CHAPTER 21 The non-compliant patient
Like it or not, orthodontic treatment imposes a measure of discipline upon our patients. Isn’t it an everyday fact of life that the more one puts in, the more one gets back? And so it is in orthodontics, both with ourselves and with each of our patients. However good the orthodontist, the result that will be achieved can be no better than the patient’s co-operation allows. Successful orthodontic treatment must be the result of the orthodontist and the patient working together as a team, with mutual understanding and a trust in the capability and efficiency of the process.
Fixed appliances are in some respects the most demanding on patient co-operation, and attempts to produce a ‘compliance-free’ fixed appliance will inevitably be thwarted by the underlying reliance on the patient for prevention of bite damage and oral hygiene control. However, it obviously behoves the orthodontist to use appliances that are as easy as possible for the patient to use.
In this, Tip-Edge has fundamental advantages. Its initial speed of alignment cannot fail to impress the patient and parent and, being a light force and light anchorage appliance, it can reach its goals with intermaxillary elastics, rather than extraoral forces or implants, for the majority of even the most challenging Class II cases. The bracket itself is smaller and aesthetically superior to twin brackets, adjustment intervals are between 6 and 8 weeks and overall treatment times are generally reduced, dramatically so in major discrepancy situations.
Yet there will always be those patients who are careless or forgetful with their intermaxillary elastics. One ingenious solution to this problem is the use of Outrigger® (TP Orthodontics Inc., La Porte, Indiana, USA) hooks, invented in the late 1990s by Dr Christopher Kesling.1 In carefully assessed cases, these may be strikingly successful in Class II treatment, although they do require to be used with considerable discretion.
These automatically remind the patient to replace the elastics. They do so by the simple method of flicking out sideways, whenever the elastics are not attached. Each Outrigger appliance consists of a pair of hooks, coiled on the end of an interconnecting span. Originally formed from continuous .014 inch stainless wire, current Outriggers are made in .016 inch to reduce the risk of fatigue breakage (Fig. 21.1). Outriggers are supplied preformed in a range of sizes, according to the desired distance between the hooks. These should be sited between the lateral incisor and canine brackets, without making contact with either. The sizes are numbered in millimetres between the mesial of the two hook coils. In practice, this means measuring from the mesial of one lateral incisor bracket to the other and adding 2 mm.