Alicia Froehlich

11/21/19

220A

Dental Specialties Observation Report: Orthodontics

For my dental specialties report I decided to observe in an orthodontic office. As a child having

braces I felt as if I had been in the orthodontist office plenty of times but still knew nothing about it.

After a few years of having the opportunity of working with general dentists, I thought I would be

interesting for this report to experience something completely different than what I’ve experienced in

my workplace and school experience. I watched two back-to-back procedures which was interesting

because I got to watch two completely separate phases of patient care. The first procedure I watched

was a full banding procedure for a patient. The patient was an adult who previously had braces so they

decided to put her on a “limited treatment”. This means that instead of being in the braces for 18

months to 3 years, the patient will have her braces on for 6-12 months. To start off the appointment,

the orthodontic assistant retrieved the patient and brought them back to the treatment area. They

made their way to the x-ray room. At her appointment, they decided to take a cephalometric x-ray

because they had a year old panoramic x-ray on file. The cephalometric x-ray was interesting to watch,

the patient wore a led apron as always, there was no bite block although there were head stabilizers.

Once they were done with the x-ray, the patient was brought into a back exam room where the

assistant took extra-oral profile photos of the patient with a straight face and then with a smile. They did

this to compare the patients bite and profile to before and after treatment. She then was brought to her

treatment chair. Once they got to the chair the assistant then used a camera again to use intra-oral

photos of the patient’s teeth and occlusion up close. They used check retractors and had the patient

help retract the cheeks as she took the photos from different angles. Once all the pre-treatment photos
were taken, the assistant showed the patient her brackets and asked her if she would like a color of

bands, the patient decided to choose both clear brackets and bands for a subtler look. Next, the

assistant needed to remove the previous bonded retainer the patient still had. The assistant used air to

clear the area and expose the glue more profoundly. She then used a hand-piece and a straight bur to

begin removing the glue. The assistant would rinse and blow air on the area occasionally to clear it of

debris. Once most of the glue was removed, the assistant used a straight scaler – that looked similar to a

sickle – to pry off the retainer. She again rinsed and dried off the area and removed any residual glue.

Next, the assistant applied the molar brackets. Before starting, she offered the patient chapstick, as they

would be open for a long period of time. After applying chapstick, the assistant put the check retractors

in and used a q-tip applicator to dry and clean off the molars along with air. Then she applied “Reliance”

brand gel etch onto the facial surfaces of the four 1st molars and let it set up for 30 seconds. She then

suctions up the excess, rinses the patient’s mouth and dries the areas again. She then places an “Assure”

brand of bonder on the etched teeth. On each of the four 1st molars, the assistant puts glue on the

bracket while holding it with orthodontic bracket forceps. She uses her mirror and scaler to place the

bracket on the facial surface of the tooth. The bracket is placed roughly on the middle of the facial area

of the tooth being slightly mesial so that the grooves on the bracket will meet up with the grooves on

the molars. Once placed in the correct position, the assistant then removes any excess glue and finishes

by light-curing the glue for 30 seconds. She repeats this process until all the brackets on the molar teeth

are positioned and secured correctly. The assistant then watches to see if the orthodontist will be

available soon before she begins her next step in the procedure. Once she confirms he will be available

soon, she moves on. She begins by etching the facials of the rest of the teeth in the mandibular arch – in

this case it was 2nd premolar to 2nd premolar. Once she applies etch to all of the remaining mandibular

teeth, she lets it set up for 30 seconds and again she rinses and dries the teeth. She applied bonder to

the whole arch as well, the bonder is applied to the same areas of the teeth that were also etched. She
then places each bracket, using orthodontic bracket forceps to stabilize the bracket as she applies the

glue. Once she places the bracket on the tooth she moves it to the approximate area of the tooth it will

be secured. In this situation, the assistant placed brackets in only ½ the mandible because the patient

chose clear brackets, which allow the outside light to begin curing the glue faster than metal brackets.

The assistant would usually place all the mandibular brackets – without curing them – when the patient

has the standard metal brackets. Once the brackets are placed, the assistant has the orthodontist come

by and make sure the brackets are in the correct spot. If any are not, he will simply move them with a

scaler. The orthodontist has the patient bite together and then open. He also uses a mirror to check the

brackets placement. Once the bracket placement is approved by the orthodontist, the assistant light

cures the brackets in place. She cures each tooth for 10 seconds, two times resulting in 20 seconds per

tooth. The assistant then repeats this same procedure on the other half of the mandible and moves onto

the maxillary – each time getting the quadrant checked by the doctor before light curing the teeth. The

etching, rinsing, drying and bonding process is the exact same as the maxillae. The assistant works in ½

of the maxillae and once the orthodontist approves of the placement she moves onto the second half.

Once all the brackets are placed, the assistant gets ready to place the wire. For this specific patient they

are only applying the wire from 2nd premolar to 2nd premolar and will incorporate the molars later in the

treatment. They begin with a very thin wire and move up in thickness as the treatment proceeds. The

assistant uses Weingart pliers and distal end cutters to cut the wire to size and to bend it so it fits

properly in the brackets. She heat treats the wire with a lighter so that when she bends the wire, it will

stay. The very thin wire is a nickel titanium and it will resist bending and return to its original shape if it

is not heat treated. Once they move up to heavier, stainless steel wire the heat treating will not be

necessary. The assistant then uses Mathieu orthodontic pliers to place the bands around the brackets.

Some orthodontic assistance will use a hemostat but she did not prefer them. The assistant places the

bands from 2nd premolar to 2nd premolar on the mandible and then on the maxillae. Occasionally as she
moved more posteriorly, the assistant would use an explorer – that looked similar to a shepherd’s hook

– to stretch the band so it went onto the bracket with ease. After placing all the brackets, wires and

bands the assistant asks the patient if she felt any sharp or poking, the patient answered no. The

assistant sat the patient up and began explaining brushing and flossing techniques and gave her oral

hygiene supplies to take home with her. She also went over a dietary guidelines and foods to stay away

from while she is in braces along with a list to bring home with her. The assistant also offered for the

patient to call in whenever if she feels like her clear bands were becoming discolored for new bands. The

assistant then let the patient know that she will be waiting 6-8 weeks for her next appointment and then

let her know every appointment after that will be a 4 week re-appoint. She asked her if she had any

questions and the patient did not so she sent her to the front office to make her next appointment. The

assistant then began to write in her notes in their computer system, Dolphin. It is a computer system

that pairs well with the needs of orthodontist records, however can be used in other specialty offices.

She included that they did a ceph x-ray, intraoral and extraoral pre-treatment photos. She also added

that they applied upper and lower bands and she made a note that they are clear bands. She noted that

the patient got molar brackets put on, because some younger patients get metal bands that encircle

their molars instead of standard brackets. She also noted that they did a “segment banding” because

they did not include the molars on her banding procedure. The assistant also noted that she went over

OHI and gave the patient a food list, she also noted the patient had good home care. Once the assistant

initialed her notes, she saved them and moved onto sterilization.

The assistant then has another short appointment right after. After she flipped her chair and

brought over a new tray she seated her next patient. This next patient was at the end of her treatment

and was scheduled to be prepared to get her braces off on her next appointment. To be prepared for

her braces to come off for her next appointment they were going to begin creating a bonded retainer.

When the patient is seated, the assistant asks if there is any problems or concerns and the patient says
no. She is then seated back and the assistant removes the bands with a scaler instrument. She then

removes the wire and places it on the tray. To prepare for the bonded retainer the assistant took a

lower impression. As she mixes the alginate, she has the patient pick out her new color of bands. The

assistant then places the alginate into the lower impression tray and removes the excess from the

posterior. She places the impression and after it hardens, she removes it, disinfects it and wraps it up for

later use. The assistant will take an upper impression on her next appointment after her brackets are

removed to create her upper retainer. Both her bonded retainer for her mandible and her removable

maxillary retainer will be ready the same day as when the patient will get their braces off. The assistant

then retrieves the orthodontist to check the brackets. He has the patient bite down and open and tells

the assistant any extra information to note in the patients chart. In this case, the patient only needed to

continue placing rubber bands on her left side. The orthodontist then adjusts the wire by bending it in

the correct areas and sets it on the tray for the assistant. The assistant then takes his place and places

the wire, again using the Weingart pliers and distal end cutters to cut the wire to size and to bend it so it

fits properly in the brackets. She then applies the new bands onto the brackets, the patient got

individual bands on the mandible and a chain on the maxillae to ensure spacing is correct on the top.

The assistant asks if everything felt fine or if there was any poking or sharp areas. She then shows the

patient where to place her rubber bands on her left side – in this case the first anchor that is most

anterior on the top and the last anchor that is most posterior on the bottom. She sends her home with

new rubber bands and written instructions on where to place them. The patient is then dismissed to the

lobby to be assisted in making her last appointment date. The assistant then completes her chart notes.

She writes in the new type of rubber band given to the patient and documents that she gave instruction.

She also notes that the patient has a full chain on her maxillae. The assistant then initials her notes and

moves onto flipping the chair. Once the chair was flipped, the assistant went to the lab area and poured
up the impressions, using white plaster stone. She will leave them for about ½ hour and take them out

and leaves the labeled model for the lab technician.

In terms of sterilization and infection control, there were some areas that were very similar to

our LCC standards but others that were very different. This office used Birex and 4x4 gauze squares to

clean their stations when they were finished. They wiped the tables, patient chair, air/water, suction

and any hand-piece lines with the Birex. This office did not use near as many barriers as LCC. They did

not barrier the tables, chairs or lines. On their trays, they did have a paper barrier the instruments sat

on. They did not use lights so there was so need to barrier the lights. In their sterilization room they had

a clean side and dirty side. While in the dirty side of the sterilization room they wore gloves. They throw

away any disposable items such as air/water tips or suctions tips. The wire fragments and etch tips went

into a sharps container. The cheek retractors were wiped down with alcohol to remove any chapstick,

they were then placed into an ultrasonic and then into a cold sterile. If there were any full sections of

rubber bands that were not used, they were placed in cold sterile as well. The instruments got put into

the ultrasonic and the hand-pieces went into the statim sterilizer. Along with the hand pieces, the

mirrors, bracket holder and the smaller instruments were placed into the statim as well. Once the large

instruments were done in the ultrasonic, they were placed into a cox sterilizer. None of their items were

bagged, except for a few of the scanner tips. After all the instruments were sterilized, they had a few

different trays were they kept the different instruments in piles – it looked similar to an assembly line.

When the instruments were cooled off, they would begin setting up trays and retrieving the specific

instruments they needed from the different piles. They were then placed above in shelves for future

appointments. The assistants had a casual look for their uniform. They all wore jeans, a long sleeve

jacket-like top with their name embroidered onto the top along with sneaker type shoes. They all wore

their hair up and wore masks, glasses and gloves during patient care. The orthodontist wore nice shoes,

pants and a button up shirt, he too wore his regular glasses, gloves and a mask during patient care. I do
not believe LCC should adopt any of the procedures, it seemed like a lot of their protocols were either a

bit dated – such as their sterilizer they used – or they were very casual in their wear – which I do not

think is appropriate for our type of work we are doing.

In this office, they did not have a hygienist employed. However, the orthodontist was happy to

have me come observe because he loved the idea of a hygienist getting some first-hand experience in

the office. He wanted to let me know that most orthodontists will work with hygienists and dentists to

benefit the patient. An example he gave was that they are able to take off the bands and wire – while

leaving the brackets – before a hygiene appointment so that it is easier for the hygienist to clean around

the braces. Of course, the patient would then have to quickly return to the orthodontist to have their

wire put back on. This is something that could be beneficial to the patient, hygienist as well as the

orthodontist, however the patient has to be compliant in the various appointments. In their office, there

seemed to be a smaller staff. It consisted receptionists, assistants and the orthodontist. The

receptionists were in charge of patient scheduling and insurance. The doctor was in charge of final

decisions, bending the wires appropriately, creating treatment plans, performing new patient and

returning patient exams, addressing any issues the patients may be having and anything else the

assistants were not qualified to perform. There were quite a few assistants working in the office. Most

of them were “just assistants” and there was one that was an assistant as well as their lab technician.

The assistants took the x-rays, intraoral and extraoral photos – pre and post treatment, explained the

importance of home care and limiting certain foods while in braces, demonstrated how to put on rubber

bands at home, prepped the teeth for the brackets, placed and secured the molar brackets, placed the

brackets in the other areas in the mouth for the doctor to check, light curing the brackets, placed the

wires and bands as well as take impressions for retainers. The assistant who is also a lab technician is in

charge of trimming models, creating bonded retainers and creating upper removable retainers. There

were a few assistants that were also being trained to become lab technicians as well.
 With many general dentists offering Invisalign, some wonder why they would go to an

orthodontist now for their malocclusion needs. There are many reasons to choose an orthodontist over

Invisalign in a general practice. First off, the orthodontist is going to have more knowledge on the topic.

Their schooling was specific to this specialty, unlike a general dentist who is offering Invisalign as an

added service. Orthodontists have the ability to work with patients with challenging occlusion that a

general dentist may not know how to tackle. They also have more knowledge on the possible

complications and advanced cases that may appear. The orthodontists are required to have an

additional 2-3 years of specialty classes. Whereas the general dentists attend continuing education

classes or additional training, but less extensive than that of an orthodontist. Another challenge some

people face with using Invisalign is the “freedom” to remove them at their convenience. While this may

be seen as a positive, a lot of times it results in a patient not following through with the treatment.

Patients will not have the motivation to remove the Invisalign between meals and to brush and place

them back in throughout the day. This results in the patients not wearing their Invisalign throughout the

day which compromises their treatment results. With braces, patients are more likely to follow through

with the treatment and therefore having better results. They are also scheduled to see their

orthodontist every 4 weeks, whereas patients choosing Invisalign through their general dentist only are

scheduled to see them every 6 weeks. This leaves a lot more time for inadequate use of the Invisalign

without corrections.

I thought it was interesting to observe this orthodontist office. In this office, their performed full

bandings, partial bandings, new patient exams, panos and other x-rays such as ceph x-rays, they also

performed removing brackets and bonded retainers. Their services directly related to braces and the

procedures to meeting patient treatment goals. As a student going for Dental Hygiene, I think a lot of

times braces and orthodontics are greatly overlooked. I appreciated them letting me know that they do

in fact want to work with the other dental personal to achieve the best patient care. I think more
hygienists and dentists should make an effort to work closely with orthodontists. They mentioned that

there is a common occurrence of children having inadequate home care that can affect their

orthodontic treatment. Having the orthodontist and hygienist work together to improve things such as

home care and oral health young children in braces would benefit the hygienist, dentist, orthodontist

and most importantly, the patient. I think this experience has opened my eyes and motivated me to be

active in working with other health care providers to give our patients the best care possible.

Jedidiah R. Gass, DDS, MSD

541-687-1161

I observed their assistant, Amanda