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Orthodontic placement Riversdale Orthodontics

Kyrrolos Hanna 16498953 Latrobe University BOH3 3/24/2015

Contents

Chapter 1: About the practice

Chapter 2: Observations

Wire placement

Removal of braces

Retainer placement

Oral Hygiene Instruction

Impressions & bite registration

Band placement

Bracket placement

Chapter 3: The role of the OHT

Chapter 4: Orthodontic competencies

Chapter 5: Conclusion

Further learning

References

Appendix 1: Supervisor feedback

Appendix 2: LATSEF sketch

Orthodontic placement Riversdale Orthodontics

Chapter 1: About the practice

Riversdale orthodontics is an orthodontic practice located at 428 Riversdale rd, hawthorn east1. It is run by Paul M. Schnider, Christopher Theodosi and Alwyn Wong, who are the leading orthodontists at the practice1. This report is in description of my observations as a student on orthodontic placement and is to be utilized in portraying my experience in practice.

Upon entering the practice, the reception is broad in its length, where a minimum of two receptionists are on deck. A ‘log in’ system was displayed at the surface of the front desk where patients can simply enter their name

which will then bring the patients up as present and waiting. I thought this was a very practical and efficient system because it would save patients the time and frustration of waiting for an available receptionist. The waiting room was made up of abstract art and reading material for the parents and children which conveyed a warm and inviting environment.

After being introduced to the supervisors I had the privilege of meeting two wonderful hygienists, Alice and Rebecca. Our attention was directed towards the work field which is made up of four chairs in an open space. A materials shelf and drug cupboard was located at the end of a narrow corridor along with a sterilization chamber, radiographic development room, a lab and personal offices for the orthodontists. The radiographic room consisted of an Ortho Pantomo Gram (OPG) machine and a Lateral Sephalometric (LATSEF) machine. I personally have been exposed to an OPG, as I’m sure many have, however it was very interesting to see a LATSEF being taken. The materials shelf was very minimal and my assumption is that there are not many tools required for orthodontic treatment.

The surgeries were small in nature but reflected a personal space for one on one communication with the orthodontist. Initial impression was that communication is a key emphasis in the orthodontic setting. All trays are prepared in advance for appointment scheduling, with all equipment allocated for the required orthodontic procedure.

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The technology present at Riversdale was also very impressive. The computer systems were made up of simple color coded prompts. For example, a wire change (done by the hygienist) would come up as a green screen which would indicate that a hygienist is needed at a specific surgery for a quick wire change. In contrast, a purple tab would indicate that an orthodontist is required at a certain surgery. This coordinates where operators can go and what type of operator is needed, which I thought was very efficient. When questioning about notes, it was discovered that most notes are done by the assistants on deck and reviewed at a later stage by either the hygienist or the orthodontist to ensure time efficiency.

The sure smile system is implemented into every computer in the practice. It is formulated on the basis of 3D orthodontic imaging where a clinician can view progress and regulate changes. The system calculates adjustments required and develops a specified code related to a wire adjustment. Hence, this program formulates tailored wires appropriate to the stage of the patient’s orthodontic treatment. The wires are lined with laser markings, three being for the upper jaw and two for the lower. These wires are stored on the shelf and are organized in manner of the patient’s details and arch profile.

Furthermore, the Riversdale orthodontic practice illustrated a very efficient working field with a high standard of equipment and resources. The friendly and hard-working staff bring forth a well-structured and professional image that gives due credit to the profession that is orthodontics.

Chapter 2: Observations

Wire placement

With regards to placing wires in the mouth, this was relatively a straight forward procedure. Strategies in place for easy placement of wires was ensuring that the wires are pre heated before placement. A light (flame) was available to the hygienist in order to force the wire to become malleable and thus ensuring easier access and

placement. Although the warmth of the mouth may cause ’bending’ of the wire this was present only as an alternative it seemed. Operator – patient communication at this point was very important in order to ascertain if there is any discomfort. This is due to the fact that after wire placement, the cheeks become tort and a patient may get the sensation of sharp or ‘pokey’ edges.

Elastic replacement

In the same sense, some patients presented with snapped elastics or were presenting for replacement of elastics for their orthodontic development. It was interesting to note that this part of their treatment was in fact in their hands as they are given a pack of new elastics upon departure. Most patients are aware of how to change place wires and it is the role of the hygienist to make the individual aware of the necessary adjustments (i.e.) placing the band at various brackets2.

Removal of braces

For a patient presenting for removal of braces the entire process was conducted by the oral hygienist. The steps involved in removing braces that were observed included:

Removal of calculus using the ultrasonic

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Bracket removal – using bracket remover pliers

Polishing enamel using fluted then fine tungsten bur

And in some cases a prophy followed by optional fluoride post-operative care

Retainer placement

The process of placing a lingual retainer were very concise and reinforced with a rubber bite block with a suction tip. The steps observed when placing a retainer included:

Air polishing – which consisted of a powder cartridge and water connected to a hand held instrument. This is used to increase retention

Ligatures were tied around the lateral incisors to hold retainer in place

Making sure that the retainer is flush against all surfaces of the teeth the lingual surfaces of the lower canines were etched for application of Tetric N-Bond

The retainer is final bonded into place using a composite resin

Step 1 – ‘tack it’: minimal curing in order to get initial set

Step 2 – ‘cure it’: final set with an second layer

OHI

Oral hygiene instruction accompanied the discussion after placement of a lingual retainer. It was very interesting to see a floss through technique when cleaning the lower anterior teeth following placement of a lingual retainer.

Because the retainer is only bonded to the canines at either side, by wrapping the floss around the tooth and pulling down, the floss falls below the wire. This makes interdental cleaning much easier and this should be stored away for future reference.

Impressions & bite registration

The role of the hygienist also falls into the category of taking bite registrations and impressions. When giving

impressions emphasis was put on keeping the patient upright to guard the mouth. At the practice, Alginate was used for impressions and were soaked in Clinidet whereas bite registrations were taken with a flowable (yet fast setting) material called Regisil Rigid.

Fit band impressions were used in developing Upper Removable Appliances (URA) and Lower Removable Appliances (LRA) which consisted of space maintainers, quad helix, maxillary arch expanders and bite plates3.

These were color coded and each given a convenient name for communication with the developers. Impressions are sent to TDL precision orthodontics for URA and LRA formation.

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Band placement

One of the hygienists explained this as “similar to putting a ring on your finger but for your tooth”. The steps observed during this procedure were:

Checking for all safely removed separators – missing ones could be subgingival and could cause severe inflammation.

Caution must be taken when there are core build ups or

enamel irregularities present, such as hypomineralization.

Prophy / air abrasion

A good fit ~ 3/4 ‘s of the band placed just by using the fingers.

Once the hygienist has prepared the bands, the orthodontist is required to cement them.

Prior to cementation the orthodontist coats the tubes of the band with a wax to prevent blockage

The bands are then cemented with Ketac Cem.

To ensure the band is well seated, a band adapter or ‘tapper’ is used on all four corners of the band.

This procedure is usually followed by wire placement, where in this case, a light wire is

placed for patient comfort.

Bracket placement

Both self-ligating and ceramic brackets were observed at Riversdale orthodontics in conjunction with various apparatus. Preparation of bracket placement is a simple clean and etching

of the buccal surfaces of the teeth and is done by the Hygienist. This consists of:

A buccal retractor.

Etching the enamel surfaces.

Cotton roll isolation (in bite).

However, the orthodontist is a required for final cementation of the brackets. Similar to band placement, Ketac Cem is their material of choice in combination with the ice block to increase setting time.

With regards to modulation of brackets there were various techniques observed while on this placement. These include:

‘Stops’ are clamped on to wires to prevent slipping and movement.

Tube converters can be used to open up tubes and place wires.

‘LLB’s’ which are metal ligatures designed to sit within the tubes of the band.

Forces springs are utilized in correcting class 2 malocclusions by attaching into head gear tubes and forcing the bite into a class 1 occlusion.

Push coils are used in combination with power chains to create space.

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Chapter 3: The role of the OHT

I have developed a list in the hopes of illustrating the scope of practice of an Oral health therapist. This is based on what I have observed on placement and what material I have at my disposal with regards to the intended learning outcomes of Latrobe University.

Tasks ORT OHT

Wire placement

Removal of braces

Retainer placement

Oral Hygiene Instruction

Impressions

Bite registration

Band preparation

Band cementation

Bracket preparation

Bracket cementation

OPG

LATSEF

*License required

In perspective, the orthodontist is authorized to do all of these tasks but in most cases, the hygienist is responsible for getting these simple chores done prior to intervention by the orthodontist.

The Australian Society of Orthodontists states that the Hygienists, Therapists and Oral Health Therapists are permitted to carry out the following procedures in supervised orthodontic practices4.

The selection of orthodontic bands.

The removal of orthodontic arch wires, bands and attachments.

The taking of impressions for study models.

Dental health education (dietary counseling, oral hygiene instruction, etc.)

The placement of intra-oral retainers.

Emergency repair of broken intra-oral appliances under direction of the Orthodontist.

The placement of orthodontist selected arch wires.

Intra & extra oral clinical photography.

Chapter 4: Orthodontic

competencies

Within the intended learning outcomes of the orthodontic aspect of my education, the tasks that I am capable of doing upon graduation include:

Comprehensive Orthodontic examination.

Separator placement – using the floss technique, mosquito forceps or separator pliers.

Placing and removing upper and lower arch wires.

Including self-ligating brackets and rubber modulation.

Oral hygiene instruction & Dietary advice.

Intra and extra oral photography.

Taking upper and lower arch impressions, including impressions for study casts.

Preparation for banding/bonding including sizing of orthodontic bands.

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Sketching of LATSEF’s and hand-wrist radiographic analysis and interpretation.

Chapter 5: Conclusion

Furthermore, the experience at

Riversdale orthodontics was very

beneficial and gave perspective into the

working system of an orthodontic

practice. Unlike many students, I have

neither seen nor personally experienced

orthodontic treatment myself, however

in light of the time I spent in observation

and my education at Latrobe University,

confidence and understanding is a

characteristic I have been fortunate

enough to attain. The orthodontic

placement program is a worthwhile

experience in the fact that the student is

able to visualize and individually

interpret the protocols in place at an

orthodontic practice.

Additionally, it provides the students

with a portal in which to view their

ambitions and future prospects.

Orthodontic practice can be a privileged

opportunity upon graduation and after

seeing its reality it stands to be a

preferable option.

Following this, it was made clear that

there is some additional requirements.

The following list entails specific

programs developed in order to

accomplish these requirements and

receive the appropriate training to

become eligible to be a working part of

the orthodontic system.

Further Learning

Additional radiographic training:

Panoramic radiograph5

TAFE South Australia

Cone Beam Computed5

Tomography Licensing Course5

University of Adelaide

Panoramic radiography5

University of Adelaide

Additional orthodontic education:

Orthodontics for Dental

Hygienists and Dental

Therapists5

University of Melbourne

Additional interests:

In-Office Whitening for Dental

Hygienists and Therapists5

University of Queensland

References

1. Riversdaleortho.com.au. Orthodontist Clinic Kew Clear Toorak and

Camberwell Braces in Melbourne [Internet]. 2015 [cited 8 April 2015]. Available from: http://www.riversdaleortho.com.au/

2. Braces H. How to Connect a Rubber Band to Your Braces [Internet].

wikiHow. 2015 [cited 8 April 2015]. Available from:

http://www.wikihow.com/Connect-a-Rubber-Band-to-Your-Braces 3. Cardiffortholab.co.uk. Cardiff Orthodontic Laboratory [Internet]. 2015

[cited 8 April 2015]. Available from: http://www.cardiffortholab.co.uk/removable.shtml

4. Draft Scope of Practice Registration Standard and Guidelines.

Australian Society of Orthodontists. [internet]. 2013. Available from:

http://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CCIQFjAA&url=http%3A%2F%2Fwww.dentalboard.gov.a

u%2Fdocuments%2Fdefault.aspx%3Frecord%3DWD13%252F11672%26dbid%3DAP%26chksum%3DO7bDEoVAcquK9c32Ev82EQ%253D%253D&ei=88QLVaPQJoC8gX0r4JQ&usg=AFQjCNH1aReQjlIy75IzeBt

EMVSoAlO6og&sig2=0uetNqw eE_STVSMOL-0SBQ

5. Dentalboard.gov.au. Dental Board of Australia - Search [Internet].

2015 [cited 8 April 2015]. Available from: http://www.dentalboard.gov.au/Search.aspx?q=opg

Appendix Supervisor feedback

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ABN: 19 039 832 265

428 Riversdale Road Hawthorn East, 3123 Victoria, Australia Ph: (03)9805 3000 Fax: (03)9805 3024

Tuesday 24th of March, 2015 Dear Mr. Kyrrolos Hanna, This is a courtesy letter confirming that you observed as a visitor in our clinic today. Thank you for coming in promptly and observing our protocols in an appropriate manner. If I can be of any further assistance, please don’t hesitate to contact me. Kind Regards, Kathleen Office Manager

Appendix LATSEPH

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