This appointment is typically halfway through their treatment time. Most orthodontists don’t do this type of reposition visit. The reason why we do a pano/repo visit for EVERY patient is because he wants each tooth to be in the most ideal position before placing their final wires (which will be next appointment).

The patient will always be scheduled for an hour so that there is plenty of time for all records. Start the appointment by making sure that the patient has brushed (You do not want their lunch in these photos :) Facial photos, an x-ray, and all intra-oral records should take no longer than 15 minutes. Once all records are taken you can seat your patient and start the appointment in the clinic for the remaining 45 minutes. If another assistant is available, have them help you load all the photos so you can continue with you appointment.

** For all records taken during this appointment, refer to the Pano Repo Records Tab**

1. Remove wires and all auxiliaries (wire ties, power chain, etc.) and give the patient a chance to brush and floss

2. While patient is brushing this is your chance to assess the photos and x-rays before the Doctor comes to the chair. Here are a few things you should be looking out for:

• How are the positions of the U/L 4’s and 5’s? The best way to check is by looking at this picture

• How does the patient’s smile arc look?

• Are the U3’s measured at the same height?

• How is the transition from front to back?

• Are the 7’s grown in yet, do we need to bracket them today?

• Most importantly, how does torque look? What torque brackets does the patient have? Is the torque being fully expressed? Do we need to change some of the brackets for different torque? (Ex will be shown below)

Now that you have an idea on what to look for in the posterior, lets talk about the anterior. (There are two major key factors that set apart Dr. Sukoff’s work and his finishes; arch width and smile arc) Dr. Sukoff believes that a flat smile (where the centrals and laterals are measured at about the same) is an old, aging smile. He creates a beautiful, youthful smile where the centrals are measured typically at 5.5-6mm, laterals at 5-5.5mm (depending on where you measured the centrals) and then the cuspids measured at 5mm always. This is what creates a gorgeous smile arc. Here are two examples of how to depict what would be repositioned at a Pano/Repo appointment to create a beautiful smile arc if it isn’t there already.

Now this patient has what you would call a “reverse smile”. His laterals are longer than his centrals. Sometimes at our Initial Bonding appointments, if a patient has severe crowding in the upper anterior, its sometimes hard to measure and place for smile arc. Once things unravel (at pano repo appt) you can measure for smile arc more successfully.

So if this were my patient, I would propose to Dr. Sukoff that we reposition both U1’s to bring down so they are a 1/2 mm longer than the laterals. It looks like the UL1 needs to come down slightly and the UR1 needs to come down a little more than slightly.

One other important thing we should be looking out for are the torques. If a patient comes in for their reposition visit and their U2-2 are flared, check Oral4D and see if patient has low torque. If patient does not have low torque, point that out to Dr and see if he thinks it would be a good idea to switch all those out today to low torque instead of standard or regular torque (what they probably have already).

For example: This is a different patient than above, but this patient also came in for a pano repo and upper and lower teeth are flared. We have been using a torquing sling to try and overcome the flaring, but it is not working as efficiently as we would like... so we checked the initial torque.... the initial torque we started with is regular torque upper and lower 2-2. Now, for some variable reasons, throughout treatment the patient became flared. This is a great appointment to catch this and determine the last half and finishing part of the patients treatment.

Now that you have an idea on what to look for, take a look and assess your patient. Write down any teeth you see that should be repositioned. Also take a look at the x-ray. Are any roots going rogue? Distal root tip?

3. On to the next step. Once you have taken a glimpse of the patient and really assessed everything, the Dr will come to the chair. This is where you introduce him to the patient and let him know that the patient is here for their pano/repo appointment. Show the Dr anything you see and he will confirm if those teeth need to be repositioned. What is so great about Dr Sukoff is that he is always teaching. So if you propose something to be repositioned that is unnecessary, he will graciously tell you why without making you feel stupid. He truly wants you to learn and loves when his assistants think outside the box and trys to treatment plan the way we think he would treatment plan.

4. Remove all brackets Dr Sukoff would like to reposition, and set them on a bracket pad. If someone is available to micro-etch those brackets for you, have them do so while you remove glue. If we are crazy busy and there is no one available to help, the best and most efficient way to do this would be; Remove all glue, place cheek retractors in, dry all teeth, dab etch on, and quickly go micro-etch brackets. It should take you no longer than 20 seconds to micro etch a few brackets. By the time you are back, you are ready to rinse your etch, dry and solo. By doing this, you don’t miss a beat and are utilizing your time to the best of you ability. By the way, any time you prep multiple teeth, follow the steps you would if you were to be bonding an initial bonding. Use the long cotton roll if you are bonding any teeth on the lower, to ensure insolation. Use the high speed and slow speed suction simultaneously if you are rinsing etch off teeth on the right and left side. If you are only prepping teeth on the right side, the high speed suction wouldn’t be necessary.

5. Once all the brackets are on and repositioned, you will place any wire ties back on (if needed) and place the same wires back in (18x25 U, 16x25 L) There are some occasions where we would have to drop in wires. 70% of the time Dr Sukoff will let you know if he thinks you should drop to an 018 or even 014. If he doesn’t mention it, don’t automatically assume you can place the same wires back in. It's up to you to take a look and see if it is necessary to drop in wires. If you are unsure, please do not guess. Have your clinical lead come over and help decide that.

*In the example given above where the patient was flared, this was the result of the reposition appointment

Upper and lower 2-2 brackets were switched for the Q2 low torque brackets!

**Next appointment the patient will be getting final wires. In this case, since the patient is flared, we would want to place a 19x25 SS upper 7-7 to fully engage the low torque brackets. This is a detail that would be great to chart in the next appointment for the next assistant to be aware of**

6. Once the patient is tied back in, confirm if any rubber bands are needed and that the patient has all hooks and rubber bands necessary.

7. If the same wire was put back in the patient will come back in 6 weeks to place final wires. (If in between appointments are needed to build back up in wires, follow standard wire sequencing).