Australasian Dentist Issue 92

CATEGORY AUSTRALASIAN DENTIST 125 COLUMNISTS responsibleforthenewpatientexamination, the diagnosis and treatment planning of the case, and if appropriate, the optimisation of the aligner set up. The dentist should purely provide guidance to the auxiliary/OHT on a visit by visit basis to make sure treatment is performed efficiently and to a high level of predictability. Orthodontics is the one area that is very scalable in the practice – and especially for a general dentist, you can be in your surgery performing high end dental care and just coming in to the Hygienist’s chair to provide them with the guidance as to what to do at that particular visit – not too dissimilar to an instructor at university level. In this way, your hygienist is now providing treatment at a very high production hourly rate and providing high quality care whilst you’re still providing the same high production in your main treatment room. Having said all that, it’s very important that any hygienist/OHT working in a patient’s mouth has adequate training in all of the areas required – and this would be the caveat that I would place on what an OHT/Hygienist can do in a general dental practice – as they require adequate training from your staff and yourself or at a minimum to enrol them in a very good course to learn the skills required to be a great asset in your practice. Personally, I would never practice again without being able to delegate these procedures to my OHT/hygienist – and I hope that you can learn to implement an OHT/hygienist in the most efficient manner in your practice and you will never ever ook back. u u u Q3 Dear Geoff, I have done other courses and I have been taught to bring an impacted canine tooth into the arch by using a piggyback arch wire for traction. I have had dental colleagues that have done your course and they say that this is probably not the best way to proceed. Can I please have your suggestion? Dr DB, New South Wales Response 3 Dear Dr DB, I am a big believer that every case needs to be assessed on its’ individual merits – this is the key to orthodontic diagnosis and treatment planning. With regards to impacted canines, this is exceptionally important as the position of the canine crown and the canine root will dictate the biomechanics required – and hence one approach is not valid in every situation. I was, very fortunate to be taught at the University of Pennsylvania by Dr Slick Vanarsdall who was the first dual qualified orthodontist and periodontist in the world and was the acknowledged world expert in the management of impacted canines back in the 1990’s and 2000’s. Firstly, for those who do not understand what a piggyback arch wire is – This means that the practitioner is using a very large stainless steel wire as a base arch wire and then overlaying a flexible NiTi wire to engage the ectopic canine and bring it into the arch. The rationale of this approach is to reduce the unwanted side effects of the adjacent teeth as the canine usually has to extrude. However, asmentionedat thebeginning of the response to this question, it really depends on the position of the crown and the root – as there is a great chance that with this piggyback approach, the ectopic canine will come into contact then with the root of the adjacent lateral incisor and cause significant resorption. In addition, the force system will cause the tooth to the dragged towards the buccal and cause bunching of the gingival/palatal tissue, which would impede the orthodontic tooth movement. As such, I believe it is imperative that with every impacted canine case – that a CBCT is obtained to assess the exact position of the crown and root of the tooth and its location with regards to adjacent teeth – and then a biomechanical assessment performed to decide the best approach to move the tooth. In some cases it’s purely distal movement first to ensure it’s out of the impaction area, whilst in other cases it may be pure orthodontic extrusion and this can then utilise even the lower arch as the anchor for that type of movement to perform orthodontic traction far more efficiently. By that I mean when one uses a piggyback arch wire approach – one cannot start any traction of the impacted canine tooth until a very heavy stabilising upper arch wire is in place, and this could take 9-12 months of treatment before one could even contemplate moving the impacted tooth. If, on the other hand, you are using the lower arch as an anchor, whether it be with braces or a modified Hall approach lingual arch, you can actually start orthodontic traction of these upper impacted canine teeth day 1 and speed the orthodontic tooth movement significantly, and even more importantly, reduce the risks associated with dragging teeth into adjacent roots or crowns. In summary, I would use the piggyback arch wire approach very rarely – and probably the best situation would be a normally angulated canine which just hasn’t erupted fully and needs traditional vertical traction without any unwanted side effects to the adjacent teeth – but this is the great minority of impacted canine cases and once again, diagnosis and correct treatment planning is the key to orthodontic treatment planning and it’s definitely no different in these difficult impacted canine situations. u Dr Geoff Hall Specialist orthodontist Founder and Director of OrthoED, Smilefast, CAPS and Clear Aligner Excellence Tel: 03 9108 0475 geoff@orthoed.com.au 1800 806 450 www.amalgadent.com.au Visit Amalgadent Booth #1 at ADX22 Sydney 17-19th March CEMENT + BUILD YOUR CORE IN ONE EASY APPLICATION REFER TO INSIDE FRONT COVER FOR MORE INFO! CoreFlo Footer #92.indd 1 04-Feb-22 10:02:16 AM