Pacific Coast Society of Orthodontists Bulletin Fall 2019 - 41

Let's Talk About That

several companies and found I could use lighter
forces and begin arch development early. Many of
us who used rectangular slotted PSL found there
was too much play in the anterior slot, as it took too
long to gain control, too long to finish, and required
too many artistic wire bends. It was also simply
too much force to fill up the rectangular slot for
three-dimensional (3-D) control. That's when I started dreaming about a square slot size with which I
could achieve early control with lighter forces.
PT: How have you managed to speed up treatment
with fixed appliances? Would you describe how
your sequence of treatment stages differs from traditional protocols of aligning, leveling, working into
rectangular wires, and then beginning elastics?
TP: Traditional protocols called for starting with
light wires to align, working up to heavier rectangular wires for leveling and opening the bite. Then
we began the work of correcting the occlusion with
heavier elastics, followed by detailing and finishing.
My protocol speeds up treatment in several ways:
Gaining 3-D control with light square wires filling
the slot. Depending on the amount of crowding,
our first or second wire can be an 0.018 × 0.018-in
super soft thermal NiTi.

▫▫ Immediate light, short elastics aid in arch

development and bite correction from day 1.

▫▫ Disarticulation through bite buttons (turbos)

hastens tooth movement. I learned from doing lingual braces in the mid-80s how easy it
was to free up the occlusion to aid in unraveling and improving bite-opening mechanics.
Manipulating the placement of the bite turbos aids in managing the vertical, manipulating the position of the upper incisors, within
the frame of the lips, as well as changing the
occlusal plane and helping with correction of
a Class II or Class III malocclusion with light
elastics. I can also immediately work on arch
development with wider archwires and the
anteroposterior (A-P) relationship when the
teeth are out of occlusion.

Fall 2019 PCSO Bulletin

I therefore start all biomechanical components
of treatment the same day fixed appliances
are placed. This addresses transverse, vertical,
sagittal, and alignment concerns simultaneously
with the 3-D control of the bracket-wire interface, saving time and appointments. Flaring of
incisors has become a thing of the past with Pitts
21 square slots in the anteriors and widened wires
with special elastic protocols.
One of the keys to case management is taking
clinical photographs at each appointment. This
allows me to see actual progress and also really
evaluate bracket position. As we all know, bracket
position is key to minimizing the number of appointments. In addition, I was able to see from serial photographs what light elastics accomplished
at each appointment. Photos of smiling and lips at
rest provide an evaluation of the smile arc/incisal
display development and guide repositioning as
necessary to reduce wire bending in finishing.
PT: Can you further describe the bracket and wires
you are currently using and the advantages they
have over other brackets in speeding up treatment?
TP: I have used rectangular slotted brackets for
50+ years and rectangular PSL for the past 25
years. Rectangular slotted PSL was problematic for others and me, because we found that
rectangular wires created too much force as we
attempted to fill up the slot and therefore took
many detailing adjustments, which added appointments and time to treatment because of the
wire play in the bracket. I have used both 0.018″
and 0.022″ appliances as well as active and passive brackets. In addition, with rectangular slotted
appliances, it takes longer to get 3-D control, so
my square wire system is much more rapid. With
Pitts 21, the six anteriors are square slots (0.021″ ×
0.021″), and the premolars and molars are slightly
variable in buccal lingual depth, but maintain
0.021″ in occlusogingival height. Because of the
lighter forces with my square wires, I can fill up
the 0.021 × 0.021-in slot with 0.020 × 0.020-in
NiTi with the third wire, which gives me much

Pacific Coast Society of Orthodontists Bulletin Fall 2019

Table of Contents for the Digital Edition of Pacific Coast Society of Orthodontists Bulletin Fall 2019