Soft Tissue
Soft tissue considerations include analysis of lips and the muscles involved in swallowing and mastication.

Lips are evaluated for the ability to close together without straining. Lip strain indicates lip incompetence. Tipping teeth forward (procliming) is unstable in the presence of lip strain when swallowing. This is a key consideration in making a decision about extracting teeth.

Muscles such as the mentalis (lower lip) are analyzed for excessive force, overpowering the tongue and contributing to arch collapse and crowding. The same analysis applies to masseters (the chewing muscles).

Habits
There are a variety of habits to identify. These include tongue thrusting, digit sucking, lip biting, mouth breathing, hyper mentalis activity, and hyper circumoral musculature activity. These habits are identified by observation of patients’ speaking and swallowing. Habit and Soft Tissue categories commonly overlap in diagnosis.

A less obvious habit is that of mandibular forward posturing. This is done to camouflage an under-bite (Class II/retrognatic). An old orthodontist called it a “Sunday Bite”. It occurs in young (in my experience, 10-12 year olds) patients who realize they have an under-bite so they “correct it” by posturing the mandible forward from Class II to Class I dental. This of course masks the problem but creates significant potential TMJ problems. These patients commonly present with early clicks. I uncover these camouflaged Class IIs by establishing centric relation. I obtain Centric Relation via muscular guidance to a hinge position. If I feel resistance or feel the patient is not in Centric Relation, I use a hard flat plane deprogramming splint.

Other habits I identify are related to patient compliance, fingernail biting, pencil/pen chewing, or chewing gum for example.
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[wptabtitle] Periodontics[/wptabtitle] [wptabcontent]Periodontics
Periodontal Type is identified. All patients 18 and older require full mouth probe and chart from your office (please). We follow your lead on all issues periodontal and will not start treatment on your patient without your clearance and special instructions, if any. For all patients, oral hygiene level is verified as good to excellent. The clinical exam documents issues such as root prominence and health of the zone of attached tissue. This is commonly an issue of the facial aspect of the lower anteriors, where there may be an absence of a zone of attachment along with excessive root prominence. This is a deciding factor regarding the extraction decision (the other factors being amount of crowding and profile and incisal flaring).

All of our patients get their “6 month check-up and cleaning at the general dentist” reminder. It is documented in the chart. All patients under the continuing care of a periodontist are reminded to return to that doctor as prescribed. Communication with the periodontist at the treatment planning stage is required to verify the appointments of the patient’s goals with our treatment plans. On more complex cases the restoring dentist, oral surgeon, prosthodontist or endodontist may be part of a comprehensive treatment plan.

Patients with failed restorations or decay that require prepping the tooth in relation of the biologic width need to be identified. A wonderful option to osseous recontouring (periodontal crown lengthening) in orthodontic crown lengthening. OCL is accomplished by placing extrusive forces that are high enough to not allow the dentoalveolar process to move with the tooth. The force must be low enough though to allow the periodontal ligaments in the socket to not fail, as failure would result in extraction. In short, the tooth moves but the bone does not. Continued occlusal reduction is needed as the tooth is extruded. This is more comfortably done on a root canal treated tooth. We have to account for additional occlusal reduction for crown prep, as well, so consideration of endodontic treatment should be made, even in a vital tooth.

The advantage of OCL is most dramatic in the anterior where the gingival contour can have much more symmetrical, esthetic and healthy anatomy.
Clearly, there are many considerations regarding periodontics in the orthodontic patient. Communication with the referring dentist and coordination with all treating doctors is essential to our job satisfaction and our patients’ well being and their satisfaction with our service.
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[wptabtitle] Skeletal[/wptabtitle] [wptabcontent]Skeletal
The lateral cepholametric analysis reveals important skeletal relationships with the antero-posterior (CL I, CL II, CL III) and the vertical (high, medium, low angle) dimensions. In the case of growing patients this information can help better predict facial growth tendencies. In all patients this skeletal analysis helps to better understand the dental condition that presents to us and how to design the most effective mechanics to deal with the situation. For example, patients with very horizontal mandibles can generate much more biting force than the long face patient with a steeply angled mandible. This is evidence in patients with horizontal (low angle) mandibles pulverizing your Kevlar molar temp crowns. So understanding biting forces and growth tendencies helps determine my treatment mechanics (materials & methods).

Transverse skeletal issues are clinically examined. Most transverse skeletal problems manifest themselves as some form of cross-bite. As odd as it may sound I always check the skull form looking onto the top of the head when the patient is reclined. Some people have narrow skulls, some broad, and some medium. The antero-posterior to transverse ratio of the skull quantifies this skull form. I look specifically at the inter-zygomatic width, i.e. the distance between the lateral most aspect of the right and left zygomatic arches.

This is important because the distance between the flexing temporalis and masseter muscles determines how wide the upper dental arch can be. If we expand too far it encroaches or the buccal corridor. As we know from denture set-ups if we violate the buccal corridor it can cause denture instability, irritation and cheek biting. If we violate it in orthodontics it creates an unstable dynamic that regresses to stabilize and narrow the maxillary width even if an interarch malocclusion results. The dental alveolar complex is going to go where those muscles that flex 1200x/day want it to go.[/wptabcontent]

[wptabtitle] Dental Dx[/wptabtitle] [wptabcontent]Dental Dx
The dental age of the patient relative to chronological age is the first analysis. If a significant discrepancy exists we take a Pano. I look at root development. Teeth typically erupt when 2/3 – 3/4 of roots are developed. If roots are well developed and the teeth unerupted then extraction of the overlying deciduous teeth is considered. Then the dental analysis is done in the three planes of space: antero posterior, vertical and transverse. The antero posterior relationship is analyzed as Class I, II, or III, the overjet and the angulations of the upper and lower incisors are measured from the cepholometric x-ray.

The vertical relationship is measured as percentage of over bite or amount of open bite.

The transverse relationship is analyzed via the buccal overjet/ cross bite and upper and lower midlines.

Arch length discrepancy, which is dental crowding and spacing is, of course an important evaluation.

Additionally, missing teeth are identified along with anomalies such as supernumerary teeth, under or over sized teeth and prior dental treatment is assessed. Finally, the TMJ is also access and centric relation/ centric occlusion discrepancies are diagnosed.
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[wptabtitle] Tx Planning[/wptabtitle] [wptabcontent]Tx Planning
The treatment plan is developed considering all the diagnostics. The first consideration is, “Is it the right time to treat?” I place many patients on recall. I always send a letter to the referring dentist explaining my findings and decision to treat now or later. Many times space maintenance is appropriate while we wait for teeth to erupt.

When it comes to active treatment there are many tools or appliances that I use depending on individual needs, such as Class I or Class II malocclusion, open bite, cross bite, crowding or spacing. Each treatment plan is individual. The extraction decision is made based on degree of crowding, lip incompetence, profile and supporting gingiva. Expansion of the maxilla (if constricted) will gain space and in some cases eliminate the need for extraction. However, when people speak of “expanding” the mandible, this is not true expansion as in the maxilla where a suture is opened. They are leveling the curve of Wilson by tipping the lower buccal segment out. I do this only when starting with an exaggerated curve of Wilson to correct it. Decision to expand is based on presence of cross bite. I use an orthopedic force that opens maxillary sutures and produces dental alveolar expansion with as little tipping as possible. I almost never expand in the absence of maxillary constriction because to do so requires “expanding” the mandible which is physiologically impossible due to the absences of patent sutures.
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[wptabtitle] Materials and Methods[/wptabtitle] [wptabcontent]Materials and Methods
Despite claims from manufactures of braces, the brand of braces used does not determine my treatment plan or quality of finished results. It is not the brand of bracket that treats the patient it is the doctor and team. These four variables determine the quality of the finished result:

• My ability to properly diagnose the stomatognathic system and develop a properly timed mechanically efficient and appropriate treatment plan.
• My team’s and my hand skills.
• My team’s and my passion for excellence.
• The compliance of my patients and our ability to inspire them to excellence.

So before any discussion of materials occurs please understand that I do not align myself with any particular manufacturer. However, I want the best materials so I am constantly reviewing new materials regardless of the manufacturers.

That said here are some of the manufactures I use:

• Lancer brackets, 018 slot anterior, 022 slot posterior, Roth Rx
• American orthodontics, self ligating brackets, same size slots and Rx
• GAC, Neosentally (heat activated) arch wires, Nickel-titanium arch wires, Stainless steel arch wires.
• Lancer molar and bicuspid bands
• GAC lower molar bands with lip bumper tubes (for Cl III patients.)
• Ormco® incisor and cuspid bands in rare instances
• Ormco® blank molar bands for lower or upper space maintenance appliances
• Mondeal Lomas® mini implants/temporary anchorage devices
• Zapo® LASER
• Opalescence® tooth whitening system

I use headgear in some young Class II patients and protraction face masks for some Class III patients. I use a variety of custom fabricated (soldered) appliances such as biteplates, Nances, pendex molar distalizer and lower lingual holding arches. The placement of bands and appliance details are custom designed for each patient’s needs.

In patients requiring maximum anchorage, I now use and place Temporary Anchorage Devices (TADs), which are essentially titanium screw-in implants that provide complete anchorage in cases that need it. TADs are a huge advancement in clinical orthodontics and it is exciting to be an early adopter.

Another advancement in orthodontics has been the use of soft tissue lasers. These devices have been around for years but only recently become affordable to the private clinician. I can now do operculectomies to band second molars and uncover teeth that are slow to break through the mucosa. This reduces treatment time because I can band or bond teeth sooner rather than waiting months.

I use Invisalign® in some cases. I started using Invisalign® when it was first introduced in 1998 and would be happy to discuss why it can be an excellent option for treatment and, for some patients, be the best option.

I use Opalescence® tooth whitening system.

For retention I use modified Hawley removable retainers. We observe our patients for two years after braces are removed.

If you have any questions regarding any of the previous topics please call.
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[wptabtitle] Ethics[/wptabtitle] [wptabcontent]Ethics
The golden rule says to do unto others as you would have done unto you. Integrity is doing the right thing when no one else will know. These two concepts we have are the core of the team approach at Cain Orthodontics. The philosophy is to provide the best possible service to our patients, including using the best materials and methods. Unfortunately, manufacturers of products are direct advertising to patients the same as the pharmaceutical television ads. They have websites that direct consumers to offices that sell these products. The consumer can then shop for the best price on these products. There is a danger of changing from being a trusted provider of carefully considered “Golden Rule” health care to a retailer of a commodity. This conversion is neither in our patients’ nor our profession’s best interest.

The November, 2008 AAO Bulletin had an important article: Would your ads claim withstand scrutiny? (AAO members are obligated to run truthful ethical ads.) In this article the author reviews the American Association of Orthodontists (AAO) ethics code regarding promotions and public statements as such: “You must have a reasonable basis to believe that your public statements are true”

“It is questionable whether such “reasonable basis” exists if an advertisement that has been developed by a third party is used without investigation, particularly if you have no prior knowledge as to the accuracy of the content.” This is why I do not connect my name to any manufacturer or to any promotion except this website. Links on this website are to the unbiased AAO website. There are no direct links to manufacturers. A high ethical standard needs constant maintenance because it requires a level of selflessness.

At our office the team statement is “Always do the right thing not the easy thing, even when it’s not convenient. Because we, the team, have a serious responsibility, our standards are high. In school a 90% is an A. Not here. We have to get it right all the time because our patients and their parents and the doctors who refer to us, trust us; and that relationship of trust is essential to maximize the overall therapeutic benefit of treatment we provide.”

Our business is orthodontics, but it’s the relationships that make the business happen; relationships based on trust which is based on high standards which is based on doing it the right way not the easy way. This is how we get the best results for our patients. I would be happy to discuss with you the science behind my treatment decisions and methods as well as my concerns about the commoditization of our profession.

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