Orthodontic Practice US - January/February 2014 Issue - Vol5.1 by MedMark, LLC

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January/February 2014 – Vol 5 No 1

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clinical articles • management advice • practice profiles • technology reviews

Efficiency by design

Life happens... Justin Harding

Dr. Mark McDonough

New study may change the face of orthodontics Dr. Juan-Carlos Quintero

Practice profile Dr. Jerry R. Clark

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Book review The Master’s Guide to Interproximal Reduction (IPR) Dr. Randol Womack

Corporate profile suresmile/OraMetrix

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EDITORIAL ADVISORS Lisa Alvetro, DDS, MSD Daniel Bills, DMD, MS Robert E. Binder, DMD S. Jay Bowman, DMD, MSD Stanley Braun, DDS, MME, FACD Gary P. Brigham, DDS, MSD George J. Cisneros, DMD, MMSc Jason B. Cope, DDS, PhD Neil Counihan, BDS, CERT Orth Eric R. Gheewalla, DMD, BS Dan Grauer, DDS, Morth, MS Mark G. Hans, DDS, MSD William (Bill) Harrell, Jr, DMD John L. Hayes, DMD, MBA Paul Humber, BDS, LDS RCS, DipMCS Laurence Jerrold, DDS, JD, ABO Chung H. Kau, BDS, MScD, MBA, PhD, MOrth, FDS, FFD, FAMS Marc S. Lemchen, DDS Edward Y. Lin, DDS, MS Thomas J. Marcel, DDS Andrew McCance, BDS, PhD, MSc, FDSRCPS, MOrth RCS, DOrth RCS Mark W. McDonough, DMD Randall C. Moles, DDS, MS Elliott M. Moskowitz, DDS, MSd, CDE Atif Qureshi, BDS Rohit C.L. Sachdeva, BDS, M.dentSc Gerald S. Samson, DDS Margherita Santoro, DDS Shalin R. Shah, DMD (Abstract Editor) Lou Shuman, DMD, CAGS Scott A. Soderquist, DDS, MS Robert L. Vanarsdall, Jr, DDS John Voudouris (Hon) DDS, DOrth, MScD Neil M. Warshawsky, DDS, MS, PC John White, DDS, MSD Larry W. White, DDS, MSD, FACD CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day BDS, VT Julian English BA (Hons), editorial director FMC Dr. Paul Langmaid CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-in-chief Private Dentistry Dr. Chris Potts BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon

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1 Orthodontic practice

New Year’s resolution: throw away the cookbook! As I have transitioned my life to dental education, I have observed that my students (graduate and undergraduate) want simple solutions to diagnosis and treatment as graduates starting private practice. They are looking for a “cookbook” approach. As you read through this journal in 2014, as well as others, I will give you the same message as I give my students. Avoid the cookbook concept. Use critical thinking every day in your practice, adapt to change, and understand that the way you practice today will not be the way you practice in the future. So, as you evaluate the articles not only in this journal, but also in others, the following New Year’s resolutions might apply to you. • All patients are not the same. Don’t treat them as though they are. For example, children should be treated differently than adults orthodontically. As Dr. Vince Kokich, who was a transcendent orthodontic and dental educator (and who is sorely missed), said, “Orthodontic treatment in children should be ideal … in adults realistic.” He meant simply that in children having no history, all considerations should be addressed, but in adults with a longer dental history, don’t fix what isn’t broken by forcing “ideal” treatment on them. All patients are individual and special. Don’t pigeonhole them. • Don’t forget that you are a dentist first. As Dr. Kokich also said, “My treatment (adult orthodontics) has been influenced greatly by my association with restorative dentistry and periodontics.” Don’t assume that referring general dentists have performed a complete examination. Do your own. Also, form an interdisciplinary team in your community that will provide the synergy and increased scope of treatment that will not only expand your practice horizons but also be beneficial to your patients. • Don’t be the first on your block to adopt new technology in your practice, but certainly don’t be the last! In my 35 years of practice, I have filled my “dental museum” with technology costing thousands of dollars, now collecting dust. Be critical; is the technology evidencebased? Will the technology improve your diagnosis or treatment outcomes? Will the expense add to your bottom line? Will the technology help promote your practice? Most importantly, does it have a track record? On the other hand, patients expect their doctors to be up-todate. For example, make sure your imaging is current (to address radiation concerns). Utilize new anchorage techniques and approaches that can decrease treatment time safely. • Constantly educate yourself. Dr. William Osler, a trailblazer in medical education and author of the renowned textbook, The Principles and Practice of Medicine, once said, “The greater the ignorance, the greater the dogmatism.” Learn to question and be critical of all information presented no matter what the source. You will be surprised at how this also helps you better educate your patients and increases treatment acceptance. As an educational exercise, I purposely give my graduate students articles that completely contradict each other so that they can discern what is scientifically valid. • You don’t have to do everything! But do what you like, and do it well. Today’s economy and patient expectations often push practitioners into doing treatment they are uncomfortable with. For example, I teach diagnosis and management of temporomandibular disorder (TMD) and orofacial pain to my students, but I emphasize that many orthodontists prefer not to deal with these patients. Some orthodontists love treating just children and have successful practices without getting overly involved with adult orthodontics. In other words, be yourself; but at the same time, if you aren’t getting the results you want, further education is the key to improvement. However, don’t ignore new trends and procedures that can be easily and productively introduced into your practice. For instance, it is my opinion that every orthodontist should include making sleep appliances for their patients (as long as risks and benefits are explained). In conclusion, as you browse journals, be critical, especially of dentists and manufacturers that offer cookbook, quick-fix, “turnkey” systems. Make sure that the journal is peer reviewed (as the clinical and CE articles in this one are). Make sure that any new changes in your practice have withstood the test of time. But just as importantly, be willing to change and adapt, evaluate the individual needs of your patients, and finally — enjoy your practice! My best wishes to all for success and a happy new year! Dr. Harold Menchel Harold Menchel, DMD, is a dentist in Coral Springs, Florida, who limits his practice to TMD, orofacial pain, and sleep-disordered breathing. Dr. Menchel teaches undergraduate and graduate education in TMD and orofacial pain at Nova Southeastern School of Dental Medicine in Fort Lauderdale, Florida. He is the director of orofacial pain at Larkin Community Hospital, one of Florida’s 12 statutory teaching hospitals, in Miami and lectures both nationally and internationally. He is a fellow of the American Academy of Orofacial Pain, a Diplomate of the American Board of Orofacial Pain, and a member of the American Academy of Dental Sleep Medicine.

Volume 5 Number 1

INTRODUCTION

January/February 2014 - Volume 5 Number 1

TABLE OF CONTENTS Orthodontic concepts BioDigital Orthodontics: Management of space closure in Class I extraction patients with

Practice profile

SureSmile: part 7 Dr. Rohit C.L. Sachdeva, and Drs. Takao Kubota and Kazuo Hayashi discuss management of space closure in patients requiring extraction therapy........................ 14

Dr. Jerry R. Clark: Reflections on faith, hope, and orthodontics Inspired by faith, Dr. Clark strives to work hard, provide the finest care for his patients, and have some fun along the way.

Research A survey of orthodontic practitioners regarding the routine use of lateral cephalometric radiographs in orthodontic treatment Drs. Matthew McCabe and Donald J. Rinchuse uncover the latest trend in the use of lateral cepahlometric radiographs ................................ 24

Corporate profile

OraMetrix

ON THE COVER Cover photo courtesy of Dr. Juan-Carlos Quintero. Article begins on page 41.

Now cloud-based, new suresmile 7.0 eliminates the need for in-office servers while providing orthodontists powerful and coordinated tools for diagnosis, treatment planning, archwire design and reduced treatment times.

2 Orthodontic practice

Volume 5 Number 1

A Force to be Reckoned With

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TABLE OF CONTENTS

Efficiency by design

Industry news.............30 Continuing education Efficiency by design Dr. Mark McDonough discusses increasing efficiency through proper treatment decisions ......................32 The biology of orthodontic tooth movement part 2: modulating tooth movement via nitric oxide and prostaglandin production Dr. Michael S. Stosich reviews the markers of bone cell activity that are intrinsic to the complex process of bone modeling and remodeling ....38

Book review The Master’s Guide to Interproximal Reduction (IPR) by Dr. Randol Womack.................40

4 Orthodontic practice

Technology New study may change the face of orthodontics Dr. Juan-Carlos Quintero discusses how 3D imaging is evolving with more applications and lower radiation.....41 Stability, longevity, and predictability in your practice management technology Drs. Shalin R. Shah and Ryan K. Tamburrino discuss the benefits of a high-quality practice management system..........................................44

Product profile Great Lakes offers a complete 3D orthodontic solution for orthodontists and their labs .....50

Practice development Automated patient appointment reminders — the data is in Diana P. Friedman shows the significant impact on no-shows, practice efficiency, and production .....................................................52

Practice management Life happens, and big screen TVs go on sale: a look at solutionbased selling Justin Harding reminds practitioners to address patients’ wants and needs .....................................................54

Diary .....................................56 Volume 5 Number 1

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PRACTICE PROFILE

Dr. Jerry R. Clark Reflections on faith, hope, and orthodontics What can you tell us about your background? I grew up in Philadelphia, Pennsylvania, and after high school attended the University of North Carolina for 8 years, completing my undergraduate work and receiving a BS degree and then obtaining my DDS from the UNC School of Dentistry. After dental school, I entered the U.S. Navy as a dentist and served a 2-year tour of duty at Naval Air Station (NAS) Oceana in Virginia Beach, Virginia. After that, I became an associate in a dental practice in Greensboro, North Carolina, for 2 years practicing general dentistry. In 1973, I entered orthodontic school at St. Louis University, and in 1975, received my Masters in Orthodontics. In 1975, I returned to Greensboro and opened my own private orthodontic practice, and since then I have been actively practicing orthodontics in Greensboro.

Why did you decide to focus on orthodontics? While growing up, I was fortunate enough to have my orthodontic treatment performed by Dr. Paul Reid, former chairman of the Department of Orthodontics at the University of Pennsylvania. Dr. Reid also served a term as president of the American Association of Orthodontists (AAO). Dr. Reid really enjoyed orthodontics, and it showed. I had never seen anyone enjoy his or her profession more than Dr. Reid. While undergoing treatment, we discussed orthodontics as a career, and he strongly encouraged me to consider being an orthodontist.

How long have you been practicing, and what systems do you use? I began my orthodontic practice in 1975. Over the years, it has been our privilege to create thousands of beautiful smiles. With new techniques and technology, it is always a challenge to keep up and ensure that we are providing the very finest care for all of our patients. Today our practice utilizes virtually all the technical advances at our disposal. We use 3D imaging, aligners, TADs, the fantastic and easyto-use Picasso™ Lite soft tissue laser 6 Orthodontic practice

CCO group

(AMD Lasers), Dentsply GAC’s Sentalloy® and BioForce® heat-activated archwires, and most importantly, we use Dentsply GAC’s In-Ovation® (Dentsply GAC) selfligating brackets and the Complete Clinical Orthodontics (CCO) system of treatment. Over the past few years I have been actively involved with Dr. Antonino Secchi and a group of leading orthodontists from all over the world in developing and promoting the Complete Clinical Orthodontics treatment system. CCO is the intelligent integration of the best concepts provided to us by our predecessors: Tweed, Andrews, Roth, and Damon, to name a few, combined with the most efficient and effective technologies available today. This group is open to every orthodontist interested in improving his or her clinical skills, and we invite all orthodontists to join us at any of our future CCO meetings. These advances have allowed us to reduce patient discomfort, decrease treatment time, decrease chair time, and decrease the number of patient visits necessary to complete treatment while at the same time improving the consistency and quality of our treatment results.

What training have you undertaken? Every year, I attend the AAO meeting which

affords me the opportunity to continually monitor what is new in our profession. I also usually attend at least four or five courses that will allow me to obtain a more in-depth knowledge of topics of interest to me and my patients. I regularly attend state, local, and alumni meetings, and have attended the meetings of the Damon Forum, the Gorman Institute, and took the Post-Graduate Week Residency Program at the University of Washington. For over 20 years, I have subscribed to the great series, Practical Reviews in Orthodontics, which monthly gives me a critical review of the literature and the important topics involving the orthodontic practitioner.

Who inspired you? My faith inspires me. I have a profound belief that we have been placed here to help others and leave this place better for those who come after us. Our practice is committed to providing the very finest care for each and every patient we have the privilege to treat. My family inspires me also to be the best that I can be at everything I do. My parents insisted that I get the best education possible. When I was a teen, my orthodontic treatment was performed by Dr. Paul Reid, former chairman of the Department of Orthodontics at the University of Pennsylvania and former Volume 5 Number 1

PRACTICE PROFILE

Dr. Clark’s team

Bentson Clark and Copple Principals

Hope Academy

president of the AAO. His love for orthodontics was contagious, and I thought as a teen that orthodontics would be a great profession. In orthodontic school at St. Louis University, Dr. Leo Mastorakos inspired me to carefully examine every detail in my approach to treatment and to accept nothing but the finest treatment results.

What is the most satisfying aspect of your practice? What a privilege it is to daily work with our patients to provide them with beautiful smiles and a dental occlusion that will last them a lifetime. Every day, patients are excited about getting their braces on, and other patients are excited about getting their braces off. During their treatment, we have the opportunity to change our patients’ lives, not only with the way their teeth and smiles look, but also to be involved in their lives hopefully always in a positive fashion. Our patients become our friends. Volume 5 Number 1

Professionally, what are you the most proud of? The close relationship our staff has with each other and all of our patients. We strive to make every patient encounter a positive one. We have developed a huge family of patients and friends who truly make every day fun and exciting. I am proud to be board certified and to have the ability to provide outstanding orthodontic care for every patient who enters our practice. I am also very proud of the company I started over 20 years ago to provide practice valuation and transition services to the orthodontic profession. Today, Bentson Clark & Copple is regarded as the premier orthodontic practice transition company exclusively serving the orthodontic profession.

make every patient comfortable and feel well cared for in our office. We are not only providing orthodontic care; we are providing care for the entire individual. We try to not just be the patient’s orthodontist; we want to create a comfortable atmosphere of fun and excitement centered on the patient’s treatment.

What has been your biggest challenge? Time management has probably been my biggest challenge. Having four children and a wonderful wife, I find it is sometimes very difficult balancing family time along with the demands of managing and running a busy orthodontic practice, in addition to being actively involved in the community and with my church.

What do you think is unique about your practice?

What would you have become if you had not become a dentist?

We love providing Ritz Carlton-type service for each and every individual who enters our practice. We do everything we can to

A major league baseball player, but I couldn’t hit the curve ball. Or a professional golfer, but I couldn’t break par. Initially, I Orthodontic practice 7

PRACTICE PROFILE

UNC football with family

Make-A-Wish wizard Dr. Clark and wife, Regina, at Pebble Beach

wanted to be an architect; I really enjoyed mechanical drawing and design work. When I entered college, I enrolled as a business major and thought about working in the public relations part of the business world. However, after three semesters in the business school, I decided that dentistry was the career that I wanted to pursue.

What is the future of orthodontics and dentistry? I see a bright future for our profession. The orthodontic supply companies continuously come out with newer and better technology and appliances to make the treatment of our patients quicker, easier, and more comfortable for them. I feel privileged to be a Key Opinion Leader for Dentsply GAC and having the opportunity to work closely with their Research and Development team in developing the next generation of products to improve the quality of orthodontic care for our patients. I see significant changes in bracket design, treatment techniques, archwires, and aligners; and most of all, I believe the new digital technology along with 3D imaging will help to revolutionize the way we provide orthodontic care. However, the key to great orthodontic care will continue to be the proper diagnosis and treatment planning of cases.

What are your top tips for maintaining a successful practice? Continuous continuing education is necessary, not only in the technical field of orthodontics, but also with the practice management side of the practice. “Raving Fans” customer service (from the book of the same name by Ken Blanchard and 8 Orthodontic practice

Sheldon Bowles) is essential to maintaining a successful practice. Keeping up with referral patterns is critical, and today the proper use of “social media” is essential in maintaining an active practice. A strong marketing program within the practice is important to maintaining contact with referring doctors and our patients. It is very important to be involved in civic activities in order to give back to the community. Twenty-eight years ago I founded the MakeA-Wish Foundation of North Carolina, and to date the organization has granted over 5,000 wishes to children under the age of 18 suffering from life-threatening illnesses.

What advice would you give to budding orthodontists? Be a constant student and keep up with all the changes that are occurring in our profession. Work hard, and provide the finest care for your patients — but most of all, have fun. Orthodontics is a wonderful profession that is highly gratifying and fulfilling. Enjoy your patients and staff, and take pride in the quality of care you provide.

What are your hobbies, and what do you do in your spare time? I really enjoy reading and learning. My favorite hobby is golf, which allows me to spend hours outside and enjoy nature. My wife, Regina, and I love to travel and experience the wonderful adventures that travel provides. I am also a big sports fan and enjoy almost every sport both as a fan in the stands and as a spectator watching on television. OP

Top Ten Favorites 1. Reading — every kind of reading — scientific, mystery, suspense, historical, and most of all, my Bible. 2. Golf — this is my relaxation. I have had the privilege of playing some of the world’s finest courses. 3. Travel — my wife, Regina, and I love to travel and experience new adventures. We have visited most of the U.S. national parks and traveled all over the world — our bucket list now includes a trip to New Zealand. Anyone from New Zealand reading this, we would love to come visit you. 4. University of North Carolina athletics — our family has season tickets for the North Carolina football and basketball teams, and we also go to some of the other UNC sporting events. 5. My practice — after all these years, it is still a wonderful privilege to go to the office every day and have the opportunity to create beautiful smiles and impact the lives of our patients in a positive fashion. 6. New technology — it is so much fun to learn about and utilize most of the new technology that continues to allow us to provide better and better care for our patients: TADs, the laser, 3D imaging, new brackets and archwires, and so on. 7. Volunteering for the Make-A-Wish® Central and Western North Carolina — I have been involved with Make-A-Wish Foundation since I helped found the organization over 28 years ago. It is a constant source of inspiration and strength to me to be able to work with the children and families who are going through such difficult times. 8. Involvement with my church — for over 15 years, I have been volunteering every Wednesday night at our church to help feed and work with the homeless people of the Greensboro community. I volunteer every Monday and Tuesday during the school year to tutor children in our church’s after-school tutoring program. I also drive the church van to take the children home after tutoring. I also have a handicapped friend whom I mentor and take to church on Sundays. 9. Nat Greene Kiwanis Club — I have been a member of this civic organization for over 30 years and have made many close and lasting friendships as we help to better serve and care for the children of our community. 10. Hope Academy — a faith-based, private school for inter-city middle school children of Greensboro. My wife, Regina, started this school in 2012 to help provide a first-class education to children living in the inter-city who had few education options. I have had the privilege of watching, and helping in some small ways, as this school has grown from a dream to a reality.

Volume 5 Number 1

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CORPORATE PROFILE

Cloud-based suresmile 7.0 from OraMetrix takes digital orthodontics to an entirely new level The smiles that dreams are made of. suresmile 7.0 from OraMetrix is designed to help clinicians achieve that goal more predictably and efficiently than ever before. Not only has treating patients digitally gotten dramatically more sophisticated, it’s also more cost-effective. Now cloudbased, new suresmile 7.0 eliminates the need for in-office servers while providing orthodontists powerful and coordinated tools for diagnosis, treatment planning, archwire design and reduced treatment times. suresmile doctors use advanced 3-D imaging, virtual simulations and robotically-bent archwires customized for each treatment plan — all while continuing to use their bracket system of choice. Chuck Abraham, CEO, suresmile/ OraMetrix, said, “suresmile 7.0 was designed by our team to advance the digital revolution within our specialty. Taking it to the cloud was essential and the result of comprehensive re-engineering, but the design goal for 7.0 was simple and focused: to build an even better way for our users to realize their treatment plans for each and every patient.” “There is a technology convergence in orthodontics now. Advances in CAD/ CAM technology, 3D scanning, advanced robotics, 3D printing, and the cloud have all helped us to take suresmile 7.0 to new levels of performance and efficiency,” Abraham continued. “We’ve developed the suresmile system to become a true treatment management platform, enabling our doctors to meet the esthetic demands of a growing adult patient population by offering lingual, lingual/labial, and even a hybrid treatment of braces and aligners with the same treatment efficiency and excellent results our doctors have always achieved.” The move to the cloud makes 7.0 easier to integrate into the practice. “The cloud acts as your ‘server in the sky,’ 10 Orthodontic practice

suresmile/OraMetrix Executive Management Team from left to right: Phil Getto, Chief Technology Officer; Glenn Lyon, Vice President, New Business Development; Jerry Metz, Vice President, Operations; Rohit Sachdeva, Chief Clinical Officer; Chuck Abraham, Chief Executive Officer; Jay Widdig, Chief Financial Officer; Bob Davis, Director, Marketing

meaning that digital file storage is much more convenient, and the system is easily accessible, regardless of the user’s location,” commented Phillip Getto, Chief Technology Officer, suresmile/OraMetrix. “You don’t have to be in the office to access a case via internet connectivity — you can be at home or a Starbucks. All patient-identifying information is encrypted, including photos, X-rays, and patient names. All communication between your browser and the servers is also encrypted, as are the servers, which, by the way, are Amazon servers, amongst the most secure in the world.” Since 1998, when OraMetrix developed the suresmile system, this revolutionary digital technology has empowered orthodontists with a powerful diagnostic, treatment, and monitoring tool to deliver the most precise, customized orthodontic care available. In fact, suresmile has been shown to reduce treatment time by an average 30%, based on a February 2011 comparison of more than 40,000 patients. Since 2004, suresmile has been used for over 125,000 patients by orthodontists in

suresmile’s new interface is designed to be more intuitive

the United States, Australia, New Zealand, the European Union, Canada, and Japan. suresmile 7.0 was developed to enhance the system’s efficiency while achieving new levels of precision planning. With the ability to view both bone and roots, it now makes case planning more predictable in achieving roots in the bone. The simplified user interface is more intuitive for the user, reducing the time required to set-up cases. The single-most significant advance in technology that empowers suresmile from its inception is robotic wire production. Patient-specific wire sequences are calculated by computer and optimized by the orthodontist to achieve the desired treatment goal. There is 100% control, tooth-by-tooth or by shape, at any point during treatment. suresmile currently Volume 5 Number 1

Recent studies show that suresmile achieves better or equal quality finishes in 30 percent less time while effectively achieving desired tooth movements. Information available upon request.

produces over 18,000 wires per month, each one of them optimized to achieve a specific treatment goal for that patient, making it truly the only system for fixed appliances that can provide proactive management of treatment objectives and appliance design. A suresmile archwire can be refined at any time, and suresmile software provides tools for analysis of results and decision-making support throughout the course of treatment. “There is a misperception in our profession that suresmile is just a finishing archwire,” commented Dr. Rohit Sachdeva, Co-Founder and Chief Clinical Officer, suresmile/OraMetrix. “In fact, the strength of the software is the ability to treatment plan cases in advance, which allows the doctor to anticipate and avoid common clinical problems that arise during treatment. The ability to visualize patients’ roots and bone is a profound advance for us in putting roots in their proper position. Even with this advanced planning, we know that patient compliance and biology can impact our best-made plans. One of the true strengths of the suresmile system is that the doctor can modify the original plan at any time, order modified archwires, and still achieve an excellent result.” suresmile empowers the orthodontist to see tooth anatomy in ways never before possible, while providing the ability to Volume 5 Number 1

suresmile/OraMetrix Firsts • 3D imaging, full-arch intraoral scanning • CBCT integration • Robotically-assisted, patient-specific archform production • 3D archwire prescription shape memory alloys • Fully integrated imaging platform • Integrated 2D-3D imaging • Workflow automation • Integrated surgical planning • Integrated restorative planning • Blended appliances: lingual, labial, aligners • User-driven 3D tooth adjustment • Total patient management system: communication, dx planning, appliance design, quality assurance • Automatic case quality scoring

visualize and simulate multiple diagnostic set-ups and design archwires accurate to .1 mm. Clinical decisions and their interdependencies are calculated across all teeth simultaneously, calculating archwire designs needed to accomplish your objectives, precisely and predictably. Several independent university studies have confirmed reduced treatment times of

up to 30% over conventional and improved quality treatment scores. Real-time treatment simulations make it possible for the treating clinician to know, precisely, where each case is going, and serve as a dynamic patient communication tool. Writing in a recent issue of Orthodontic Practice US, Dr. Randall Moles commented on this aspect Orthodontic practice 11

CORPORATE PROFILE

University Studies

CORPORATE PROFILE of suresmile: “The digital systems facilitate information transfer so much more easily and effectively. Treatment proceeds quicker (there is no need to reposition brackets) and more easily for both them and us. Along the way, they can see our proposed targets and even be involved in their development. Finally, after appliance removal, we can create digitally-formed retainers, which are also aligners, to make any post-treatment adjustments.”1 In his article, “The Optimized Digital Practice,” Dr. Bruce Goldstein puts it like this: “suresmile is the only comprehensive system that blends the best diagnostics available with accurately prescribed therapeutics. suresmile technology provides the practitioner with the tools needed to treat patients with greater efficiency and accuracy.” (suresmile clinical report No. 1).”2 Dr. Jeff Johnson, concludes his article, “Treating an Asymmetric Class II Case with suresmile,” with this summary: “1. Have confidence that dramatically reduced treatment times are possible and not for isolated patients, but for all patients in general…We must be willing to step outside our orthodontic boxes while still trying to adhere to timeworn orthodontic principles. 2. The confidence that can be conveyed to patients is most often our greatest motivating factor. We basically discuss with them that we all have our jobs to do… and are able to backup these claims by telling them that 65-70% of all our patients complete their treatment in 15 months or less. 3. Our planning becomes very transparent and allows the patients to be an integral part of their treatment to the degree they desire… 4. We are able to create a target that, for all intents and purposes, has been optimized during the mid-treatment planning process. This allows us to monitor treatment more efficiently and not try to achieve what likely is not possible with the given conditions.” (suresmile clinical report No. 2).3 There is more to come. “2014 will be an exciting year for the suresmile team,” commented Bob Davis, suresmile/OraMetrix’s Director of Marketing. “We have entered into a joint marketing agreement with Specialty Appliances to offer labial indirect bonding service and lingual case design exclusively powered by suresmile software. Indirect 12 Orthodontic practice

suresmile case by Dr. Jeff Johnson3

Initial CBCT scan (optional) Treatment plan based on root-and-bone position suresmile digital images provided by Dr. Bruce Goldstein2

“...the design goal for 7.0 was simple and focused: to build an even better way for our users to realize their treatment plans for each and every patient.” — Chuck Abraham, CEO, suresmile/OraMetrix

bonding setups are digitally designed using suresmile software, which enables greater accuracy of bracket placement and case design, as they will have access to our library of over 20,000 brackets and buccal tubes. Specialty Appliances will also offer lingual case planning and setups, including suresmile wires for lingual treatment.” With over 125,000 patients already benefitting from suresmile treatment globally, suresmile 7.0 is now delivering advanced functionality, more intuitive and easy-to-use features, and greater

operational efficiency. To put it simply, suresmile 7.0 was designed and engineered to help orthodontists achieve their clinical goals more precisely than ever before. OP This information OraMetrix.

was

provided

References 1. Moles, R. Treating digitally and the new orthodontic practice. Orthodontic Practice US.2013;4(5):46-52. 2, 3. suresmile clinical reports are available upon request from suresmile. 888.672.6387.

Volume 5 Number 1

surezen.

To see is to know is to treat. Dr. Randy Moles Racine, WI

November 2007

July 2008

January 2009

Initial intraoral

Planned result Four bicuspid extraction

Actual result (Final)

For our most recent detailed suresmile case studies, please call 888.672.6387.

suresmile.com

to be sure.

ORTHODONTIC CONCEPTS

BioDigital Orthodontics: Management of space closure in Class I extraction patients with SureSmile: part 7 Dr. Rohit C.L. Sachdeva, and Drs. Takao Kubota and Kazuo Hayashi discuss management of space closure in patients requiring extraction therapy Introduction The purpose of this article is to discuss the application of SureSmileÂŠ technology1-6 in managing space closure in patients requiring extraction therapy. Strategies to optimize the use of SureSmile prescription archwires and various Clinical Pathway Guidelines (CPG) developed by the first author (Sachdeva) to manage space closure are discussed. These are highlighted with patient histories where possible.

Space closure with SureSmile Efficient and effective management of patients requiring extraction therapy requires proactive care planning, the appropriate choice and design of appliances driven by sound biomechanical principles, and the vigilant follow-up of the patient during treatment based upon a well-designed clinical protocol. When using SureSmile, two clinical strategies are generally considered in closing the extraction space, namely: Type 1- Space Closure with SureSmile The first involves achieving sufficient alignment and overbite correction with conventional mechanics followed by closing the majority of the residual space with sliding mechanics on a SureSmile

Rohit C.L. Sachdeva, BDS, M Dent Sc, is the co-founder and Chief Clinical Officer at OraMetrix, Inc. He received his dental degree from the University of Nairobi, Kenya, in 1978. He earned his Certificate in Orthodontics and Masters in Dental Science at the University of Connecticut in 1983. Dr. Sachdeva is a Diplomate of the American Board of Orthodontics and is an active member of the American Association of Orthodontics. He is a clinical professor at the University of Connecticut, Temple University, and the Hokkaido Health Sciences Center, Japan. In the past, he held faculty positions at the University of Connecticut, Manitoba and the Baylor College of Dentistry, Texas A&M. Dr. Sachdeva has over 80 patents, is the recipient of the Japanese Society for Promotion of Science Award, and has over 160 papers and abstracts to his credit.

14 Orthodontic practice

Table 1: Anchorage classification scheme developed by Burstone7 is used by the first author (Sachdeva) in designing his strategy for space closure mechanics

Table 2: Guideline developed by Sachdeva to assess the relative degree of control offered by various space closure appliances

archwire (Type 1). An example of this is shown in the treatment of patient A.S. (Figures 1-6). With proper consideration to the design of the slideline* in a SureSmile archwire, one can plan to move teeth over a long span with no collision between an archwire bend and bracket (Figure 4). Type 2- Space Closure with SureSmile The second strategy (Type 2) involves using conventional mechanics to close the majority of the space followed by using SureSmile wire. The choice of the space-closure device is driven by the nature of malocclusion and the anchorage

requirements. The appliance types that a clinician may use to achieve space closure are numerous. However, a prime consideration in their use is driven by anchorage considerations, the desired nature of tooth movement, i.e., controlled tipping or translation (Table 1), and patient cooperation. The relative effectiveness of various space closure devices used by the first author (Sachdeva) in controlling tooth movement during orthodontic space closure is provided in Table 2. Furthermore, it must be appreciated that timely and effective care of a patient with SureSmile technology warrants Volume 5 Number 1

Patient I- A.S. (Space Closure Protocol A CPG- Sachdeva ) Patient A.S. presented with a Class II canine and Class I molar respectively with a deep bite and minor upper and lower crowding with retained upper E’s, missing upper right 5, and ectopic erupting upperleft first bicuspid. Based upon the treatment plan, it was decided to extract the retained E’s and upper left second bicispid and treat to a Class I canine and Class II molar relationship respectively. The treatment pathway for patient A.S. followed Protocol A CPG closely (Table 3). Details of patient management are shown with the Figures 1-6.

Figures 1A-1B: Patient I- A.S. 1A. Initial Diagnostic records Class II canine and Class I molar respectively with a deep bite and minor upper and lower crowding. 1B. Initial lateral ceph and panorex radiographs

Figures 2A-2B: Patient I- A.S. 2A. Upper E’s were extracted and initial alignment and leveling accomplished with .016” NiTi and .016” x .022” NiTi archwire in both the upper and lower arches. Therapeutic scan was taken at this stage of treatment. 2B. Mid-treatment ceph and panoramic view was taken at time of therapeutic scan

Figures 3A-3C: Patient I- A.S. 3A. Virtual Therapeutic Model (VTM). 3B. Virtual Therapeutic Simulation (VTS) with upper space closed and prescription archwire designed. 3C. Prescription sliding archwire viewed against VTS. Since the upper anteriors are being retracted, the archwire appears lingual to the teeth

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Orthodontic practice 15

ORTHODONTIC CONCEPTS

avoiding any reactive care processes. One approach to keeping the patient “on-track” is to establish and follow clinical protocols. The first author (Sachdeva) has developed a number of guidelines to clinically manage extraction patients with SureSmile (Tables 3-5). These protocols are driven by the nature of the presenting malocclusion and anchorage requirements. It must be recognized that these CPGs provide a general framework for managing the course of patient care, and a clinician may need to deviate from the pathway at times to cater to the prevailing circumstances and the patient’s response.

ORTHODONTIC CONCEPTS

Figures 4A-4C: Patient I- A.S. 4A. Shows the straight archwire at the time of the therapeutic scan. 4B. Shows the Virtual Therapeutic Model and the design of the sliding SureSmile precision archwire. 4C. Shows the SureSmile sliding prescriptive precision archwire design. The areas in green are the slide planned in the archwire. This is the straight length of the archwire that allows unimpeded slide of the teeth during space closure

Figure 5: Patient I- A.S. Shows simulated staged events against the archwire (A-I). Note: mesial slide planned in front of the upper right molar and the distal slide behind the upper cuspid and bicuspid. This slide refers to the straight length of the segment between the brackets that allows for uninterrupted movement of teeth

Figure 6: Patient I- A.S. Entire space was closed with .019â&#x20AC;? x .025â&#x20AC;? NiTi SureSmile sliding precision archwire with power chain. Note: No collisions are seen between the archwire bends and the brackets 16 Orthodontic practice

Volume 5 Number 1

ORTHODONTIC CONCEPTS

Table 3: Clinical Pathway Guideline for managing space closure in patient presenting with minimal crowding

Table 4: Clinical Pathway Guideline for managing patients with moderate crowding

Volume 5 Number 1

Table 5: Clinical Pathway Guideline for patients requiring maximum anchorage. Note: â&#x20AC;&#x153;Câ&#x20AC;? Anchorage situations may also represent clinical situations requiring maximum anchorage. In such situations, the anterior teeth A-P position may need to be maintained, and depending upon which arch is being treated, Class I or Class III elastic wear may be required to enable a differential force system

Orthodontic practice 17

ORTHODONTIC CONCEPTS Patient II- T.Y. (Space Closure Protocol C CPG- Sachdeva ) Patient T.Y. presented with a Class I malocclusion with severe upper and lower arch crowding. Based upon the treatment plan (Figures 7B and 8B1), it was decided to extract the upper and lower first premolars and treat the patient to a Class I with “A” anchorage The treatment protocol for patient T.Y. was very closely adhered to as shown in the Protocol C CPG (Table 5), and the duration of treatment for this patient was 11 months.

Figure 7: Patient II- T.Y. Initial diagnostic records. Patient presents with a Class I malocclusion with severe upper and lower crowding. Extraction of first four bicuspids was planned for this patient

Figures 8A-8C: Patient II- T.Y. 8A. Virtual Diagnostic Model (VDM). 8B. Virtual Diagnostic Simulation (VDS) designed with the use of the Virtual Diagnostic Model (VDM). The upper and lower first bicuspids have been extracted. Note: The soft tissue simulation in the lower anterior region shows the appearance of black triangles (B-1). 8C. Comparison between VDM and VDS. There is considerable retraction of the anterior teeth, especially of the lower incisors. “A” anchorage of the buccal segments is planned. Note the significant arch-width changes planned in the lower left premolar canine area

Figure 9: Patient II- T.Y. The initial phase of treatment involved separate canine retraction in both the upper arch and lower arch with sliding mechanics. The current image, 7 months from the start of treatment, is the time at which the therapeutic scan was taken. Most of the space has been closed, and the space among the upper anteriors is being consolidated en masse with .017” x 025” stainless steel teardrop loops in a continuous archwire. Note that the buccal segments in both arches are slightly dumped because of the lack of control of the couple-toforce ratio

18 Orthodontic practice

Volume 5 Number 1

Figures 11A-11E: Patient II-T.Y. Treatment re-evaluation of space closure was done at the Therapeutic stage. VTM model is in white and the “best fit” superimposed on the VDM in green to evaluate the nature of anchorage loss. Note that most of the anchorage was lost in the maxillary buccal segments. Also, note that about 4 months into treatment, dumping of the buccal segments becomes obvious, and at this stage of treatment, about 50% of the space has been closed

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Orthodontic practice 19

ORTHODONTIC CONCEPTS

Figures 10A-10C. Patient II-T.Y. A. Virtual Therapeutic Model (VTM). Note the arch widths are reasonably controlled; however, it is apparent that the buccal segments are “dumped.” 10B. Shows the Virtual Target Setup with the accompanying SureSmile archwire design. 10C. Shows the Suresmile archwire design against the virtual therapeutic model (VTM). A full expression .017” x 025” SureSmile prescription archwire was designed. Also, note the brackets used in this patient have a .018” prescription

ORTHODONTIC CONCEPTS

Figures 12A-12H: Patient II- TY. Re-evaluation of the VTM against the VDM in both the upper and lower arch. The VTS is in white and the VDS in green. Note some buccal lingual dumping of the lower buccal segments is noted. However, the arch widths at the molar level were controlled. The anchorage in the upper right buccal segment was better controlled than that in the upper left. Maximum anchorage control was achieved in the lower arch. Also, note as the upper right canine was retracted distally, the palatally blocked upper right lateral first moved laterally, probably as a result of the transseptal fibers, and once it was engaged with the archwire, it was tipped labially into the arch

Figures 13A-13B: Patient II- T.Y. 13A. Shows the comparison between the initial plan (VDS) in white and the initial model (VDM) which is blue. 13B. Shows the comparison between the initial diagnostic model plan (VDS) in white and the Virtual Therapeutic Model (VTM) in green. Note the similarity in the plan movement versus the executed

Figure 14: Patient II- T.Y. SureSmile archwires were inserted 7 weeks post Therapeutic scan. Note Check elastics are worn along with the SureSmile .017â&#x20AC;? x 025â&#x20AC;? NiTi precision archwires 20 Orthodontic practice

Volume 5 Number 1

ORTHODONTIC CONCEPTS It’s amazing what a great image can do for your practice. The CS 9300C Select is ready to work hard for your practice. This technologically-advanced system will finally give you clarity, flexibility and, most importantly, complete control of your image quality and dosimetry. • One system with superior 3D scans with multiple fields of view, 2D panoramic imaging and optional one-shot cephalometric imaging • Optimize your image quality and dosimetry • Cut treatment time by 30% with SureSmile* certification Figure 15: Patient II-T.Y. Recall visit 8 weeks post SureSmile archwires insertion. Note the Class I buccal segments relationship and the substantial correction of the dumped segments achieved

• Experience seamless integration To learn more about what a great image can do for your practice, visit carestreamdental.com/cs9300 or call 800.944.6365 today.

*SureSmile is a trademark of OraMetrix. © Carestream Health, Inc. 2013

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Orthodontic practice 21

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ORTHODONTIC CONCEPTS

Figures 16A-16C: Patient II- TY. 16A. Debonded 4 weeks later. 16B. Final X-rays cephalogram and pano. 16C. Virtual final records achieved

Figure 17: Patient II- T.Y. Shows a comparison of the initial simulation (VDS) in green versus the final model (VFM). Note the initial plan was closely adhered to

Figures 18A-18B: Patient II-TY. 18A. Note the development of black triangles was predicted in the lower anterior region using the Virtual Diagnostic Simulation (VDS). 18B. These are also seen in the frontal intraoral image at the end of treatment 22 Orthodontic practice

Volume 5 Number 1

SureSmile technology, when used appropriately within the framework of the clinical pathway guidelines developed by Sachdeva, offer a unique approach to providing both efficient and effective treatment of Class I patients requiring extraction therapy. Future articles will provide more clinical patient histories to demonstrate the benefits of using SureSmile technology in improving patient outcomes, providing it is driven by a skilled clinician who is willing to follow a proactive care approach to managing patients. *Slideline is the length of the straight segment between the teeth in a SureSmile archwire along which a tooth may slide uninterruptedly.

Acknowledgments The authors are most grateful to Con Vanco, BDS, D Clin Dent, M Orth RCSEd, MRACDS (Ortho), FRACDS, from Adelaide, Australia, for sharing records of Patient A.S. for this paper. The authors also wish to thank Sharan Aranha, BDS, MPA, for the invaluable assistance she continues to provide in the preparation of this series of articles. OP

ORTHODONTIC CONCEPTS

Conclusions

YOUR PRACTICE. OUR PASSION.

CS ORTHOTRAC CLOUD

CS 9300C SELECT References 1. Sachdeva R. BioDigital orthodontics: Designing customized therapeutics and managing patient treatment with SureSmile technology: part 2. Orthodontic Practice US. 2013;4(2):18-26. 2. Sachdeva R. BioDigital orthodontics: Diagnopeutics with SureSmile technology: part 3. Orthodontic Practice US. 2013;4(3). 2013;4(3):22-30.

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3. Sachdeva R. BioDigital orthodontics: Outcome evaluation with SureSmile technology: Part 4. Orthodontic Practice US. 2013;4(4):28-33.

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4. Sachdeva R. BioDigital orthodontics: Planning care with SureSmile Technology: Part 1. Orthodontic Practice US. 2013;4(1):18-23.

INTEGRATED software for seamless workflow,

5. Sachdeva R. BioDigital orthodontics: Management of Class 1 non–extraction patient with “Fast–Track”©– six month protocol: Part 5. Orthodontic Practice US. 2013;4(5):18-27. 6. Sachdeva R, Kubota T, Hayashi K. BioDigital orthodontics: Management of Class 1 non–extraction patient “Standard–Track”©– nine month protocol: Part 6. Orthodontic Practice US. 2013;4(6):16-26. 7. Burstone CJ. The segmented arch approach to space closure. Am J Orthod. 1982;82(5):361-378. 8. Fontenelle A. Challenging the boundaries of orthodontic tooth movement. In: Sachdeva RCL, ed. Orthodontics for the Next Millennium. Glendora, CA: Ormco Publishing; 1997: 248. 9. Sachdeva R, Bantleon H. Cantilever based orthodontics—biomechanical and clinical considerations. In: Sachdeva RCL, ed. Orthodontics for the Next Millennium. Glendora, CA: Ormco Publishing; 1997.

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Orthodontic practice 23

Volume 5 Number 1 8765_Bundle ad-Ortho-3.8x10.7_02.indd 1

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RESEARCH

A survey of orthodontic practitioners regarding the routine use of lateral cephalometric radiographs in orthodontic treatment Drs. Matthew McCabe and Donald J. Rinchuse uncover the latest trend in the use of lateral cepahlometric radiographs Abstract Introduction: The purpose of this study was to survey orthodontists in North America to assess the routine use of lateral cephalometric radiographs in orthodontics. Methods: A 20-item survey questionnaire was e-mailed to 2,215 randomly selected active members of the American Association of Orthodontists for 2013. The questionnaire assessed the percentage of patients on whom lateral cephalometric radiographs were taken and to what extent these records were being evaluated. Results: Of the 2,215 orthodontists contacted, 232 completed the survey for a response rate of 10.47%. • 60.34% reported always taking “pretreatment” lateral cephalometric radiographs, and 38.53% reported always performing a cephalometric “analysis” on pretreatment cephalograms. • 30.30% reported always taking “posttreatment” lateral cephalometric radiographs, and 6.49% reported always performing a cephalometric “analysis” on post-treatment cephalograms. • 75.11% reported using centric occlusion (maximum intercuspation), and 18.34% reported using centric relation for patient positioning in lateral cephalograms. • 37.95% reported at least inspecting the lateral cephalogram for diagnosis when a cephalometric “analysis” was not performed, and 81.94% reported using clinical findings over the lateral cephalometric analysis when a disparity existed between the two.

Matthew McCabe, DMD, MS, MBA, is in private practice of Orthodontics and Dentofacial Orthopedics in Gautier, Mississippi. Donald J. Rinchuse, DMD, MS, MDS, PhD, is a Professor and Graduate Orthodontic Program Director, Seton Hill University Center for Orthodontics, Greensburg, Pennsylvania.

24 Orthodontic practice

• 68.47% reported using a digital-tracing software program, while 31.53% still utilize hand tracing. • 52.16% report having diagnosed pathology from a lateral cephalometric radiograph at some time in the past. Conclusion: This study demonstrated the varying opinions of orthodontic practitioners on the routine use of lateral cephalometric radiographs in orthodontic diagnosis and treatment planning. There is a current trend toward the utilization of digital software and a decrease in the amount of practitioners routinely tracing lateral cephalometric radiographs.

Introduction Orthodontic diagnosis and treatment planning can be accomplished through the use of a multitude of orthodontic records. These records generally include a clinical exam, diagnostic study models, extraoral and intraoral photographs, a panoramic radiograph, and a lateral cephalometric radiograph.1 When considering all of the diagnostic information gained from these records, one may begin to wonder if all of this information is overlapping or does each piece individually lead us to a better and more thorough diagnosis of the patient. The cephalometric radiograph has been around for nearly a century since it was introduced by Broadbent in 1931.2 Since then, multiple cephalometric analyses have been developed to evaluate patients’ skeletal and dental patterns. In practice, most orthodontists in the United States routinely obtain a lateral cephalometric radiograph with orthodontic records to use in diagnosis and treatment planning. As with any medical radiograph, dental radiographs expose patients to ionizing radiation.3,4 Because of this, any unnecessary exposure should be avoided due to the cumulative effects of radiation exposure. The As Low

As Reasonably Achievable (ALARA) principle is a concept that recommends reducing ionizing radiation exposure to levels as low as reasonably achievable for minimization of potential risks and adverse consequences.5,6,7 As healthcare providers, orthodontists have the ethical obligation to do no harm to patients under the Hippocratic Oath. With this in mind, orthodontists should always consider the amount of additional information that is gained by taking radiographs. A major problem that orthodontists sometimes face is conflicting data obtained from the various analyses of orthodontic records. The soft tissue may present the clinician with one picture, the dental evaluation with yet another, and the skeletal evaluation with a third. Not only can there be potential for variability in findings from different sources, but there can also be errors with each source. For example, from one cephalometric analysis it may be concluded that the patient is of a certain dental or skeletal classification, whereas with another the exact opposite may be decided. This can cause confusion when trying to properly diagnose and treatment plan a case, particularly for a new orthodontist. So how does the clinician know how to prioritize information? If there is ambiguity, should the soft tissue dictate the treatment decisions? Should the cephalometric analysis? The answer is probably neither and both. Studies questioning the usefulness, or validity, of different orthodontic records are not a new topic by any means. It has been shown that variability exists on the intraexaminer8 (agreement among a single examiner) level and on the interexaminer9,10 (agreement among examiners) level when treatment planning. Proffit11 attributes the difference in treatment opinions to the lack of scientific data to support what works best under which conditions. It has also Volume 5 Number 1

RESEARCH Table 1: Respondents’ demographics

Demographic

Response

Gender

79.65 % - male 20.35 % - female

Age

14.66 % - 34 years or less 24.57 % - 35-44 years 25.86 % - 45-54 years 32.33 % - 55-64 years 2.59 % - 65 years or more

Years in practice

15.58 % - 4 years or less 14.29 % - 5-9 years 22.08 % - 10-19 years 48.05 % - 20 years or more

ABO certified

30.74 % - yes 48.48 % - no 20.78 % - in the process of becoming certified

Region of residency training

25.65 % - Northeast 19.13 % - Southeast 33.04 % - Midwest 13.91 % - Northwest 7.83 % - Southwest 0.43 % - Canada

Region of practice

21.12 % - Northeast 22.84 % - Southeast 26.29 % - Midwest 18.97 % - Northwest 10.34 % - Southwest 0.43 % - other

been suggested that the cephalometric radiograph is not essential for making treatment planning decisions.12 In a study by Han, et al.,8, it was found that in 55 percent of patients, study models alone provided adequate information for treatment planning, and the incremental addition of other diagnostic records made minimal difference. Nonetheless, orthodontic clinicians continue to routinely take cephalometric radiographs. Orthodontists are taught to gather a plethora of information from the initial records. This is especially important for new orthodontists with less experience. Once this clinical experience is gained, the orthodontists’ judgment may be perceived to be as accurate as the cephalometric analyses.13 Therefore, rightfully or wrongly so, an experienced orthodontist may feel there is no need to collect all of the 26 Orthodontic practice

records or to trace lateral cephalometric radiographs. According to the American Board of Orthodontics (ABO), a fundamental component of orthodontic records includes the lateral cephalometric radiograph and tracing.14 However, in a recent study published in the American Journal of Orthodontics and Dentofacial Orthopedics, it was suggested that the availability of a lateral cephalometric radiograph and its tracing did not make a significant difference in treatment-planning decisions.15 Due to the tremendous confusion concerning what records are “necessary” from a medical/ legal standpoint verses a clinical one for diagnosis and treatment planning, a study is needed to determine what orthodontic practitioners are doing in practice. Therefore, the primary goal of this study was to survey a representative sample of orthodontists in North America regarding the routine use of lateral cephalometric radiographs in orthodontic diagnosis and treatment planning. The aim of the study was not to determine whether it is good or bad to use or not use cephalometric radiographs and tracings, but simply to determine what is being done in practice.

Materials and methods The research protocol was approved by the Seton Hill University Institutional Review Board. Upon permission from the American Association of Orthodontists (AAO), a 20item survey consisting of multiple-choice, Likert scale, and narrative questions was e-mailed to 2,215 randomly selected active members of the American Association of Orthodontists. The questionnaire was developed to assess in what percentage of patients’ lateral cephalometric radiographs are taken in practice and to what extent these records are being used for evaluation. In the survey, the first 14 items included questions regarding lateral cephalometric use in clinical practice. The remaining six questions consisted of demographic information, such as age, years in practice, board certification, gender, area of residency, and area of practice. The survey was pretested with residents, full-time faculty, and part-time faculty at Seton Hill University Center for Orthodontics. Minor changes and corrections were then made, and the survey was finalized. The survey and supporting materials were then sent to a random sample of practicing orthodontists in North America.

The initial e-mail, containing a description and the actual survey, was sent out on February 26, 2013, and a reminder e-mail was sent approximately two weeks later on March 11, 2013. The survey was closed on April 10, 2013, and the responses were collected. SurveyMonkey® was used as the survey instrument and for data collection and analysis. Descriptive statistics were used to analyze the data.

Results Of the 2,215 who were sent the survey, 232 responded for a response rate of 10.47%. Table 1 summarizes the respondents’ demographic information, and important findings from the survey are listed in Table 2. The six demographic questions addressed gender, age, time in practice, ABO certification, region of orthodontic education, and region of practice. The results indicated the majority of practitioners almost always took pretreatment lateral cephalometric radiographs. 60.34% reported always doing so, and 34.05% reported doing so in 66%–99% of patients. The amount of clinicians who traced pretreatment lateral cephalometric radiographs varied. 38.53% reported always tracing them, 19.05% did so in 66%–99% of patients, and 25.97% reported doing so in 1%–32% of patients. The amount of clinicians who took post-treatment lateral cephalometric radiographs also varied. 30.30% reported always doing so, 24.68% did so in 66%99% of patients, 23.38% did so in 1%32% of patients, and 14.29% never took post-treatment lateral cephalometric radiographs. The majority of clinicians did not trace post-treatment lateral cephalometric radiographs, as 29.87% never did and 48.48% only did so in 1%32% of patients. The number of clinicians who used a cephalometric radiograph for diagnosis when no cephalometric analysis was performed varied greatly. 37.95% reported always doing so, 16.07% did in 66%–99% of patients, 17.41% did in 1%–32% of patients, and 20.09% never did. Very few practitioners reported utilizing cone beam computed technology (CBCT) to make lateral cephalometric radiographs. 71.55% never did and 22.84% did in only 1%–32% of patients. The majority of respondents selected all of the available choices when asked about reasons for taking lateral cephalometric radiographs. 90.09% selected for better diagnostics, 81.90% selected to monitor growth, Volume 5 Number 1

Topic

Results

% of patients in which a pretreatment lateral cephalometric radiograph is taken

0.86% – in 0% of patients 3.02% – in 1%-32% of patients 1.72% – in 33%-65% of patients 34.05% – in 66%-99% of patients 60.34% – in 100% of patients

% of patients in which a pretreatment cephalometric analysis is performed

7.79% – in 0% of patients 25.97% – in 1%-32% of patients 8.66% – in 33%-65% of patients 19.05% – in 66%-99% of patients 38.53% – in 100% of patients

% of patients in which a post-treatment lateral cephalometric radiograph is taken

14.29% – in 0% of patients 23.38% – in 1%-32% of patients 7.36% – in 33%-65% of patients 24.68% – in 66%-99% of patients 30.30% – in 100% of patients

% of patients in which a post-treatment cephalometric analysis is performed

29.87% – in 0% of patients 48.48% – in 1%-32% of patients 9.09% – in 33%-65% of patients 6.06% – in 66%-99% of patients 6.49% – in 100% of patients

% of patients in which a cephalometric radiograph is used for diagnosis when no analysis performed

20.09% – in 0% of patients 17.41% – in 1%-32% of patients 8.48% – in 33%-65% of patients 16.07% – in 66%-99% of patients 37.95 % – in 100% of patients

% of patients in which a CBCT is used to make a lateral cephalometric radiograph

71.55% – in 0% of patients 22.84% – in 1%-32% of patients 0.86% – in 33%-65% of patients 2.16% – in 66%-99% of patients 2.59% – in 100% of patients

Reasons for taking lateral cephalometric radiograph (multiple answers allowed)

90.09% - for better diagnostics 81.90% - to monitor growth 75.86% - for legal reasons 11.21% - other

Patient positioning for lateral cephalometric radiograph

75.11% - centric occlusion (maximum intercuspation) 18.34% - centric relation 6.55% - other

If a disparity exists which record do you go with

81.94% - clinical findings 18.06% - lateral cephalometric analysis

How do you trace

68.47% - use a digital-tracing software program 31.53% - hand trace

Who completes the tracing

76.13% - the orthodontist 23.87% - the staff

Reason for using an analysis (multiple answers allowed)

54.87% - use analyses that work best based on their practice 47.79% - use analyses they learned in residency 18.14% - use analyses that literature states is most valid/reliable 11.06% - other

Diagnosed pathology from a lateral cephalometric radiograph

52.16% - yes 47.84% - no

Agree or disagree that cephalometric tracing is important in making treatment decisions

Volume 5 Number 1

9.96% - strongly disagree 9.09% - somewhat disagree 12.12% - neutral 36.80% - somewhat agree 32.03% - strongly agree

and 75.86% selected for legal reasons (multiple answers were allowed here). The majority (75.11%) of practitioners reported using centric occlusion (maximum intercuspation) for patient positioning in lateral cephalometric radiographs. Most (81.94%) reported going with clinical findings over the lateral cephalometric findings when a disparity existed between the two. More clinicians (68.47%) reported utilizing digital tracing software programs over hand tracing. In most offices (76.13%), the orthodontist completes the tracing instead of the staff. Multiple reasons were selected for using a particular analysis. 54.87% selected they use the analysis that works best based on their practice, 47.79% selected they use the analysis they learned in residency, and 18.14% selected they use the analysis the literature states is the most valid or reliable (multiple answers were allowed here). 52.16% reported diagnosing pathology on a lateral cephalometric radiograph at some time in their career. Lastly, the majority of clinicians strongly agree (32.03%) or somewhat agree (36.80%) that cephalometric tracing is important in making treatment decisions.

Discussion Cephalometric radiography and analyses have long since been considered a part of the “gold standard” for orthodontic diagnosis at the start of orthodontic treatment.12,16,17 Additionally, the American Association of Orthodontists Clinical Practice Guidelines14 includes pretreatment and post-treatment lateral cephalometric radiographs as a standard of care for orthodontic treatment. Keeping this information in mind, orthodontic practitioners have the obligation to ensure the patient is given the correct diagnosis and best treatment options available. However, it was not the intention of the present study to offer an opinion on the benefit or validity of cephalometric use. The results of this study demonstrate that the majority of orthodontic practitioners are routinely taking “pretreatment” lateral cephalometric radiographs. A total of 60.34% of respondents reported taking them on all patients, and 34.05% reported taking them on at least 66%-99% of patients. This finding was in line with what was expected. It was also found that 38.53% of the respondents routinely performed a cephalometric analysis on all pretreatment lateral cephalometric Orthodontic practice 27

RESEARCH

Table 2: Cephalometic radiograph data summary

RESEARCH

radiographs; 19.05% on 66%-99% of patients; 8.66% on 33%-65% of patients; 25.97% on 1%-32% of patients; and 7.79% on none at all. According to a similar study performed by the Journal of Clinical Orthodontics (JCO) in 200818, 74.2% reported routinely performing a cephalometric analysis on pretreatment cephalometric radiographs. This was down from 82.2% in 2002 and 89.9% in 1996. These findings demonstrate that although clinicians are still routinely taking pretreatment lateral cephalometric radiographs, they are selectively choosing on which patients to perform a pretreatment cephalometric analysis. According to Silling, et al.,13, the priority given to cephalometric analysis in treatment planning seems to vary considerably. Some practitioners feel that it is indispensable in every case. Others are of the opinion that it is useful to them only in specific instances or in particular types of malocclusion. Obviously, many factors influence the extent to which an orthodontist relies on cephalometric analysis in arriving at a treatment plan. The most important of these are probably educational background and degree of experience. In todayâ&#x20AC;&#x2122;s age of technology, digital radiographic systems and digital tracing software programs are rapidly replacing traditional hand tracing of lateral cephalometric radiographs. These digital images offer several advantages over conventional film-based radiography: faster data processing; elimination of chemicals and associated environmental hazards; and the ability to alter and improve the image and correct for exposure errors, thus virtually eliminating the need for a second exposure.19,20,21 Digital radiographic images are easy to store and facilitate communication between healthcare providers. Additionally, depending on the system used, they can require lower levels of radiation.22 The findings of this study illustrate the trend away from hand tracing of lateral cephalometric radiographs. Of those who traced, 68.47% reported doing so utilizing a digital software tracing program, and only 31.53% reported still hand tracing. These findings illustrate the increased use of digital technology in practice today and are in agreement with the results obtained in the 2008 JCO study.18 They found the percentage of orthodontists still hand 28 Orthodontic practice

tracing cephalograms to be 28.7%, which was down from 48.0% in 2002 and 61.2% in 1996. The increased use of digital radiography and digital software tracing programs has elicited some clinicians to critically examine the reliability of this new technology. For example, Santoro, et al.,21 assessed the accuracy of digital and analog cephalometric measurements. Although digital imaging introduces new errors, such as resolution, pixel size, shades of gray, and so forth, the differences noted between cephalometric measures identified on digital images compared to manual tracing of conventional films were clinically insignificant. It was concluded that both methods could be safely regarded as reliable.

multiple treatment records available for orthodontic evaluation, it is important to ensure that orthodontists are using all of the records they have decided to take in diagnosis and treatment planning. Also, we are in a time when more attention is given to ionizing radiation than ever before, so orthodontists should be judicious in their use of cephalometric radiographs and ensure they benefit treatment decisions. If these records are being taken but not evaluated, orthodontists must decide the worth of putting patients through the additional radiation exposure created when taking lateral cephalometric radiographs. If these records are being evaluated and used in diagnosis and treatment planning, the justification for their routine use is warranted.

This study demonstrated the varying opinions of orthodontic practitioners on the routine use of lateral cephalometric radiographs in orthodontic diagnosis and treatment planning. There is a current trend toward the utilization of digital software and a decrease in the amount of practitioners routinely tracing lateral cephalometric radiographs.

It seems logical that if radiographic records are taken, we are examining them at a minimum. A total of 52.16% of the respondents in this study reported diagnosing pathology from a lateral cephalometric radiograph at some point in their career. This value was higher than originally expected but illustrates one of the additional values of the lateral cephalometric radiograph. In addition, potential legal implications may be involved in the event of missing a diagnosis that was present on records taken but not examined. Nijkamp, et al.,12 goes as far to suggest that cephalometric radiography is only justified if it directly influences information on non-radiographic records used for orthodontic treatment planning. With the

As 51.52% of the respondents reported being board certified or in the process of becoming certified, lateral cephalometrics will continue to be an important piece of the â&#x20AC;&#x153;gold standardâ&#x20AC;? for orthodontic records, as per the AAO Clinical Guidelines.14 As a requirement for case submission for board certification with the American Board of Orthodontics, pretreatment and post-treatment lateral cephalograms will most likely continue to be routinely taken. There were several limitations of this survey. The data from this study are based on the assumption that answers were an accurate and honest representation of what is currently occurring in practice. As noted earlier, the survey results are based Volume 5 Number 1

on the responses of 232 orthodontists of the 2,215 surveyed. Although lower than ideal, this rate of 10.47% was within the expected range of 10%-12% that the American Association of Orthodontists considered a typical response rate based on the sample size. Future studies related to this topic may include devising a system to help determine which types of patients would benefit from having a lateral cephalometric analysis performed. A second future study could possibly evaluate treatment-planning decisions when only four of the five traditional records (clinical exam, diagnostic study models, extraoral and intraoral photographs, panoramic radiographs, and lateral cephalometric radiographs) are available. This potential study could be designed where the four available records vary from case to case to help determine which records are most valuable to the clinician.

Conclusion There are a number of conclusions that can be drawn from this survey investigation of lateral cephalometric use in practice. As previously mentioned, there is a current trend toward the utilization of digital software and away from traditional hand tracing, which is in agreement with results obtained from other studies. Also, the current number of orthodontic practitioners routinely tracing lateral cephalometric radiographs appears to be decreasing consistently since the surveys completed in 1986, 1990, 1996, 2002, and 2008 by the JCO.18 However, cephalometric records are still considered by the AAO and the ABO to be a part of the “gold standard” for orthodontic records and are recommended as the standard of care in orthodontics. Other salient findings from this study follow: • 60.34% reported always taking “pretreatment” lateral cephalometric radiographs, and 38.53% reported always Volume 5 Number 1

performing a cephalometric “analysis” on pretreatment cephalograms. • 30.30% reported always taking “posttreatment” lateral cephalometric radiographs, and 6.49% reported always performing a cephalometric “analysis” on post-treatment cephalograms. • 75.11% reported using centric occlusion (maximum intercuspation), 18.34% reported using centric relation, and

6.55% reported other for patient positioning in lateral cephalograms. • 81.94% reported valuing the finding of a clinical exam over that of a lateral cephalometric analysis. • 52.16% reported having diagnosed pathology from a lateral cephalometric radiograph at some time in the past. OP

References 1. Dykhouse VJ, Moffitt AH, Grubb JE, Greco PM, English JD, Briss BS, Jamieson SA, Kastrop MC, Owens SE Jr. A revision of the adult intraoral radiograph protocol for ABO clinical examinations. Am J Orthod Dentofacial Orthop. 2007; 131: 303-304. 2. Broadbent B Sr, Broadbent B Jr, Golden W. Bolton Standards of Dentofacial Developmental Growth. St Louis, MO: Mosby; 1975. 3. Wall B, Kendall G, Edwards A, Bouffler S, Muirhead C, Meara J. What are the risks from medical x-rays and other low dose radiation? Br J Radiol. 2006;79:285-294. 4. White SC. Assessment of radiation risk from dental radiography. Dentomaxillofac Radiol. 1992;21:118-126.

12. Nijkamp P, Habets L, Aartman I, Zentner A. The influence of cephalometrics on orthodontic treatment planning. Eur J Orthod. 2008;30:630-635. 13. Silling G, Rauch M, Pentel L, Garfinkel L, Halberstadt G. The significance of cephalometrics in treatment planning. Angle Orthod. 1979;49(4):259262. 14. Clinical Practice Guidelines for Orthodontics and Dentofacial Orthopedics 2008. American Association of Orthodontists, 2008. 15. Devereux L, Moles D, Cunningham S, McKnight M. How important are lateral cephalometric radiographs in orthodontic treatment planning? Am J Orthod Dentofacial Orthop. 2011;139:e175-e181. 16. Proffit WR, Fields HW, Sarver DM. Contemporary Orthodontics. 4th Ed. St. Louis, MO: Mosby; 2007.

5. Tyndall DA, Matteson SR, Soltmann RE, Hamilton TL, Profitt WR. Exposure reduction in cephalometric radiology: A comprehensive approach. Am J Orthod Dentofacial Orthop. 1988;93:400-412.

17. Graber TM, Vanarsdall RL, Vig KWL. Orthodontics: Current Principles and Techniques. 4th Ed. St. Louis, MO: Mosby; 2005.

6. Kimura K, Langland OE, Biggerstaff RH. The evaluation of high-speed screen/film combinations in cephalometric radiography. Am J Orthod Dentofacial Orthop. 1987;92:484-491.

18. Keim RG, Gottlieb EL, Nelson AH, Vogels DS III. 2008 JCO study of orthodontic diagnosis and treatment procedures, part 1: results and trends. J Clin Orthod. 2008;42(11):625-640.

7. Preece J. Radiation hazards and prevention. In: Langland OE, et al. Textbook of dental radiology. Springfield, IL: Charles C Thomas, 1984:185.

19. Quintero JC, Trosien A, Hatcher D, Kapila S. Craniofacial imaging in orthodontics: historical perspective, current status, and future developments. Angle Orthod. 1999;69:491-506.

8. Han UK, Vig KW, Weintraub JA, Vig PS, Kowalski CJ. Consistency of orthodontic treatment decisions relative to diagnostic records. Am J Orthod Dentofacial Orthop. 1991;100:212-219. 9. Brown W, Harkness E, Cousins A, Isotupa K. Treatment planning from study models: an examiner variability study. Angle Orthod. 1977;47:119-122. 10. Ribarevski R, Vig P, Vig K, Weygand R, O’Brien K. Consistency of orthodontic extraction decisions. Eur J Orthod. 1996;18:77-80. 11. Proffit WR. The evolution of orthodontics to a data-based specialty. Am J Orthod Dentofacial Orthop. 2000;117:545-547.

20. Wenzel A, Gotfredsen E. Digital radiography for the orthodontist. Am J Orthod Dentofacial Orthop. 2002;121:231-235. 21. Santoro M, Jarjoura K, Cangialosi TJ. Accuracy of digital and analogue cephalometric measurements assessed with the sandwich technique. Am J Orthod Dentofacial Orthop. 2006;129:345-351. 22. Naslund EB, Kruger M, Petersson A, Hansen K. Analysis of low-dose digital lateral cephalometric radiographs. Dentomaxillofac Radiol. 1998;27:136139.

Orthodontic practice 29

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In today’s age of technology, digital radiographic systems and digital tracing software programs are rapidly replacing traditional hand tracing of lateral cephalometric radiographs. These digital images offer several advantages over conventional filmbased radiography: faster data processing; elimination of chemicals and associated environmental hazards; and the ability to alter and improve the image and correct for exposure errors, thus virtually eliminating the need for a second exposure.

INDUSTRY NEWS Announcing DEXIS Mac

ClearCorrect, LLC, appoints new Chief Technology Officer Manufacturer of clear aligners, ClearCorrect, LLC, announced that orthodontist, Dr. James Mah, DDS, MSc, DMSc, has been appointed as its new chief technology officer to help develop improved treatment protocols, training resources, and brand-new products to be unveiled in 2014. Dr. Mah is a practicing orthodontist as well as a clinical professor and the program director in orthodontics Dr. James Mah at the University of Nevada, Las Vegas. He has pioneered research and developments in 3D imaging and modeling in orthodontics for the purposes of diagnosis, treatment planning, and therapeutics as well as anthropology and forensics. He is also involved in the research and development of 3D facial imaging devices, intraoral scanners, CAD/CAM applications in dentistry, and cone-beam CT scanners.

DEXIS, an industry leader and the manufacturer of the highly awarded DEXIS® Digital X-ray system, is now in the process of completing its development for the Mac platform and will soon be expanding its Imaging Suite of products to natively support Apple® hardware and the OS X operating system 10.8.0 and above. DEXIS Mac™ is an innovative dental imaging solution that offers dentists a unified experience across Mac and iOS products. Once released, the native OS X software will provide clinicians with a highly efficient digital imaging workflow and seamless integration with Mac-based practice management programs Viive™ and MacPractice®. This DEXIS software product will provide an intuitive user interface and advanced functionality that Mac users expect — combined with tried-and-true DEXIS image management and enhancement tools, as well as a tight integration with the award-winning DEXIS go® app for patient communication, and the just released DEXIS photo™ app for extra-oral image acquisition. For more information, visit www.dexis.com.

New additions at OrthoAccel Technologies OrthoAccel® Technologies, Inc., announces two new additions to its senior management team, Jeff Layton as the company’s new chief operations officer and Doug Bukaty as vice president of sales. As chief operations officer, Layton oversees OrthoAccel’s product engineering, design, development, and manufacturing as well as supply chain, quality assurance, and customer service. Most recently, he was the vice president of operations for Xtreme Power®, a manufacturer of renewable energy storage systems. Layton’s 25-year career also includes management positions at Dell, where he was the director of power and reliability engineering, and at 3M, where he was the plant engineering operations manager for the company’s dental products division. A graduate of the U.S. Naval Academy, Layton was a nuclear submarine engineering operations officer in the U.S. Navy. As the leader Jeff Layton Doug Bukaty of OrthoAccel’s sales division, Bukaty oversees all aspects of business development and revenue growth. He comes to the company from Sarnova, a private, equity-backed specialty medical distribution business where he served as vice president of sales for Bound Tree Medical. Bukaty has more than a decade of corporate experience in the orthodontic industry with past sales positions at Align Technology and Johnson & Johnson’s “A” Company Orthodontics. A graduate of the University of Kansas, Bukaty also completed professional development programs at Northwestern University’s Kellogg School of Management.

Ortho Organizers’ Obstructive Sleep Apnea Program for 2014 Ortho Organizers® is pleased to announce new 2014 dates for the educational program centered around one of the leading topics in the orthodontic industry today, Obstructive Sleep Apnea (OSA). The speakers, Drs. Lou Chmura and David Paquette, will provide orthodontists and staff with an understanding of the physiology of sleep apnea and the current diagnostic and treatment options, as well as a new orthodontic approach and its protocols. The orthodontic approach is intended to provide patients with immediate relief from OSA, as well as changes to the airway that may address an underlying cause. This program is the first of its kind in the orthodontic industry and includes a complete, evidencebased system to implement into a practice now. http://www.orthoorganizers.com/obstructive-sleep-apnea-course-info.php 30 Orthodontic practice

Date

Location

Feb 28-March 1

Atlanta, GA

May 16-17

Scottsdale, AZ

Sept 12-13

Washington, D.C.

Dec 5-6

Las Vegas, NV

Volume 5 Number 1

Ormco™, a manufacturer and provider of advanced orthodontic technology and services, recently unveiled its strategy to be the market leader in digital orthodontics. The company plans to increase its investments to accelerate its strategic initiative to complete the development of an end-to-end digital software solution — which fully integrates 3D digital scanning, diagnostics, outcome visualization, treatment planning, custom appliances, and custom lab products. With 110 globally filed patents in digital orthodontics, Ormco has plans to scale its digital business aggressively in 2014, building upon its current digital suite of fully integrated products, which in 2013 have grown in revenue by 121 percent in North America alone. These digital solutions from Ormco include the new Lythos™ Digital Impression System, Insignia™ Advanced Smile Design™, Clearguide™ Express aligners, DigiCast™ study models, and custom lab appliances through Ormco | AOA Lab. Beyond Ormco’s digital platform expansion in 2014, the company has plans to introduce many more exciting high-tech advancements. In the short term, Insignia will expand to incorporate all of the appliance types an orthodontist might need to treat any patient, including a wider selection of customized aligners, as well as self-ligating lingual, new esthetic, and traditional twin-appliance options. Another future development will be the integration of Cone beam 3D dental imaging systems to provide doctors with more accurate root-based data in Insignia, simulated patient outcomes, and advanced treatment planning with 3D ceph analysis, airway analysis, and more. An expanding list of powerful tools and ease-of-use enhancements will follow. For more information, visit ormco.com.

Research study shows significant radiation dose reductions New research on cone beam 3D imaging has found that there is a solution for dental professionals who are seeking a low-exposure alternative CBCT scanner. Dr. John Ludlow, a distinguished researcher in imaging technology and radiation dose, has recently published his newest study comparing doses from the newest i-CAT® model of CBCT technology, the i-CAT® FLX, with those from conventional 2D and medical CT imaging alternatives. The study, published in December in the American Journal of Orthodontics and Dentofacial Orthopedics, assessed effective doses of radiation for adults and children resulting from various combinations of field of view size and field location in Imaging Sciences’ i-CAT FLX.1 The study showed, “the QuickScan+ protocol provided a substantial 87% reduction in dose compared with the standard exposure protocols in both child and adult phantoms. Thus, when QuickScan+ protocols can be used, they will provide a clinically meaningful reduction in dose.” While reductions in dose are accompanied by reductions in image quality, these low-dose volumes are useful for specific tasks. Dr. Ludlow noted that the study indicated, “The Quick Scan+ image volume provides 3D information with minimal geometric distortion that is unavailable in any 2D image and at a comparable dose.” To access the Abstract for Dr. Ludlow’s latest research on radiation dose, visit: http://www.ajodo.org/article/S08895406%2813%2900774-9/abstract?source=aemf To learn more about i-CAT, visit www.i-cat.com.

Volume 5 Number 1

Orthodontic practice 31

INDUSTRY NEWS

Ormco Corporation strives to be a market leader in digital orthodontic technology

CONTINUING EDUCATION

Efficiency by design Dr. Mark McDonough discusses increasing efficiency through proper treatment decisions Introduction There has been a lot written in the orthodontic literature recently about efficiency related to types of braces, wires, clear aligners, vibrating devices, and micro-perforations all designed to increase the efficiency of tooth movement. If you look at orthodontists’ websites, they will prominently display the names and logos of these braces and devices. My concern is that the focus on the type of appliance makes the orthodontist a marketing arm of the manufacturing companies. Once the orthodontist is considered simply to be an offshoot of these dental manufacturers, it is very easy for these same companies to market these appliances to general dentists. The public is easily confused about the difference between orthodontics and an orthodontist. The end result is that these companies are devaluing the specialized services of an orthodontist by changing the focus to the products or technology instead of the beneficial patient-focused profession that it is. This has already happened with Invisalign® (Align Technology) since general dentists currently provide more Invisalign treatment than orthodontists. The manufacturers’ marketing is designed to have the public look for a provider of their product instead of an orthodontist. As far as the public is concerned, they often want to be treated by an “insert the name of your favorite appliance” provider instead of a highly qualified dental specialist. The message orthodontists should

Mark W. McDonough, DMD, is an orthodontist who has been practicing in Pennington, New Jersey, since 1994. He earned his dental degree from the University of Pennsylvania, completed a general practice residency at Lenox Hill Hospital in New York City, and received his Certificate in Orthodontics from Albert Einstein Medical Center in Philadelphia, Pennsylvania. He has also been a part-time clinical instructor at Albert Einstein Medical Center in Philadelphia since 1995. He is a Diplomate of the American Board of Orthodontics and was recently appointed to serve on the board of the Greater Philadelphia Society of Orthodontics.

32 Orthodontic practice

Educational aims and objectives This article aims to discuss how the greatest efficiency is found through beginning treatment at the appropriate time while managing the growth and development of our patients and applying appropriate force systems. Expected outcomes Correctly answering the questions on page 37, worth 2 hours of CE, will demonstrate the reader can: • Recognize certain treatment for leeway space. • Define “driftodontics.” • Identify how driftodontics leads to useful treatment methods. • Realize the pros and cons of extractions. • Discuss the necessity of space maintenance.

be marketing to the public is not that they are the providers of the latest technology but that they are the most qualified professionals to treat malocclusions and dental facial discrepancies. The greatest service we as orthodontists provide to our patients is our understanding of growth, development, force systems, timing, and a complete and an honest diagnosis and treatment plan. These skills are what make the orthodontist uniquely positioned to manage the often-complex needs of our patients. I am not trying to make a statement against the wonderful technological advances and the companies that promote them. I use many technological advances on a daily basis in my practice, and I am grateful to the companies that continue to push the envelope of efficient treatment. The take-home message for this article is that efficiency is primarily a product of proper treatment decisions, not necessarily technology decisions. The following examples demonstrate how to efficiently manage moderate and severe crowding. You will see moderate crowding relieved prior to the placement of braces. You will see two 4-premolar extraction patients treated in 14 and 15 months, and an upper premolar extraction patient treated with Invisalign express in 5 months. You may expect to read about a breakthrough in a revolutionary new bracket or adjunctive therapy. The reality is our greatest efficiency is found through beginning treatment at the appropriate time while managing the growth and development of our patients and applying appropriate force systems. This is the

message we need to promote to our dental colleagues and the public. This message will prevent orthodontists from becoming a commodity that is easily replaced. The greatest service to the future of our profession is to provide excellent results for our patients in the shortest treatment time at a reasonable cost. The following are a few examples to keep in mind when diagnosing and treatment planning. These concepts will improve your efficiency, create beautiful stable results, and save you money.

Leeway space treatment

and

efficient

Lower incisor crowding is one of the most prevalent chief complaints that present to the orthodontist. An efficient way to help relieve the mandibular crowding is by utilizing the leeway space. This concept was presented by Dr. Anthony Gianelly1, who showed that 4-5 mm of mandibular incisal crowding could routinely be relieved by utilizing a passive lingual holding arch. He demonstrated that the increase in arch length was due to a combination of the leeway space, growth, and development. The following patient is a typical late-mixed dentition adolescent who was referred to our office for evaluation of the lower incisor crowding (Figures 1 and 2). A mandibular lingual holding arch was fabricated, and 11 months later she was ready for fixed appliances. The ideal time to place the lower lingual holding arch is approximately 4 to 12 months prior to loss of the first mandibular primary molar. Once the patient enters the adult dentition, the crowding has Volume 5 Number 1

Figure 4: Pretreatment photographs

resolved (Figure 3). Due to our focus on efficiency, we have developed a simple method to fabricate soldered appliances. We are able to complete records, separators, case presentation, fabrication of the soldered appliance, and insertion in two visits. On the first visit, full orthodontic records, including study models, are taken, and the appropriate separators are placed. When they returned 1 week later, bands are fit on the molars, an impression is taken for the soldered appliance, and the patient is brought to the consultation room for the case presentation. At the same time as the case presentation, the assistant has already pre-bent the lower lingual holding arch from the study models and has poured the impression in quickset stone. Five minutes later the model is ready for soldering, and the pre-bent lingual holding arch is finished by the time the case presentation is completed. This allows us to insert the lower lingual holding arch immediately following the case presentation, and the patient has spent approximately 60 minutes in our office. This same protocol is also utilized for Hyrax expanders and space maintainers. Patients appreciate this Volume 5 Number 1

Figure 2: Pretreatment panorex

Figure 3: Post-lingual holding arch and ready for fixed treatment

Figure 5: Posttreatment photographs

type of efficiency, and on our posttreatment surveys, one of the most frequent words to describe our office is “efficient.” Due to the improvement in the lower incisors, this patient’s fixed-appliance treatment lasted 15 months, and she had 10 office visits during the fixed-appliance phase (Figures 4 and 5). This type of result is very predictable. Alleviating the lower crowding prior to placement of the fixed appliances shortens the time in braces, which leads to multiple efficiencies: fewer emergency appointments, better oral hygiene, increased profitability for the practice, and most importantly, happier patients.

Driftodontics and efficiency “Driftodontics” is a term that can be attributed to Dr. R.G. “Wick” Alexander in his 1986 textbook2. He defines it as the late placement of orthodontic appliances after removal of permanent teeth. He notes that lower incisor crowding tends to unravel, and the premolars and canines drift distally into the extraction space. I have found driftodontics to be useful when adolescent patients present in the adult dentition, and they are borderline extraction cases.

If extractions are indicated, the premolars are extracted, and patients return in 6 months. Most of the advantages of driftodontics have occurred in the first 6 months, and they are generally ready for placement of their braces. This strategy is most successful if there is minimal skeletal discrepancy and an average overbite. For example, this 11-year 3-month old female (Figure 6) presented with moderate maxillary and mandibular crowding, moderately procumbent incisors, and minimal overbite/overjet. Since she has advanced dental development relative to her chronological age, she is an ideal candidate for driftodontics since there are not as many social pressures to start treatment at age 11. Also, she has not yet entered her adolescent growth spurt, which has been shown to be the most efficient time to move teeth. Parents and patients easily understand that waiting 6 months without braces may shorten her time in braces by approximately 4 to 6 months. Everyone appreciates this strategy, and patients do not wish to spend any more time in braces than necessary. Six months following the extraction of her second premolars (Figure 7), the Orthodontic practice 33

CONTINUING EDUCATION

Figure 1: Pretreatment photo

CONTINUING EDUCATION

Figure 6: Pretreatment photographs for driftodontics

Figure 7: Six months of driftodontics

Figure 8: Driftodontics’ final result

majority of her extraction space is closed, and the crowding has improved. Also, note the improved position of her canines and the slight deepening of her overbite. Her orthodontic appliances were placed, and she had a total of 11 visits over 14 months (Figure 8). She was treated with .022 Roth prescription twin brackets and finished with full-size stainless steel wires that were left in place for the final 2 months of treatment. Had she been treated with selfligating braces, the manufacturer would be advertising, “a four-premolar extraction 34 Orthodontic practice

case treated in only 14 months!” The reality is that teeth do not know what type of brace is used, and the brace is only a handle to deliver a force system. Forces move teeth, not the highly marketed name-brand brackets and gadgets. Orthodontists are best able to manage these force systems, and there are a large number of excellent force systems on the market.

Serial extraction and efficiency Despite the improvements in technology that allow for fewer patients to require

extractions, there are always patients who have significant enough crowding to eventually require removal of premolars. This 9-year 9-month old female (Figure 9) presented with early loss of her primary canines, and retroclined mandibular incisors (IMA = 84.4). Her space analysis indicated that even with extraction of four premolars, there would be minimal excess space. The other concern is that with extractions, the mandibular incisors may tip further lingual, causing a deepening of the bite and flattening of her profile. Therefore, a mandibular lingual holding arch was placed, and once the first premolars erupted, progress records were taken, and I decided to extract the four first premolars. When she presented 2½ years later, her crowding had been resolved, and there was no significant change in the overjet or overbite, and her mandibular incisor angulation had been maintained (Figure 10). Once the upper-left canine erupted, she was ready for her fixed appliances. Her fixed-appliance therapy lasted 15 months, and she had 13 visits in our office (Figure 11). The key to achieving the shortest treatment time and fewest visits is to wait for all the teeth to erupt prior to placing appliances. Patients and parents understand that the goal is not to place the appliances; it is to remove the appliances in the shortest, most efficient time possible. It is also important to note that many of the manufacturers promote “broad smiles and full lips” as a product of their non-extraction treatment. While I agree that Volume 5 Number 1

CONTINUING EDUCATION

Figure 9: Pretreatment serial extraction

Figure 10: Almost ready for fixed appliances

Figure 11: End of fixed appliances

Figure 12: Comparison of facial profile for four premolar extractions

lip position is influenced by tooth position, extraction treatment that is properly diagnosed and managed can result in full lips as was demonstrated by this patient (Figure 12).

Space maintenance and efficiency Patients are often referred to an orthodontist due to early loss of primary teeth. The orthodontist must decide either to regain the space or to manage the lost space with the possibility of premolar extraction in the future. Some of our patients not only demand minimal time in braces, but also may request treatment with removable aligners. The following patient demonstrates that a Class II maxillary firstpremolar extraction case can be managed with Invisalign express in only 5 months Volume 5 Number 1

of aligners. This is the ultimate in efficient orthodontic treatment. This 7-year 1 month-old female (Figure 13) was referred by her dentist due to early loss of her maxillary primary second molars, which had resulted in a Class II molar relationship. She was presented the following options: moving the maxillary first molars distal to create sufficient room for eruption of the second premolars, or utilizing a transpalatal arch to minimize further drift of the molars and re-evaluate for possible extraction of maxillary first premolars. After reviewing both options, the patient and her parents decided upon the transpalatal arch and re-evaluation in the future. At age 10, it was decided to extract the maxillary first premolars and re-

evaluate for fixed appliances when she entered the adult dentition. In retrospect, this was the most efficient decision she could have made because the result was so good that it was not until age 15 that the patient decided she would like to finish her treatment (Figure 14). Her request at this time was not to have braces at all and have treatment with Invisalign appliances to improve the alignment of her teeth. In fact, she was a candidate for Invisalign express and required only 10 aligners (Figure 15). With the advent of Invisalign, I am often finishing phase I treatment with the goal of being able to offer patients Invisalign for phase II if they request it. This has been an important change in phase I treatment planning.

Orthodontic practice 35

CONTINUING EDUCATION

Figure 13: Early loss of maxillary primary second molars.

Figure 14: Prior to Invisalign Express

Figure 15: Post-Invisalign express treatment

Conclusion Orthodontists often present efficiency to the public as a product only of high technology that is often expensive. The patients presented in this paper show that efficiency can be achieved with proper diagnosis and treatment planning that is not expensive and does not rely on “high technology” products. This type of efficiency is a product of education, experience, and honest treatment options. Some of these extraction patients could have been treated non-extraction, however they could not have been treated more 36 Orthodontic practice

efficiently with a more stable result. These are treatment options that should be presented to the patient. If our profession is to survive, we must market ourselves to the public not as providers of technology, but as highly trained and educated orthodontists who provide excellent results for our patients in the shortest treatment time at a reasonable cost. If we present only technology, the manufacturers will market us as “providers” instead of orthodontists. We all know what has happened to our medical colleagues once insurance companies labeled them

as “providers” instead of doctors. Patients are not loyal to providers since anyone can provide a service. Patients who receive excellent results in the shortest treatment time are very loyal to their orthodontists. OP References 1. Brennan MM, Gianelly AA. The use of the lingual arch in the mixed dentition to resolve incisor crowding. Am J Orthod Dentofacial Orthop. 2000;117(1):81-85. 2. Alexander RG. The Alexander Discipline Contemporary Concepts and Philosophies. Orange, CA: Ormco Corporation; 1986.

Volume 5 Number 1

Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 12/1/2012 to 11/30/2016 Provider ID# 325231

REF: OP V5.1 MCDONOUGH

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Efficiency by design 1. Lower incisor crowding is one of the most prevalent chief complaints that present to the orthodontist. An efficient way to help relieve the mandibular crowding is by _____. a. utilizing the leeway space b. delaying treatment until adulthood c. utilizing extractions d. utilizing clear aligners before braces 2. He (Dr. Anthony Gianelly) demonstrated that the increase in arch length was due to a combination of the _____. a. leeway space b. growth and development c. both a and b d. none of the above 3. The ideal time to place the lower lingual holding arch is approximately _____ prior to loss of the first mandibular primary molar. a. 1 to 2 months b. 2 to 3 months c. 4 to 12 months d. 16 to 18 months 4. Alleviating the lower crowding prior to placement of the fixed appliances shortens the time in braces, which leads to multiple

Volume 5 Number 1

efficiencies: _______, and most importantly, happier patients. a. fewer emergency appointments b. better oral hygiene c. increased profitability for the practice d. all of the above 5. ________ is a term that can be attributed to Dr. R.G. “Wick” Alexander in his 1986 textbook. a. Hyrax expansion b. Driftodontics c. Leeway space d. Fixed appliance therapy 6. Despite the improvements in technology that allow for fewer patients to require extractions, there are always patients who have _______to eventually require removal of premolars. a. significant enough crowding b. significant enough decay c. enough of a flattened profile d. a slight enough deepening of the overbite 7. The key to achieving the _______ is to wait for all the teeth to erupt prior to placing appliances. a. least extractions

b. shortest treatment time c. fewest visits d. both b and c 8. It is also important to note, that many of the manufacturers promote ______ as a product of their non-extraction treatment. a. “broad smiles” b. “full lips” c. “less social pressure” d. a and b 9. Patients are often referred to an orthodontist due to ______of primary teeth. a. early loss b. excessive staining c. drifting d. retroclining 10. The patients presented in this paper show that efficiency can be achieved with proper diagnosis and treatment planning that is not expensive. This type of efficiency is a product of ____. a. education b. experience c. honest treatment options d. all of the above

Orthodontic practice 37

CE CREDITS

ORTHODONTIC PRACTICE CE

CONTINUING EDUCATION

The biology of orthodontic tooth movement part 2: modulating tooth movement via nitric oxide and prostaglandin production Dr. Michael S. Stosich reviews the markers of bone cell activity that are intrinsic to the complex process of bone modeling and remodeling Modulation of bone for orthodontic tooth Movement In the ever complex process of bone modeling and remodeling, certain markers of bone cell activity have been shown to act as key players that in part govern the process. Nitric oxide (NO) and prostaglandin (PGE2) production have been used as parameters in bone cell mechanosensitivity in the study of bone remodeling. Turner, et al.,1 have shown that NO and PGE2 act as mediators in the bone formation process in vivo. Loading bone cells mechanically is also associated with an increased production of PGE2.2 When nitric oxide synthase (iNOS) is inhibited, the loading response in bone ceases.3 This indicates the essential role of NO in the early stages of bone remodeling. The production of NO and PGE2 by primary bone cells is dependent upon applied stress. Bone cells might detect mechanical signals through fluid flow, and mechanical loading of bone causes flow of interstitial fluid through the canalicular network.4 Using cyclic strains, PGE2 nor NO could be detected; however, under low levels of fluid flow, rapid production of both agents was induced.4 Bone cells treated

Michael S. Stosich, DMD, MS, MS, has performed orthodontic and craniofacial reconstruction work throughout the world, but his first priority is his patients at iDentity Orthodontics in the Chicagoland area. With educational credentials and training twice that required of an orthodontist, Dr. Stosich has published and lectured throughout the United States and abroad. His sincere interest and dedication toward the study of stem cell tissue engineering, combined with a rare creativity toward scientific discovery, paved the way for Dr. Stosich to serve as lead scientist in a variety of studies. This yielded numerous publications that lead to important advancements in craniofacial cases. His achievements were also awarded by the National Institutes of Health, which endowed grants toward future study. Dr. Stosich is also faculty at the University of Chicago Medicine. Dr. Stosich believes in giving back to the communities he serves and focuses on charitable giving where it can do the most good by treating underserved and unprivileged children through his involvement in the Smiles Change Lives foundation, Smiles for Service, and his work on the Chicago craniofacial team. Dr. Stosich is also involved in local community programs linking orthodontics to philanthropy. drstosich@identityortho.com

38 Orthodontic practice

Educational aims and objectives This article aims to identify markers of bone cell activity that have been shown to act as key players in the process of bone modeling and remodeling. Expected outcomes Correctly answering the questions on page 39, worth 2 hours of CE, will demonstrate the reader can: • Identify the roles that nitric oxide (NO) and prostaglandin (PGE2) production play in the process. • Realize the therapeutic range of ultrasound in stimulation of bone formation and osteoblast proliferation.

with pulsating fluid flow (PFF) of increasing flow rate rapidly stimulate the production of NO in a manner that is dose dependent.5 PGE2 production tended to be higher as a result of increased shear stress on the cells, which was achieved by increasing the flow rate.5 These results offer sound evidence for the importance of shear stress as a stimulus on bone cell walls in the process of bone cell mechanotransduction remodeling.

Ultrasound stimulates NO and PGE2 production of human osteoblasts Reher, et al.,6 have shown that in bone repair both osteogenesis and angiogenesis are essential, and it has been shown that the therapeutic range of ultrasound stimulates bone formation and osteoblast proliferation, and stimulates the synthesis of angiogenic factors, endothelial growth factors, basic fibroblast growth factors, and interleukin-8. The ultrasound may in fact act like mechanical stress on the bone and stimulate PGE2 and NO production, which are essential for bone remodeling. NO production in bone showed a marked increase when treated with 45 kHz of therapeutic ultrasound. Furthermore, iNOS and L-NAA had an inhibitory effect on the ultrasound therapy. Similarly, higher levels of PGE2 were detected when the bone was subjected to ultrasound, and COX-2 inhibited PGE2 synthesis at a frequency of 45 kHz. These results show that when bone is subjected

to a therapeutic range of ultrasound, osteoblasts are stimulated to produce NO and PGE2. The synthesis of PGE2 appears to be promoted by the inducible cycloxygenase pathway (COX-2). It may also be inferred that L-arginine is crucial in the NO pathway. It has been shown that NO and PGE2 are essential in the bone remodeling process. The studies here support the idea that varying forms of mechanical therapy, be it from shear stress or ultrasound, elucidate a prominent increase in NO and PGE2 activity, which may in turn lead to new possibilities for increasing turnover time in bone remodeling, and potentially more rapid orthodontic tooth movement. OP

References 1. Turner CH, Owan I, Jacob DS, McClintock R, Peacock M. Effects of nitric oxide synthase inhibitors on bone formation in rats. Bone. 1997;21(6):487-490. 2. Binderman I, Zor U, Kaye AM, Shimshoni Z, Harell A, Sömjen. The transduction of mechanical force into biochemical events in bone cells may involve activation of phospholipase A2. Calcif Tissue Int. 1988;42(4):261-266. 3. Fox SW, Chambers TJ, Chow, JW. Nitric oxide as an early mediator of the increase in bone formation by mechanical stimulation. Am J Physiol. 1996;270(6 Pt 1):E955-E960. 4. Smalt R, Mitchell FT, Howard RL, Chambers TJ. Mechanotransduction in bone cells: induction of nitric oxide and prostaglandin synthesis by fluid shear stress, but not by mechanical strain. Adv Exp Med Biol. 1997;433:311-314. 5. Bakker AD, Soejima K, Klein-Nulend J, Burger EH. The production of nitric oxide and prostaglandin E(2) by primary bone cells is shear stress dependent. J Biomech.2001;34(5):671-677. 6. Reher P, Harris M, Whiteman M, Hai HK, Meghji S. Ultrasound stimulates nitric oxide and prostaglandin E2 production by human osteoblasts. Bone. 2002;31(1):236241.

Volume 5 Number 1

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The biology of orthodontic tooth movement part 2: modulating tooth movement via nitric oxide and prostaglandin production 1. Nitric oxide (NO) and prostaglandin (PGE2) production have been used as parameters in bone cell mechanosensitivity in the study of _____. a. bone remodeling b. shear stress c. epithelial growth d. fluid flow 2. Turner, et al., have shown that NO and PGE2 act as ______in the bone formation process in vivo. a. fibroblast inhibitors b. mediators c. osteoblast synthesizers d. interleukin stimulators 3. Loading bone cells mechanically is also associated with an increased production of _____. a. PFF b. iNOS c. PGE2 d. COX-2 4. When nitric oxide synthase (iNOS) is inhibited, the loading response in bone _____.

Volume 5 Number 1

a. ceases b. increases c. remains stable d. becomes cyclic 5. The production of NO and PGE2 by primary bone cells is dependent upon _____. a. ultrasound stimulation b. cessation of fluid flow c. canalicular response d. applied stress 6. Bone cells treated with pulsating fluid flow (PFF) of increasing flow rate rapidly ______the production of NO in a manner that is dose dependent. a. inhibit b. stimulate c. cease d. turnover 7. PGE2 production tended to be _____as a result of increased shear stress on the cells, which was achieved by increasing the flow rate. a. lower b. stopped c. higher d. unaffected

8. Reher, et al., have shown that in bone repair both osteogenesis and angiogenesis are essential, and it has been shown that the therapeutic range of ultrasound stimulates bone formation and osteoblast proliferation, and stimulates the synthesis of ______ and interleukin-8. a. angiogenic factors b. endothelial growth factors c. basic fibroblast growth factors d. all of the above 9. NO production in bone showed a marked increase when treated with ____of therapeutic ultrasound. a. 15 kHz b. 20 kHz c. 45 kHz d. 65 kHz 10. The synthesis of PGE2 appears to be promoted by the inducible _____. a. angiogenic factors b. cycloxygenase pathway (COX-2) c. nitric oxide synthase d. pulsating fluid flow (PFF)

Orthodontic practice 39

CE CREDITS

ORTHODONTIC PRACTICE CE

BOOK REVIEW

The Masterâ&#x20AC;&#x2122;s Guide to Interproximal Reduction (IPR) by Dr. Randol Womack Dr. Randol Womack has combined his knowledge and experience in interproximal enamel reduction with the technical expertise of the OrthoMatics company to produce this highly useful booklet that serves as a clinical guide to this important feature of contemporary orthodontic therapy. This manual makes clear in the prologue that it does not intend to offer diagnostic or treatment planning advice. Those aspects of orthodontic treatment belong solely to the clinician. That said, however, this guide furnishes the orthodontic practitioner with a practical and applicable guide for interproximal enamel reduction, which has enlivened orthodontic patient management. The indications for IPR and the location and amount of enamel reduction are covered as well as tooth shape. IPR principles are noted and accompanied by

40 Orthodontic practice

excellent color illustrations. Dr. Womack illustrates enamel reduction with the OrthoSlenderizer by OrthoMaticsâ&#x201E;˘, which offers reduction with a minimum of patient discomfort. Dr. Womack describes the use of thickness gauges to measure the amount of enamel removed during the reduction process. The use of diamondencrusted discs is covered in exacting detail, and the precautions with their use are described. The manual, at a cost of $95, provides an ample bibliography for the rationale of IPR plus a companion DVD that illustrates the technique with clinical patients. Actual viewing under ordinary clinical conditions makes the technique more realistic and relevant and offers a valuable supplement to the written narrative. OP Review by Larry White, DDS, MSD

For more information on this booklet, contact: OrthoMatics P.O. Box 1515 Englewood, CO 80150-1515

Volume 5 Number 1

Dr. Juan-Carlos Quintero discusses how 3D imaging is evolving with more applications and lower radiation

one beam computed tomography (CBCT) was first introduced in the United States in 2001. Since its inception, CBCT has been slowly gaining acceptance as the premier diagnostic tool of choice in just about every specialty in dentistry, both as a research and clinical tool. Its advantages over traditional 2D imaging in orthodontics have been well documented, and its use in clinical practice varies from no use at all, to routine use for every patient. A 2011 independent study showed 4/5 of all orthodontic residency graduate programs in the U.S. utilize CBCT for specific applications, and 1/5 of all such programs use CBCT as a routine radiograph on all patients.1 That number is likely increasing and represents a significant trend towards CBCT replacing panos and cephs in orthodontics due to lowering dosimetry levels and continued reductions in pricing. 3D diagnostics is a mental quantum leap for most orthodontists when faced with the prospect of transitioning from a 2D to 3D mindset. As a specialty, we’ve grown so accustomed to asking diagnostic questions derived from 2D information (i.e., cephs, pano, FMX), that our instinct now is to ask the same 2D questions from 3D information. We will never be satisfied with our answers if we continue such mental trickery because our anatomy is simply not 2D. For instance, cephalometrically speaking, is it really appropriate to ask about lower incisor angulation from a 3D data set? Which lower incisor are we talking about (i.e., the right or the left, the central, or the lateral)? Which mandibular plane (i.e., the right or the left; which humanly located anatomic landmarks define our plane)? First, it is well documented that

Juan-Carlos Quintero, DMD, MS, received his dental degree from the University of Pittsburgh in Pennsylvania and his degree in Orthodontics from the University of California at San Francisco (UCSF). He also holds a Master of Science degree in Oral Biology. He has served as national president of the American Association for Dental Research-SRG, is a faculty member at the L.D. Pankey Institute, and an attending professor at Miami Children’s Hospital, Department of Pediatric Dentistry, as well as immediate past president of the South Florida Academy of Orthodontists (SFAO). He currently practices in South Miami, Florida. His academic interests include applications of 3D craniofacial imaging and airways in orthodontics.

Volume 5 Number 1

Figure 1A: Dynamic digital modeling (DDM) is a product of CBCT data, producing a single all-inclusive orthodontic 3D digital record. This DDM product is Anatomodel from Anatomage Corporation

Figure 1B:Traditional plaster study models used in orthodontics

Figure 1C: Anatomic segmentation from CBCT data is now readily available using third parties, such as Anatomage Corporation, to perform enhanced orthodontic studies. This presents dentitions with roots within actual jaw structures, instead of flat plaster bases as used in traditional models with no roots

cephalometrics is fraught with error. Second, we’ve grown accustomed to having a set of multiple diagnostic pieces that geometrically do not correlate well with each other (i.e., photographs versus 2D radiographs versus physical models) like different languages speaking to each other. CBCT offers a relatively low-risk solution to these diagnostic and geometric shortfalls. There are now over 20 CBCT manufacturers, most offering different products. The competition has lowered prices and, more importantly, lowered dosimetry levels, a major concern and obstacle for most orthodontists considering embracing CBCT for their practices. With

the introduction of newer generation machines such as the i-CAT® FLX (Imaging Sciences International), whose independent validation studies recently showed a ceph-sized scan (16 cm x 13 cm) to deliver less than half the radiation of a panorex2, it is now foreseeable that the orthodontic and possibly the pediatric community will shift toward CBCT as the routine imaging modality of choice in everyday practice. The tide seems to be turning. Will panos, cephs, and periapical radiographs in orthodontics soon be considered outdated, even irresponsible imaging? Dynamic digital modeling (DDM) is a Orthodontic practice 41

TECHNOLOGY

New study may change the face of orthodontics

TECHNOLOGY

Figure 2: Dynamic modeling through segmentation allows for interactive virtual treatment planning. Here teeth can be colored, labeled, and even moved using proprietary software from i-CAT and Anatomage Corporation

Figure 3: Software allows for computerized surgical treatment planning of orthognathic cases and soft tissue predictions using 3D data acquired from low-dose CBCT scans

Figure 5. Eruption management in the mixed dentition using 3D imaging is one of the most exciting applications of new technology in light of the new low-dose i-CAT FLX

product of CBCT data producing a single all-inclusive orthodontic 3D digital record (Figures 1A and 1C). Because volumetric imaging captures information in the form of voxels, not pixels, this comprehensive digital data set can produce an array of useful diagnostic information in the form of accurate, interactive, segmented anatomy in 3 dimensions. The i-CAT FLX captures a ceph-sized 3D scan in 11-18 microsieverts (data on file with i-CAT). In comparison, a digital panorex is 15-25 microsieverts.3 It’s all software modeling after that. The Anatomodel™ (Anatomage Corporation) is an all-inclusive orthodontic record file made from DICOM, producing impressionless digital orthodontic models with segmented roots, jaws, condyles, bone, and crowns (Figures 1A, 1C, and 2). Additionally, a 3D photograph is easily produced and perfectly wrapped over the soft tissue facial mapping, resulting in perfect correlations of soft and hard tissue. Much more than just a pretty picture, once these individualized pieces of anatomy have been digitally 42 Orthodontic practice

Figure 4: Temporary anchorage devices (TADs) can be strategically mapped in 3D for ideal placement and best surgical planning and communication with patients and specialists

Figure 6A: Airway segmentation and measuring tools allow for orthodontists to treatment plan around the airways and screen for patients at risk for obstructive sleep apnea

Figure 6B: Multiplanar reconstruction views (MPR) of CBCT data allow orthodontists to better evaluate the paranasal sinuses and nasal cavity as it potentially affects the oral cavity

and independently segmented with Tx STUDIO™ (Imaging Sciences International) or Invivodental™ (Anatomage Corporation) software, it is easy to perform virtual 4D treatment planning involving tooth movements (Figure 2), OMFS movements, soft tissue predictions (Figure 3),

computerized planning for TAD placement (Figure 4), eruption management of the mixed dentition (Figure 5), and airway management in all patients. Airway segmentation and measuring tools allow for orthodontists to treatment plan around the airways and screen for patients at risk for Volume 5 Number 1

Figure 7. Volume rendering (VR) with airway segmentation using a low-dose scan on a patient. This example shows what is possible using a ceph-sized (16 cm x 13 cm ) 11 microsievert scan (data on file with i-CAT)

Figure 8: The future of orthodontics has arrived. A 3D interactive Anatomodelâ&#x201E;˘ with airway information, created using an 11 microsievert scan. An average digital panorex is 24 microsieverts as per Ludlow, et al., 2013

obstructive sleep apnea. It is foreseeable that airway-centered treatment planning will become standard in orthodontics with the arrival of low-dose imaging using CBCT technology (Figures 6A and 6B). As a patient education tool and practice management tool, 3D CBCT is extremely useful. The visual nature of CBCT, enhanced with dynamic modeling, makes the information being presented to patients easier to understand - in particular the complexities of treatment that often go missed or misunderstood. CBCT, in the form of dynamic models helps present treatment expectations and treatment limitations. Some legal experts argue that, from a medical-legal perspective, one is better off with a CBCT than without one. Not only does the file serve as an accurate Volume 5 Number 1

treatment record, but can also help reduce treatment liability and risk of litigation because to see is to know; to not see is to guess. The future has arrived. Last year, i-CAT released the i-CAT FLX, yet another improvement in their generation of machines making cone beam CT technology better and safer. Using the QuickScan+ setting, the i-CAT FLX can produce a ceph-sized (16 cm x 13 cm) extended field of view volumetric scan at a dosimetry level as low as half of a panorex. These levels were recently confirmed though an independent academic institution-based study by Dr. John Ludlow at the University of North Carolina that measured the dosimetry levels of the new i-CAT FLX machine.2 These findings, recently published in the

American Journal of Orthodontics and Dentofacial Orthopedics (AJODO), reports that the i-CAT FLX can produce a 16 cm x 13 cm extended field of view image using the QuickScan+ mode at a relatively low level of 11-18 microseverts according to lab-controlled phantom studies. To give you an idea of how low this is, a digital panorex is about 25 microseverts in similar studies.3 The implications of this in orthodontics and even pediatric dentistry are enormous. There are still CBCT machines out there that deliver over 500 microsieverts, so clearly, CBCT dose varies substantially depending on what machine and what parameters are used. Whatâ&#x20AC;&#x2122;s more, is that dynamic modeling and anatomical segmentation of airways and other structures can just as easily be performed with this new low-dose scan. Figures 7 and 8 are examples of what is readily possible today using a combination of the i-CAT FLX QuickScan+ settings and the Anatomodel dynamic modeling at 11 microseverts. Will this set a new standard as an orthodontic diagnostic record? Has the radiation-overexposure argument now been suddenly flipped on its back? One thing is for sure: With extremely low radiation doses, CBCT scanners, such as the i-CAT FLX and its QuickScan+ setting now on the market, mark not only the end of the CBCT-in-orthodontics controversy, but likely the future death of panos, cephs, and plaster (Figure 1B). OP References 1. Smith BR, Park, JH, Cederberg RA. An evaluation of cone-beam computed tomography use in postgraduate orthodontic programs in the United States and Canada. J Dent Educ. 2011 Jan;75(1):98-106. 2. Ludlow, J and Walker, C. Assessment of phantom dosimetry and image quality of i-CAT FLX cone-beam computed tomography. Am J Orthod Dentofacial Orthop. 2013;144:802-17. 3. Ludlow J, Davies-Ludlow L, White S. Patient risk related to common dental radiographic examinations. The impact of 2007 International Commission on Radiological Protection recommendations regarding dose calculations. J Am Dent Assoc. 2008; 139;1237-1243.

Orthodontic practice 43

TECHNOLOGY

Since its inception, CBCT has been slowly gaining acceptance as the premier diagnostic tool of choice in just about every specialty in dentistry, both as a research and clinical tool.

TECHNOLOGY

Stability, longevity, and predictability in your practice management technology Drs. Shalin R. Shah and Ryan K. Tamburrino discuss the benefits of a high-quality practice management system Introduction Orthodontists have the wonderful ability — and equally important responsibility — to provide each patient with a lifelong healthy smile. We achieve this goal through proper diagnosis and treatment planning, thereby affording the patient a smile that is stable, long-term, and based upon predictable treatment. We strive to achieve these three pillars for everyone we see and treat; it can be argued that our patients expect us to deliver on all three as well. Our ability to deliver that smile relies upon an environment that also consistently delivers. For example, the equipment we use — including our bracket systems and wires — must be reliable and accurate. Our staff must be competent and dependable. The same applies for the technology we

Shalin Raj Shah, DMD, MS, received his Certificate of Orthodontics and Masters of Science in Oral Biology from the University of Pennsylvania and is a Diplomate of the American Board of Orthodontics. He is also a graduate of the University of Pennsylvania College of Arts and Sciences and School of Dental Medicine. Currently, Dr. Shah is Clinical Associate of Orthodontics at the University of Pennsylvania and is in private practice (Center for Orthodontic Excellence) in both Princeton Junction, New Jersey, and Philadelphia, Pennsylvania. Dr. Shah currently does not consult or speak on behalf of tops Software. His involvement with tops Software is limited to being their customer and being an avid supporter of their team, vision, and products/services. Dr. Shah has no financial interest in the company. Ryan K. Tamburrino, DMD, co-founder of the Center for Orthodontic Excellence, graduated from Duke University with a double major in biomedical engineering and mechanical engineering/materials science. He attended the University of Pennsylvania for dental school, as well as for specialty training in orthodontics. Dr. Tamburrino is on faculty as an attending clinician in the graduate orthodontic clinic at the University of Pennsylvania. Additionally, he is on faculty and lectures internationally/nationally with the Complete Clinical Orthodontics (CCO) courses. His involvement with tops Software is limited to being their customer and being an avid supporter of their team, vision, and products/ services. Dr. Tamburrino has no financial interest in the company.

44 Orthodontic practice

Figure 1: An easy-to-use user interface for essential data entry. The authors have significant experience with topsOrthoTM, which possesses sound design and stability

employ in our offices. Each of these components builds a trustworthy and efficient system, and that system must consistently perform and meet expectations. This enables us to predictably execute our treatment and deliver those stable, long-term results that patients expect. In our extensive orthodontic education, we are exposed to many concepts and techniques. But many orthodontists would agree that technology and business/ practice management education could be stronger. Orthodontic residencies — and education as a whole — are burdened with the challenge of sharing and teaching an ever-increasing amount of information in a finite amount of time. This is in part due to the growth of technology. Therefore, when a practicing orthodontist chooses a technology solution, that technology must be reliable and require minimal troubleshooting. It is even more beneficial if our critical business and practice management needs are integrated and supported by the latest high-quality technology and reliably delivered. This is what topsOrtho™ and other practice

management software programs do — and do well. There are many high-quality practice management software programs, but the authors have routinely used topsOrtho and have learned from experience that this technology possesses all of the critical attributes and more. This software will serve as the model for this article.

Practice management technology expectations Orthodontists often see practice management software as somewhat of a digital Rolodex for patient information, while also maintaining the ability to electronically annotate treatment provided and providing some statistical information on the practice’s performance. These are reasonable expectations and are the essentials of any practice management solution. However, in an age where data is more than names and numbers, it is important to expect more from your “electronic Rolodex with notes.” Data is king in the database world. Dr. John H. Holmes, a clinical epidemiology Volume 5 Number 1

TECHNOLOGY

Figure 2: Database queries and report generation are essential tools in data analytics. Proper database design allows a host of data compilation possibilities

Figure 3: Data reports evolve with time, and with the needs of a practice and the profession. Practice management systems should be able to generate new reports easily and effectively, especially in an era when new technology advancements necessitate different types of data interpretation

professor at the University of Pennsylvania, told his students in the introductory class, “You will never view data the same … and you will learn the difference between data, information, knowledge, and wisdom.” Data goes beyond regurgitating information on demand; it is the source of what we know, Volume 5 Number 1

helps derive understanding in what we see, and serves as a cog in the sprocket of more complex thoughts and hypotheses. A practice management system is a carefully planned collection of data and is appropriately called a database. Databases are created from well-

thought-out models and based upon entities and the entities’ attributes. The technology’s realization and usability is derived from its competent engineers and architects, as much as it is from the repeated end-user satisfaction and success. Of course, most of its success is Orthodontic practice 45

TECHNOLOGY

Figure 4: With technology advancements, our methods of interaction with data are constantly changing. Ubiquitous data access across multiple platforms enables the orthodontist, practice, and patient to benefit from timely solutions

predicated upon seamless and uneventful data entry and retrieval (Figure 1). However, database stability and robustness, as well as queries and report generation (Figure 2), are equally essential. When evaluating the right practice management system, these all are important factors to consider. Database stability provides a reliable interface to access your data, which is important in a thriving and demanding orthodontic setting with multiple users. Database robustness allows scalability of the model as future needs arise and technology evolves. Robustness is important in an age when platforms and our daily needs are changing. Queries and report generation are equally important, if not more so. They enable us to analyze our data with regard to practice performance and efficiency. A database that is properly structured also allows different reports to be generated and tailored to the needs of the orthodontic practice (Figure 3). These are some of the critical elements that you should expect from your practice management software.

Demand more The concept of Moore’s Law originated around 1970. The simplified version of this law states that “processor speeds, or overall processing power for computers will double every two years. To break down the law even further, it specifically states that the number of transistors on an affordable 46 Orthodontic practice

CPU will double every two years.”1 At the time, critics said that was not possible or likely, but nowadays the rate is doubling almost every year. Similarly, practice management software and technology should be growing with the times and with the rapid changes in platform software and hardware capabilities. Part of today’s practice management growth begins with data being ubiquitous. Data accessibility across multiple platforms (for example, laptops, smartphones, tablets, and so on) enables the orthodontist to quickly access and comprehensively review necessary background on a patient or situation, then provide informed solutions (Figure 4). In turn, this allows the patient to have shorter turnaround times and allows the orthodontist to address matters promptly. Prompt service is always a positive contributor to growth and is essential in the equation of good business practices. There are multiple mechanisms by which data can be made globally accessible, but we are going to briefly focus on two of the more commonly discussed ones. Public or private clouds? Dr. Mark Sanchez, orthodontist and founder of tops Software™, has extensively researched this topic and has live data points over the last decade that illustrate the strength of private clouds in our profession. To begin the framework of this discussion, it is important to understand the concept

Figure 5: topsEcho effectively implements the efficiency and data security of private clouds

Volume 5 Number 1

3SHAPE ORTHODONTICS™

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TREATMENT PLANNING & ANALYSIS

CAD DESIGN OF ALL TYPES OF APPLIANCES

3Shape Orthodontics™ 2013 3D scanning, archiving, treatment planning & analysis, patient management, communication tools, and CAD appliance design. 3shapedental.com/orthodontics

TECHNOLOGY of elasticity, an important facet of public clouds. National Institute on Science and Technology defines rapid elasticity this way: Capabilities can be elastically provisioned and released, in some cases automatically, to scale rapidly outward and inward commensurate with demand.2 In the evaluation of an orthodontic practice, it is evident that the workload is relatively constant. An article in Wired published in August 2013 features an entrepreneur by the name of Eric Frenkiel, who founded MemSQL, a tech startup. In the interview, Frenkiel discusses his company’s use of Amazon’s cloud (public cloud) and delves into analytics on the pros and cons of private clouds. He reveals that, as the company adds more servers, MemSQL’s server costs “won’t come anywhere close to the fees it was paying Amazon. Frenkiel estimates that, had the company stuck with Amazon, it would have spent $900,000 over the next 3 years. But with physical servers, the cost will be closer to $200,000. ‘The hardware will pay for itself in about 4 months,’ he says.”3 This is only one example presented, but it delineates some important points. Our profession’s needs align better with the benefits of the private cloud, and practice management solutions employing this technology and that thought process can transfer cost savings to the end users. Another important aspect of cloud computing is data security. Wired features another article that states the concerns about security in public clouds. “The truth of the matter is that many enterprises and government agencies still question the privacy and security of public cloud services. ‘This level of control is very important in regulated industries: financial services, and healthcare,’ says Michael R. Overly, a lawyer with the international firm Foley & Lardner LLP.”4 Privately owned servers that support private clouds demonstrate an ideal fit for the orthodontic profession, while serving the needs of ubiquitous data and our increasing demands. topsOrtho employs private clouds and has successfully implemented data access across multiple platforms in a stable and efficient manner (Figure 5). The topsOrtho team has also been able to interface this private cloud with other technologies, such as web patient portals, thereby enhancing the strengths and offerings of the practice management software. Ultimately, data accessibility 48 Orthodontic practice

When a practicing orthodontist chooses a technology solution, that technology must be reliable and require minimal troubleshooting. It is even more beneficial if our critical business and practice management needs are integrated and supported by the latest high-quality technology and reliably delivered.

across multiple platforms enables the orthodontist to properly prepare for emergencies, schedule changes, and so on at a moment’s notice. In turn, this enables a more efficient system that begins with you, the orthodontist.

The rate limiting factor Software can only be as dependable as the platform on which it runs. This article will not serve as the forum for the pros and cons of different operating systems. However, it is noteworthy to discuss that a strong practice management software can only deliver on a functioning operating system. If the operating system fails to achieve consistency and maintain stability, the potential and great deliverables of the practice management technology will be compromised.

Key points In Walter Isaacson’s biography of Steve Jobs, he includes an interesting story about Jobs’ adoptive father. “I thought my dad’s sense of design was pretty good,” Jobs told Isaacson, “because he knew how to build anything. If we needed a cabinet, he would build it. When he built our fence, he gave me a hammer so I could work with him…” He said that his father refused to use poor wood for the back of cabinets, or to build a fence that wasn’t constructed as well on the backside as it was the front. Jobs likened it to using a piece of plywood on the back of a beautiful chest of drawers. “For you to sleep well at night, the esthetic, the quality, has to be carried all the way through.5,6” A high-quality practice management system needs to possess the same

characteristic: The usability, esthetic(s), and quality has to be carried all the way through. This results in practice management technology that maintains a stable environment with predictable actions and allows longevity of data entry, retrieval, and scalability. In turn, we can focus on the smiles and smile because our practice management technology and team have the right focus.

Acknowledgments The authors thank and acknowledge the continued efforts of Dr. Mark Sanchez, Kirsten Lambert, and the tops Software team. They were instrumental in providing the necessary graphics and openly discussed any and all questions on their product and services. OP References 1. Moore’s Law.org. Moore’s Law or how overall processing power for computers will double every two years. Available at: http://www. mooreslaw.org/. Accessibility verified December 23, 2013. 2. Mell P, Grance T. US Department of Commerce. The NIST Definition of Cloud Computing. Recommendations of the National Institute of Standards and Technology. NIST Special Publication 800-145. Published September 2011. 3. Metz C. Why some startups say the cloud is a waste of money. Available at: http://www. wired.com/wiredenterprise/2013/08/memsqland-amazon/. Published August 15, 2013. Accessibility verified December 23, 2013. 4. Metz C. Amazon’s invasion of the CIA is a seismic shift in cloud computing. Available at: http://www.wired.com/wiredenterprise/2013/06/ amazon-cia/. Published June 18, 2013. Accessibility verified December 23, 2013. 5. Panzarino M., Steve Jobs’ obsession with the quality of the things unseen. Available at: http://thenextweb.com/apple/2011/10/24/ steve-jobs-obsession-with-the-quality-of-thethings-unseen/. Published October 24, 2011. Accessibility verified December 23, 2013. 6. Isaacson W. Steve Jobs. New York, NY: Simon & Schuster; September 2013.

Volume 5 Number 1

AUTHOR GUIDELINES

Orthodontic Practice US is a peer-reviewed, bimonthly publication containing articles by leading authors from around the world. Orthodontic Practice US is designed to be read by specialists in Orthodontics, Periodontics, Oral Surgery, and Prosthodontics.

Submitting articles Orthodontic Practice US requires original, unpublished article submissions on orthodontic topics, multidisciplinary dentistry, clinical cases, practice management, technology, clinical updates, literature reviews, and continuing education. Typically, clinical articles and case studies range between 1,500 and 3,000 words. Authors can include up to 15 illustrations. Manuscripts should be double-spaced, and all pages should be numbered. Orthodontic Practice US reserves the right to edit articles for clarity and style as well as for the limitations of space available. Articles are classified as either clinical, continuing education, technology, or research reports. Clinical articles and continuing education articles typically include case presentations, technique reports, or literature reviews on a clinical topic. Research reports state the problem and the objective, describe the materials and methods (so they can be duplicated and their validity judged), report the results accurately and concisely, provide discussion of the findings, and offer conclusions that can be drawn from the research. Under a separate heading, research reports provide a statement of the research’s clinical implications and relevance to orthodontic dentistry. Clinical and continuing education articles include an abstract of up to 250 words. Continuing education articles also include three to four educational aims and objectives, a short “expected outcomes” paragraph, and a 10-question, multiple-choice quiz with the correct answers indicated. Questions and answers should be in the order of appearance in the text, and verbatim. Product trade names cited in the text must be accompanied by a generic term and include the manufacturer, city, and country in parentheses. Additional items to include: • Include full name, academic degrees, and institutional affiliations and locations • If presented as part of a meeting, please state the name, date, and location of the meeting • Sources of support in the form of grants, equipment, products, or drugs must be disclosed • Full contact details for the corresponding author must be included • Short author bio • Author headshot Volume 5 Number 1

Pictures/images

Disclosure of financial interest

Illustrations should be clearly identified, numbered in sequential order, and accompanied by a caption. Digital images must be high resolution, 300 dpi minimum, and at least 90 mm wide. We can accept digital images in all image formats (preferring .tif or jpeg).

Authors must disclose any financial interest they (or family members) have in products mentioned in their articles. They must also disclose any developmental or research relationships with companies that manufacture products by signing a “Conflict of Interest Declaration” form after their article is accepted. Any commercial or financial interest will be acknowledged in the article.

Tables Ensure that each table is cited in the text. Number tables consecutively and provide a brief title and caption (if appropriate) for each.

References References must appear in the text as numbered superscripts (not footnotes) and should be listed at the end of the article in their order of appearance in the text. The majority of references should be less than 10 years old. Provide inclusive page numbers, volume and issue numbers, date of publication, and all authors’ names. References should be submitted in American Medical Association style. For example: Journals: (Print) Greenwall L. Combining bleaching techniques. Aesthetic & Implant Dentistry. 2000;1(1):92-96. (Online) Author(s). Article title. Journal Name. Year;vol(issue#):inclusive pages. URL. Accessed [date]. Or in the case of a Book: Greenwall L. Bleaching techniques in Restorative Dentistry: An Illustrated Guide. London: Martin Dunitz; 2001. Website: Author or name of organization if no author is listed. Title or name of the organization if no title is provided. Name of website. URL. Accessed Month Day, Year. Example of Date: Accessed June 12, 2011. Author’s name: (Single) Doe JF

(Multiple) Doe JF, Roe JP

Permissions Written permission must be obtained by the author for material that has been published in copyrighted material; this includes tables, figures, pictures, and quoted text that exceeds 150 words. Signed release forms are required for photographs of identifiable persons.

Manuscript Review All clinical and continuing education manuscripts are peer reviewed and accepted, accepted with modification, or rejected at the discretion of the editorial review board. Authors are responsible for meeting review board requirements for final approval and publication of manuscripts.

Proofing Page proofs will be supplied to authors for corrections and/or final sign off. Changes should be limited to those that are essential for correctness and clarity. Articles should be submitted to: Mali Schantz-Feld, managing editor mali@medmarkaz.com

Reprints/Extra issues If reprints or additional issues are desired, they must be ordered from the publisher when the page proofs are reviewed by the authors. The publisher does not stock reprints; however, back issues can be purchased.

Checklist for article submissions: 3 A copy of the manuscript and figures/ captions, including all pictures (low res) necessary for reviewers 3 Manuscript: double-spaced including separate references, figure legends, and tables 3 Abstract, educational objectives, expected outcomes paragraph 3 References: double-spaced, alphabetical, American Medical Association style 3 Tables: titled and cited in the text 3 Mandatory submission form, signed by all authors Please contact managing editor Mali SchantzFeld with any questions via email: Mali@medmarkaz.com

Orthodontic practice 49

PRODUCT PROFILE

Great Lakes offers a complete 3D orthodontic solution for orthodontists and their labs The ultra-fast 3Shape TRIOS® Ortho System™ is a key digital solution for improving impression taking, clinical results, and patient satisfaction An increasing number of orthodontists are investing in digital impression systems to increase efficiency and to offer patients a positive experience that fosters referrals. You want to stay competitive, but how do you decide which technology options make the most sense for your practice? Great Lakes Orthodontics has been immersed in digital technology for years and is the only distributor to offer a fullline 3D solution for orthodontic practices and labs. Although the company’s digital product line includes the Stratasys 3D printer and desktop scanners, this product profile will focus on the highly acclaimed 3Shape TRIOS® Ortho System™. While the benefits of digital impression taking are clear, not all digital impression solutions are equal. The TRIOS® Ortho System™ offers the latest technology and upgrades along with key innovations. This powerful, open format system combines the ultra-fast TRIOS 3D impression solution with 3Shape’s Ortho Analyzer™ software. The system integrates intraoral 3D scanning, scan validation, and seamless communication with the orthodontic lab. Ortho Analyzer™ software gives orthodontists the tools for creating digital study models from the impression as well as advanced tools for accurate treatment planning and case analysis. The open format system allows for seamless file sharing and compatibility.

Fast, easy, accurate, and no powder needed 3Shape’s TRIOS® Ultrafast Optical Sectioning™ technology enables orthodontists to rapidly and easily achieve accurate scans. The final 3D digital impression is based on real data rather than interpolated artificial surfaces, allowing scans to be captured quickly. In fact, users have reported that both upper and lower arches and bite registration can be scanned in less than 5 minutes. Digital impressions can be viewed live as they are being built on the PC screen during scanning. Designed for optimal accuracy, patient comfort, and speed, the TRIOS 50 Orthodontic practice

scanner is powder-free. This is a huge advantage, as powder is not only messy and unpleasant for the patient, it is also extremely technique-sensitive, difficult to obtain an accurate scan, and expensive. The ergonomic handheld scanner easily moves along the teeth, capturing the impression in real time. No need to hold the scanner at a specific distance or angle to focus. The autoclavable tip is equipped with an anti-mist heater to ensure that scanning is clear and undistorted. The tip rotates for ideal positioning. A unique motion sensor interface allows the scanner to act like a gaming controller to virtually rotate and turn the digital impression on screen. The SmartTouch Screen provides full control without a mouse or trackball.

Ortho Analyzer™ Software — Advanced tools for treatment planning and case analysis Ortho Analyzer™ makes it easy to create digital study models, including virtual bases, and perform treatment planning and case analysis using 3D and 2D tools, virtual setups, and digital articulators. Case analyses can be customized according to your own methods, needs, and workflows. Software also includes analysis wizards to guide users step-by-step through the process and allows easy comparison of Before and After treatment situations. Complete case histories are accessible from anywhere, and with 3Shape Communicate™, orthodontists can share and discuss cases online with colleagues and their lab, or present treatment plans to patients.

Convenient options The TRIOS® Ortho System™ is available with RealColor™ Technology that allows you to create scanned images in realistic color to clearly distinguish between teeth, gingiva, and materials. This new technology enables recognition of bleeding areas, color transitions on teeth, and margin lines. An alternative to the TRIOS Cart, the optional compact TRIOS Pod solution offers optimum mobility and flexibility when working in multiple locations or limited space. The TRIOS Pod can be connected to multiple laptops or PCs and allows scanning from an iPad.

Exceptional service and support Great Lakes provides 2-day setup and training in your office, as well as access to training information and videos and ongoing software support from experienced technicians. For more information, please call 800828-7626 or visit www.digital-ortho.com. OP

This information was provided by Great Lakes Orthodontics, Ltd. Volume 5 Number 1

Attention: Orthodontists

Orthodontics is going digital Are you ready?

3Shape TRIOS® Intraoral Scanner with Ortho Analyzer™ software

Stratasys Objet30 OrthoDesk 3D Printer

3Shape R700™ Orthodontic Scanner

FREE

Hands-on digital seminars

coming to a city near you!

Join Great Lakes at one of these cities: City

Dates

Miami, FL

2/3 or 2/4

Orlando, FL

2/7 or 2/8

Jacksonville, FL

2/12 or 2/13

Atlanta, gA

2/21 or 2/22

Raleigh, NC

2/27 or 2/28

Nashville, tN

What you will learn: •

How integrating intraoral scanning and other digital technology can advance your practice

•

What are the important considerations in choosing an intraoral scanner

3/6 or 3/7

•

What are the key features of the 3Shape TRIOS® Intraoral Scanner

Phoenix, AZ

3/17 or 3/18

•

What does the 3Shape Ortho Analyzer™ software allow you to do

Las vegas, Nv Portland, OR

3/21 or 3/22 3/28 or 3/29

•

Why 3D printing is now practical for clinical in-office labs

Seattle, WA

4/3 or 4/4

•

What are the capabilities of the Objet30 OrthoDesk 3D Printer

Louisville, KY

5/14 or 5/15

Indianapolis, IN

5/21 or 5/22

Columbus, OH

5/30 or 5/31

Chicago, IL

6/5 or 6/6

Detroit, MI

6/12 or 6/13

at www.DIgItALORtHOLIvE.com or Call 1.800.828.7626

The seminar begins with a brief overview of intraoral scanning and 3D printing, followed by over two hours of actual hands-on learning. You will have the opportunity to get your questions answered in a friendly, relaxed forum. SMPP458Rev111513

Digital Intraoral Scanning | 3D Printing | Desktop Scanning

Your digital solutions partner

PRACTICE DEVELOPMENT

Automated patient appointment reminders — the data is in Diana P. Friedman shows the significant impact on no-shows, practice efficiency, and production

n the Internet age, digital communications have extensively replaced face-to-face communication and interaction. Channels for digital communications expanded vastly over the past years. Considering the fact that existing and prospective patients are online, orthodontic practices have had to identify effective ways to best leverage these new channels of communications to acquire, engage, and retain their patients while maintaining practice efficiency and profitability. Research has consistently shown patients welcome these innovative ways of communicating. A national research study by Sesame Communications documented that 92% of orthodontic patients stated they find it more convenient to find answers online rather than calling the practice. The same study found that orthodontic patients prefer SMS text and email reminders over phone reminders 4 to 1.

Automated appointment reminders Being accessible to patients online not only provides a great convenience and benefit to the patients, it drastically improves efficiencies for the practice as well. Automated patient reminders enable the practice to confirm scheduled appointments via email, text messages, or automated voice reminders. Practice production is at the epicenter of a practice’s financial performance. Production not only impacts the cost structure of the practice, it more significantly defines revenue flow — and ultimately, profitability. In an orthodontic practice, it is further important to keep patient treatment on track to minimize costly delays and

Diana P. Friedman, MA, MBA, is president and chief executive officer of Sesame Communications. She has a 20-year success track record in leading dental innovation and marketing. Throughout her career, Ms. Friedman served as a recognized practice management consultant, author, and speaker. She holds an MA in Sociology and an MBA from Arizona State University.

52 Orthodontic practice

complications with delivery of orthodontic care. For this reason, appointment noshows have a devastating impact on practice financial performance and its ability to complete treatment plans on schedule. Orthodontists clearly recognize this fact. In a 2012 national research study, 20% of orthodontists stated their top need is to reduce no-shows in the practice, and 22% noted improving patient communications was a priority. Improving patient communications generally has positive impacts on compliance with treatment completion and appointment attendance. Automated reminders have the potential to cost-effectively and efficiently address these needs. Research shows that today almost 70% of orthodontic practices have some form of automated appointment reminder solution. However, until recently there has been very limited research to document the impact these solutions have on noshow rates and practice production. With advanced systems costing $300 per month on average, the return on investment (ROI) justification for this investment has, to date, been a challenge. The following sections provide detailed findings and analysis of a longitudinal study research tracking orthodontic practice production and efficiency pre- and postactivation of Ortho Sesame automated appointment reminders.

Impact on practice production Sesame Communications, a leading provider of orthodontic patient portals, announced the results of a breakthrough study measuring the impact of automated patient appointment reminders on practice production. The study spanned 5 years of actual performance data, and tracked the detailed confirmation and patient attendance rates on 19,773,041 scheduled appointments across 427 practices. The research study tracked noshow appointments documented in the practice management software. Since many practices do not consistently input no-show appointment codes in patient

records, the findings of the study are likely to be a conservative baseline of the upside for practices activating automated appointment reminders. The objective was to analyze how noshows changed post-implementation of automated appointment reminders. The data spanned 24 months of appointment data prior to the activation of Ortho Sesame automated appointment reminders and 36 months post-activation. The study found that in the first 36 months of implementing automated appointment reminders, no-shows were reduced by 21.83% in orthodontic practices. The financial implication of schedule compliance is significant. This research documented $105,322 in incremental production for orthodontic practices due to schedule compliance — revenue that would otherwise be lost. The benefits of practice production improvements continued throughout the 36-month postactivation period.

Incremental practice production achieved through improved appointment show rates As the preceding data clearly demonstrates, there is a substantive and significant productivity impact to activating automated patient appointment reminders in the practice. Evaluation of ROI on automating patient appointment reminders is straightforward. The annual costs of automated appointment reminder software packages range from $600 for very basic limited functionality solution to $3,600 for the most sophisticated packages. Even at the high end of the spectrum, the ROI is astounding, and the practice recovers the entire first-year fees within the first 6 months post-activation.

Impact on practice efficiency Management of the appointment schedule has pivotal importance on practice production and collection. In most practices, a key component of management is the development and Volume 5 Number 1

PRACTICE DEVELOPMENT

Automated appointment reminders dramatically reduce practice no-shows and positively impact production. An added benefit is the fact that automated reminders allow practices to communicate with their patients in the manner they prefer.

implementation of detailed scheduling systems and confirmation procedures. Implementation of these systems is extremely time-consuming as it requires the execution of an inordinate amount of personal outbound calls. In the fast-paced environment we all live in, connecting with patients in person to confirm appointments is often challenging and time-consuming. Administrative team members focus significant energy and time on managing patient flow. This is valuable time that may best be leveraged creating relationships with existing patients, marketing the practice, re-activating patients, following up on incomplete diagnosed treatments, and more. Evaluation for ROI on automating patient appointment reminders is, once again, straightforward. An average hourly cost of an administrative team varies between1 $14.28 and $26.08. Even a conservative 20-hour weekly focus on appointment confirmations and last moment appointment cancellation and noVolume 5 Number 1

show management placed a weekly burden on the practice of $275.60 to $521.60. This may not seem significant, but at an average 50 weeks of practice operations, the annual costs range between $13,780 and $26,080. Even at the high end of investment in automated appointment reminders, the savings in administrative costs of the practice allow for a quick recovery of the investment. The impact is not only in cost savings, but also the team’s ability to use the time savings to grow the practice and to increase production and collections.

Conclusion Automated appointment reminders dramatically reduce practice no-shows and positively impact production. An added benefit is the fact that automated reminders allow practices to communicate with their patients in the manner they prefer. Interestingly, 98% of dental professionals surveyed by Sesame Communications stated that letting patients choose their

preferred method of communications not only provides excellent care, but also further supports the practice’s commitment to individualized treatment. Production and efficient operations of the practice are imperative to achieving growth and profitability. Notwithstanding these core benefits, in a national survey almost 90% of dental professionals agree that automating patient reminders gives them peace of mind that all patients are consistently contacted prior to appointments. Sophisticated, fully integrated portals provide practices with significant functionality far beyond the automated appointment reminders. Most patient and practice portals incorporate other valuable features, such as patient marketing functionality (including education and re-activation tools); patient engagement tools (including newsletters, special event e-cards, and appointment review tools); financial past due e-reminders; patient referral functionality; and the ability to view and share treatment images and animations of treatments to patients’ social media channels. These features generally do not require any incremental investment, yet help drive new patient acquisition, increase treatment plan adoption and completion rates, and increase collections — all critical components in maintaining a healthy, thriving practice. OP

Reference PayScale Data, January 2013.

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PRACTICE MANAGEMENT

Life happens, and big screen TVs go on sale: a look at solution-based selling Justin Harding reminds practitioners to address patients’ wants and needs

eople have never liked the way amalgam looks. The only difference between now and its introduction is that for a while, another option did not exist. That lack of an option created a need, and based on that need, composite was born. Both of them serve the same purpose, but composite does so in a more esthetically pleasing way. While composite is not the sole contributor, its introduction highlights the shift in focus for advancing technology in the dental field. This shift has moved the emphasis heavily into the advancement of esthetics. Unfortunately, the result is an increasing perception that dentistry as a whole is largely cosmetic. For many patients, the reason for their visit is esthetic rather than therapeutic. In fact, it is an increasing perception that the reason for orthodontics is primarily cosmetic and, therefore, discretionary. It is, therefore, necessary to tap into the patients’ purpose at an early point. Humans categorize things into two distinct columns: needs and wants.

Justin Harding currently serves as a Practice Account Manager at OrthoSynetics. He works with the Practice Development team to assess practice performance, grow leaders, enhance culture, and set and achieve goals. He graduated from the University of Mississippi in 2006 and has over 7 years of healthcare sales and management experience.

54 Orthodontic practice

Cosmetic services fall into the want category. Since our current approach is from the perspective of orthodontic treatment as a need, it creates misalignment with patient goals. That is because wants and needs are created by fear but are differentiated by emotion. The fear of ridicule, due to a person’s crooked smile, is an emotionbased fear. It’s what prompts individuals to seek you, the doctor, out and hope to engage in a discussion based around a want, not a need. Too often we are having a need-based conversation, which fails to address the true reason they came to you. It is important for you to convey what it is that you actually provide. You provide a solution to a problem. However, in an industry where want is dominant, that solution must address the emotional motivation that created the demand. Too often we present treatment at face value: “You need treatment to ensure the proper long-term function of your teeth.” For patients who perceive your service as cosmetic, correctly aligned teeth for proper function is not what motivated them to make an appointment. Getting teased at school or being too embarrassed to smile is why they are sitting in your exam chair. That is their emotional motivation,

and it is what should be the focus of your discussion. The problem that we often face is that patients do not readily tell us what their emotional motivation is. In order to determine and address the true goals for your patients, it is important to create a personal environment for them. It’s not uncommon for patients to come in contact with six different people on their initial visit to an office. That’s why it is imperative that your treatment coordinator be the main source of contact and the driver behind your new patient flow. To start that process, the treatment coordinator should reach out to the new patients prior to their first appointments. It should be a personal call, and the focus should be on answering the patients’ questions and building goodwill. When patients arrive for their exams, the treatment coordinator should be there to greet them and introduce them to others in the office. The doctor should be the last new person patients meet, and if there is one person in an office responsible for losing a patient, it’s you. This is about the patient, and it is your opportunity to prove it. When patients get to the doctor, remember this: People will always enjoy a Volume 5 Number 1

Volume 5 Number 1

Now it’s time to shift gears and discuss finances. When access to information is almost instant, it is safe to assume that most of your patients have some idea of what treatment will cost. Knowing that, it’s also safe to assume that they have already worked out what will fit into their budgets. So, the financial discussion should be easy, right? Absolutely! Then why isn’t it? Put it into perspective; how many hands of poker would you win if you laid your cards face up on the table? If you’re unfamiliar with poker, the answer is not many. The current approach is to lay out all of the payment

end in a contract. When following up with those patients, it’s inherent that you continue the personal value you and your team have created. In this situation, the Courtesy and Concern (2 x 2) Method is preferred. At 2 days past the visit, you give your patients a courtesy call to thank them for coming in and to answer any of their questions. If they happen to reach two weeks past their initial visit, you follow that call with another call to express your concern for their well-being and, if needed, provide them with permission to seek treatment elsewhere. It is important

You provide a solution to a problem. However, in an industry where want is dominant, that solution must address the emotional motivation that created the demand.

options with various discounts and caveats like auto-draft. It’s done that way because assumptions are made about patients, or projections are put onto them. Instead, a successful financial discussion begins with presenting the fee with confidence. “Jennifer, your copay will be $3,500.” The next step is to quietly wait while patients go through the five stages of change (denial, anger, bargaining, depression, and acceptance). At acceptance, the most common response is an inquiry about payment plans. You must resist flipping over your hand. Instead, answer that question with a question, and give patients the opportunity to solve their own problems. “Jennifer, what did you have in mind for payment?” Unbeknown to you, Jennifer may offer to pay that $3,500 off in 3 months instead of the $99/month option you were about to push on to her. Of course, not all financial discussions

to remember that when following up in a personal manner, twice will always suffice. Continuing to express your interest in only them and their goals (instead of their pocketbooks) will net more patients in the end. Technology will continue to advance, and the esthetic trends in dentistry are here to stay. Whenever you find yourself lacking in a certain aspect of your practice, it will always be helpful to recall this rhyme: remaining effective requires perspective. Take a moment to view your practice from your patients’ perspectives. Without them, it wouldn’t exist. OP

Orthodontic practice 55

PRACTICE MANAGEMENT

conversation if they’re given the opportunity talk mainly about themselves. Take some time to make that happen. For a doctor that has done thousands of exams, it typically takes patients about 10 minutes. But would you trust a mechanic that popped open your car’s hood, took a quick glance, and told you it would be $5,000? Of course not! Invest the time to make this a memorable and personal experience. Cut out the technical jargon, and ask patients more personal questions. Patients don’t care about how much you know about the self-ligating brackets you’re going use. When you’re asked a question, answer it with a question — never assume you know why it was asked. It’s the only way you will ever find patients’ emotional motivations. Once you’ve identified the patients’ emotional motivations, you can approach it with the Problem, Consequence, and Solution Method (PCS), and validate their concerns. “Jennifer, I know what it’s like to be embarrassed to smile. Many people have gone through the same thing, including me.” (Problem) “But as time goes on, it’s only going to get worse.” (Consequence) “The good news is we’ve treated many people just like you. Seeing their newfound confidence at the end of their treatment is the most rewarding part of what we do.” (Solution) By this point, a personal environment should be established, and you can focus on gaining their commitment to treatment. A commitment starts with a personal invitation to join the practice and the opportunity to clarify any remaining issues. “Jennifer, we’d love to have you in our practice. Is there anything on your mind that would keep you from starting treatment with us?” Be prepared to answer patients’ questions, but leave the financial discussion to your treatment coordinator. Once patients are satisfied, make sure to emphasize your involvement with their cases. Discuss the records, X-rays, and any impressions you may have taken and what they mean to you and your team. Let patients know your time investment. If you’re not doing same-day bandings, reconsider! One of the single greatest decisions you can make to instantly increase your business is to offer sameday bandings. Remember, life happens, and big screen TVs go on sale. Your service as a want can be superseded by a new TV, and if your patients leave without any commitment to you, that replacement becomes a very real possibility.

DIARY

lllllllllllllllllllllll OF EVENTS llllllllllllllllllllllllllllllllllllllllllllllllllll DIARY First Phase Fixed and Removable Appliances Dr. Robert Wilson January 29, 2014 San Bernardino, CA www.rmortho.com First Phase Fixed and Removable Appliances Dr. Robert Wilson January 30, 2014 San Bernardino, CA www.rmortho.com First Phase Fixed and Removable Appliances Dr. Robert Wilson January 31, 2014 San Bernardino, CA www.rmortho.com JSOP (Just Short of Perfect) XXII Session 1: The Business of Orthodontics Dr. Ronald Roncone February 6-9, 2014 Vista, CA www.forestadent.com/forestadent-us/ index.php Golf & Learn with 3M Unitek – Efficient, Reliable Methods for Class II Correction Dr. Moe Razavi February 21, 2014 La Quinta, CA 3munitektraining.com Golf & Learn with 3M Unitek – Efficient, Reliable Methods for Class II Correction Dr. Herbert Hughes February 22, 2014 La Quinta, CA 3munitektraining.com The Essence of Effciency: Dr. Anoop Sondhi’s Two-Day In-Office Course Dr. Anoop Sondhi March 13, 2014 Indianapolis, IN 3munitektraining.com

56 Orthodontic practice

Efficiency in Practice: The Alvetro Orthodontics In-Office Seminar Dr. Lisa Alvetro March 20-21, 2014 Sidney, OH 3munitektraining.com

State of the Art Orthodontic Bonding 2014- Indirect Bonding Dr. Fredrik Bergstrand March 28, 2014 3munitektraining.com

17th Annual Summit – Progressing Your Practice to Peak Profitability Dr. Herbert Hughes Dr. Mohammad Razavi Dr. Nick Salome Dr. Anoop Sondhi Dr. Paul Tran Dr. Juli Cote March 21 – 22, 2014 Scottsdale, AZ 3munitektraining.com

AAO 2014 Winter Conference February 7 – 9, 2014 Las Vegas, NV www.aaoinfo.org/meetings/2014-winterconference

In-Office Course – Practice Expansion Dr. Stephen Tracey March 28-29, 2014 Upland, CA 909-981-8789

Online training Biostar/ MiniStar Courses For existing and prospective Biostar® or MiniSTAR® owners. March 26 Other online courses from Great Lakes Orthodontics Great Lakes Spot Welder Ortho-Lab Soldering Ortho-Lab Wire Bending Orthodontic Retainer (Hawley) Ricketts Retainer Wrap Around Retainer www.greatlakesortho.com

Live CE Webinars Strategic Philanthropy: Giving Back and Gaining Patients Dr. Lisa Alvetro January 31, 2014 3munitektraining.com

Events

Alabama Association of Orthodontists February 28 – March 1, 2014 Birmingham, AL www.signup4.net/Upload/ SOUT25A/2014882E/ALAOAOAFRegistrationFlyer2014.pdf Florida Association of Orthodontists March 7 – 9, 2014 Tampa, FL www.faortho.org IAO Annual Meeting March 26 – 30, 2014 Kissimmee, FL www.orthoorganizers.com/event.php

Rocky Mountain Orthodontics Annual Ski Meeting March 14-15, 2014 Vail, CO www.rmortho.com American Association of Orthodontists 2014 Annual Session April 25-29, 2014 New Orleans, LA www.aaoinfo.org/meetings/2014annual-session

Introduction to the Unitek Temporary Anchorage Device System Dr. Moe Razavi February 28, 2014 3munitektraining.com

Volume 5 Number 1

PLANMECA’s ProMax has won Townie Choice Awards for its pan/ceph model 2006-2013

• Advanced imaging programs include improved interproximal pan program for better spacing and root positioning for TAD placement • Pediatric mode reduces radiation by 35% • Face-to-face patient positioning • Patented SCARA technology allows unlimited movement to accommodate complex and unique jaw shapes • Integrates with Dolphin, Ortho II, and other ortho imaging programs • Upgradable to 3D at any time

For a free in-office consultation, please call

1-855-245-2908 or visit us on the web at www.planmecausa.com

ORTHOPHOS XG 3D The right solution for your diagnostic needs.

Implantologists Endodontists

Orthodontists will benefit from highquality pan and ceph images for optimized therapy planning.

will enjoy instantly viewable 3D volumetric images for revealing and measuring canal shapes, depths and anatomies.

will appreciate the seamless clinical workflow from initial diagnostics, to treatment planning, to ordering surgical guides and final implant placement.

The advantages of 2D & 3D in one comprehensive unit

General Practitioners will achieve greater diagnostic accuracy for routine cases.

ORTHOPHOS XG 3D

ORTHOPHOS XG 3D is a hybrid system that provides clinical workflow advantages, along with the lowest possible effective dose for the patient. Its 3D function provides diagnostic accuracy when you need it most: for implants, surgical procedures and volumetric imaging of the jaws, sinuses and other dental anatomy. For standard 2D images, it offers the most comprehensive selection of pan and ceph programs to meet virtually all needs, from standard panoramic programs for adults and children, to extraoral bitewing, sinus, TMJ options and many more.

Automatic patient positioning The new Auto-Positioner measures the exact tilt of the patientâ&#x20AC;&#x2122;s occlusal plane and automatically adjusts the height for an optimal panoramic image within the sharp layer, thereby preventing incorrect positioning and reducing re-takes.

For more information, visit www.Sirona3D.com or call Sirona at: 800.659.5977