George Antonopoulos : So Peter tell us please, what is IN-tendo and why / how was it developed?

 

Peter Sheffield : IN-tendo basically is a ‘Hybrid technique’ blending CLASS, TARG and BEST theories for working in the lab. We are able to do this because the instruments allow it!back in 2008 I started measuring cases before working on them. This was when we used just Dr. Fillion’s B.E.S.T. technique. It occurred to me that I wasn’t applying all those years of looking at dental models, different arch-forms and tooth morphology!

After reading A LOT of Ortho Books, papers and attending seminars about Lingual and more congress meetings, I could start to see what the Dr’s were trying to do, the difficulties they encountered and the many varied solutions they used. This made me realize ( and the big one course, wasn’t about lingual at all, but rather Dr Kokitch’s ‘Adult Orthodontics in the 21st Century’! ) that we had quite a lot of work to do in the lab and could no longer apply ‘standard’ prescriptions if the Dr’s were to minimize their clinical workload. As I had ideas I would ‘bounce’ them off willing clients and friendly Dr’s who were experienced in the field of Lingual...

Rafi Romano being one of these and he was always very helpful and supportive. Asif being a long term client also, and other Dr’s from around the world who enjoyed ‘exploring’ new ideas.So in 2008 I started experimenting with some of Asif Chatoo’s cases. We would survey the case and then estimate the amount of torque or tip we wanted to change in degrees. This is harder than it seems, but still a logical process and first step to really individualizing lingual ( or labial ) cases, without the need of s set-up model! Time and cost being the target. In 2010 I started to do diagnostic set-up models for some clients who wanted this service. At first they asked me to bond on the set-up like the Hiro technique, but with a difference. Using only the BPD to measure the heights, but they quickly did a U-turn when it was evident they would have to endure individual jigs for the bracket bonding! Then I decided to start measuring what looked like ‘nice’ set-up models with nice arch alignment, leveling and occlusion to see just what the values would be for Tip and Torque. I used the same criteria as the paper we previously did with CMU for the WJO.

So for this I needed to reference all models to the ‘Invisible Horizontal Occlusal Line’ as described by Andrews. Later I realized that this was not necessary if we were to bond using the instruments T.A.D and B.P.D (which is the same theory as the TARG, just electronic with increased precision, more flexibility and ease of use) and we should be taking the best flat plane with regards to the instrument base. After all wire / slot interface will be relative between all teeth in the arch and will move in unison.This really was the birth of what I call the Full ‘IN-tendo’ service. Although for a cheaper service I re-wrote several new bonding charts for those who could manage cases well and knew generally what they needed, hence the three basic prescriptions, as for some Dr’s lab service cost is an important factor! Before we didn’t make wires,as we were told, and also believed it was the Dr’s responsibility, but turning away new clients for this reason was not good enough! So we also started using all the measurements to work out the final wore template for the customized individual set-ups. For this I was inspired by Dr. Henrique Valdetaro’s technique he used instead of a computerized D.A.L.I program innovated also by Dr. Fillion. From the final wire template we could roughly envisage the wire sequence needed when it was transposed over the master model with brackets bonded.It wasn’t long before I also realized in 2011 that sometimes extra bends were required between canines and incisors if we were to keep the brackets as close to the teeth as possible and reduce the size of the composite pads, especially in the upper arch. This would depend on the torque used in relation to the tooth morphology and of course the heights of the bracket slots...the flat wire plane.

Now 75% of our upper cases have an ‘Optimized’ wire...note this was done way before Harmony released theirs. As work increased ( my team had already been bonding many cases using the B.E.S.T. system since 2004 for another lab) we decided to dedicate our lab to the Lingual technique. First it was at 50% then quickly to 75% causing us to drop all resin ortho retainer work and finally today it is at around 97% of our total lab work.We have a small team of 4 female technicians who have various tasks ( girls have better hands for the trays !!) and 4 males which includes myself. 4 people can bond, 2 technicians prepare models and 1 does the wires. All of the girls can also do the silicone trays.Over the years we introduced new protocols to the lab techniques. Starting in 2006 I decided to micro blast all bracket bases with 110 micron Alumina, steam clean and finally degrease with pure Acetone just prior to bonding. This increased the bonding strength between bracket base and composite pad. The trays were also evolved from what we did before. We used some different materials and modified the techniques based on important feedback from the clients...most of them find the ‘Memosil Blue Top” trays very easy and quick to use.A few years ago my engineer and partner in the TAD and BPD died. He was vital to the electronics and QC side, so therefore production stopped. However demand kept coming and after many thousands of wasted hours with various engineering faculties on my new designs, (which originally were to be non digital, due to the fact I had realized all the TAD and BPD precision of 0.1 degree and 0.01 mm was superfluous) I came out with the TTS and BPI. The principle is the same, but they are more user friendly and importantly easier to repair! They are lighter, more robust and can be manually reset to zero in the two axis.Our future aims are to combine 3D technology for diagnostics, but still bonding manually, and new bracket designs which are more flexible in use for the various stages of working Lingual Orthodontics...as my good friend Dr. Henrique says...Ideal, working and finishing prescriptions!