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January 15, 1999 / Dental Practice Magazin
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Orthopeadic Orthodontics
Ed Bonner BDS MDent attended Triple O / Skip
Truitt's mind-blowing course
Teeth are terrific, bone is boring
From our earliest undergraduate
educational experience we are taught
to be concerned about the shape,
appearance, position and function of
teeth. This is why we become dentists.
We are also taught something about the
supporting structures of teeth but the
further away from the teeth these are
the less the interest appears to
get.
Thus teeth are fascinating, gums
important, bone less interesting and
TMJs and muscles too frequently almost
ignored. Put another way, what we see
easily we treat more readily than what
we cannot see or observe only with
difficulty. What we can see we treat
(restorative, endodontics [via x-ray])
or refer (periodontics, orthodontics);
what we can’t see we at best refer and
at worst ignore (TMJ and muscular
dysfunction).
The purpose of this article is to
raise the profile of the remote and
the ignored, and to tell of a
mind-blowing course I attended
recently, organised by that most
excellent group of specialised
technicians, the Birmingham-based
Triple 'O' Laboratory
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3D Schwarz
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Schwarz
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Jackson
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Crozat
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J. W. Truitt
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Skip Truitt
J. Wellington Truitt jun. is less well
known than "Skip" Truitt but they are
one and the same. Skip is the high
priest of orthopaedic orthodontics and
has been running courses on the
subject all over the world for years
and years.
He has not endeared himself to the
dental “establishments” in some
countries, less because of the fact
that he is a non-orthodontists
practising orthodontics than because
he encourages other general
practitioners to do so; and also
because his views are seen as
heretical by members of the same
establishments. He is, in short, a
slayer of sacred cows.
Many hundreds of dentists have
attended his courses but, more’s the
pity, many thousands have not. I
waited for more than 20 years before
enrolling, and I shall regret to my
dying day that I did not do so much
sooner.
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Questions asked – and answered.
Questions with which I have wrestled for 20 years
in general and specialised prosthodontic practice
were answered comprehensively in three
days.Questions like:
Are dental malocclusions to be viewed differently
from skeletal abnormalities?
Can a skeletal abnormality be viewed as
functionally acceptable – as aesthetically
acceptable? When should it be corrected? How
should it be treated ?Should a skeletal
“abnormality” be treated if there is a “normal”
dental relationship?
Does orthopaedics have a role in dentistry ?If
so, is it within the realm of the specialist or
the domain of the general dental practitioner?
Relationship between orthopaedics and
orthodontics
Skip in unequivocal; although many patients who
walk through the door have a combination of
orthodontic and orthopaedic problems, there is a
definite line of demarcation between orthopaedics
and orthodontics.If, like many practitioners, you
use only one treatment technique, you will try to
fit every patient that walks through that door to
that technique.
This is as true of orthodontics as any other
dental discipline.If you have only orthodontic
(tooth moving) techniques or appliances, you are
going to have problems treating all your
patients.By the same token, using only orthopaedic
appliances will not solve problems that are not of
a skeletal nature.“We should never attempt to
correct skeletal problems dentally.Nor should the
problem of simply crooked teeth be approached from
a skeletal standpoint.”
Proper diagnosis
The secret to successful therapy is proper
diagnosis.“You can be a good diagnostician and a
mediocre mechanic and end up with super
results.”The corollary to this is that you can be
a super technician but, if your diagnosis is
wrong, the patient will end up with a disaster in
his/her mouth and you with one on your
hands.Skip’s message:“Properly diagnose the
problem and then select the technique that best
treats that particular problem; learn to integrate
the right appliance to achieve the total desired
therapeutic results.
Dental v structural classification
The best part of the course’s first day is
learning diagnostic techniques. Considerable time
is spent spelling out a dental v structural
classification.
Angle’s classification is the relationship of
lower to upper teeth, not of mandibular to
maxillary bone, and the canine is considered to be
a posterior tooth. A structural relationship
refers to the skeletal relation of the mandible to
the maxilla to the anterior cranial base.
Because the Angle classification is applied to
permanent teeth, it does not take sufficient
cognisance of the growing child in the mixed
dentition where early interception can be such a
powerful and relatively easy treatment
modality.
Cephalometrics
In order to understand the relationship between
mandible, maxilla and anterior cranial base, a
basic working knowledge of cephalometrics is
essential.The anterior cranial base is a stable
measurement in females at age seven and males age
eight.This measurement is related to the length
and position of the maxilla as well as the size of
the mandible and the position of the glenoid
fossa.
Skip spends a fair amount of the first day
patiently explaining how to understand the
fundamentals of a Bimler cephalometric analysis
(which evaluates the skeletal as well as the
orthodontic relationship) and how to apply this to
the selection of different types of structural
appliances such as the Crozat or the Bionator.
Appliances
What seemed impossible to comprehend or assimilate
on the first day, miraculously appeared to have
been osmotically absorbed overnight. Thus the
second day was less about the understanding of
fundamental principles than their application in
the selection, construction and activation of
appliances. Triple 'O' Dental Laboratories, in the
persons of Rob, Rod and Suzie, were on hand with
appliances and instruments of every conceivable
shape. Their kindness and patience,
professionalism and expertise made the handling
and adjusting of Schwarz, Jackson, Sagittal, Twin
Block, Crozat, Bionator, Williams and other
orthopaedic appliances seem less than difficult,
while Skip’s patient attention to first principles
made the selection of the right one a
straightforward procedure.Suddenly correction of
crossbites, anterior and posterior open bites and
closed bites no longer seemed mysterious and
unintelligible.
Marketing
For years I’ve been observing and
prosthodontically treating the effects of such an
ill-considered treatment modality as extraction
therapy which is absolute anathema to me.Here was
a wonderful and far less invasive alternative. But
having all this newfound knowledge of orthopaedics
would be of limited use if we did not apply it and
if we were unable to sell it as a private option
instead of standard NHS extraction therapy.The
last day was about marketing and the change of
pace seemed almost yogic by comparison to the
intensity of the first two, but no less
valuable.
I left feeling that there were dental problems
that I could now diagnose more thoroughly and
intelligently.I learnt to have a pretty good idea
which of those I was competent to treat and
perhaps more important, which I was not.
The Future
There are four more courses available, mostly
hands-on, covering fixed appliances (including the
revolutionary Viazis technique); cephalometrics;
advanced orthodontic, orthopaedic and TMJ therapy;
and extraction therapy (yes, it does occasionally
have its place!).
Over the next year I would like to attend as many
as possible; even at this advanced stage of my
professional career it is still possible to become
enthused all over again and to look forward to
practising new and valuable techniques feeling
confident that my newly-acquired knowledge will
support me to the full, and that I will have Skip
and Triple ‘O’ to underpin this. As I said, I wish
I had done this years ago!
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