·       Panoramic Xray: Overview of jaws & teeth
·       Lateral ceph Xray: Jaw relationships
·       Left handwrist Xray: Skeletal aging
·       Periapical Xrays: U&L incisor roots shape
·       9 photographs: Description below
·       1 short video: Description below
·       You will get a link to your digital records

  1. While the parent is reading this explanation at reception the team will do the records (please see our fees page on our website for more information) – There is no consultation fee
  2. After the records are taken, the parent will then be shown into a discussion area where the hygienist / nursing sister will:
    • Give the parents a copy of the Xrays which Dr Hugo will evaluate to design the treatment plan
    • These Xrays may need to be taken to your dentist or MFOS if extractions are needed
    • The photographs & video will be shown to the parents on a TV screen
  3. The hygienist / nursing sister will not make any diagnosis or recommendation or answer specific questions about the possible orthodontic treatment
  4. The hygienist / nursing sister will however give you general information about braces and recommendations about oral hygiene issues

Dr Hugo will prepare a treatment plan and quote:

  • Dr Hugo will email a treatment plan & quote to you, usually within 1-2 weeks.
  • Dr Hugo will meet the patient at the “Apply Braces” appointment
  • If the patient or parent has any questions about the proposed treatment they can email or Whatsapp or sms these to Dr Hugo (082 377 4409)
  • If the patient would like to meet Dr Hugo to discuss the treatment, before the day the braces are placed, a Case discussion appointment can be booked – this will be a morning appointment and a consultation fee will be charged

Extra-oral photographs with the head in Frankfort horizontal position:

  • neck vertical above the spinal column
  • ear-hole and bottom of bony eye rim parallel to the floor

Extra-oral photographs:

  1. Full face – serious: Check face symmetry and vertical proportions
  2. Full face - smiling (80% smile): Check tooth display and symmetry
  3. Profile with the head in Frankfort horizontal: Check jaw positions eg. chin projection

Intra-oral photographs with the teeth in retruded contact position:

  • Tip of tongue up and back against the palate & the head tipped backwards
  • This tongue and head position moves the lower jaw backwards to the position where the jaw joint (TMJ) is in the correct position in the fossa.
  1. Bite from the front:  This shows the size and shape of the teeth and the U & L centre-lines
  2. Bite from the R side (close-up):  Shows the amount of overjet and overbite from the R
  3. Bite from the L side (close-up): Shows the amount of overjet and overbite from the L
  4. Bite from R side: Shows the occlusion of all the upper to lower teeth on the R
  5. Bite from L side: Shows the occlusion of all the upper to lower teeth on the L
  6. Photograph of the tongue:
    • Shows the size & posture of the tongue (scalloping = tongue pressure on teeth)
    • Shows amount of debris on the tongue (dead cells and plaque) requiring a tongue-scraper
  7. Photograph of the throat:
    • Inflammation or swollen tonsils are usually associated with acid reflux (modify diet)
    • Tonsil stones or other pathology
  8. Upper arch with mirror: To check the symmetry and arch form of the upper dental arch
  9. Lower arch with mirror: To check symmetry and arch form of the lower dental arch

A video is taken of the face and mouth with the following instructions:

  1. With a serious face say the name EMMA: To evaluate tooth display on talking
  2. Bite together, showing your teeth open at least 4 fingers wide, now close your teeth together and then your lips: Smooth, straight, wide opening is indicative of healthy TM joint.


  • Patients must learn how to check their own bite in retruded contact – close on back teeth with the tongue tip far back on palate and head tip backwards
  • Patients need to monitor their bite, watch for changes & modify elastic wear accordingly
  • Patients are encouraged to send cellphone photographs of problems if they are unsure or have any queries about their braces


  • Cellphones on SILENT or FLIGHT MODE
  • Texting is fine if you are not being worked on & you are not in a consultation
  • If you need to make a call please do so OUTSIDE our building


  • These are not permitted in our practice because of the right to privacy of other patients in the practice.


A.      Recommend recalling the patient in 6 or 12 months: Sometimes no intervention is recommended and the patient is scheduled for recall in 6-12 months time.
B.      Removal of some (usually primary) teeth and recall in 6-12 months:

  • The early removal of upper primary canines (C’s) is sometimes recommended to allow spontaneous alignment of the upper incisors and to discourage the upper lateral incisors from erupting into a cross-bite
  • The removal of lower primary canines is less often recommended because this sometimes causes a narrowing of the lower dental arch
  • Sometimes the removal of the primary canines (C’s) & first molars (D’s) is recommended to encourage the first premolars to erupt sooner
  • This temporarily creates more space for the permanent canines and reduces the chance of root resorption of the permanent lateral incisors
  • Usually the retention of the lower primary molars (E’s) is recommended because they are important space maintainers for the permanent teeth.

C.     The following orthodontic treatments may be recommended:

  • Retainer wear to protect the teeth
  • First Stage orthodontic treatment
  • Full Fixed orthodontic treatment
  • Invisalign orthodontic treatment
  • Combined orthodontics and jaw surgery


  • First stage orthodontic treatment is sometimes recommended while primary (baby) teeth are still present (usually age 8-11 years)
  • Because of the effectiveness of modern orthodontics, early treatment is recommended less frequently these days and more patients can wait until the second molars erupt before orthodontics needs to commence (usually age 12-13 years)
  • However, early treatment is still indicated in the following types of cases:
  1. For psychological or social reasons - Young patients who are self-conscious or are being teased about their teeth  
  2. Edge-to-edge occlusions or anterior cross-bites (especially pseudo class IIIs), where the possibility exists for permanent damage to the incisal edges  
  3. In cases where the permanent canines are so unfavourably angulated or positioned that without the early creation of space, they are unlikely to erupt in an acceptable position or may cause root resorption of the upper lateral incisors
  4. In patients who have habits such as thumb-sucking, tongue-thrusting and mouth-breathing
  5. which are impediments to normal development

The First stage appliance:

  • Usually we place brackets only on the 4 upper & the 4 lower incisors and on the first permanent molars
  • In the upper & lower jaws a partial fixed appliance (utility arch) will be used for arch length control and incisor alignment  
  • Elastics  are used between the upper and lower partial fixed appliances to correct the relationships between the jaws
  • The precise placement and compliance with the required hours of wear of the prescribed elastics are critical to a successful outcome of first stage treatment
  • The active treatment time will be approximately 6-12 months followed by a phase of retention until the cuspids and premolars erupt
  • Almost certainly on the eruption of the premolars, a second stage of treatment will be necessary
  • Retainer wear and maintenance as described below.


  • In early cases having dental class III features, we prefer to achieve a class I bite early on, because forward growth of the maxilla is dependant to a large extent on stimulation from mandibular growth with a positive overbite
  • Crossbites are known to be an impediment to normal development and should be corrected as soon as possible
  • Uncorrected anterior crossbites often result in unsightly wear of the incisor edges, which could mean that restorative work is necessary later and we all know how unsatisfactory it is to repair incisor edges
  • Posterior crossbites are associated with reversed chewing patterns and temporo-mandibular joint dysfunction and should also be corrected as young as possible
  • In addition a narrow maxilla results in a space deficit and causes ectopic eruption of particularly the cuspids The appliances used in the early correction of a class III problem are a partial fixed appliance (utility arch) in the upper jaw combined with a utility arch in the lower jaw  
  • These appliances are employed for arch length control and class III elastics will be used to achieve a class I occlusion with a positive overbite
  • The active treatment time will be approximately 6-12 months followed by a phase of retention until the cuspids and premolars erupt
  • However the definitive correction of the severe class III problems will only be done at the end of growth with a combined surgical orthodontic approach
  • Retainer wear and maintenance as described below.



  • A full fixed orthodontic appliance will be placed aimed at achieving a cephalometrically correct incisor positions and coordinating and aligning the arches in a class I occlusion   Synergy and In-Ovation or Empower appliances are preferred in our practice nowadays  
  • Synergy is a metal bracket which has the advantage of acting as a passive bracket (not actively engaging the arch wire, thus facilitating tooth movement) when only the central wings are ligated and an active bracket when the mesial and or distal wings are also ligated  
  • In-Ovation brackets are self-ligating and are passive brackets until larger diameter arch wires are used, when they become active and express the bracket prescriptions with respect to torque, angulations and rotation  
  • In-Ovation C or Empower is a tooth-coloured (white) bracket with a nickel-titanium clip which makes these the favoured tooth-coloured brackets with excellent colour stability  
  • Because Labial braces result in more consistantly excellent occlusions, Lingual braces are recommended far less frequently and then only in selected cases
  • Lingual appointments are longer, more frequent & in the mornings on selected days
  • The active treatment time will be approximately 18 months followed by a phase of retention  
  • Retainer wear and maintenance as described below.


  • The latest generation of Invisalign aligners are extremely effective if the patient wears them 20-22 hours per day
  • A payment for the appliance of USD 2500 (about R35 000) the day impressions are taken
  • Slight reshaping of some of the teeth may be necessary before Invisalign impressions are done
  • Building up of some of the teeth with composite may be necessary to obtain favourable tooth dimensions (no charge) before Invisalign impressions are done
  • If interdental odontoplasty, composite buildups or extractions have been done, an Essix-type invisible retainer may need to be made to prevent any changes occurring after impression taking and new photographs will be done (no charge)
  • For a good result, diligent aligner wear of at least 20-22 hours per day is necessary
  • The only time aligners are removed is during eating and brushing and flossing
  • You should ideally only drink water while wearing aligners
  • Upper and lower Invisalign will be worn for about 18-24 months to level, align & coordinate the U&L teeth
  • Each set of aligners is to be worn for one week before progressing to the next set
  • When progressing to a new set of aligners this should be done at night after brushing and flossing
  • Only progress to a new set if the previous set fits perfectly and there are no gaps between the aligner and your teeth
  • You will be shown how to use “chewies” when inserting a new of aligners
  • We will try to resolve your problem without premolar extractions – to be reassessed and discussed if extractions become necessary during treatment
  • If there is a Mid-course correction such as extractions, new records are taken and sent to Invisalign for which there is no additional charge
  • A Frenectomy may be required during or after treatment
  • When there is enough space a false tooth (pontic) will be placed in the aligners where there is a missing front tooth
  • The lower jaw is growing slower / faster than the upper jaw so we have to consider that this growth may become so excessive that jaw surgery is recommended at the end of growth (optional and unlikely)
  • The lower jaw underdeveloped and overclosed and we may recommend lower jaw surgery (BSSO) if necessary to get a perfect bite or profile – this is optional and unlikely
  • Rather than having jaw surgery some patients choose to live with an imperfect bite and / or an imperfect profile
  • Debanding, Retention and Observation
  • Life-long retention wearing retainers as prescribed (progressively less over time)


  • When the discrepancy between the jaws exceeds about 4 mm, a combined orthodontic and jaw surgery (orthognathic surgery) approach sometimes is recommended
  • The orthodontist first aligns the teeth and the Maxillo Facial and Oral Surgeon (MFOS) then surgically places the jaws in the correct position for an improved bite and facial balance
  • Jaw surgery is usually only recommended at the end of general body growth, as determined by the left handwrist Xray
  • People with big lower jaws usually need to wait till 2 years after general growth is complete because a late mandibular growth spurt often occurs in these patients
  • Many patients opt not to undergo these procedures and prefer to accept imperfect bites, profiles and facial proportions
  • Patients opting not to undergo surgical correction of their jaw relationships will usually need to wear retainers more often over the years and may be more susceptible to temporomandibular joint dysfunction (TMD).
  • Please note that all surgery and anaesthetics have additional associated risks and that these risks should be discussed with the dentist / Maxillofacial and Oral surgeon / Periodontist / Anaesthetist or other practitioner who will be performing the procedure
  • Dr Hugo and Hugo Orthodontics carry no reponsibility or liability for procedures performed by other practitioners


  • The chin may be made more or less prominent thereby creating a more pleasing profile and Lip-Chin-Throat angle
  • A genioplasty can also make the chin vertically shorter or increase the height of the chin depending on the aesthetic requirements of the face
  • The genioplasty is often performed simultaneously with the surgical removal of impacted wisdom teeth.

The lower jaw may need to be expanded, contracted, moved forward, backwards, upwards or downwards to achieve improved facial dimensions.

  • In preparation for surgery in these patients full fixed orthodontic treatment will be aimed at coordinating and aligning the upper and lower dental arches so that they will fit properly after the jaw surgery
  • The upper incisors will be positioned to maintain a favourable nose-lip angle and tooth display on talking and smiling
  • Usually after 6-15 months, with the braces still on and often with the simultaneous removal of impacted wisdom teeth, a Bilateral Sagittal Split Osteotomy (BSSO) is performed, to place the lower jaw into the correct bite


  • In patients with short lower jaws the the lower jaw is advanced
  • In patients with overclosed lower jaws the lower jaw is rotated to open the bite increasing the lower face height
  • In patients with long faces & open bites the lower jaw is rotated to close the bite, decreasing the lower face height
  • In patients with prominent lower jaws (class III) the lower jaw is moved backwards


  • Following the orthognathic surgical correction there will be 3-6 months of post-surgical orthodontic treatment to refine and stabilise the occlusion in a class l relationship
  • Retainer wear and maintenance as described below


  • The upper jaw area, also referred to as the mid-face may need to be expanded, contracted, moved forward, backwards, upwards or downwards to achieve improved facial dimensions, lip support or tooth display on talking and smiling
  • The upper jaw surgery most frequently employed is the Le Forte I osteotomy, which may involve moving the upper jaw in one, two or 3 pieces
  • If the upper jaw needs to be moved downwards, sometimes a small bone graft from the hip is used.

Sometimes both upper and lower jaws need to be moved simultaneously to achieve more correct facial proportions

  • Periodontally Accelerated Osteogenic Orthodontics (PAOO) is a surgical intervention at the start of orthodontics, which promotes rapid tooth movement by increasing the rate of bone remodelling
  • PAOO also provides additional bone in the desired direction of tooth movement and augments areas with insufficient bone
  • This is a rather expensive but excellent surgical procedure which, with good oral hygiene, dramatically speeds up treatment and ensures good bone support for the teeth
  • PAOO is particularly useful in cases where patients have inadequate bone around their teeth
  • Patients requiring PAOO may either have lost bone volume due to periodontal disease or they may have inherited a thin bone volume in the tooth bearing areas of the jaws (thin Biotype)
  • See



  • Braces can be very uncomfortable & it is impossible to predict which patients will tolerate the braces well and which will suffer discomfort more than others:
  • We estimate about 1 in 20 patients has significant discomfort requiring one or more additional visits during their treatment
  • Additional visits for discomfort are done during normal working hours – never at night
  • If you need advice after hours Whatsapp / sms Dr Hugo (082 377 4409) or text or phone Claire (083 253 7157)
  • In some patients the braces irritate the lips, cheeks and tongue – rinse with salt water or apply chewed sugar-free gum or wax to the sharp areas
  • In other patients the teeth become tender - massaging the teeth or chewing sugar-free gum immediately after the appointment helps prevent this.
  • The first few sets of archwires often need to bulge towards the cheeks to create space – this sometimes makes grooves in the cheeks:
  • Often some teeth are bypassed during the space creation phase
  • These initial archwires are usually quite thin and floppy and because they are round can rotate in unpredictable ways causing the ends of the archwires to change their position
  • The ends of the archwires are difficult areas and can be ended in a number of different ways depending on the case and each method has pros and cons:
  • These archwire ends can be bent away from the cheek or up or down towards the gum - these bends are called cinches:
  • Cinches sometimes must be long cinches if the teeth need to slide backwards along the archwire
  • The cinches will be short and tight against the last tooth if we don’t want spaces to open
  • The end of the archwire can also be cut flush with the end of the tube on the last tooth:
  • Cut flush can be quite scratchy depending on the proximity of the cheeks or if the tongue is too inquisitive
  • Cut flush can also allow the archwire to pull out of the tube and be really irritating
  • Cut flush also doesn’t prevent spaces opening which have been closed
  • These problems can sometimes be helped by cutting the archwire 2mm longer and crimping a stop on the end of the archwire
  • Depending on the proximity of the cheeks we can also put a small rounded blob of composite over the stop to make it smooth


  • Patients must know how to check their own bite in retruded contact – close on back teeth with the tongue tip far back on palate and head tip backwards
  • Patients need to monitor their bite, watch for changes & modify elastic wear accordingly
  • Patients are encouraged to send cellphone photographs of problems if they are unsure or have any queries about their braces

You and your parents are aware that:

  • First stage treatment just makes space for the permanent teeth but
  • We cannot straighten the permanent teeth until they come through later
  • More braces will be recommended later when all the permanent teeth including the 2nd molars have come through (3rd molars – wisdom teeth very seldom fit in)
  • Sometimes if we have made sufficient space to fit in the canines and both premolars for a fuller smile there may not be enough space for the 2nd or 3rd molars
  • We prefer a smile with both premolars and would not usually extract a premolar to make space for a 2nd molar because these are less important teeth aesthetically and functionally.


  • You and your parents are happy with your teeth and want the braces to come off
  • You know how to check your bite and you are aware that it is not correct to have 2 bites – one where your jaw joint is in the “home” position and another where your teeth fit best
  • There are no spaces that aren’t there intentionally for teeth to be built up etc
  • You are aware that retainers have to be worn as outlined below.


  • You and your parents are aware that your teeth are not perfect
  • You and /or your parents have signed the debanding on request form.
  • You are aware that you will need to wear your retainer as below and more over the years than people whose teeth are perfect.

You and your parents are aware that:

  • Braces should be replaced at the end of growth usually1-3 months before the jaw operation, braces remain on during the jaw operation & usually for 3 -6 months after the jaw operation
  • Wisdom teeth can usually be removed at the same op.

You and your parents are aware that:

  • It is a good idea to have retainers made so that we can preserve the progress made to date
  • When we start again a new quote will be given based on the estimated duration of treatment remaining

Retention is essential after all the different types of orthodontic treatment discussed above

  • Retention appliances should be worn as follows:
  • For the first week: Full time, except when eating, drinking and brushing  
  • For the second week: Afternoons & nights  
  • Thereafter for the first year: sleeping hours at night  
  • From the second year: every second night  
  • It is very important to keep checking the retainers and to wear them as necessary for the rest of your life, whenever they start feeling tight  
  • Should your retainer break it is very important to contact us to arrange for a new one to be made

Wash retainers in cold water using soap or diluted Sunlight liquid   Sterident can also be used but only with cold water  
We don’t routinely use fixed retainers for the upper teeth, because the lower teeth usually bite onto the upper fixed retainers if there is a correct relationship of lower to upper incisors.
A lower fixed retainer is routinely fitted in cases treated to completion with fixed appliances, where there was significant lower crowding and if there is good oral hygiene.
We do not believe that fixed retainers are an acceptable long-term solution because the presence of the fixed retainer very significantly enhances the risk of decay and gum disease and it is an impediment to excellent brushing and flossing. Fixed retainers are certainly never fitted for any length of time in patients with inadequate oral hygiene. Clear plastic retainers are the best form of retention as they can be worn progressively less over time and always allow for excellent hygiene.
In addition many people grind or clench their teeth at night and the clear retainer protects the teeth from damage.
After the first year of wearing the clear retainers patients who have TMD or who grind or clench the teeth should wear their retainers intermittently to reduce the frequency and intensity of the habit.

  • Usually the first visit will be 6-12 weeks after debanding at which time the retainers will be checked and final records will usually be done at this visit  
  • The next post-treatment visit will be after 6 months
  • Thereafter post-treatment visits will be at 6-12 month intervals depending on the nature of the case  
  • If the patient had a first stage of orthodontics, they will usually be monitored every 6 months until they are ready to start the next stage of treatment
  • Almost certainly on the eruption of the premolars, a second stage of treatment will be necessary and a full fixed appliance will need to be placed to co-ordinate and align the arches  
  • If the patient needs to have jaw surgery at the end of growth, they will be monitored until growth is complete as determined by a hand-wrist Xray, at which time braces will be replaced in preparation for the osteotomy  
  • It is extremely important that the patient brings the retainers to each visit  


  • We remind you that the orthodontic surgery and patient waiting area is a parent-free zone (as agreed by you in the informed consent form)
  • If you feel that the team should know something before starting your child’s treatment, please send a note to the surgery with your child
  • The only time you can consult with Dr Hugo or a member of the clinical team is after the appointment in an off-surgery office so that we have up to date information and photographs to refer to.

Due to the fact that most of our staff members have children and other family responsibilities, we have limited numbers of staff members who are willing or able to work on Saturday mornings.
Consequently, we have to restrict the types of appointments we can manage on a Saturday to the following:

  1. New patient appointments - making it easier for both parents to attend
  2. Place braces appointments - since this is our longest appointment it is logical to make this option available on a Saturday morning.
  3. Routine checkup appointments are only available to
  • Patients living 40 km or more from either of our practices
  • Patients at boarding school 40 km or more from either of our practices

Please note that Braces removal is not possible on a Saturday, since our laboratory is not available to make retainers on Saturdays.
We know that it is often difficult for patients to attend appointments during normal working hours but in the interests of fairness and running an efficient practice we cannot make exceptions to this policy.

  1. Please note that your quote specifically states that breakages will be charged (code 8848). This charge applies to each bracket and/or arch-wire which is broken.
  2. When the braces are placed, the patient is instructed about what foods could not be eaten. Specifically biltong and dry wors are serious culprits, not only breaking the braces, but resulting in sinewy strands of biltong / dry wors wrapping themselves around the braces for three weeks afterwards, resulting in an unhygienic situation.
  3. Any hard food should first be made soft or small. Certain ‘foods’ like toffees or fizzers cannot be made soft enough and should not be eaten at all – Please consult your booklet for additional guidelines, if you are unsure about what you should eat with your braces.
  4. Patients sometimes say that they were eating something soft and the brace just broke. This is not possible – what really happens is that the bracket or arch-wire is fractured due some earlier insult, such as grinding or clenching the teeth or eating hard food.
  5. We use the best quality braces and composite adhesives (glues). If the brackets can withstand the forces involved in placing the arch-wire, they will withstand careful chewing of the correct foods.
  6. It is true that some patient’s do tend to break braces often and others go the entire treatment without breakages. 
  7. It is also true that some people who have deep bites also tend to more commonly have grinding or clenching (bruxing) habits and are more prone to breaking their braces – this is a factor beyond our control and breakages will still be charged for.
  8. Charging for breakages is NOT A PUNISHMENT BUT A FINANCIAL NECESSITY. If we arbitrarily charged more for all patients to allow for the breakage factor, this would be unfair to the patient’s who seldom or never break their braces.

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