam staff• 4 orthodontic technicians (allowed to work in the

mouth)• 1 associate orthodontist (1 day/week)• 15 clinic days/month• Approx. 330 case starts/year• 30-40% growth in production EVERY YEAR for the

past 3 years

• 1/3 are full lingual, MTM lingual, or combination

History of Lingual Orthodontics

Wick Alexander Power 2 Reason Nov. 2013• Craven Kurz was the inventor of the lingual

bracket in the US (Beverly Hills, CA) – Charismatic, interesting lifestyle 1976 patent

• Ormco – Kurz appliance (Seven Gen)• Someone leaked their existence too early• National frenzy in the early 80’s

– Press conferences all around the US– Front page of all national newspapers– HUGE demand


-BUT . . .

• Poorly understood mechanics frustrated all US orthodontists

• Released later in Europe and Asia after case selection was better understood

• Much more successful in Europe and Asia – As a result this is where most of the advancement

has been made

• Currently <5% of US orthodontists use lingual


• Kinya Fujita in Japan was developing lingual braces at the same time as Dr. Kurzindependently in Japan. He still works on lingual product development at Kanagawa Dental University

Recent Evolution of Lingual

• STB bracket

– STB social 6

Recent Evolution of Lingual

• I brace – Incognito –Incognito Light

New Lingual Systems

• Harmony • Adenta

New Lingual Systems

• Forestadent 2D

• New companies emerging• Many more offerings in Europe and Asia than the

US

GAC In-Ovation L

• Full – MTM No Trace

My history with lingual braces

• Frustrated with results with clear aligners, I started with limited lingual in 2007

• I tried Ormco STB “social six” and In-Ovation L-MTM

• Self ligation made my decision easy

• Two years later, I began full lingual (Incognito, Harmony, and eClips)

• I began with easy cases• Initially started 5-20

lingual cases per year• This year on track to start

110 lingual cases– 30 full arch lingual– 80 MTM In-l on upper and

or lower arch

Invisalign patient-lingual

Problem Focused Orthodontics

• Vincent Kokich Sr.– Paradigm shift from “Only treat to ideal”– New emphasis on improving selected items from the

problem list– Many adult patients are not willing to do optimal

treatment • Long treatment times• Invasive treatment mechanics (surgery, extractions)

– Many adults would like to improve the function or cosmetics if alternative options are presented

– IS IT BETTER TO MAKE SOME IMPROVEMENT RATHER THAN NONE AT ALL?

– IT IS VERY IMPORTANT NOT TO MAKE THINGS WORSE.

Anterior tooth alignment

• This is the best way to learn/begin to use lingual– Easier visualization for all appointments in the anterior

– Lighter mastication forces (fewer debonds)

– Fewer porcelain or gold crowns (weaker bond strength)

• The In-Ovation L bracket is the easiest bracket that I have ever worked with for lingual (and my entire staff agrees)

• It is very versatile:– Can be used for a variety of cases and can be bonded in

numerous ways

Hands-on

• Opening the doors

• Remove the wire

• Engage the wire

• Close all the doors

Case Selection

• Start with very easy cases (best to begin with 3-3)

• Once you gain proficiency, try being creative; you can expand the number of potential MTM lingual patients– Consider upper MTM Lingual/Lower labial

– A considerable number of patients fit well in this treatment category

– Consider doing more difficult cases as well

Which teeth should be bonded:

Canine to canine (3-3) vs. 1st premolar to 1st premolar (4-4)• I try to do 3-3 whenever possible (other users prefer

using 4-4 almost always-there is no wrong answer)1. It is more comfortable for the patient (anatomy of the

teeth)2. Less cost for the brackets and wires3. Less complicated wire bending and wire shaping4. When bonding premolars, I will usually remove the

premolar brackets early if possible • Space is closed• Arch shape looks good• Canine and 1st premolars are in good alignment

Case selection (canine to canine)

Which teeth should be bonded:

Bonding premolar to premolar (4-4)

• Spacing/closing lower incisor extraction site

• Severe crowding

• Opening a deep overbite

• Changing arch shape

• Significant malalignment between canine and premolar

• Incisal plane cants

Bonding: premolar to premolar

Bracket positioning

• Bracket positioning

• 1st order-This is primarily determined by how far incisally or gingivally you place the brackets (staying above the cingulum is typically ideal)

• 2nd order-same as labial

• 3rd order–solution pending-currently not possible with MTM No Trace

Bonding Protocols

Direct Bonding

• Advantages-– No lab work is involved

– Fast bonding when anterior teeth are involved

– No tray materials required

• Disadvantages-– More difficult to measure and visualize bracket

position

– Requires preparing (shaping and measuring) wires intraorally

Bonding Protocol (Direct Bonding)

1. Clean teeth (cotton rolls or pumice on rotary)

2. NOLA dry field (moisture from breathing)– High speed suction adaptor used in our office

3. Add cotton rolls labial to the anterior teeth if the lips are contacting the teeth

4. Etch – 37% Phosphoric acid (I use blue gel for visual)– 20-40 seconds per tooth

5. Clean all etch with water and dry completely

Bonding Protocol (Direct Bonding)

6. Apply primer and gently dry7. Place orthodontic composite on the brackets,

and place brackets on the teeth8. Position brackets/clean excess adhesive9. Light cure 10-20 seconds/tooth (depending on

light)10.ETCH PRIME AND ADD COMPOMER BAND

CEMENT TO OCCLUSAL SURFACES OF RIGHT AND LEFT POSTERIOR TEETH IF LOWER INCISORS HIT THE UPPER BRACKETS

Bonding Protocols

Indirect Bonding• Advantages-

– Direct vision for bond placement and measurement– Allows time to look at records and photographs during positioning– Allows shaping of all wires before the bonding appointment

• Saves chair time and treatment time

– Accurate placement and wire shaping reduce treatment time– Easy/low stress bonding appointment

• Disadvantages-– Additional time required for setup– Additional cost (materials and time)– Requires time between records and bonding appointment (no same

day bonding appointments)

Bonding Protocol (Indirect Bonding)

• STEPS DONE BY MY ASSISTANTS:1. Alginate impressions2. Pour up alginate impressions in a stronger stone (must

be accurate with no distortion or bubbles – small bubbles can be filled in with blue block out resin or other material).

3. Paint with liquid foil (liquid separator). I dilute the separator 1 part water:1part separator.

4. Let dry for 1 hour or longer5. Use Neobond composite and place on the In-L MTM

brackets and then set it on the teeth in the proper position (discussed shortly)


6. Clean excess composite (unless they haven’t been doing it for very long – better to leave more composite during training)

7. Place it in a dark box to avoid light curing the composite

8. Set it on my desk

Indirect Bonding


MY STEPS:

1. Patient’s chart records are loaded on my computer monitor

2. I open the box and refine the positions of the brackets to optimize root positions and esthetics

3. Once final positioning is done, I set the model in a light curing box (also can use your normal light curing gun) (3-5min in the light curing box or 10-20 seconds per tooth with light cure gun).

Bonding Protocol (Indirect Bonding)CANINE TO CANINE

MY STEPS:

4. Once the composite is set, I prepare all the wires for the case

5. Then I put the model box in an out deck pile with the wires in a bag labeled with patient name and wires included which my assistant will pick up

Bonding Protocol (Indirect Bonding) Maxillary Arch

• Canines and central incisors – 4-6mm from the gingival portion of the slot to the cusp tip or incisal edge

• Lateral incisors – 0.5mm less than the canines

• My general rule is to stay off the cingulums of the canines if possible.

• I will break this rule on occasion, but you must warn the patient that their canines will become prominent at first and then you can bring them back with wire adjustments(adds 3 months to treatment time) or put inset bends on both the starting and finishing wire to overcome this movement.

• Visualize the wire going through to assess tip.

Bonding Protocol (Indirect Bonding) Mandibular Arch

• Canines – 4-6mm from gingival slot to cusp tip

• Incisors – 0.5-1mm less than the canine (depending on the case and tooth shape)

• Premolars for upper or lower are placed wherever they fit. Wires will be bent to fit – Vertically (step down)– Bucco-lingually (inset

bend)

Hands on Bracket Positioning

• Bond upper 3-3 and lower 4-4

• Set upper arch on its back and use mirror to simulate direct bonding

Wire preparation canine to canine

Nickel Titanium (.014”)

• Cut a standard lower labial .014”NiTi at the midline

• Use the anterior (curved portion)

• Measure appropriate length

• Leave 3mm excess on each side

• Heat treat ends and bend an L towards the teeth (90 deg.) or a ring on each side (more wire length needed)


Stainless Steel wire (.014”)

• Bend a small ring to identify right side

• Shape the wire to follow the desired final arch shape and arch length


• Leave slight excess in length and bend an L on the left side (leave additional excess if you will be resolving a lot of crowding)

• I recommend the following as these wires are easy to flip:– Ring=Right– L=Left

Wire preparation premolar-premolar

NiTi wire (.014”)• Use the GAC Lingual arch

template to determine which size of wire to use

• CHOOSE FINAL ARCH SHAPE FOR CROWDED CASES– If you don’t have the

template, you can hold the different sized wires above the model

– If you do not want to use GAC lingual wires, use a lower .014” labial NiTi, measure distal to canines, heat treat and bend the wire


• Trim ends leaving excess for some play and to heat treat and bend 90 degree bends toward the teeth for patient comfort


• Place NiTi wires in the sleeve and place in the indirect bonding box when the bracket positioning is complete


Stainless steel wires (.014’)

• Bend ring for right side

• Leave 3-4 extra mm around bracket (1.5-2mm on each side).

• Bend wire 90 degrees step out and incisally.

• Shape desired FINAL arch form


• Measure the arch length and do a 90 degree bend (again estimated based on prediction of how much arch length is needed when the teeth are aligned).

• Make a 90 degree bend in and gingivally• Leave 2-4 mm depending on anatomy.• Hold over bracket position to verify arch

shape and wire length• Bend 90 degrees again and leave 8-10 mm of

extra length• I wait to bend the final L bend and trim the

excess length until we insert the steel wire. This way fine tuning is very quick and easy (Huge advantage to Indirect Bonding – very difficult to bend this chair-side

Wire preparation

• Stainless Steel wires are kept in a bag in a drawer in alphabetical order so they are easily found when we transition from NiTi to SS

• NiTi wires go in a separate bag and stay with the models until bonding when they are immediately used

Hands on Wire Shaping

Upper 3-3/lower 4-4 NiTi and Steel wires

• Measure and prepare the .014” NiTi (do not place in the slot)

• Shape with a .014” Steel wire to approximate final arch shape for the upper and lower arches

• Create a ring on the right and a L on the left in the steel wires

Multiple Indirect bonding tray possibilities

• VPS Putty

– Fast/expensive/only chemical cure bonding

• Mouth guard-rigid plastic suck down

– Slow/expensive/light cure possible

• Clear VPS

– Fast/expensive/light cure possible


ASSISTANT STEPS:1. Create indirect bonding tray

with clear VPS (Memosil 2). Make sure to fully encapsulate the bracket (mesial, distal, incisal, and gingival) and cover the incisal edges of the teeth covering the incisal 1/3 of the labial surfaces as well

2. Other tray options: Opaque VPS, Mouth guard suck down, two phase suck down, 3D printer

3. Soak models in a bowl of water to dissolve liquid separator for 10 min or longer

4. Pull bonding tray and brackets off the model


ASSISTANT STEPS

5. PLACE THE TRAY WITH THE BRACKETS IN A LIGHT CURE BOX or use light cure gun to set the composite in the middle of the bracket pad. transmission of the light to the internal composite, and it remains unset. – Failure to do this step can result in significant bond failures

– 3-5 min in curing box or 10-20 seconds per tooth with curing gun

6. Clean with scaler or rubbing alcohol

7. Store with the model and wires in the box until the bonding appointment.

Bonding Appointment

• ASSISTANT STEPS -• Scrub teeth with a cotton roll to clean plaque/debris• We do not micro-etch for limited lingual (we do use 60

micron Aluminum Silica for full lingual)• Place a light coating of flowable composite on each

bracket in the tray and cover with thick paper to avoid setting.

• NOLA dry field isolation system connected to a HIGH-SPEED Saliva evacuator with an adaptor to keep the area dry and prevent mouth breathing.

• May need 1-2 cotton rolls on the labial of the incisors if the lip is still resting against the teeth

Bonding Appointment

ASSISTANT STEPS • 37% Phosphoric acid blue

etching gel for 20-30 sec/tooth

• Etch teeth to be utilized for bite props/turbos

• Rinse thoroughly and dry completely

• Apply primer (liquid bonding agent) to appropriate teeth and to teeth for bite turbos

• Lightly dry

Bonding Appointment

DOCTOR STEPS-• Start with lower arch 1st

• Place the indirect bonding tray loaded with the flowable composite on the teeth

• Hold the tip of the light cure gun on the right distal most tooth and set for 3-10 seconds

• Move to the adjacent tooth all the way around the arch.

• Add Compomer band cement (Neobondband cement or Ultra Bandlok white) to right and left for turbos and set each for 10-20 seconds

Bonding Appointment

ASSISTANT STEPS –• Finish setting the composite and turbos 9-20 seconds per

tooth• Remove NOLA isolation• Peel indirect bond tray from facial toward lingual• Allow the patient to rinse and rest• Use scaler to make sure no composite is locking any teeth

together and clean obvious excess. • Place preshaped wires with all appropriate coils or

crimpable stops• Discuss what to expect with lingual braces for the first

month

Bonding Appointment

DOCTOR STEPS –

• Check wires, remove flash with handpiece if needed.

• Check centric relation with Bimanual manipulation/guidance and balance the turbos in centric relation assuring there is no CR – MI shift.

Bite Turbos

• Prevents lower teeth contacting the upper brackets

• Any material can be used– We use a compomer band cement (UltraBandlok or

Neobond band cement)-easier to remove than composite

– Also can use flowable composite

• My 1st choice for placement is the Mn 1st molars– Large surface area

– Good visualization for removal

Bite Turbos

• But we always avoid teeth with crowns– May need to move to premolars or Mx molars– Sometimes we need to do the right on the Mx and the

left on the Mn (last resort)

• Make surfaces large and flat and check centric relation at the end of appointment to make sure it is balanced to this position (this is where the bite will go after previous 1st point of contact is removed with the turbos)

• We use blue turbos for labial treatment, but lingual patients do not like it showing

Turbos

Summary of Pre-bonding Steps: (Indirect)

Assistant-1. Pour up model in strong stone2. Liquid separator (leave to dry 1+

hours)3. Position brackets on teeth with

orthodontic composite and clean flash

4. Place model in dark box and give to the Dr.

Doctor-5. Refine bracket position6. Light cure (box or gun)7. Shape NiTi and SS wires8. Place all items in the box and

leave for Technician to retrieve

Assistant-9. Make indirect bonding

tray10. Soak for 15 min or more11. LIGHT CURE COMPOSITE

AGAIN TO SET THE MIDDLE OF THE PAD

12. Clean the composite with scaler or rubbing alcohol

13. Store for bonding

Summary of Bonding Steps (Indirect)

Assistant-1. Clean teeth (pumice or cotton roll)2. Flowable composite on each bracket

in the tray3. Isolation – NOLA4. Etch 37% phosphoric acid blue gel

20-30 sec each tooth to bond and turbos

5. Clean etch and dry6. Prime (for brackets and for turbos)Doctor-7. Seat tray and Light cure 3-10

sec./tooth8. Compomer band cement for turbos

Assistant-9. Clean flash10. Insert wires11. Braces instructionsDoctor-9. Check wires and clean flash10. Check turbos in Centric Relation and

adjust so there is no shift

Instruments

Tools used for MTM Lingual

• Scaler

– Open doors/remove ties/power chain

– Engaging wires

– Closing the door

– PLACING TIES/POWERCHAIN

• Engaging tool (TENVIS)

– Engaging difficult wires or crowded cases

Instruments

Tools used for MTM Lingual

• Small Hemostat– PLACING

TIES/POWERCHAIN

• Lighter– Heat treating NiTi wire

ends before bending

• Otherwise, we use same instruments as labial treatment

Auxiliary Items for MTM Lingual

GAC SHORT SUPERCHAINELASTIC THREADAND NITI OPENCOIL

Auxiliary Items for MTM Lingual

GAC .012” single ties

Wire selection

• Options for starting wires:– .012” NiTi

– .014” NiTi

– .016” NiTi

• Options for finishing wires– .014” SS

– .016” BetaTi

– .016” SS

– .018” BetaTi

Slop with various wire sizes.014 1st order 10 degrees each direction

Total 1st order slop-.014”20 degrees total/10 degrees each direction

Total 1st order slop-.014” WITH SINGLE TIES10 degrees total/5 degrees each direction

Total 2nd order slop-.014”6 degrees total/3 degrees each direction

Total 2nd order slop-.016”5 degrees total/2.5 degrees each direction

Total 2nd order slop-.018”2 degrees total/1 degree each direction

Wire selection (my preference)

My goal is to finish with only 2 wires for each arch• Starting wire - I almost always use a .014” Sentalloy

wire. It works well for almost any scenario.– If there is a lot of crowding, a .012” NiTi is also a

reasonable choice, but if you can’t engage a .014” NiTi, you probably shouldn’t engage the tooth anyway (use coils instead)

– .016” NiTi can be used for cases where the teeth are already straight and you are closing spaces or correcting a deep bite, but the .014” NiTi seems to do well in these situations as well

• Using the same wire also keeps inventory low and allows consistency


• I very rarely use an intermediate wire

• My finishing wire - .014” Stainless Steel (95% of cases)

• For the other 5%, I typically use a .016” Stainless Steel wire– Changing arch shape

– Opening a deep overbite

– Closing spaces

• In very rare cases, I have used a .018” NiTi– Multiple ceramic crowns where brackets continually

debonded with a .014” SS. Placed exaggerated bends in the NiTi (no heat treating)


• Advantages to finishing in an .014” steel wire

– Wire slop allows you to not move teeth you don’t want to move

– Allows for relatively large step bends to be placed in a single visit

– Avoids an intermediate wire

– This works best for people who like wire bending to detail their cases

Wire selection (Alternative)

• For those who do not like wire bending:

– A slot filling wire (.018” Beta Titanium) wire would work best for finishing

– A good example of a typical wire sequence would be 014”NiTi/.014”Steel/.018”BetaTi

– Advantages:

• Less slop=more control with more predictable expression of bends

Hands on

• Add 1-2 open coils

• Place crimpable stops and insert the wire

Alignment phase of treatment

Cases

Open coils to open space

Crimp stops (advancing wire opening space) E thread to rotate

canines

AC

Bond 3-3

Engage 14 NiTi

LWBond 3-3

14 NiTi

Open Coil Between central incisors

LWBond 4-4Skip LL3 and LL1Crimpable stops mesial to 4’s (expansion wire)Open coil for LL3, LL1, and between LR1 and LR2

JB-Missing LL3Bond LL4-LR3

Use extra large mushroom wire (straight on Rt/Mushroom on Lt)

Coil LR2 to LR3

LLBond 3-3

Do Not Engage LR1

Coil for LR1

Open coils have improved alignment 2-3. New one to be

added 1-1

Day of Bonding

What would you do to ligate?

Detailing stage of treatment

• Wire bending

• Terminal tooth

Ligation

• Typically, we will use the doors only for ligation while the initial wire is in place

– This reduces friction and increases the interbracket distance

– We do use single ties on any premolars for patient comfort

Powerchain

Wire adjustmentsSingle ties

Step UR2 to the Lingual

Step out LR3 Step out LL1

Debonding

• Right angle debond plier

– We use this for both labial and In-Ovation L removals

• Harmony and Incognito require additional tools

– They can be very difficult to remove (especially Harmony with Geristorecement)

Debonding

Retention

• Retention with MTM has been more difficult for me than conventional orthodontics in the past BECAUSE:– Adult patients– Short treatment times

• Both these factors increase risk of relapse• I prefer fixed retainers on the lower arch (canine to

canine bonded to each tooth)– We use Reliance gold flat wire

• For the upper arch I typically like a fixed retainer (braided stainless for the four incisors)– Canine to canine breaks more due to tension during

chewing

Retention

• We also make clear retainers for night time use on the lower arch and full time for 2 months on the upper arch

• If bite turbos were used and caused an opening of the bite, we will cut the clear retainers so they do not extend to those teeth to allow them to settle back together

• If the patient chooses not to do fixed retainers, we use clear retainers full time for 3-4 months or we will leave the braces on the teeth with no adjustments for 3 months and then they can use them only at night time

• This is the only treatment where the retainers are actually more visible and less comfortable than the braces– They also affect speech more

What cases qualify for lingual

• Any case

• We offer lingual as an option to EVERY patient– If they qualify for MTM, that is what we show

– If they do not, we show them Full Lingual

• WHY?– This is how we increase awareness in our area

– Often mothers are interested in treating when they see this option (even though they come in for their kids)

What cases qualify for MTM Lingual

• Obvious

• Combination this comes up extremely often

– Can you treat to a limited degree on the upper arch and do complete treatment on the lower arch

• Interdisciplinary cases (Forced eruption, veneers or crowns, implants, etc.)

CASES

MTM Lingual

HF (initial) UR1 veneer falls off

HF 3 months to complete

AC-Initial

AC-Progress

AC (comparison)

AV (Initial)

AV (Progress)

EB (Initial)

EB (Progress)

EB (Comparison)

JU (Initial) wants upper only

JU (Final)

JU (Comparison)

JW Before-After (Class III correction with retainer to lower clear braces

KP (Initial)

KP (Final)

KP (Comparison)

KD (Initial

KD (Progress)

KD (Soft tissue laser)

KD (Progress 2)

KD (Comparison)

SW (Comparison U/L MTM)

KH (Initial)

KH (Final)

KH (Comparison)

LH (Initial)

LH (Final)

LL (Comparison)

LL (Comparison

LF (Before and After)

LD (Before)

LD (Progress)

LD (Final)

LD (Comparison)

MC (Initial)

MC (2month progress)

MC (Comparison)

SS (Initial)

SS (Progress)

AW (Initial)

AW (Progress)

AW (Final)

AW (comparison)

Potential issues with lingual

Common:• Speaking – typical timeline is less than 1 week

(huge variation.– They will notice it, but those around them will not

• UNLESS they tell them about the braces

– Quicker speech adaptation vs. Aligners because they are fixed (vs. in and out and in . . .) so the tongue adapts faster

• Tooth soreness – typically less than labial braces because lighter forces are used and movement is not as significant

Potential issues with lingual

Common:

• Eating – bite turbos make chewing difficult

– This is usually the longest lasting noxious result of MTM treatment, but it is not usually severe

Potential issues

Rare:• Laceration of the tongue on wire or bracket

– Only 1 time in my history with lingual• Applied pressure, and it stopped within 10 min

• Frenulum cleft hooked the terminal end of the wires• Bite did not close when turbos were removed

– Required placement of buttons and use of elastics to close the bite (also only 1 time)

• Severe discomfort with lingual braces (tongue bracers)– 3 times. We removed and placed clear labial braces at no

additional charge. I make them try for at least 1 month before offering this option

Frenulum Cleft (one day change)

MR (Initial)

MR (Final) Posterior open bite

MR with settling elastics

Problem Solving

• If you don’t see alignment after 1 month TRY:– Adding coils if there is overlapping of the teeth

– Moving into a larger wire and placing bends

• Tongue soreness:– Give normal wax and silicone wax (different people

prefer each)

– Gishy Goo VPS for severe tongue discomfort

• Can’t achieve alignment of the last tooth– Aggressive bend for terminal tooth or add additional

brackets

In Ovation L compared to other lingual braces

• My staff and my favorite bracket to use– Vs. Stb– Vs. Incognito– Vs. Harmony– THIS IS MUCH EASIER TO USE THAN THE FULL CUSTOM

OPTIONS– Disadvantages-With full lingual, lack of metal custom pads

is sometimes problematic when bonding to crowns– Lack of positioning jigs for full custom lingual as well– FOR MTM THERE REALLY ARE NONE

• Very low debond rate (low profile, limited number of anterior teeth have ceramic/metal on the entire lingual surface)

Fees for MTM Lingual

• How I price MTM in my office

• Starting off (while you are learning) I recommend charging 70-90% of your labial fee

• I charge 25-35% less for a single arch

• Once proficient-90-110% of your fees

• For upper lingual/lower labial I charge the same fee as I would for full upper and lower labial.

Fees for MTM Lingual

• Example: Using 3000 GBP for normal case fee

While you are learning:

– 2100-2700 GBP (upper and lower MTM)

– 1400-1900 GBP for a single arch

Once you are proficient:

– 2700-3300 GBP for upper and lower lingual

– 1800-2310 for single arch

COST PER VISIT

• Assume I charge 3000 GBP for an MTM case and 3000 GBP for a traditional labial case.

• Assume I have 1 very long or 2 long bonding/banding appointments for the full case and 1 long bonding appointment for MTM

• Assume I need 7 adjustments (average counting bonding and removal) to complete the MTM case vs. 14 for the traditional

• Assume a little shorter debonding appointment

COST PER VISIT

• Assuming 7 visits for 3000 GBP vs. 14 for the same fee– MTM Lingual group yields 428 GBP/visit (not

counting exam or retention)

– Labial is 214 GBP/visit (not counting exam or retention)

– Relatively low cost of supplies (vs. aligners)

• The bottom line is this is the most profitable treatment I do in my office

Laboratory generated setup

• Set teeth to desired position by sectioning the teeth and resetting in wax (or do a digital setup)

• Use preshaped or hand bent wires.

– Then use wires to guide bracket positioning

– Make small indirect bonding tray for each tooth

– Transfer it back to the original model and connect all the individual bracket trays

– Follow indirect bonding protocol (as discussed earlier)

– This requires a significant amount of time

Digitally guided setup

• Use input device to obtain a digital replica of the teeth– Intraoral scanner (iTero, Trios, Lava 2, Lythos, many more

coming soon)– Desktop scanner in orthodontist office to scan an alginate

impression– Desktop scanner in a lab: typically requires VPS impression or a

stone model to avoid distortion of alginate over time

• Post processing software segments each tooth and is used to position teeth in the desired position

• Orthodontist reviews/modifies setup• Bracket positioners are printed from a 3D printer and then

are used to bond the case with extreme precision

Digital/Lab fabricated appliances

How does this change the workflow, treatment and pricing• Need to determine best input for you (intraoral scanner,

VPS, desktop scanner, stone model)• Makes more sense to use more wires to get into slot filling

wires to allow full expression of the setup (likely best finishing wire for MTM would be .018 BetaTi or Stainless

• Much less need for finishing/detailing bends• Takes longer usually to fabricate and the patient will need

to wait longer for their braces as a result• Must charge more to cover additional lab expense, but it

makes lingual treatment much easier

Testimonials

• “I am so excited to get started”

• “I wish I would have known about this years ago”

• “This was so easy”

• “My friends can’t believe I have braces”

• “This hasn’t been difficult at all”

• “I have told so many people about your office”

• “My husband didn’t even know I had braces for 4 days, and then he only found out because I was upset he didn’t notice”

Consider Implementing this system

• What orthodontist wouldn’t want to see:

– Happy patients, WHO-

– Pay on time AND

– Send their friends BECAUSE

– They are so satisfied with their treatment.

• If I could, I would only see these patients

• I am wearing lower MTM on myself now (no one ever notices!!!!!)

In-Ovation L MTM No Trace Bracket Systemtimockfamilyortho.com/wp-content/uploads/2015/08/... · 7....

Documents

Transcript of In-Ovation L MTM No Trace Bracket Systemtimockfamilyortho.com/wp-content/uploads/2015/08/... · 7....