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Vol. 7, No. 1 - January 2014
The FROG Maxillary Molar Distalizer
Early Orthodontic Treatment
Utilising a Combined Restorative and Orthodontic Approach A Predictable Solution
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Vol.7 No.1 - January 2014
Advisory Board
Publisher Ettore Palmeri, MBA, AGD B.Ed., BA
Clinical Editor L. F. Cooper, DDS, PhD
Associate Editor Saj Jivraj, DDS, MS.Ed
Technical Editor Lee Culp, CDT
Dr. Katya Archambault
Dr. Allen Aptekar
Dr. Paul L. Child
Dr. Carla Cohn
Dr. Mauricio Diaz
Dr. Joseph Fava
Dr. Hubert Gaucher
Dr. Larry Gaum
Dr. David Gratton
Luke Kahng
Dr. Les Kalman
Dr. John Kois
Dr. Greg Kurtzman
Dr. Sonia Leziy
Dr. Ziv Mazor
Dr. Dennis Nimchuk
Dr. Mamaly Reshad
Dr. Paresh Shah
Dr. Lee Silverstein
Dr. John Sorensen
Dr. Rick Soordhar
Dr. Douglas Terry
Dr. John Zarb
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PALMERI MEDIA GROUP
Palmeri Media Group
Makes Your Message STAND OUT
Publisher: Ettore Palmeri, MBA, AGDM, B.Ed., BA Editor (Clinical): Dr. Lyndon Cooper Editor (Technical): Lee Culp, CDT
As a leader in publishing, online media and marketing operations, Palmeri Media Group maximizes the power of your online campaigns. Leveraging a combination of scale, efficiency and cost saving we deliver best-in-class digital services and solutions for dental marketers in the world.
We can help you MAXIMIZE your digital world...
DIGITAL u u u u u u
Website Creation Website Updates Digital Reprints Targeted Email Marketing Digital Editions Digital Newsletter Delivery
u Digital Data
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Office Administrators: Tina Ellis – accounting@palmeripublishing.com Sanaz Moori, B.SC, Eng. – sanaz@palmeripublishing.com Bahar Palmeri, B.SC – manager@palmeripublishing.com Sales and Marketing: Gino Palmeri – gino@palmeripublishing.com Editorial Director: Frank Palmeri, H.BA, M.Ed – frank@palmeripublishing.com Graphic Art: Lindsay Hermsen, B.Des.Hons. – lindsay@palmeripublishing.com Internet Marketing Director: Rashid Qadri Event Coordinators: Eva Fowler – events@palmeripublishing.com Pamela Raynor – seminars@palmeripublishing.com Canadian Office: 35-145 Royal Crest Court, Markham, ON L3R 9Z4 Tel: 905.489.1970, Fax: 905.489.1971 Email: info@palmeripublishing.com Website: www.palmerimediagroup.com Dental Teamwork is published nine times a year by Palmeri Publishing Media. Dental Teamwork is a clinically focused publication that recognizes the contribution and importance of various specialties that comprise the dental team in providing high standard dental treatment for dental patients. Articles published in Dental Teamwork express the viewpoints of the author(s) and do not necessarily reflect the view and opinions of the Editor and Advisory Board. All right reserved. The contents of this publication may not be reproduced either in part or in full without written consent of the copyright owner. Publication Dates: January, February, March, April, May, June/July, August/September, October, November/December Printing: Point-one Graphics Inc.
Call: 905.489.1970, 1.866.581.8949 Visit our website: www.palmerimediagroup.com
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Printed in Canada. Canadian Publications Mail Product Sale Agreement 40020046. Dental Teamwork ISSN #1922-7558 is published nine times a year by Palmeri Publishing Inc., 35-145 Royal Crest Court, Markham, ON. Canada, L3R 9Z4. Periodicals Postage Rates paid at Niagara Falls, NY 14304. U.S. Office of publication 2424 Niagara Falls Blvd, Niagara Falls, N.Y. 14304. U.S.
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the
Orthodontic issue JANUARY 2014
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The FROG Maxillary Molar Distalizer
Viewpoint
Making It Happen in 2014 Nadean Burkett
News & Views People and Product News Ask the Experts The FROG Maxillary Molar Distalizer
Early Orthodontic Treatment
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Dr. Kevin Walde
FEATURES Early Orthodontic Treatment
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Dr. Brock Rondeau
Utilising a Combined Restorative and Orthodontic Approach to Correct Occlusal and Aesthetic Issues
Ilan Preiss, BDS
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In My Practice
Are You a Multi-Tooth Dentist? Dr. Michael Racich
Ultra Lightweight Loupes
Tony Beale
Adlink
A Predictable Solution
Dr. Thomas Meneaud
Cover Art by Lindsay Hermsen, B.Des.Hons.
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Making It Happen
Viewpoint
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in 2014
Nadean Burkett
hat are your goals for 2014? The start of a new year brings with it retrospection and opportunity to start anew.
Retrospectively, many solo practitioners may find that their performance was less than they had hoped for. We have been hearing this over the past several months from all over North America. They are not alone. Whether we consider the rising expectations of practitioners in terms of growth and return on investment or simply the year over year performance, clearly the challenges of a solo practitioner have multiplied over the past 15 years.
“We can't solve problems by using the same kind of thinking we used when we created them.” - Albert Einstein The rising costs of capital improvements and operating costs, attracting and retaining patients, recruiting and retaining auxiliaries, training and managing employees, promotion, technology integration, and other management responsibilities are either pushed aside, ignored or take time away from clinical production. We hear this from GPs and specialists regularly, and with increasing frequency over the past couple of years. Advice from consultants so far has been: • Decrease expenses • Be more efficient • Improve customer service to your patients • Expand your services
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If it sounds like some of these are conflicting, that is because they are. Every business student learns the 2/3 rule – you can only provide two of the following consistently: quality product/service, low cost, fast delivery. Think pizza delivery… Then, marketing consultants jumped into the fray. Their advice?
• Build a web site presence • SEO (search engine optimization) • Sell homecare products (whitening kits, toothpaste, electric toothbrushes, mouth rinses, etc) • Cosmetic services for children • Invisalign • Expand your footprint (multi-locations)
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More, better and different of the same isolationist model; do more with less and expect a different result. This has proven to do one thing: commoditize dental services. Dentistry is a business that has been based on trust and respect between patient and their healthcare professional. Over the past 20 years, we have managed to reverse this relationship 180 degrees: Promotional offerings such as free whitening or bleaching, discounted fees for new patient visits and restorative services (an implant for $600). The dental profession has encouraged the commoditization of dentistry by doing all of these things in retail settings where they are sandwiched between the dollar store and an ice cream shop.
We teach people how to treat us by how we present ourselves and how we treat them. What is the chance that your $25,000 treatment plan will be accepted by a new patient who has just visited your practice because you offered a new patient visit for $99? If you don’t see the correlation between discounting your fee to attract new patients and their reluctance to pay $1,500 for a crown, let alone the comprehensive treatment plan that will cost them $25,000; you are doomed to continue the same pattern of behavior and will continue to get the same results. You are invited to review 2013 and prepare for 2014 in a new way. Rather than only looking at your P & L report as
your gauge of determining your success or failure, consider your quality of life and culture of your practice (team morale) as well as monitoring your patient satisfaction and loyalty. Patient satisfaction and loyalty can be quantified with the right KPIs and reporting systems. Stop using “horse and buggy” thinking to address today’s challenges.
Your feedback and questions are always welcome. Contact Nadean via email nadean@mypracticematters.com or visit our website www.mypracticematters.com. Follow us on Twitter; like us on Facebook; connect with Nadean on LinkedIn. Nadean Burkett is a career and business transition coach with more than 30 years experience in the dental profession – now assisting accountants and other professionals in private practice by referral. Trusted practice evaluator, business planner and respected coach and advisor for the past 10 years - Nadean facilitates The EMPOWERMENT Program series, Career & Practice Management for Dentists both online and from NBAI’s head office situated in beautiful Vancouver, British Columbia. Visit www.mypracticematters.com, email nadean@mypracticematters.com for listings, job postings, and more resources with your practice transition coach.
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News & Views Bacteria Responsible for Gum Disease Facilitates Rheumatoid Arthritis
Does gum disease indicate future joint problems? Although researchers and clinicians have long known about an association between two prevalent chronic inflammatory diseases - periodontal disease and rheumatoid arthritis (RA) - the microbiological mechanisms have remained unclear.
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n an article published in PLoS Pathogens, University of Louisville School of Dentistry Oral Health and Systemic Diseases group researcher Jan Potempa, PhD, DSc, and an international team of scientists from the European Union's Gums and Joints project have uncovered how the bacterium responsible for periodontal disease, Porphyromonas gingivalisworsens RA by leading to earlier onset, faster progression and greater severity of the disease, including increased bone and cartilage destruction. The scientists found that P. gingivalis produces a unique enzyme, peptidylarginine deiminanse (PAD) which then enhances collagen-induced arthritis (CIA), a form of arthritis similar to RA produced in the lab. PAD changes residues of certain proteins into citrulline, and the body recognizes citullinated proteins as intruders, leading to an immune attack. In RA patients, the subsequent result is chronic inflammation responsible for bone and cartilage destruction within the joints. Potempa and his team studied another oral bacterium, Prevotella intermedia for the same affect, but learned it did not produce PAD, and did not affect CIA. "Taken together, our results suggest that bacterial PAD may constitute the mechanistic link between P. gingivalis periodontal infection and rheumatoid arthritis, but this ground-breaking conclusion will need to be verified with further research," he said. Potempa said he is hopeful these findings will shed new light on the treatment and prevention of RA. Studies indicate that compared to the general population, people with periodontal disease have an increased prevalence of RA and, periodontal disease is at least two times more prevalent in RA patients. Other research has shown that a P. gingivalis infection in the mouth will precede RA, and the bacterium is the likely culprit for onset and continuation of the autoimmune inflammatory responses that occur in the disease.
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Story Source
The above story is based on materials provided by University of Louisville. Note: Materials may be edited for content and length. For further information, please contact the source cited above.
Reference
1. Katarzyna J. Maresz, Annelie Hellvard, Aneta Sroka, Karina Adamowicz, Ewa Bielecka, Joanna Koziel, Katarzyna Gawron, Danuta Mizgalska, Katarzyna A. Marcinska, Malgorzata Benedyk, Krzysztof Pyrc, Anne-Marie Quirke, Roland Jonsson, Saba Alzabin, Patrick J. Venables, Ky-Anh Nguyen, Piotr Mydel, Jan Potempa. Porphyromonas gingivalis Facilitates the Development and Progression of Destructive Arthritis through Its Unique Bacterial Peptidylarginine Deiminase (PAD). PLoS Pathogens, 2013; 9 (9): e1003627 DOI: 10.1371/journal.ppat.1003627
Get a DNA Sequence
The bacteria in the human mouth - particularly those nestled under the gums - are as powerful as a fingerprint at identifying a person's ethnicity, new research shows.
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cientists identified a total of almost 400 different species of microbes in the mouths of 100 study participants belonging to four ethnic affiliations: non-Hispanic blacks, whites, Chinese and Latinos. Only 2 percent of bacterial species were present in all individuals -- but in different concentrations according to ethnicity -- and 8 percent were detected in 90 percent of the participants. Beyond that, researchers found that each ethnic group in the study was represented by a "signature" of shared microbial communities. "This is the first time it has been shown that ethnicity is a huge component in determining what you carry in your mouth. We know that our food and oral hygiene habits determine what bacteria can survive and thrive in our mouths, which is why your dentist stresses brushing and flossing. Can your genetic makeup play a similar role? The answer seems to be yes, it can," said Purnima Kumar, associate professor of periodontology at The Ohio State University and senior author of the study. "No two people were exactly alike. That's truly a fingerprint." Kumar used a DNA deep sequencing methodology to obtain an unprecedented in-depth view of these microbial communities in their natural setting.
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When the scientists trained a machine to classify each assortment of microbes from under the gums according to ethnicity, a given bacterial community predicted an individual's ethnicity with 62 percent accuracy. The classifier identified African Americans according to their microbial signature correctly 100 percent of the time. The findings could help explain why people in some ethnic groups, especially African Americans and Latinos, are more susceptible than others to develop gum disease. The research also confirms that one type of dental treatment is not appropriate for all, and could contribute to a more personalized approach to care of the mouth. "The most important point of this paper is discovering that ethnicity-specific oral microbial communities may predispose individuals to future disease," Kumar said. Though it's too soon to change dental practice based on this work, she said the findings show that "there is huge potential to develop chairside tools to determine a patient's susceptibility to disease." The research was published in the Oct 23, 2013, issue of the journal PLOS ONE. Kumar and colleagues collected samples of bacteria from the saliva, tooth surfaces and under the gums of the study participants. More than 60 percent of bacteria in the human mouth have never been classified, named or studied because they won't grow in a laboratory dish, so the researchers identified the different species -- or species-level operational taxonomic units -- by sequencing their DNA. The DNA sequences represented 398 units overall, with an average of about 150 different species per person. Using only the bacteria found under the gums -- which are called subgingival microbes -- the classifying machine performed best at positively identifying African Americans according to their microbial communities, followed by positive identifications of Latinos at 67 percent and Caucasians at 50 percent -- but with 91 percent specificity, meaning the classifier determined how often a sample did not come from a white person 91 percent of the time. Kumar and colleagues then expanded the selection of total microbes in all areas of the mouth, and identified surrogate communities of bacteria that were present in at least 80 percent of participants of each ethnic group. These communities showed a prediction likelihood of 65 percent for African Americans, 45 percent for Caucasians, 33 percent for Chinese and 47 percent for Latinos. "Nature appears to win over nurture in shaping these communities," Kumar noted, because African Americans and whites had distinct microbial signatures despite sharing environmental exposures to nutrition and lifestyle over several generations. Kumar and her colleagues have embarked on a multistudy investigation of the role the body's microbial communities play in preventing oral disease. The group
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already has determined that smoking disrupts the healthy bacterial community in the oral cavity, giving diseasecausing microbes easier access to the mouth. Multiple diseases of the mouth are caused by bacterial infections, ranging from cavities to oral cancer. Bacteria live together in communities called biofilms, and it's within that infrastructure that they communicate with each other and with the immune system. "A key to overall human health," Kumar said, "is keeping those oral biofilms themselves in good health." Kumar didn't expect ethnicity to produce significant differences in the bacterial collection in the mouth. But the patterns became clear during the DNA analysis. The overarching goal here is to say, 'If you're healthy, are biofilms similar between individuals?' We know, in fact, that they are not similar. "Among healthy people, there is a core group of species everybody seems to have. But then there is personalization. What factors contribute to this personalization? Gender, age, other parts of genetics?" It did make sense to Kumar that bacteria below the gums are most closely linked to ethnicity identification because they are the least likely to be disrupted by environmental changes in the mouth, such as food, toothpaste and tobacco. "Bacteria under the gum line are protected but are also the first opportunity your body gets to be educated about the bacteria that hang out in your mouth," she said. The power of bacteria in the body remains misunderstood to some extent. Though many people are inclined to blame disease susceptibility on lifestyle and behavior, this work suggests that humans can be predisposed to certain disease risks solely because of the microbes that set up shop in their mouths. "We underestimate these bugs and their power to do good and evil to us. As long as we harness their good side, we're healthy," she said. Exercise, healthful eating, avoiding smoking, brushing and flossing the teeth, preventing diabetes and obesity -- all of these factors are in our control, she explained. But when it comes to genetic factors, Kumar said, "It makes you want to ask: 'Am I in charge or not?'"
Story Source
The above story is based on materials provided by Ohio State University. Note: Materials may be edited for content and length. For further information, please contact the source cited above.
Reference
1. Matthew R. Mason, Haikady N. Nagaraja, Terry Camerlengo, Vinayak Joshi, Purnima S. Kumar. Deep Sequencing Identifies Ethnicity-Specific Bacterial Signatures in the Oral Microbiome. PLoS ONE, 2013; 8 (10): e77287 DOI: 10.1371/journal.pone.0077287
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People and Product News Gilles Poitras Appointed Eastern Canada Regional Manager at BioHorizons
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ioHorizons Canada is pleased to announce the appointment of Gilles Poitras as the Eastern Canada Regional Manager. Gilles comes back to BioHorizons with a long list of achievements in the field of international business development, which were always people driven. After 2 years as the Director of the Canadian Implant Institute and 5 years as a Product Support Specialist at BioHorizons, Gilles went on to be the Vice-President International Business Development of a high-tech company as well as Director of International Business Development for a division of high-end stainless steel wine fermenters. We are proud to have Gilles back at BioHorizons. With the entire team of BioHorizons’ Product Support Specialists for Eastern Canada and everyone else at BioHorizons, Gilles will pursue his goal of providing our customers with the means to grow the care to their clientele.
Ivoclar Vivadent Supports the Victims of the Typhoon in the Philippines
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voclar Vivadent AG will donate 200,000 USD to support the people in the Philippines affected by Typhoon Haiyan with immediate relief measures. A total of 100,000 USD of the donation will be provided to the Philippine Red Cross for direct emergency relief. A further 100,000 USD will be used for the re-establishment of dental health care measures for the population at large. Christoph Zeller, Chairman of the Supervisory Board, explains the company’s commitment: “We feel great sympathy for the Philippine people and we share their suffering and despair. We hope that our donation will provide at least some relief to the survivors and speed up the reconstruction of the affected regions.” Ivoclar Vivadent has been operating a manufacturing plant for ceramic and resin teeth near the Philippine capital Manila since 1993. The company employs about 300 people at this location. Neither the employees nor the manufacturing plant were directly affected by the typhoon’s devastating force.
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High Accolade for Robert Ganley
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obert Ganley, CEO of Ivoclar Vivadent, was inducted as Honorary Fellow into the International College of Dentists (ICD). The accolade was awarded in honour of Mr Ganley’s outstanding and meritorious service to the dental profession and community. In addition to Robert Ganley, a further three nondentists involved in teaching, scientific research and branches of science allied to dentistry and who have positively contributed to the advancement of dentistry were inducted as Honorary Fellows. The ceremony took place on the occasion of the 84th Annual Convocation of the ICD in New Orleans. Additionally to the new Honorary Fellows, 300 dentists from the United States were invited into the College. The ceremony was witnessed by hundreds of members and guests. The College, with representative chapters in more than 80 countries, has over 11,000 members, including 6,500 in the US.
Straumann Invests in Medentika and Createch, Two Fast-growing Brands in the Tooth Replacement Industry
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traumann announced two important acquisition agreements that will advance its strategy to become a global leader in the ‘value’ segment of the toothreplacement market. The Group’s first step outside the premium segment, which it leads, was taken last year when it acquired 49% of Neodent, the market leader in implant dentistry in Brazil. Straumann disclosed that it has signed an agreement to purchase 51% of Medentika GmbH and 51% of Medentika Implant GmbH (collectively referred to as ‘Medentika’) for a total agreed price of 32 million Euros – subject to approval by the German antitrust authority (Bundeskartellamt).
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Established in 2006 and located in Mendaro, Spain, Createch Medical is the Medical Division of the Egile XXI Corporation. Createch employs a staff of 30 and specializes in the research, development and manufacture of high quality, innovative, implant-borne prosthetics. Its products, including CAD/CAM bridges, bars and abutments, are designed for a variety of implant systems and are sold mainly in Spain, Germany and other markets in Europe. Createch is smaller than Medentika and the financial details of the deal were not disclosed. The agreement provides Straumann with options to increase its stake up to 100% by 2020. For further information on Createch Medical please consult www.createchmedical.com.
Dentsply Presents Essix® PLUS™ Plastic
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ssix® PLUS™ plastic is proven to look clearer, last longer and resist more staining. That means greater patient compliance and better case outcomes. Its proprietary formulation is extremely user friendly. Appliances remove easily from models, and trim effortlessly. Your staff will love the improved handling. When it comes to meeting the needs of patients and practice alike, Essix® PLUS™ plastic is your clear choice for retention. For more information or to place an order, please contact DENTSPLY Canada directly at 1.800.263.1437.
MTM® Clear•Aligner
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TM® Clear•Aligner is a custom-fit, virtually undetectable and cost-effective way to straighten your patient’s teeth without the complication of traditional braces. This treatment method is based on a proven technique in use for over a decade to correct many typical misalignment cases at a fraction of the time and cost of many other aligner or bracket treatments. For more information on this or any other Minor Tooth Movement (MTM) products, please contact DENTSPLY Canada directly at 1-800-263-1437 or visit www.dentsply.ca.
The Andrews2™ Appliance
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uilding upon the original Straight-Wire Appliance, the Andrews Foundation™, has developed an improved appliance system which has been through 20 years of research and development. Be at the forefront of Orthodontics. Call Cerum Ortho Organizers at 800-661-9567 to order the Andrews2™ Appliance.
Maestro™ Mini-Twin® Bracket System
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ontemporary in form and function, the Maestro MiniTwin Bracket System achieves the optimum in metal aesthetics and comfort that patients seek, without sacrificing the precision and control that practitioners need. Maestro Brackets are engineered using Metal Injection Molding (MIM) technology, which translates into rounded contours, and complex structures that machined brackets cannot duplicate — providing corrosion resistance, strength, and proven performance. The brackets feature a convenient long-axis, scribe line that not only runs the entire length of the pad, but also the bracket for an accurate placement cue. They feature an 80 gauge, microetched, bondable mesh pad for proven bond adhesion and an anatomically contoured base and pad that nestle each tooth for precise positioning. In combination with Maestro Buccal Tubes, they provide doctors a complete appliance system, resulting in controlled treatment, reduced chair time, and increased satisfaction for both practitioner and patient. These non-convertible single tubes are color-coded and feature a large funneled entrance with notch as guide for wire insertion. A defined buccal indent assist with accurate stability and placement and side grip areas allow tweezers to easily hold and position the bracket. For more information on the Maestro Bracket System please call Cerum Ortho Organizers at 1-800-661-9567.
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Ask the Experts
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What is Truth?
I am bombarded with information on a daily basis – from all sources. How do I know what the truth is?
Nadean Burkett answers:
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hat we perceive as truth may come from information delivered in print or electronic media (telecasts, internet, newspapers and periodicals, etc), what we hear from peers, friends, family, mentors and other trusted sources then interpreted by our past experience. So how do we determine what is factual and what is opinion, gossip, rumor, assertion or assumption? Assertion is defined as, “the act of stating emphatically that something is true.” Assumption is defined as, “something that is believed to be true without proof.” Opinions can be delivered in either of those ways. Personal bias and past experience are influential in both of these contexts. In our experience, dentistry is fraught with opinions that have no factual basis. When it comes to formulating decisions and making choices, particularly for one’s livelihood (business) and career, we encourage everyone to be empowered through knowledge. This means getting facts so that you have “proof ” when you make an assertion and to avoid making assumptions. It also means that one should not blindly accept the opinions expressed by anyone unless they have provided evidence to support their assertion. We find that most people are easily convinced by opinions from trusted sources whether that be an accountant, lawyer or other professional; information published online (i.e. blogs, websites, and even Wikipedia), video
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Nadean Burkett is a career and business transition coach with more than 30 years experience in the dental profession – now assisting accountants and other professionals in private practice by referral. Trusted practice evaluator, business planner and respected coach and advisor for the past 10 years - Nadean facilitates The EMPOWERMENT Program series, Career & Practice Management for Dentists both online and from NBAI’s head office situated in beautiful Vancouver, British Columbia. Visit www.mypracticematters.com email nadean@mypracticematters.com for listings, job postings, & more resources with your practice transition coach.
Dale Tucci is owner and president of Tucci Management Consultants Inc. Dale and her team offers a wide variety of custom practice management solutions, transition planning, business coaching, associate recruiting, marketing and human resource services. You can reach Dale Tucci directly at 416.450.8769; via email at: dale.tuccimgmt@gmail.com www.daletucci.com.
and podcasts and print media. After all, if someone has authority to disseminate information publically, it must be true! Not always. Fact checking is highly recommended before accepting an opinion as true and especially before relying on such to make decisions that will affect one’s life and career. Review what you are hearing and seeing with a discerning eye and a healthy dose of skepticism – develop critical-thinking skills. Ask open-ended questions – those that start with “who”, “what”, “when”, “where” and “how”. And most of all use your common sense.
Dental TEAMWORK Vol.7 No.1 - January 2014
Glenys Bridges is an independent dental coach, practice management mentor and trainer with 20 years experience working with general dental practices. She is a Chartered Member of the Institute of Personnel Development, founder and Fellow of the Association of Dental Administrators and Managers (ADAM) formerly the British Dental Practice Managers Association (BDPMA). Her work includes CPD training, coaching and practice-development servies.
Andy McDougall has over 25 years’ experience of business planning and brings techniques and expertise from a wide range of commercial and competitive business sectors. Andy now delivers businessplanning services to help members of the dental community to respond to the dynamics of an increasingly commercial and competitive environment. He helps businesses to reach the next level and to turn around poor performance.
Q
New Year... Time to Set Goal
As the New Year begins I would like to establish goals for the practice for 2014. Can you give me some suggestions about setting goals? Dale Tucci answers:
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his is a wonderful time to establish goals for the practice and share them with the team. The energy and anticipation of a New Year help set the stage for discussing new ideas and creating a practice plan. If you are the business owner or practice manager and are undertaking this for the first time, you can discuss goals for 2014 with the team and get
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their input prior to formulating a detailed improvement plan.
To make this important task easier I recommend breaking your practice goals down into categories and defining specific goals under each category. For example, the practice may have goals to increase new patient flow, increase production, improve business and clinical systems, improve human resource management, decrease practice expenses or develop their practice brand. You may have some or all of these in your practice plan or others I have not mentioned. There’s no right or wrong because it’s your practice and your goals.
Now comes the tough part! Under your practice categories, list the specific targets under each along with the time line expected to realize these goals and the resources required to achieve them. For most dentists and practice managers this is where this task can be derailed. Take the time to record specific practice targets under each category then review these targets to ensure they are attainable.
In order to define new targets you must know where you are now then establish attainable goals over the first quarter. For example, if a goal is to increase new patient flow monthly, record the number of new patients the practice is currently attracting and the new target. Next detail the action plan to ensure this goal can be attained. The strategies may include training team to ask for referrals, improving customer service and increasing the practice social media presence. The success of the practice plan rests to a great extent on the accuracy of the planning phase. The time necessary to gather information, discuss plans and document specific targets cannot be short changed. If you are faced with insufficient time then scale back the number of areas within
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the practice you wish to improve and identify one or two key areas of practice performance to develop. Remember it is essential to seize the momentum early in the New Year. One of the most important things to focus on as a practice leader is the ability to make the short term goals realistic as team will become disillusioned if the goals are out of reach. In your planning phase the short term goals all build toward success over the course of the year.
Early in the year set up a team meeting describing where the practice was in 2013 then clearly communicate your practice plan for 2014. This meeting may be two or more hours in length as the team should have time to comment and address questions. As you move through the goals for the year express the long term goals as attainable and explain the execution of the plan being broken down into ninety day actions with everyone involved in the process. By explaining the practice plan as a series of actions to be completed in quarterly segments, staff should not feel overwhelmed. The next step is to invite individuals to bring forth their ideas around implementation. In my experience the more involved team members are in the process the better. This level of communication affords the owner the opportunity to hear directly from staff members ideas to improve the execution of the plan. Perhaps the most significant benefit of team input is that they are “in the trenches” and can see the land mines. Team members who will be held accountable for implementation of practice improvements will be more likely to rally around practice strategies they helped develop.
Especially if you are a business owner with long term staff members! These team members truly see
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themselves as stakeholders so neglecting to ask for and listen to their input is not wise. Collectively they have a more in-depth view of the practice and usually have good insight into patient expectations. Regardless of the number of years you have been in business, reviewing practice results, at a minimum one time yearly is a useful and necessary exercise. Planning to improve the business and team performance year over year enables the owner to reflect on performance and plan for the future.
I’ll close with a question. How much time do you spend working in the business compared with working on the business?
Q
Finding the Right Team Members
Please can you advise us? We are dental team of two dentists, one hygienist and six nurses/ receptionists, some of whom are fulltime, others part-time. Until January ZOT3 we were all the original staff of a scratch practice in 1983. Last December a part-time nurse/ receptionist retired. We thought that we had found a suitable replacement but how wrong we were. We are proud of; and want to maintain the quality of the care we provide to our patients. (The CQC inspector congratulated us on our wellstructured systems). However, so far we have tried three different replacements for our retired friend and colleague and each time been more disappointed. Surely we are right to expect our new team member to fit-in with our working practices? Glenys Bridges answers:
S
uccessful recruitment is dependant upon: firstly finding the right
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person; and secondly on how well you can smooth their way into the existing team by creating a supportive environment to enable them to shine.
Recruitment experts will tell you that staff selection skills are a mixture of technique and experience gained through trial and error. During their interview candidates will say what they think you want to hear, so questions such as "give an example of how you worked in a team" are only helpful when supported by scientific psychometric information such a Belbin’s Team Roles assessment. This is one of many profiling tests available online. Psychometric tests are the most valuable when you have a scientific profile of the person you are replacing. Then you can select based on whether you want the new recruit to be someone very similar to, or quite different from their predecessor. Having selected the right person you must recognise that over the past 30 years your systems have evolved and become second nature to the existing team. This is the first time you have needed to train someone new, so take care to check that the procedures are well documented and available in the practice handbook. lt would be advisable to use a mentoring approach to ensure the new person gets a working overview of the whole practice and has a named person to support their induction. This will provide them with practical support and supportive interactions. Success will be the result of finding the right person and being the right practice, a practice in which they can flourish.
Q
Service a Debt?
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What does a bank mean when they ask if you can service a debt?
Dental TEAMWORK Vol.7 No.1 - January 2014
Andy McDougall answers:
W
hen borrowing money from a bank they will want to know if you can service the debt so it is important to understand what they are asking.
Cash and profit are commonly misunderstood. The most important fact is that they are not the same thing — generating profit does not necessarily mean you have sufficient cash.
Net profit is the surplus when you have deducted the costs of running your business from your income. Some costs are accounting adjustments, such as depreciation of your assets and amortization of your goodwill — in other words they are non cash flow items. Similarly there are some expenses that are cash flow items, which are not charged against profit. For example your net profit will need to be taxed, you will need to draw money out of the business to live on and you might have purchased some new fixed assets, known as capital expenditure. It is only after these adjustments have been made that you will know whether there is enough cash left to repay the capital element of any money you borrow, i.e. is there enough money to service the debt.
Your bank will ask you to complete a personal assets/liabilities statement to ensure your drawings in the above example are sufficient to fund your lifestyle. Different banks will also have different attitudes to the amount they will lend and the security they seek to share the risk with you. You could borrow money for lots of reasons but where there is a substantial amount to borrow, a good business plan will identify the serviceability of the loan. Going armed with that information gives the bank a much better impression of your business acumen and therefore increases their confidence in you and your business.
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D D
The FROG Maxillary Molar Distalizer
istalizing maxillary first molars is often an objective in treatment plans involving Class II malocclusions and it is sometimes indicated for non-extraction treatments with maxillary crowding. Patient compliance, or, more accurately, the increasing lack of patient compliance, has become a factor in choosing effective orthodontic appliances. In recent years various appliances that do not require patient compliance have been developed to drive maxillary molars distally. They include the Jones Jig, the Pendulum appliance and the Distal Jet, among others.
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Dr. Kevin Walde
Some of these appliances produce unwanted tipping of the maxillary molars and the Pendulum appliance has a tendency to create crossbites (Fig.1). While all of these appliances can distalize maxillary molars, they can be difficult to fabricate, deliver to the patient or difficult to activate. This article describes the fabrication, delivery and use of the “FROG� (Simplified Molar Distalizer, SMD). Fabrication and delivery are relatively simple and it is extremely easy to activate. It utilizes a modified Nance button bonded to premolars or primary molars as an anchor unit (Fig.2). Recent modifications have incorporated
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Fig. 1
Fig. 2
Fig. 3
Fig. 4
palatally placed mini-implants for anchorage which makes the appliance even more efficient (Fig.3). It is easily activated from the anterior by simply turning the screw counterclockwise (Fig.4).
Fabrication
Prior to laboratory construction the appliance is supplied as three pieces:
Fig. 5a
1) the main body, 2) the universal distal spring or legs, and 3) an activation tool (Figs. 5a & 5b).
First molar bands with lingual sheaths are cemented in the patient’s mouth. An alginate impression is taken with particular attention being given to the detail of the palate, occlusal and lingual surfaces of the teeth, and the lingual sheaths of the molar bands. If tooth bourne anchorage is being used .028" round stainless steel wires are bent to attach the anchor teeth to the Nance button. The anchor wires should lie in the
Fig. 5b
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embrasures distal to the anchor teeth. Alternatively, as mentioned above, mini-implants can be used as anchorage. The Nance button is fabricated using self-curing acrylic. Anterior extensions are embedded in the acrylic locking the appliance securely in place. Antero-posteriorly the appliance should be positioned so that the distal is flush with, or slightly distal to, the mesial aspect of the lingual sheaths. Occluso-apically it should be positioned at approximately the trifurcation of the maxillary first molars, about 10 to 12 millimeters from the occlusal surface (Fig.6). This will place the appliance at approximately the center of resistance of the molars for bodily tooth movement. If the appliance is placed too far occlusally more crown tipping will occur, too far apically, more root tipping will occur. Occlusoapical positioning is the most critical factor for proper bodily molar distalization.
Fig. 7a
Fig. 8
Fig. 7b
Fig. 9
A removable spring is fabricated from an .032" stainless steel wire (universal distal spring provided with kit). The lingual sheaths are carved off of the model for accurate adjustment of the spring. Loops are provided bilaterally for fine tuning
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Fig. 6
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adjustments before insertion or during use. The mid-portion of the spring is inserted into a slot in the distal of the appliance and the assembly is secured with an elastic or stainless steel ligature to be delivered to the patient (Figs. 7a & 7b).
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Fig. 10
Fig. 11a
Fig. 11b
Patient Delivery
Activation
The lateral ends of the spring are inserted into the lingual sheaths on the molar bands. The Nance button is held firmly in place against the palate with finger pressure. The appliance is then bonded to the anchor teeth using a light cured composite (Fig.8). If mini-implant anchorage is being used a self-curing acrylic is injected into the holes around the mini-implants and the appliance is held in place until the acrylic has cured (Fig.9).
The appliance is activated with a tool that is inserted from the anterior into the head of the screw and rotated counterclockwise. Each turn of 360 degrees opens the appliance .4 millimeter. Three to five turns per appointment are effective. Activation is quick and simple and takes a matter of seconds. Appointments are made at four week intervals for 3 turns (1.2mm) and eight week intervals for 5 turns (2mm) depending on operator preference and patient tolerance.
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Fig. 12a
Fig. 12b
The Advantages of the SMD 1. 2. 3. 4. 5. 6. 7. 8. 9.
Easy assembly Easy activation Three dimensional molar control Easily removable and adjustable distalizing spring Bodily molar movement Bilateral or unilateral molar distalization Works with fully erupted second molars Patient cooperation is not required Invisible
Once the desired amount of distalization is achieved, the screw should be sealed with composite resin or acrylic to prevent backup while retracting the premolars, canines and incisors. When using mini-implant anchorage the premolars will drift distally somewhat along with the molars and some space in the canine region will be developed spontaneously.
Applications
The Frog can be used bilaterally or unilaterally in various applications. It can be used for distalization in first phase
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orthodontics or single phase orthodontics in combination with fixed appliances. When used in combination with fixed appliances the archwire is usually sectioned distal to the second premolars. Approximately 1 to 1.5 mm per month of distalization can be achieved with little or no crown tipping. Maintaining molar distalization once it is achieved should be done with some type of retainer or with fixed appliances. Figure 10 is a panoramic radiograph that illustrates the bodily movement produced by the Frog. Figures 11a & 11b and 12a & 12b illustrate two cases completed with the Frog. *U.S. Patent #US 6,435,870 SNF Forestadent Orthodontics, A Div of Swiss NF Metals, Inc. 416 510-2220 / 800 -387-5031 • www.forestadentcanada.com
Dr. Kevin Walde is in the private practice of orthodontics in Washington, Missouri and is an Assistant Clinical Professor in the Department of Graduate Orthodontics at the Center for Advanced Dental Education, St. Louis University. He graduated from the UMKC School of Dentistry in 1983 and he completed his orthodontic residency at St. Louis University in 1985. He is a member of the American Association of Orthodontists, a Diplomate of the American Board of Orthodontics, past president of the Greater St. Louis Orthodontic Study Club and a past president of the Orthodontic Education and Research Foundation. Dr. Kevin Walde, has a financial interest in the product.
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I I
Early Orthodontic Treatment
t has been estimated that 70% of children under age 12 have a malocclusion. The question is “When is the best time to treat these orthodontic and orthopedic problems?� I am a strong advocate of early treatment. Since 90% of the face is developed by age 12, we must treat the children early if we want to guide and positively modify the growth of our younger patients. The key to beautiful broad smiles which all children and adults desire is to develop the arches with functional appliances preferably at an early age. This critical arch development also makes room for all the permanent teeth which avoids the extraction of permanent teeth. Mothers
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Dr. Brock Rondeau
will seek out orthodontic practitioners who advocate nonextraction techniques. Children with crowded teeth, retrognathic mandibles, protruding upper teeth etc, are extremely self-conscious. When these problems are solved their self image improves and they become more positive which helps determine a better future for them.
Orthodontic clinicians, including orthodontists, pediatric dentists and general dentists must determine whether they want the children in their practice to be treated early or to delay treatment until all the permanent teeth erupt.
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Throughout the years the orthodontic profession has been divided into two different groups regarding philosophy of treatment. 1. The Retractive Technique is the treatment of patients mainly in permanent dentition with the use of fixed appliances and extra oral forces (cervical facebow headgear). This is still the technique which is being taught in the vast majority of the orthodontic graduate programs today.
2. The Functional Technique is the treatment of patients in the mixed dentition utilizing removable functional appliances. Patients with abnormal habits such as thumb sucking, tongue thrusting, snoring, airway problems, mouth breathing or abnormal maxillamandibular (skeletal problems) are treated early in order to prevent the problems from getting worse. Functional appliances are also used to treat anterior and posterior crossbites as well as deep overbites.
In my practice I have been utilizing functional appliances for over 30 years in mixed dentition to solve 80% of the transverse, sagittal and vertical problems. The fixed technique is merely used as a finishing appliance to properly align the teeth, and establish proper torque, tip and ideal occlusion when all the permanent teeth erupt. While the total treatment time is usually longer, the patients much prefer this technique because it means much less time involved in fixed braces. Clinicians who practice with this philosophy know that it is much easier to motivate an 8year-old to wear a functional appliance than it is a 12-yearold to wear braces, elastics and headgear.
Charles Tweed, often called the world’s greatest orthodontist, produced great results throughout his career with fixed appliances. Near the end of his career he stressed the importance of treating in mixed dentition. He stated, ‘In other words, knowledge will gradually replace harsh mechanics and, in the not too distant future, the vast majority of orthodontic treatment will be carried out in the mixed dentition period of growth and development and prior to the difficult age of adolescence.” He made these remarks in 1963. Fifty years later I suggest that most orthodontic clinicians have not embraced Dr. Tweed’s philosophy. The retractive technique, which is still being taught in the majority of the orthodontic programs in North America, is primarily a bicuspid extraction technique. Proponents believe the overjet is due to a protruded maxilla and the solution is either to distalize the molars with cervical facebow headgear or distalization appliances or
extraction of the first bicuspids. This retraction of the anterior teeth frequently results in posteriorly displaced condyles which result in the compression of the nerves and blood vessels in the bilaminar zone. It also has a negative effect on the patient’s profile and upper lip. They do not believe that arches should be developed, but rather lean towards extraction as a way of eliminating the crowding problem. This can lead to a constriction of the maxillary arch which subsequently prevents the mandible and condyles from assuming their correct forward position.
Charles Tweed, often called the world’s greatest orthodontist, produced great results throughout his career with fixed appliances. Near the end of his career he stressed the importance of treating in mixed dentition. Proponents believe that excessive overbite is due to overerupted incisors and the solution would be to intrude the incisors with fixed mechanics. The objective of the retractive philosophy is to align the teeth on the lower arch and then move the upper teeth distally to achieve a proper occlusion. This retractive technique frequently impacts negatively on the health of the TMJ. The key to the functional philosophy is the proper development of the maxillary arch transversely and sagittally. This is necessary to accommodate all the permanent teeth and to allow the mandible and condyles to come forward to their proper position.
Two prominent orthodontic clinicians and researchers, Dr. Robert McNamara and Dr. Robert Moyers, made the startling revelation that 80% of Class II malocclusions have retrognathic mandibles. Dr. McNamara has further stated that less than 5% of Caucasian maxillas are truly prognathic. Joint Vibration Analysis and TMJ clinical exams routinely showed disc displacement in Class II patients with retrognathic mandibles prior to treatment and normal disc/condyle relationship after functional treatment. In light of these facts, how can orthodontic practitioners continue to apply mechanics which cause retraction of the maxilla? Functional clinicians favor the advancement of the receded mandible with functional (orthopedic) appliances such as the Twin Block, Rick-A-Nator or MARA appliances for the correction of overjet problems. This forward movement of the condyle almost routinely eliminates TM dysfunction in these Class II patients. Advocates of functional treatment believe that an excessive overbite is due to overclosed posterior vertical Dental TEAMWORK Vol.7 No.1 - January 2014
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dimension. The problem is easily diagnosed by the presence of bruxism and numerous sore muscles upon palpation, notably the deep masseter, posterior digastrics and lateral pterygoids. The functional solution would be to utilized jaw repositioning appliances to prevent the eruption of the anterior teeth and to encourage the eruption of the posterior teeth and alveolar processes. The treatment allows the posteriorly displaced condyles to move to a downward and forward position in the glenoid fossa which helps to reduce the signs and symptoms of TM dysfunction. Patients show a vast improvement in symptoms when functional appliances are utilized which develop the maxillary arch to its proper width and length and allow the mandible to be in the proper relationship with the maxilla in three dimensions, transversely, sagittally and vertically.
Most general dentists know that they are the ones treating most of the patients in mixed dentition. One only has to talk to the owners of the labs who fabricate functional appliances to confirm this fact. General and pediatric dentists use the majority of functional appliances utilized in North America today. Most general dentists are also painfully aware of the fact that the majority of orthodontic clinicians have geared their practices to treating patients in permanent dentition. They know this because on countless occasions mothers have complained about their children’s orthodontic problems and have requested early treatment. In the majority of cases, mothers and general dentists were frustrated with the response, “No treatment is indicated at this time, the patient is too young, the malocclusion will be observed and treated only when the permanent teeth erupt.” For practitioners trained with a preventive philosophy, this approach is unacceptable and illogical when statistics prove that malocclusions left untreated worsen over time.
Most general dentists are also painfully aware of the fact that the majority of orthodontic clinicians have geared their practices to treating patients in permanent dentition. Some may think of this as “supervised neglect”. The bottom line is that mothers will often not accept this answer and frequently seek out practitioners who have taken courses on early treatment. In the future, general dentists and orthodontists must learn to treat these children who have malocclusions in the mixed dentition.
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Phase 1: Mixed Dentition (Orthopedic Phase)
Thumb sucking, digital habits, anterior and lateral tongue thrusts, airway problems including mouth breathing and snoring, and jaw joint problems must be corrected early with functional appliances. Anterior and posterior crossbites, as well as deep overbites are ideally corrected early with functional appliances. Skeletal problems such as constricted maxillary or mandibular arches, retrognathic mandibles and maxillas are best treated as early as possible with functional appliances in mixed dentition.
Phase 2: Permanent Dentition (Orthodontic Phase)
Dental problems are solved with straight wire appliances in permanent dentition. Our goal must be to provide the best possible service for our patients. Orthodontic practitioners must treat patients as early as the problems are diagnosed so they can utilize functional appliances to help modify the growth and to correct the skeletal and facial dysplasias that are present.
In 1985 the American Journal of Orthodontics changed its name to the American Journal of Orthodontics and Dentofacial Orthopedics. In 1994, nine years later, the American Association of Orthodontics changed their name to the American Association of Orthodontics and Dentofacial Orthopedics. Hopefully the Association takes this change in its name seriously and starts to stress the importance of Phase 1 treatment for dentofacial orthopedic problems.
At the present time, most of the functional orthopedic appliances are being fabricated by general dentists. Many general dentists have taken courses in functional appliances because they want to help their patients and were frustrated by the lack of interest in the majority of the orthodontic profession in helping these children. I have been teaching courses on the use of functional appliances for the past 35 years and have not yet met a general dentist who thought they received adequate training in early treatment in dental school. I would submit that the educational system has failed to provide our graduate dentists with adequate training in orthodontics and orthopedics. Approximately 70% of children under age 12 have some form of malocclusion. Therefore, it is time for the entire profession to take this subject more seriously. Perhaps at this time it might be prudent to itemize some of the indications for early treatment.
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1. Constructed maxillary arch with resultant unilateral or bilateral crossbite. These arches must be developed to their normal width in order to ensure that: a) There will be adequate space for the eruption of all the permanent teeth.
b) Allow room to advance the mandible in cases of Class II skeletal with retrognathic mandibles. Patients and parents much prefer the use of functional appliances such as the Twin block, Rick-A-Nator, Herbst Appliance, and MARA (Mandibular Anterior Repositioning Appliance) to advance the mandible non-surgically in mixed dentition rather than delay treatment until permanent dentition and have it treated surgically. c) When the maxilla expands the palate drops and this increases the size of the nasal cavity which helps encourage nasal breathing. d) When the maxilla expands this helps provide more space for the tongue which helps eliminate speech problems.
e) The development of the maxilla encourages the patient to have a broad smile.
f) Some patients with unilateral posterior crossbites have facial asymmetries due to a shifting of the mandible to one side during closure. It is critical that the crossbite be corrected as early as possible in order to eliminate this facial asymmetry.
g) The proper development of the maxillary arch allows the mandible to assume its correct position and allows the condyles to move downward and forward. This helps eliminate the signs and symptoms of TM dysfunction. Clinicians who treat and monitor the health of the TMJ routinely find that the proper development of the maxillary arch is one of the main keys to TMJ health. Treatment Removable: Schwarz Appliances Fixed: Maxillary Banded Hyrax
Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 1: Narrow arch - no room for laterals
Fig. 3: Constricted upper arch - no room for laterals
Fig. 2: MX Schwarz appliance
Fig. 4: Room for laterals
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Fig. 5
2 Fig. 7
Fig. 6
Fig. 8
Fig. 5: Constricted upper arch - no room for laterals
Fig. 7: Narrow arch - no room for laterals
Fig. 6: MX arch expanded
Fig. 8: Straight teeth
2. Anterior crossbites must be eliminated as soon as possible. If an anterior tooth is in crossbite this can result in the mandible being locked in an unfavorable position which adversely affects the occlusion as well as the health of the TMJ. Parents are most concerned about the appearance of these teeth as one is frequently
Treatment Removable: Anterior Sagittal
Fig. 9: Anterior crossbite
Fig. 10: Posterior pads 2mm
longer than the other and a different height. Also, the problem of traumatic occlusion and gingival recession must be addressed.
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Fig. 11
Fig. 12
3 Fig. 13
Fig. 14
Fig. 11: Anterior screw appliance
Fig. 13: Anterior crossbite
Fig. 12: Anterior screw open 4mm
Fig. 14: Crossbite corrected
3. Anterior open bite caused by a digital habit such as thumb sucking or tongue thrusting must be corrected as early as possible. These habits are much harder to correct when the patient has permanent teeth and much easier to correct in mixed dentition when the children are much more cooperative.
Treatment Fixed: Maxillary Banded Hyrax with Tongue Crib
Fig. 15: Anterior tongue thrust
Fig. 16: Maxillary banded hyrax tongue crib
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4. Deep overbites can often cause headaches in children. If left untreated the majority of females over age 20 develop severe headaches on a regular basis. In an effort to avoid headaches present and future, the deep overbites should be corrected as soon as possible. The appliance of choice is the Rick-A-Nator. This fixedfunctional appliance consists of an anterior bite plate lingual to the six anteriors connected to the first permanent molars by two .050 connector wires. The Rick-A-Nator helps to correct the deep overbite by preventing the eruption of the anterior teeth. The Rick-A-Nator is ideal for patients with deep overbites and overjets less than 3mm. The construction bite is taken with midlines aligned and a 1mm overbite, 1mm overjet. The mandibular first and second primary molars have buildups with composite to fill in the posterior open bite after the Rick-A-Nator is inserted. These composite buildups provide posterior support which is necessary for TMJ health and to allow the patient to chew their food properly. The mandibular first molars will then passively erupt to occlude with the upper molars within 3-4 months. The objective is to establish a new correct occlusal plane into which the bicuspids will erupt into their proper position.
Fig. 17
Fig. 18
Problem Deep Overbite
Solution Fixed Upper Rick-A-Nator
Deep overbites can often cause headaches in children. If left untreated the majority of females over age 20 develop severe headaches on a regular basis.
Fig. 19
Figs. 17 and 18: Maxillary banded hyrax tongue crib Fig. 19: Anterior tongue thrust Fig. 20: Corrected habit normal overbite Fig. 20
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Fig. 21
Fig. 22
Fig. 23
Fig. 24
Fig. 25
Fig. 26
Fig. 21: Class II molar overbite 6mm
Fig. 24: Composite buildups lower primary molars
Fig. 22: Rick-A-Nator cemented
Fig. 25: Overbite 6mm
Fig. 23: Class II molar overbite 6mm
Fig. 26: Rick-A-Nator
My objective in writing this article was to make general dentists aware of the advantages of early orthodontic treatment for children. I strongly believe that general dentists can help prevent malocclusions from worsening and improve the self-esteem of their younger patients by treating
these children at an early age. Functional appliances are extremely prevalent all over Europe and South America. I would encourage general dentists to take courses to learn how to treat these simple orthodontic cases as I have shown in this article.
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Fig. 27: Retrognathic profile
Fig. 28: Insert Rick-a-nator - straight profile
The problem is that at this time, although the trend is certainly towards non-extraction, the majority of orthodontic clinicians are not treating in the mixed dentition. Mark Twain made an interesting comment, “When you find yourself on the side of the majority, it is time to pause and reflect”. The parents and the children in your practice will appreciate the results and it will give you a greater sense of satisfaction from your practice. It is my opinion that these simple functional appliances should have been taught in dental schools in North America but in many cases were not. You need to ask yourself the questions, “If this was your own child with a malocclusion would you want to treat early with functional appliances and non-extraction or would you want the alternative treatment.” The problem is that at this time, although the trend is certainly towards non-extraction, the majority of orthodontic clinicians are not treating in the mixed dentition. Mark Twain made an interesting comment, “When you find yourself on the side of the majority, it is time to pause and reflect”.
I think the time has come for general dentists to consider what is the best treatment for their younger
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patients with malocclusions. I would like to suggest that either they get adequate training to treat the children in their practice or refer their younger patients to an orthodontist or general dentist that practices with a functional philosophy. It has been my clinical observation, having treated orthodontic patients for the past 35 years, that patients treated early with the functional philosophy have less temporomandibular joint problems and are less likely to suffer from life threatening obstructive sleep apnea later in life. Think carefully about how you want to treat your younger patients as it has far reaching effects on their total health and quality of life. Brock Rondeau, DDS is a Diplomate of the Inter national Board of Orthodontics, Diplomate American Board of Craniofacial Pain, Diplomate-Academy of Clinical Sleep Disorders Disciplines, Master Senior Certified Instructor for the International Association for Orthodontics and was awarded the IAO's highest honor - the Leon Pinker Award and Duane Stanford Award. He has published over 30 articles and numerous videos on orthodontics and is also a contributing editor for the Journal of Clinical Pediatric Dentistry and the Journal of General Orthodontics. Dr. Rondeau is one of North America's most sought after clinicians whose practice is limited to the treatment of patients with orthodontic, orthopedic, TMJ and snoring and sleep apnea problems for the past 30 years. His expertise in teaching, combined with his insatiable thirst for knowledge in the orthodontic arena has pushed Dr. Rondeau to the very top of the orthodontic/orthopedic lecture circuit. He is without a doubt perhaps the most prolific speaker on the topic of functional orthodontic treatment.
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Utilising a Combined Restorative and Orthodontic Approach
to Correct Occlusal and Aesthetic Issues Ilan Preiss, BDS
Presenting Condition
The patient presented to the practice in acute muscular discomfort, with a history of chronic TMJ and muscular pain in and around the joint. She was a 31-year-old female in the dental profession and was looking for an enhancement in her smile, whilst improving her ability to chew. In addition she felt unhappy with the appearance of her lower teeth and felt they looked crooked and over crowded.
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In photos the patient would not smile in full-face photographs since she was very embarrassed by how the teeth looked therefore, in the pre-op photo she is not showing any teeth (Figure 1). Prior to seeking treatment with us she had seen another dentist who had tried to lengthen her centrals with composite to aid with relief of her bite problems. However, this had not fully worked. The dentist had also carried out the first stages of an equilibration yet she was still in a lot of discomfort.
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Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 1: Full face pre-op
Fig. 3: Lower occlusal view pre-ortho
Fig. 2: Full smile pre-ortho and restorative work
Fig. 4: 1 to 2 smile anterior view post ortho (please note widening of buccal corridor and improved gum positions)
Baseline Monitoring
A detailed oral health evaluation was carried out and periodontally there was no significant issues bar slight supra gingival calculus and mild gingivitis. No pockets were greater that 3mm. No decay was noted and oral cancer screening was negative. A careful and thorough examination of the TMJ and surrounding muscles showed up the following:
• Tenderness from joint on opening both when pressure placed on joint and without. • Inability to load joint without pain • Limited opening • Tenderness from left and right medial pterygoids, trigger point tenderness elicited from left temporalis and left masseter. The remaining muscles felt slightly sore. • Large centric relation to centric occlusion slide, with a large vertical small horizontal slide.
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• Large numbers of working and non-working side interferences both in left and right movements.
Study models and facebow were taken and a centric bite was taken with the aid of a lucia jig and using bimanual manipulation. Careful analysis of these models with the technician and orthodontist led to the following treatment option.
Cosmetic Exam (Figure 2)
• The centre line was off to the left and non-coincident upper to lower teeth. • There was a cant from the left to right. • Gingival levels and zeniths of upper anterior teeth were not in the ideal positions with the left side being higher than the right. • High smile line was noted. • Incisal edge position was short and the crown height to width ratios was not ideal.
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Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10
Fig. 5: 1 to 1 retracted anterior left pre-op Fig. 6: 1 to 1 retracted anterior pre-restorative stage Fig. 7: 1 to 1 retracted anterior right Fig. 8: 1 to 2 retracted right pre-restorative stage Fig. 9: 1 to 2 retracted anterior pre-restorative stage Fig. 10: 1 to 2 retracted left pre-restorative stage Fig. 11
• 11, 21, 12, 22 were not symmetrical and the height to width ratios of these teeth were not symmetrical. • Golden proportion was not correct since the 13, 23 were in the wrong position. • The buccal corridor was too narrow on both sides and so in full smile the teeth distal to 13,23 could not be seen properly. • Incisal embrasures were not developed enough, but especially on the left side. • The colour and incisal translucency caused by the placement of the composite additions have left the teeth looking unnatural and stained. • Crowding of lower anterior teeth.
Treatment Options Discussed
After carefully explaining occlusal disease and the link with the joint and muscles, we advised that before placing any
Fig. 11: Lava crowns
restorations on the front of the mouth we would have to improve the condition of her joint and muscles. In addition we spoke of veneers versus crowns for the front teeth. Since over 30% of the tooth height had been lost and replaced with composite and since we still needed to lengthen incisal edge further, and control the palatal contour for anterior guidance, crowns would be a better option. Since she had a high smile line, lava crowns were chosen for the natural look and ability to blend cervically with the surrounding tissues.
Phase 1
Stabilise bite and joint and ensure muscle symptoms decrease. This would be carried out with an upper hard occlusal splint, initially worn as much as possible with numerous adjustments over a number of weeks. A positive response was immediately noted by the patient and the acute pain was relieved. Dental TEAMWORK Vol.7 No.1 - January 2014
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Fig. 12
Fig. 13
Fig. 14
Fig. 15
Fig. 16
Fig. 17
Fig. 18
Fig. 19
Fig. 12: 1 to 2 smile view post-op anterior
Fig. 15: 1 to 2 smile view left side post-op
Fig. 18: 1 to 1 retracted anterior post-op
Fig. 13: to 2 retracted anterior post-op
Fig. 16: 1 to 2 retracted left side post-op
Fig. 19: 1 to 1 retracted left side post-op
Fig. 14: 1 to 2 smile view right side post-op
Fig. 17: 1 to 2 retracted right side post-op
Phase 2
New bite taken in centric relation since the muscles and joint were more relaxed and analysis for an equilibration carried out. Equilibration of the teeth to remove the slide between centric relation and centric occlusion was carried out, as well removing some of the interferences in lateral movements. However, since orthodontics would be carried out to adjust the position of the canines, the remaining equilibration would be carried out at a later date.
Phase 3
Lingual fixed upper and lower orthodontics was carried out (Figure 3). Fixed orthodontics to align the lower teeth so aesthetically better as well as improve the anterior guidance. Widening of the buccal corridor in the upper teeth and
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improve the cant that is on the upper teeth, in addition to improving the position of the canines to aid with lateral guidance. Correct gingival heights of upper anterior teeth were also achieved. This phase took one year and was carried out by Dr. Asif Chatoo (orthodontist).
Phase 4
New study models were taken and mounted with a centric bite. Careful history showed all joint and muscle pain had been resolved and full range of movement was noted. Full mouth photographs were taken and analysis of these in addition to occlusal requirements led us to design the anterior crowns at the correct incisal edge as well as correct palatal anatomy for guidance.
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Fig. 20
Fig. 21
Fig. 22
Fig. 20: 1 to 1 retracted right side post-op Fig. 21: Lower occlusal view post-op Fig. 22: Upper occlusal view post-op Fig. 23: Full face post-op Fig. 24: Pre-op smile Fig. 24
Fig. 23
Fig. 25
A diagnostic wax-up was constructed and 13-23 waxed up to full contour for crowns. The wax-up was designed to meet the above criteria. A full discussion about colour and characteristics of the crowns was undertaken with the patient and technician. The patient really wanted a natural look with translucency and that would blend with her natural teeth.
Phase 5
Minor equilibration was carried out to ensure light centric stops in all the correct places and no lateral interferences. Preparation of 13, 12, and 11,21,22,23 for lava crowns was undertaken. Impressions were taken and chairside temporary crowns were made, based on the diagnostic waxup. Facebow and stick bite were also taken. Two weeks later the laboratory made acrylic crowns which were fitted. The patient was tested over a three month period for function and form as well as all speech issues, to ensure that the crowns were within her envelope of function. In addition,
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Fig. 25: Post-op smile
the laboratory sent off for the Lava 3M copings for the permanent crowns. Once the patient and I were happy, we took pick up impressions of the Lava 3M Copings with the surrounding periodontal tissue in the ideal natural position. The laboratory processed the Lava crowns and copied the temporary crowns which had been very well tolerated. These were cemented after approval from the patient with RelyxUnicem (3M espe) (Figure 11). All occlusal movements in anterior and lateral excursions were checked to ensure contacts were even (Figures 12 -23).
Phase 6
Owing to the fact that the patient had a habit of grinding, I felt it was prudent to protect the porcelain, protect the joint and maintain crowns in the position we placed them by constructing a night time upper occlusal splint. In addition the lower anterior teeth had a permanent retainer left to keep these teeth in the post orthodontic position.
Conclusion
We felt that the treatment carried out was a great success on many levels and exceeded all of the patient’s expectations. She was free of pain, and her bite is in a stable position that will remain this way. In addition she has a beautiful smile to compliment her natural jovial nature (Figures 24-27). She is proudly showing off her new smile, and we are delighted to have helped her. This case required very
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Fig. 26
Fig. 26: Pre-op close up
careful management of her occlusal scheme. We then matched this to her final restorations creating beautiful natural results aesthetically, as well as relief of pain from muscles and joints. Acknowledgements I would like to thank my technician Atsuyoshi Kakinuma for his fabulous ceramic work and Dr. Asif Chatoo for his invaluable help with the orthodontic aspects of this case. References available on request.
Fig. 27
Fig. 27: Post-op close up
Ilan Preiss, BDS, qualified from Leeds in 1998 and has been working in London in private practice since 2000. Ilan has been part of the award winning Bow Lane Dental practice since 2002. He has been nominated for many dental awards, winning the 2009 Restorative Smile Of The Year Award at the prestigious Smile Awards. He is currently working with 3M lecturing on LAVA crowns and is one of a select group of dentists in the UK to be using and lecturing on the Lava Chairside Oral Scanner.
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P
A Predictable Solution
As patients present with more aesthetic problems it is important to offer the solutions they need.
P
atients are attending with ever increasing aesthetic demands and we need to be able to provide predictable solutions to aesthetic problems. This patient was unhappy with the appearance of his anterior all-ceramic crown 12 (Fig. 1). He was happy with the aesthetics of the crown but was concerned with the grey discolouration at the gingival margin, which he felt made it look obvious the tooth was a crown. The patient had a high
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Dr. Thomas Meneaud smile line and a combination of a metal post, discoloured root and thin gingival biotype resulted in a grey appearance at the gingival margin, which can be seen in Figure 2. The preoperative radiograph is shown in Figure 3. Three options were discussed: either accept the current situation, replace the metal post 12 with a glass fibre post bonded with white opaque cement and new Lava crown,
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Fig. 1
Fig. 2
Fig. 1: Patient was unhappy with the appearance of his anterior all ceramic crown Fig.2: Combination of a metal post, discoloured root and thin gingival biotype resulted in a grey appearance at the gingival margin Fig. 3: The preoperative radiograph Fig. 4: The existing crown and metallic post
Fig. 3
Fig. 4
Fig. 5
Fig. 6
or carry out soft tissue grafting to increase the gingival thickness over the root 12 in order to mask the root discolouration. The patient was keen to proceed with replacement of the existing metal post.
The Procedure
The existing crown and metallic post (Fig. 4) were removed using a high speed turbine and ultrasonics. The
Figs. 5, 6 and 7: RelyX glass fibre post at try-in and cemented with white opaque RelyX Unicem
Fig. 7
post space was minimally prepared with twist drills (RelyX Fibre Post, 3M Espe) and was etched with 37% phosphoric acid (Scotchbond etchant 3M Espe) and washed and dried with paper points. The post was cemented (Figs. 5, 6 and 7).
The core was built in composite resin (Z100MP, 3M Espe) after etching and bonding the root face (Adper Scotchbond 1XT adhesive, 3M Espe) (Fig. 8). Dental TEAMWORK Vol.7 No.1 - January 2014
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Fig. 8: Composite core Figs. 9 and 10: The final result Fig. 11: Before Fig. 12: After
Fig. 8
Fig. 9
Fig. 10
Fig. 11
Fig. 12
The tooth was then prepared for a Lava all-ceramic crown, which was selected as the Zirconia core works well at masking out any underlying discolouration.
The preparation was then scanned with the Lava C.O.S and digital impressions were sent to the laboratory. The pre-scanning procedure involves soft tissue control with retraction cord (Ultrapak, Ultradent), moisture control/isolation (Optragate, Ivoclar Vivadent) and a light powdering with aluminium oxide powder. The teeth are then scanned by placing the scanner head over the tooth and moving around the arch. This creates a digital model that can be reviewed at the chairside before being emailed to the laboratory for crown fabrication.
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Dr. Thomas Meneaud joined Primley Park Dentistry in 2007 as a partner and principal dentist. Originally qualifying in Liverpool in 2003,he has since completed Royal College of Surgeons exams as well as undertaking postgraduate studies both in this country and abroad. Thomas has a special interest in aesthetic dentistry and complex restorative treatments. He is an Associate Member of the British Academy of Cosmetic Dentistry. In his pursuit of excellence, Thomas has completed many hours of advanced training in modern aesthetic dentistry procedures. He has also been trained in and regularly uses digital oral scanners to assist the production of the highest quality work. He has spent time mentoring and speaking to other dentists on this subject and takes referrals in this area. Thomas is an active member of the local dental committee, and is the current Chairman of Leeds and District British Dental Association.
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Are You a Multi-tooth Dentist?
In My Practice
W
hen a patient presents for major restorative or prosthodontic treatment it is important for the dental team to have a coordinated approach for evaluation, consultation and managing of the patient’s wants and needs. 1 Once we have decided that all medical considerations are taken care of and we are pretty well assured that we can focus on the dentition, we then have to decide the overall specific approach we will take. For in doing comprehensive care we need to take a broad view of the particular case and be able to see the whole picture. We need an appreciation of the forest before we start observing, pruning, or planting trees. We have to be able to conceptualize the final result before beginning.2 In other words, we have to be multi-tooth not single tooth dentists.3 We have to be able to work on arches, not just quadrants (Figures 1 and 2).
Although it is possible to work one tooth at a time, for example single unit crowns over a period of years, it is important not to lose sight of the fact that when multi-tooth dentistry is complete it should function and be harmonious just as if it was all done at the same time. We have all seen
Fig. 1
Dr. Michael Racich
cases that have literally been done one tooth at a time and they look like it: Occlusal form and occlusal planes being irregular and less than ideal, opposing arches showing pronounced wear due to non-compatible dental restorative materials, and disregard of the soft tissues as evidenced by recession and irregular levels to name but a few.
We need, therefore, comprehensive treatment planning and therapeutic execution.4 This requires time and energy spent in patient evaluation and communication presenting practical, evidence-based options and outcomes as well in meticulous case work-up. Case work-up involves thorough charting, photographs, imaging, mounted diagnostic study casts, diagnostic wax-ups, interdisciplinary consultation, cost and time estimates, and risk assessment. We also need to be able to carry out the tasks. That means, of course, training. Training is completed either via postgraduate formal education (for example, a graduate prosthodontic program) or via one of the numerous superb continuing education programs that are offered.5-7 Once appropriately trained, we must also remember not to bite off more than we can chew.
Fig. 2
Figs. 1 and 2: Before and immediate after of a mandibular bonding case that re-established form, function, and esthetics. A multi-tooth, single appointment approach was used.
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Fig. 3 Fig. 4
Fig. 5
Do the cases that we are competent to do! Take baby steps or work in conjunction with a mentor to gain the confidence and learn some tricks of the trade. Failure to follow this advice or being just complacent with too much bravado will only get us into a pickle or two. Once bit twice shy and we do not want to be in this predicament. We want to be doing multi-tooth dentistry predictably and as they are required by our patients.
There is nothing wrong with being a single tooth dentist so long as we respect the fact that that is what we are. We work within our skill level providing optimal, thorough care. We refer the more complex cases out either for second opinion or treatment to be provided by the clinician we refered to. We live happily ever after since we remain in our comfort level and stress is minimized. We sleep well, have strong social relationships, and we pursue activities that we enjoy. We respect our collegues that have taken the time and dedication to learn the ins and outs of comprehensive dental care and become incredible multi-tooth dentists. We learn how to do comprehensive dental care if this is where our interests lie. We do what we do and we do it well (Figures 3-6). I hope you have enjoyed reading my brief thoughts on this topic as much as I have enjoyed sharing them with you. I look forward to spending time with you again soon. And please, always feel free to contact us at your convenience.
Further Suggested Reading and References
1. Racich MJ. The basic rules of facially generated treatment planning. Markham: Palmeri Publishing; 2013. p. 7-16.
Fig. 6
2. Racich MJ. The basic rules of oral rehabilitation. Markham: Palmeri Publishing; 2010. p. 80-2. 3. Roblee RD. Interdisciplinary dentofacial therapy: a comprehensive approach to optimal patient care. Chicago: Quintessence; 1994. 4. Racich MJ. The basic rules of occlusion. Markham: Palmeri Publishing; 2012. p. 17-25. 5. Dawson Center. info@DawsonCenter.com 6. FOCUS Dental Education Continuum. www.DrRacich.ca 7. Pankey Institute. Info@pankey.org Dr. Michael Racich, a 1982 graduate from University of British Columbia, has a general dental practice emphasizing comprehensive restorative dentistry, prosthodontics and TMD/ orofacial pain. Dr. Racich is a member of many professional organizations and has lectured nationally and internationally on subjects relating to patient comfort, function and appearance. He is a Fellow of the Academy of General Dentistry and the American College of Dentists as well as a Diplomate of the American Board of Orofacial Pain and the International Congress of Oral Implantologists. Dr. Racich has published in peer-reviewed scientific journals such as the Journal of Prosthetic Dentistry and the Canadian Dental Journal and has authored the books: The Basic Rules of Oral Rehabilitation (2010), The Basic Rules of Occlusion (2012) and The Basic Rules of Facially Generated Treatment Planning (2013). Currently he mentors the didactic/clinical FOCUS Dental Education Continuum (study clubs, proprietary programs, coaching, 2nd opinions only).
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Ultra Lightweight Loupes
L
A look at how dental professionals can gain maximum benefit by making the correct choices when purchasing loupes.
L
oupes can now be regarded as being an absolute necessity for all clinicians. They will not only help dental professionals achieve better dentistry, but will help them maintain better overall levels of health, and can significantly contribute to the creation of a comfortable working environment. However, when deciding to buy dental loupes the choice of product should not be simply based on trying to obtain the maximum level of magnification for the minimum cost.
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Ergonomic Jigsaw
Tony Beale
Studies based on ergonomics have shown that dental professional, when working in upright or seated positions, will assume working postures far from ideal. Inevitably they will have to adapt their working positions so that they may see clearly into the patient’s oral cavity and may be further restricted by the limitations of their own visionary capability. Loupes will of course serve to
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enhance the wearer’s visionary capability, making clinical procedures less taxing, but they can also prove to be beneficial in other ways. Some studies have shown that 65% of dental professionals will suffer from some form of neck strain, shoulder pain, or backache, and that the everyday regular use of quality made loupes can help to significantly reduce these. Together with the advances that have been made in dental chair and stool design, which have taken on board the principles of better ergonomics, there is a recognized understanding that correct spinal and musculoskeletal body positioning will contribute to a comfortable working environment for the dentists and hygienists. Purchasing a new optical solution is not just about choosing a frame and magnification. It can be an opportune time to adopt a new, better working position. It also offers an opportunity to determine the best possible focus and ideal working distance. Loupes are therefore an important part of the “ergonomic jigsaw” and are deserving of particular attention.
Professional Fitting - Bespoke Loupes
Quality loupes should be purchased from a company that “custom-makes” them to suit the individual operators needs, and makes their loupes to the highest standards, using only high grade materials. Many loupe sales representatives will work closely with dental professionals to explain various options. They will also offer professional advice to determine the most favourable working position as a fundamental requirement in the fitting and choice of the best optical system for each dental professional.
Magnification Additionally leading loupe suppliers will help the dental professional “de-code” the wide range of magnification and options available within their range of product offerings. For those practitioners who are perhaps not familiar with the use of loupes and who may be purchasing for the first time, most loupe suppliers offer a wide range of magnification that can be evaluated to meet individual needs. New users should generally consider lower power loupes in the 2.0 to 2.8 range, and can be termed as “entry-level”. These loupes provide adequate magnification for more basic procedures, and are also very suitable for dental hygienists. As loupe wearers become more experienced they commonly seek out higher magnification levels for more precise procedures such as crown preps and endodontics. These higher magnification loupes are often “Kepler” style, with lensing systems that per mit levels of magnification that are unattainable by traditional “Galilean” lensing systems.
Win for All
With many dental procedures becoming increasingly more sophisticated and with the need for dentists to meet higher standards of care, the relevance of maintaining their own good health, with less work strain, has become all the more important. The use of loupes in every day dental practice can significantly contribute to this aim, with direct benefit being felt by both dental professionals and patients, but with better dentistry being the ultimate winner!
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