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This month's topics include congenitally missing teeth and management tips.

1. What are your criteria for handling congenitally missing upper lateral incisors?

Nearly 80% of the practitioners said that closing the spaces left by missing maxillary lateral incisors was their first choice when this was possible. Criteria that they believed favored space closure included a Class II molar relationship, an increased overjet, a full profile, a high mandibular plane angle, and a moderate amount of space in the lateral incisor area. Opening spaces for restorations was indicated when there was a Class I or Class III dental relationship, a low mandibular plane angle, a flat profile, or minimal crowding.

What are your criteria for handling congenitally missing lower incisors?

The majority of respondents favored space closure and were willing to accept the potential overjet and overbite caused by the resulting tooth-size discrepancy.

What are your criteria for handling congenitally missing lower bicuspids?

Space closure was again the treatment of choice for most clinicians. The root length and potential for ankylosis of the remaining primary molars were often cited as important factors in making this decision, as was the cost of restorations with fixed bridgework or implants.

If you open space, how do you maintain it during and after treatment?

During treatment, many practitioners used coils on the archwires to maintain space. During retention, the overwhelming choice was pontics added to removable retainers. Maryland bridges were also advocated as fixed temporary appliances for younger patients. Another possibility for growing patients was the use of acrylic blocks in edentulous areas to maintain the occlusal table.

Specific comments included:

  • "I am more apt to open space for missing maxillary laterals on girls than boys to keep the "feminine" look. The shape of the canines also has a great deal to do with the decision. Really long cusps are not good, even with smoothing and restoration."
  • "If the patient has a good facial profile and a full-step dental Class II, and the cuspids have erupted into the lateral incisor position, I close the spaces."
  • "I use clear, suck-down invisible retainers; if it is an anterior missing tooth, I place a pontic tooth where the tooth is missing. Usually the patient is given two retainers, because many times they will eat in the retainer when they have a missing anterior tooth, and then they will wear through the retainer."
  • 2. What is the most important thing you have done to increase case acceptance?

    By far the first choice among the respondents was spending more time with patients at the start of treatment. Some practitioners felt this time was best spent in an extensive initial patient examination, while others favored a more detailed consultation, with a thorough explanation provided by the doctor.

    Other answers included high-tech adjuncts such as computerized tracings and images, or the provision of a videotape of the consultation for the patient to take home. Another step that was believed to contribute to increased case acceptance was the hiring and effective use of a treatment coordinator.

    Comments included:

  • "Develop a reputation for excellence, fairness, and openness. Don't compromise treatment quality for a GP or parent, and never quit on a kid."
  • "Leave sufficient time to properly explain the case and discuss fee arrangements. This appointment should not be 'squeezed in'."
  • What is the most important thing you have done to increase referrals?

    Maintaining constant contact with referring general dentists was the most important factor mentioned by many respondents. This included taking the dentists to lunch, sending them examination/consultation reports (often including computer-printed pictures of their patients), and making sure they got the message that the orthodontist truly cared about their patients.

    Other suggestions:

  • "Have my wife become president of the board of education in town."
  • "Provide good-quality orthodontics with Nordstrom-style service in a caring atmosphere."
  • What is the most important thing you have done to improve staff efficiency?

    Better staff training, starting with identifiable job descriptions and responsibilities, was the major solution for many offices. A morning huddle to preview the day and to get the staff prepared on time was thought to be of great importance, as were regular staff meetings. Cross-training staff was also emphasized, along with hiring a staff person with the specific duty of sterilizing instruments.

    A specific comment:

  • "Read the 'One-Minute Manager' and apply it, empowering staff to know their job, do it right, and do it without supervision."
  • What is the most important thing you have done to improve staff morale?

    Praising employees in staff meetings, giving positive feedback, and showing appreciation were all felt to be highly important. Holding regular staff meetings, or occasional training or retreat days, was also reported as beneficial in resolving problems.

    Comments included:

  • "Show that I care about them and that they are valued as a part of the team."
  • "Be a cheerleader--always be up! Recognize birthdays and anniversaries of employment years, and have fun."
  • "Have 'non-patient' days to get the office restocked and do internal marketing."
  • What is the most important thing you have done to reduce broken and canceled appointments?

    No single answer predominated; many responses were along the lines of "I don't know--please tell me. Confirming appointments by telephone one day in advance was one idea mentioned by several respondents as reducing but not eliminating the problem.

    Suggestions included:

  • "Don't give prime-time appointments to repeat offenders."
  • "If a patient cancels or fails an appointment in 'prime time', they must be seen as soon as possible but not in prime time."
  • "We use an automatic phone-call system each night to remind patients of their appointments, but it is still a problem."
  • What is the most important thing you have done to reduce emergency visits?

    There was a wide variety of responses to this question. Suggestions included paying careful attention to detail at each appointment--double-checking before dismissing the patient. Other practitioners recommended keeping a record of emergency visits, logging the types of problems, and trying to resolve the biggest offenders. Discussing office policies and procedures with patients and parents before treatment was also thought to be helpful.

    What is the most important thing you have done to reduce stress in your practice?

    Having a workable schedule with a well-trained staff was the most popular answer. This was closely followed by the ability to delegate and empower the staff to deal with problems as they arose, rather than having the doctor micromanage everything.

    Specific comments included:

  • "Be on time--demand it, reward it, require it. Ten minutes is the maximum any patient should have to wait."
  • "We have daily morning meetings as well as 'clearing' meetings once every week or two as needed to clear up staff tensions and problems."
  • JCO would like to thank the following contributors to this month's column:

    Dr. W. Douglas Beaton, London, Ontario

    Dr. Jerry F. Cash, Springfield, MO

    Drs. Norman L. Chmielewski and John W. Randall, Bay City, MI

    Dr. Gary Cornforth, Jamestown, ND

    Dr. Carl Dann III, Orlando, FL

    Drs. Gerald L. Fine and Michael S. Apton, Stony Brook, NY

    Dr. Mark S. Geller, Plano, TX

    Dr. Elizabeth K. Gesenhues, Jacksonville, FL

    Dr. Bradley Goldsamt, Cedarhurst, NY

    Dr. Lawrence C. Henig, Rohnert Park, CA

    Dr. Herbert M. Hughes, Alexandria, VA

    Drs. Daniel Levy and Lisa DeMarco, Silver Spring, MD

    Drs. Judy R. Lynch and Vicki A. Ross, Newport News, VA

    Dr. W. Bonham Magness, Houston, TX

    Dr. Domenic A. Mazzocco, Hanover, MA

    Drs. DeWayne B. McCamish and Marie B. Farrar, Chattanooga, TN

    Dr. Beechard C. McConnell, Jr., Anderson, SC

    Dr. Michael L. Ovens, Phoenix, AZ

    Dr. John E. Pappel, Nanaimo, British Columbia

    Dr. Gus C. Petras, Redding, CA

    Dr. Billy L. Powell, Jr., Humble, TX

    Dr. W. Ronald Redmond, San Clemente, CA

    Drs. Richard J. Rozehnal and Kevin C. Chapman, Wheat Ridge, CO

    Dr. Thomas H. Sears, Jr., Greensboro, NC

    Dr. Lawrence Simon, Glen Rock, NJ

    Dr. Joseph F. Zgrodnik, Northampton, MA


    Dr. Sinclair is an Associate Editor of the Journal of Clinical Orthodontics and Professor and JCO on CD-ROM (Copyright © 1998 JCO, Inc.), Volume Apr Chairman, Department of Orthodontics, University of Southern California School of Dentistry, Los Angeles, CA 90089.

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