Ortho Classic: A Leading Authority in Orthodontics by Kyle Patton, Editorial Assistant, Orthotown Magazine

Orthotown Magazine caught up with Dr. Thomas Pitts, Ortho Classic's executive clinical director, to discuss the impressive work he's brought to the company's clinical arena. Ortho Classic is a leading supplier of orthodontic products to 85 countries. Pitts has practiced orthodontics since 1970 and currently serves as an associate clinical professor of orthodontics at University of Pacific. His work focuses on smile arc protection, product development, continuing education success and more.

How did you get your start in orthodontics?

Pitts: In dental school I thought I wanted to become a prosthodontist, until I met Dr. Arthur Dugoni in my senior year of dental school. As anyone who has met Art will testify, he is one of the most charismatic and motivating people alive. He came back to University of Pacific to teach undergraduate orthodontics and I became infatuated with orthodontics. He soon became my mentor as I followed him around like a little puppy and observed in his office. Art was committed to aesthetics in his treatment. That was my start. After practicing general dentistry in Reno and then in the Army Dental Corp, I attended the University of Washington orthodontic residency program, graduating in 1970. I began my orthodontic career in my hometown of Reno, Nevada, and immediately began studying some of the greats at the time, including Dr. Steven Dugoni, Dr. Ronald Roth, Dr. Peter E. Dawson and Dr. Robert Ricketts.

What is your passion in orthodontics?

Pitts: Great question! My biggest passion is creating the highest and best smile and facial aesthetics possible for any given patient, without compromising the functional occlusion. Dr. Dugoni and I, along with several good orthodontists from the San Francisco Bay area, went to the Ricketts course back in 1975. That was one of the best courses I attended, as it really enlightened me to improving and using my creative sense. I started focusing on smile design and treatment. After Dr. David Sarver started classifying the facial and smile aesthetics, I began to study my cases and soon after, I created the Smile Arc Protection (SAP) bracket positioning protocols along with nine other factors that I refer to as top 10 aesthetic goals in my orthodontic treatment.

What is the Smile Arc Protection (SAP) concept that you created all about?

Pitts: My close friend and fellow teacher, Dr. Duncan Brown, is the one that came up with the name SAP to describe my smile arc protection bracketing (Fig. 1). Sarver described the smile arc as the curve (or lack thereof) of the maxillary anterior incisal edges when looking from the frontal view of the smile (curved incisal plane). The more curved the incisal edges of the upper anteriors, the more youthful and attractive the individual. Sarver described this arc as consonant, when the incisal edges follow the curve of the lower lip upon smile (Fig. 2). I have created the SAP bracket position for the upper arch, which has been effective at protecting or enhancing this arc. Far too many orthodontic finished cases have an incisal plane that is too flat for my preference. SAP positioning can also enhance the enamel display when more incisor display is needed for the smile (Fig. 3). I've never treated a patient with SAP where I've achieved too much curve. Occlusion won't let it happen. I have applied and researched this clinically since the mid-1990s. In addition, I've also been studying the SAP position at UOP, Dugoni School of Dentistry, and its department of orthodontics, where I enjoy teaching. Many high quality orthodontists are now using SAP around the world.

So I understand that in order to maintain or enhance the smile arc, the brackets are placed more gingival on the upper centrals and laterals. Does this mean that the orthodontist must settle for a deeper anterior bite?

Pitts: Not at all! SAP positioning compensates for more apical bracket positioning on the upper arch, by bracketing the lower incisors and canines more incisally. We correct the deep overbite with bite buttons to disarticulate the buccal segments, while simultaneously erupting the posterior teeth with the use of short, very light Class II elastics (ELSE). So it is a combination of lower incisor intrusion and molar eruption that idealizes the anterior bite.

A lot has been said lately about bracket torque. Explain your preferences on bracket torque, particularly in the anterior region.

Pitts: You are asking all the right questions for me. One of the biggest problems I have seen throughout orthodontics today is proclined or flared upper incisors. As practitioners attempt to treat more cases non-extraction, attaining the proper inclination of the upper incisors is a challenge. This is true for various types of cases, including crowding, mild bi-maxillary protrusions, and Class IIIs that are treated non-surgically. Proclined incisors are unsightly to most patients (and to me) so I have developed case management protocols to combat this. As a side note, going back to Dr. Dick Eastham's research, I agree with him that the most aesthetic labial lingual inclination of the upper incisor is when the tangent to the facial surface of the incisor is perpendicular to the floor (or corrected FH) (Fig. 4). That is when the light reflects most aesthetically.



Some advocate using a constellation of variable torque brackets to control axial inclination. Doesn't that address this problem?

Pitts: Not for me. Variable anterior bracket torques are confusing to many orthodontists. I have loved Roth's upper anterior torques for the past 40 years. (Upper centrals, +12, and the upper lateral are +8.) When using these anterior torques, I like to either use them right side up or upside down to apply active lingual crown torque (Fig. 5). Today, I know that I want to treat most cases non-extraction for aesthetics, so I see very little need for high or super torque brackets. In most of the non-extraction cases I treat today, the challenge is to get enough lingual crown torque. This is handled by a combination of flipping upper anterior brackets (I started flipping anterior brackets in 1976 after the Ricketts course), using arch wires that engage and couple early in treatment, widening the arch with appropriate arch forms, and light elastics. This combination, I call active early. Of course one must be careful when dealing with active lingual crown torque with the anterior roots pressing lightly against the labial plate. That's why I'm teaching advanced courses to enlighten practitioners on this technique. Current low torque PSL being used by many right now don't meet my requirements. There is not enough lingual crown torque in the maxillary central (+2) for me, and the maxillary lateral incisor torque (-5) is too much negative torque to match up with the central (the lateral root being smaller). For me, a torquing couple needs to activate on the central prior to the lateral incisor torque being brought into play. For the canine torques, both upper and lower, I like Ricketts' +7. For the most part I want to upright the maxillary and mandibular canines with labial crown torque. If the canines are flared, I can always invert or flip the brackets. For the lower anterior torque, I like the MBT prescription of -6. For Class III mechanics, with retroclined lower incisors, I can flip or invert them as well. Thankfully, Ortho Classic has used these torques for their standard prescription and this provides me with all the torques required for virtually all clinical situations (Fig. 6), while carrying a minimal inventory.



So what made you decide to work with Ortho Classic over other companies?

Pitts: When the time came for me to search for a new project, I looked for a company that was into the highest quality manufacturing, and I shopped for a slot that had a capacity to increase efficiency in quality treatment. Ortho Classic is the best company I have found, with respect to slot tolerances, as they use torques that make sense for the upper and lower 6 anterior teeth, and they have slot dimensions that activate the appliance earlier, for both rotation and torsional control. The corporate culture at Ortho Classic is most refreshing to me. They are located in McMinnville, Oregon, not too far from Portland. I am currently consulting and working with this dynamic company on product development, testing new concepts and teaching. The owners' interest is providing products to assist the orthodontist in delivering quality patient care. Due to the quality manufacturing, tightened tolerances and slot dimensions, I now have less bends in my wires for detailing and finishing. Ortho Classic is really setting itself apart from other manufacturing and supply companies, and doing it with lower pricing. I love passive self-ligation for many reasons, but they also manufacture precision twin brackets, wires, clear twin brackets, clear PSL brackets, elastics, power chains, etc. Ortho Classic is very innovative. They also have a simple, clear, low profile bracket that they call C-Thru. This bracket uses very small round wires, and can be used in place of aligners or in conjunction with aligners, which is very useful for re-alignment cases. There is so much enjoyment in working with a company that is so responsive, and doesn't have to look at the stock price each morning to decide if they are going to enhance their products or not. As I stated previously, the corporate culture and atmosphere is refreshingly positive.

Please elaborate a bit on your active early concept.

Pitts: Yes, the term active early was suggested by my partner in crime, Dr. Brown, when describing my case management protocols for treatment efficiency (He is the same one who came up with the term SAP). Active early refers to a concept of activating fixed appliances early in treatment in relation to torque control, arch width development, leveling, AP and vertical correction. Today, orthodontists can activate the appliance as early as possible, using the SAP bracket position to adjust vertical position of the incisors, inverting groups of brackets (as necessary) to activate torsion in the appliance sooner, selecting arch wire progressions that control axial inclination early in treatment, using arch forms that develop the posterior segments of the arches sooner, early light short elastics (ELSE), and appropriate disarticulation buttons. It makes a big difference in control early in the case, and will lead to a more efficient treatment for the practitioner who is into fantastic aesthetics. For years in order to control torque and inclination, we were limited to initiating torsion within the slot in 19x25 arch wire, and frequently complex wire bending was required to add more lingual crown torque to upright teeth. Today, working with Ortho Classic, we have tightened up the slot, and developed square thermal nickel-titanium wire that begin torque activation within three to four months. We are also widening the arches in the molar region from the outset, using a newly designed arch form with more arch width in the molars. Long story short, I'm very excited about attaining extraordinary aesthetic and occlusal quality results using fantastic SAP bracket placement, active early protocols, and well-priced exceptional appliances for speeding up treatment. Information about my courses can be found at Ortho Evolve. I can be contacted by email at tom@orthoevolve.com.