Pitts lecture review

Madrid Review and Follow-up

Dr. Tom Pitts

© 2014 ALL RIGHTS RESERVED - DR. NAME

My Background

• Great interest in occlusion & esthetics

• I did my first restorative case on a Stuart Instrument in Dental School-1964

• I had decided that I would specialize in Prosthodontics in Dental School

• Till I met Dr. Art Dugoni

• Started practicing general dentistry in 1965 and immediately was disappointed in the results of patient referrals to the orthodontists

© 2014 ALL RIGHTS RESERVED - Dr. Tom Pitts

My Background

• Fortunately I was drafted into U. S. Army in 1966 and then it was easy to apply to orthodontic specialty training. Univ of Washington-Seattle

• Started practicing orthodontics in 1970 Reno, Nevada, and immediately started trying to study esthetics and occlusion

• I studied under Ron Roth, Peter K Thomas, Tom Basta, and other gnathologists

• Found some practicality with Pete Dawson


My Background

• Esthetics… Robert Ricketts 1975, Chuck Hulsey, David Sarver, Pitts Progressive Study Group

• Eventually began teaching at UOP ortho program

• Worked for Ormco for years. Left Ormco 2012

• Glad to be away from them

• Now working with a new company (OrthoClassic) that is into innovation and helping the orthodontist

• Still teaching UOP San Francisco

© 2014 ALL RIGHTS RESERVED - DR. Tom Pitts

My Background

• Practicing orthodontics and clinical research in Texas with Dr. Scott Law

• Lecturing globally on excellence in orthodontic finishing… OrthoEvolve.com

• Created my “Master’s in Finishing” continuum course — 4 sessions every 6 months


My Emphasis

•Extraordinary Esthetics and Beauty in Dentistry

•Team Tx Planning

•Healthy Occlusion/Perio

•Team and family building

•Networking

In orthodontics, there are many restrictive “laws”

about treatment & treatment planning, based

mainly on “Stability”

Restrictive and ConflictingThought..

• Can’t widen arches much

• Upright Lower incisor position ala Tweed

• Never wear inter-arch elastics until heavier wires

• Should not recontour canine incisal tip.

• Must use RPE early or Surgery to expand upper arch


• Must end up with the lower incisor in the Tweed triangle for stability

• Can’t widen canines at the cusp tip

• Must open the maxillary suture to widen the upper arch!

• Must treat Upper incisors to Lower incisor position

• Bad to propulse the mandible forward with a functional appliance


• It’s been researched fully

• “Nothing is Stable” in the human dentition, whether treated or untreated orthodontically

• Arches collapse as we age!!!

I began looking closely at Facial and Smile

esthetics in the early 1970’s

• Karl Nishimura/Frankel/Bionator

• Dr. Robert Ricketts…Non-extraction..upper lip.

• 1979 Pitts Progressive Study Group

Esthetics

The Upper Lip & Teeth are very precious to the Beauty in

All Ethnicities

Today, The world over-- !

!

!

Most Want Full Lips

*all rights reserved

Re-looking at traditional hard and soft tissue analyses

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Illustration Courtesy Rungsi Tavarungkul


In orthodontics, we used to base our diagnosis and treatment plan on the position of the lower incisor

My diagnosis is based on the upper incisor

My Top 10 features for Facial & Smile Esthetics

to look more youthful and attractive

That the Orthodontist and the Dental Team can control

© 2014 ALL RIGHTS RESERVED - Tom Pitts.

1. Full Dental Mass

2. Proper Inclination of Incisors/Cuspids

3. Smile Arc Curvature

4. Incisal and Gingival display

5. Wide Arch Width in Bi’s and Molars

•My Top 10… Smile Esthetics


6. Esthetic Arch Shape

7. Rounded and softened Incisal edges and Manicured Canines.

8. MicroEsthetics.No “Pepper Spots”—-Long Connector Contacts, Crown Proportions, Tissue,etc

9. Full Upper Lip

10. Nice Soft Chin Projection

•My Top 10… Smile Esthetics

All 10 under our control


*all rights reserved

• “Increasing dental mass over skeletal volume increases the perception of youthfulness" - Sarver

1. Full Dental Mass

A smile full of teeth

Initial

Final

Inclination is major to Esthetics!*all rights reservedCourtesy Toru Hoshino 2010

2. Inclination of Upper Incisors/Canines

Courtesy Tom Pitts


© 2014 ALL RIGHTS RESERVED - Tom Pitts

3. Smile Arc Curvature

Smile line-Smile arcFrush & Fisher “The dysesthetic interpretation of the

dentogenic concept” J Prostate Dent 1958;8:558

Bracket Position

#1 !!!

Biggest help with Smile Arc !

Bracket Position &/or Restorative

© 2014 ALL RIGHTS RESERVED - Dr; Tom Pitts

© 2014 ALL RIGHTS RESERVED Tom Pitts

SAP Bracket Position

4. Incisal and Gingival Display

© 2014 ALL RIGHTS RESERVED - Dr; Tom Pitts

5. Wide Arch Width in Buccal Segments

We can now deliver more of what the people want esthetically

Cindy CChristy B

Arch Development is easier for me with passive self-ligation


Arch development is one thing I concentrate on for

every case!!

• Not too wide in the canine area


6. Arch Shape

© 2014 ALL RIGHTS RESERVED Thomas Pitts

7. Rounded and Softened Incisal Edges


• No “Pepper Spots”

• Flattening Contacts (Long Connectors)

• Root inclinations

• Gingival shapes and contours

• Proper Zeniths /gingival heights

• Proper Proportionality

8. MicroEsthetics

9. Full Upper Lip

• Vermilion Curl/Vermilion Display

• Naso-labial angle approaching 90 degrees

• Determined by the AP position of maxillary Incisors


10. Chin Projection

It’s much more than just putting plaster on the table

or straightening the front teeth

Facial Driven Orthodontics

Our Philosophy, In Summary• Esthetics means everything to the patient!

• Don’t adversely affect esthetics to create a good bite!

• Patients, today, want full smile and protrusive lips!

• Protect and/or enhance the facial and smile esthetics we can control!

• When necessary, creat a proper foundation prior to restorative


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Exaggerated SAP!

To enhance incisal display!

! and Smile ArcBracket progression continues through the anteriors to create the smile arc


Courtesy Rungsi Thavarungkul © all rights reserved

SAP- Keys off of the the recontoured Canine and the length of the lateral

Incisor


Bracket progression in the anterior is mild

Prior Bracket PositionBracket progression continues through the anteriors to create the smile arc


Courtesy Rungsi Thavarungkul © all rights reserved

Prior versus SAP Approaches

Lower Incisors are positioned for Over-bite and Over-correction

*all right reserved

© all rights reserved Courtesy Tom Pitts 2009

Positive Coronoplasty prior to bracketing


Finishing = Case Management

Managing the patient with whatever appliance you use!

Facial Driven Finishing

Finishing is not just about the “bracket” ….

!

it’s how we “manage” the particular Bracket we are

using


• I.O. Photographs every appointment

!

Very important to Case Management Constant Assessment - every appointment actions


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• Evaluation of Progress

• Evaluation of Bracket Position

• Evaluation of Cooperation/rubber bands/Oral Hygeine

• Communication with Parent

• Motivation of Patient/Parent

• I see things that I don’t pick up clinically.

Clinical Photos every time-Why?1. Clinical Reasons

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• Internal Marketing/Validation by patient

• External Marketing with Dental Hygienists/PCDentist/Dental Assistants/Public

Clinical Photos every time-Why?

2. Marketing Reasons

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Clinical Photos every time-Why?

3. Documentation… Medical Legal…White

spots, etc.

4. Training and Teaching


1. Torque/bracket selection (Inversion as necessary) 2. Enamel recontouring (Before placement) 3. Bracket Position 4. Disarticulation 5. ELSE (beginning) 6. Wire Selection, Sequence & Timing 7. Habit/Muscle Training 8. Patient Motivation 9. Pan/Repo

14 Keys to Pitts Case Management

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Stage I

10 Overcorrection/patient cooperation 11. Wire Manipulation 12. Finishing Elastics /cooperation 13. Occlusal Adjustments/Esthetic Recontouring

14. Tooth Size Refinement

9 .Pan/Repo ReassessmentSecond Stage


14 Keys to Pitts Case Management

The Research is Clear!

• All orthodontic treatment is unstable!

• Whether treated with extraction or nonextraction

• The fundamental objective in orthodontic treatment is to maximize Facial/Smile esthetics and anti aging

Reduced Biologic Availability

•I still have more recession if I extract on Periodontally compromised patients or very thin labial alveolus

Early light short Elastics/Disarticulation

Dr. Tom Pitts

Posterior Bite Buttons/Turbos

• In the Fossa whenever possible: seems to be more comfortable

• If need buccal root torque on molars, place on palatal cusp

• OptiBand Plus in syringes/Pink Triad

• Triad Gel

WHY?——Intrude molars

I almost never place bite buttons without beginning Elastics

Why Anterior Bite Buttons?

• Level by eruption Buccal segments

• Prevent intrusion U anteriors which protects Smile

• Immediate bracketing on lower • No reverse curve wires • Control OB throughout

treatment© all rights reserved

Why do I not use posterior bite buttons on Deep OB

• Causes Intrusion of Molars rather than Extrusion

• Adds time to the Treatment if a deep bite

• Used for open bites and high angle cases


A fresh look at non-surgical correction of

mild to moderate Cl III

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Principles of Cl III!Non-Surgical Tx.

•Proper Bracket Placement!•Bite buttons!•ELSE!•Keep Elastics forward of center of resistance of maxilla!

•Profile doesn’t look to be severe Cl III!•Sleeping plus Squeeze exercises as needed!•Muscle Stretching!

Principles of Cl III!Non-Surgical Tx.

•Proper torquing of buccal segments!•Lower tip backs as needed at first.!•End L wire distal to L6. 20 degree tip back bend in front L6!

•Over correct if possible. Deepen bite!• I like to flip U 2-2 or U 3-3 = Critical!•Use Beta Titanium wires instead of Stainless Steel!!

Manditory to follow Cl III treatment with night-time

Muscle Training Splint

Torque control and Arch Development are Keys to finishing with excellence

Early My new project

involves getting an early jump on these

protocols© all rights reserved

1. Torque/Bracket Selection (Inversion as necessary)

2. Enamel recontouring (Before placement) 3. Bracket Position 4. Disarticulation 5. ELSE 6. Wire Selection, Early Arch Development 7. Habit/muscle training 8. Patient Motivation 9. Pan/Repo

14 Keys to Pitts FinishingFirst Stage

© all rights reserved © all rights reserved

10. Overcorrection/patient cooperation 11. Wire Manipulation/Coordination 12. Finishing Elastics/cooperation 13 Occlusal Adjustments/Esthetic Recontouring

14. Tooth Size Refinement

14 Keys to Pitts Finishing

9 .Pan/Repo ReassessmentSecond Stage


Once I get anterior bite in order and I’m in adjustable wires,!

I like to have 3-4 adj/detailing appts

*all rights reserved Courtesy Dwight Damon 2009, Duncan Brown 2009

Difference: Torquing roots Labially 1.)Root-end Resorption 2.)Roots through labial plate 3.)Labial-Gingival Recession

*all rights reserved Courtesy Dwight Damon 2009, Duncan Brown 2009

!

Torquing roots Labially 1.)Activity of wire in slot=Torsion 2.)Gentle Torsional Forces 3.)Must have space or Widen the arch (Light Cl III elastics

Why widen arches?• Looks better!!! Much better!!

• Allows for uprighting of incisors when proclined!

• Crossbite correction!

• Gains much space

My most beautiful cases involve arch development !

I’ve been widening archwires for 30 plus years

I don’t just widen a slight amount.

H4

• Slot Depth

• Tie wings

• All one piece (no braising pad)

Proponents of non-expansion argue that the original arch shape and

width are the most stable dental configuration & are

least likely to have post treatment gingival recession

• The research is clear: ALL orthodontic tx is inherently unstable, whether treated with extraction on non-extraction!

• The research is also reasonably clear that retainers, when worn properly, work pretty well!

• Conclusion: Stability is NOT a consideration in Tx Planning…All tx protocols need retention.

Case Management• impact of Tx Mechanics!

• In Theory, slow & gentle tooth movements have a greater ability to “draw” the alveolar bone!

• My early light elastics, “active early” torquing and widening, disarticulation and slow vertical correction, I feel, increases the envelope of tooth movement.

So my search has been to find a way to achieve maximum

smile esthetics while respecting periodontal biotype

• We will look at ways that I increase the envelope of tooth movements

Stability with widening

• Retention for life!

• Tongue training all the way along!

• Ricketts found that buccal expansion was relatively stable with long term retention

Buccal Inclination is critical with Arch Development

Courtesy Tom Pitts

Remember..• All orthodontic treatment is inherently unstable,

whether extraction or non-extraction!

• Wider smiles are more attractive. Arch shape makes an esthetic difference!

• My primary goal in ortho tx. is facial and smile esthetics!

• The real reason patients want orthodontics is to look better

Remember..• Don’t inhibit arch development (especially in the

molars) unless the lower arch is too wide!

• Keep the upper anteriors and upper lip forward!

• I don’t quit until the anterior and posterior torque is finished!

• Take IO photos each visit!

• Work on patient cooperation

Class II correction

•I never treat the Upper Teeth to the Lower with a retrusive Chin

© all rights reservedCourtesy Tom Pitts 2014

Tom Pitts

I still see the majority of Orthodontists trying to treat the upper arch to the lower arch without regard to the

face or the airway

• Molar distallizers

• Upper extraction with Head Gear/elastics

• TAD’s for anchorage to retract upper ant.

• Proclining Lower anteriors with the lower arch


Tom Pitts

Pitts Principles(Skeletal Cl II)

• Initial activation of Cl II mandibular propulsion to be no more than 4 mm.

• Successive activation no more than 3 mm.

• Go slowly

•Overcorrect • Leave appliance in Overcorrected

position for 4 plus months minimum

• Follow up with forward posturing Splint if begin Cl II treatment in mixed


Tom Pitts

Pitts Principles(Skeletal Cl II)

• Do anything possible to not procline lower anteriors

•When we procline lower anteriors we don’t get the favorable chin, lips, nose relationship.

!

•What happens to the PDM when we place braces on the teeth and use orthodontic wires?

© all rights reservedCourtesy Tom Pitts 2014Tom Pitts

Cl II Elastics for Cl II Tx Can also use Forsus Springs

Must have good chin

Use disarticulation

Elastics from the start…Must be full time

Low Torque on Lower Anteriors

Generally, Standard torque U ant.

Generally, High Torque on U canines.

Master’s 2 year continuum 4 session

Beginning Reno, NV March 26, 27, 28, 2015

Facial Driven Orthodontics


Tom Pitts Duncan Brown Sabrina Huang John Pobanz

Tomas Castellanos Daniela Storino

[email protected]

[email protected]

orthoevolve.com

mailto:[email protected]

http://orthoevolve.com

Pitts lecture review

Education

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