Orthodontic Practice US - March/April 2014 - Vol5.2 by MedMark, LLC

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March/April 2014 – Vol 5 No 2

PROMOTING EXCELLENCE IN ORTHODONTICS

Posterior occlusal guides

The biology of orthodontic tooth movement, part 3 Dr. Michael S. Stosich

Dr. Colin Gibson

The use of Propel to increase the rate of aligner progression Dr. Thomas S. Shipley

Practice profile Dr. Stuart Frost

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Occlusal philosophy: investigating the reasons orthodontists have for occlusion preference Drs. Colin M. Webb and Donald J. Rinchuse

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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

AAO consumer messaging impacts adults’ orthodontic treatment decisions In today’s image-conscious world, professional adults who did not have the opportunity for treatment while they were growing up are flocking to orthodontic offices. These new orthodontic patients are happy with their results posttreatment, according to a recent American Association of Orthodontists (AAO) survey of individuals who, as adults, had orthodontic treatment provided by orthodontists: • Of adults surveyed, 75% reported improvements in career or personal relationships, which they attributed to their improved post-orthodontic treatment smiles. • Citing newfound self-confidence, 92% of survey respondents say they would recommend orthodontic treatment to other adults. The AAO recently debuted a public relations initiative, the Adult Patient Hall of Fame. The Hall of Fame celebrates the choices of adult professionals who have compelling stories and who pursued orthodontic treatment from AAO member orthodontists. Inductees include Amielle Zay Abshire, a private jet pilot in her early 30s who flies celebrity and high-profile passengers around the world and wanted to greet them with a wonderful smile. Another inductee, Dr. Steven Couch, is an ophthalmologist affiliated with Washington University in St. Louis, one of the most prestigious medical centers in the country. Dr. Couch did not have orthodontic treatment as a youngster, and in his early 30s felt the time was right. The number of adult orthodontic patients increased 14% from 2010 to 2012, to a record high of 1,225,850 patients ages 18 and older. More men are also opting for orthodontic treatment. As of 2012, 44% of adult patients were male, a 29% increase as compared to 2010 survey results. These data are from the 2012 AAO’s “The Economics of Orthodontics” survey. The AAO is working to ensure that all adults who are candidates for orthodontic treatment seek out qualified orthodontists when they are ready to begin. The AAO Consumer Awareness Program, which began in 2006, has utilized national advertising in all types of media, as well as public relations campaigns and social networking initiatives, to educate the consumer as to the orthodontist’s unique qualifications. In 2012, the Consumer Awareness Program expanded its focus beyond reaching parents of children and teens to messaging and media placements intended for adults who could benefit from treatment. Ads from the 2012-2013 My Life. My Smile. My Orthodontist.® campaign appeared in national media outlets in the United States and Canada and regional outlets in Puerto Rico. The ads continued the core message that orthodontists are specialists with advanced training in straightening teeth and aligning jaws, with many of the ads showcasing adult patients. The 2013-14 My Life. My Smile. My Orthodontist.® campaign is taking a similar approach and will reach nearly 350 million consumers by this summer. Adult patients are also profiled in a series of professionally produced testimonial videos that the AAO makes available for member use and are showcased on the AAO consumer website — mylifemysmile.org. Data indicate that the My Life. My Smile. My Orthodontist.® campaign is having a positive impact on adult patient decisions about orthodontic treatment. In 2010, Millward Brown, a research company retained by the AAO, began conducting consumer research designed to track consumer decisions about orthodontic treatment before and after the launch of the My Life. My Smile. My Orthodontist.® campaign in 2012. Adults wearing braces and receiving treatment from orthodontists increased from 76% in 2011 to 83% in the third quarter of 2013. Adults utilizing clear aligners and receiving treatment from orthodontists increased from 56% to 59% during the same time period. The Adult Patient Hall of Fame and other current initiatives were designed to help expand these positive trends. Materials from the My Life. My Smile. My Orthodontist.® campaign are not just for use by the AAO. They are also available to develop customized advertising for member practices and/ or for use on member websites and social media pages. Many AAO members use association materials in local promotion of their practices. Dr. James “Jep” Paschal, current chair of the AAO Council on Communications, recently offered some insightful remarks on this topic. “The value of the Consumer Awareness Program (CAP) program for the individual orthodontist is more than just marketing your practice, although the materials are often very effective for that purpose,” said Dr. Paschal. “It provides an opportunity to reinforce the AAO’s national campaign and help shape the thinking of the public so that when people think of orthodontic treatment, they automatically think of an orthodontist.” To learn more about the AAO Consumer Awareness Program and customizable marketing materials, visit the AAO member website www.aaoinfo.org. Dr. Gayle Glenn Gayle Glenn, DDS, MSD, has an orthodontic practice in Dallas, Texas, and is president of the American Association of Orthodontists.

Volume 5 Number 2

INTRODUCTION

March/April 2014 - Volume 5 Number 2

TABLE OF CONTENTS Clinical Posterior occlusal guides Drs. Larry W. White and Kim Fretty discuss simple, inexpensive, and patient-friendly supplements to the Class II corrector armamentarium ................................................... 18

Practice profile

Dr. Stuart Frost

Research Evaluating the diagnostic value of lateral cephalogram radiographs Drs. Jay V. Patel, Harold Slutsky, Jeffrey Godel, Jie Yang, and James J. Sciote study the necessity of lateral cephalograms for orthodontic diagnosis .................................... 28

Technology, creativity, and patient care are hallmarks of Dr. Frostâ&#x20AC;&#x2122;s practice

Occlusal philosophy: investigating the reasons orthodontists have for occlusion

Drs. Rohit C.L. Sachdeva, Steve Moravec, and Takao Kubota discuss the application of SureSmileÂŽ technology in the management of patients presenting with Class 2 malocclusions

preference Drs. Colin M. Webb and Donald J. Rinchuse delve into functional occlusal schemes ....................... 32

Orthodontic concepts Management of Class 2 non-extraction patients: part 8

ON THE COVER Cover photo courtesy of Dr. Thomas S. Shipley. Article begins on page 52.

2 Orthodontic practice

Volume 5 Number 2

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TABLE OF CONTENTS

Case study ClearCorrect™ correction of a Class I impinging deep bite with crowding Dr. Colin Gibson presents a case that previously would need fixed-appliance therapy .........................................37

Banding together Thu’s story After 2 decades, a postcard from a former patient proves to Dr. Jerry Clark that changing a smile also changes a life................................40

Product profile New innovations from Ormco Corporation.................................42

Continuing education Buccolingual inclinations of maxillary and mandibular first molars in relation to facial pattern Drs. Lindsay E. Grosso, Morgan Rutledge, Donald J. Rinchuse, Doug Smith, and Thomas Zullo investigate buccolingual inclinations of patients with dolichofacial, brachyfacial, and mesofacial vertical facial growth patterns ........................................43 The biology of orthodontic tooth movement part 3: the importance of magnitude Dr. Michael S. Stosich delves into the clinical consequences of force magnitude.....................................50 4 Orthodontic practice

Buccolingual inclinations of maxillary and mandibular first molars in relation to facial pattern

Product insight The use of Propel to increase the rate of aligner progression Dr. Thomas S. Shipley discusses increasing the bone remodeling rate for more rapid aligner progression .....................................................52

Practice management 3 reasons you need to re-evaluate your digital marketing strategy Diana Friedman discusses ways to keep online marketing strategies fresh .....................................................60

Service profile

Industry news

Who is ”minding the store” of your practice?.....................................58

Groundbreaking clinical trial evaluates faster tooth movement with clear aligner treatment using AcceleDent® OrthoAccel® Technologies, Inc., enrolls first patients to start 12-week orthodontic evaluation...................64

Materials & equipment .....................59

Volume 5 Number 2

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PRACTICE PROFILE

Dr. Stuart Frost What can you tell us about your background? My father was a dentist, and my twin brother and I would go down to his office when we were teenagers and fool around in his dental lab. We knew we would be dentists when we graduated from high school. I have three brothers-in-law that are dentists as well. After graduating from dental school at the University of the Pacific School of Dentistry (UOP), I worked with my father for 5 years before going back to school. I spent a year doing a TMJD fellowship in Rochester, New York. I learned how to read MRIs and make splints to treat patients who suffered from acute and chronic pain. After that, I completed my orthodontic residency at Eastman Dental Center. I have been in practice for 13 years, and my passion is creating beautiful smiles.

Why did you decide to focus on orthodontics? I have always had a fascination with the creating process, especially in dentistry. I loved cosmetic restoration cases as a general dentist, but I wanted more. I wanted to be able to create a beautiful smile without grinding the teeth down and adding porcelain to create the smile. The other motivation for me to go into orthodontics was the fact that patients want to be at the orthodontist. They love braces, and it is fun to see them so excited about improving their smiles. Going to work each day is a pleasure! Not a downer!

How long have you been practicing, and what systems do you use? I have been practicing for 13 years with the Damon™ System.

Who has inspired you? I have been inspired by Dr. Dwight Damon and Dr. Tom Pitts. I learned early on in my career which orthodontists had the most beautiful cases. Dwight and Tom are two of the best orthodontists in the world.

What is the most satisfying aspect of your practice? The most satisfying aspect of my practice is the end result. It is very satisfying when 6 Orthodontic practice

The most satisfying aspect of my practice is the end result. It is very satisfying when treatment is finished, the final shaping of the smile and teeth are done, and seeing the patients so happy with their new smiles.

treatment is finished, the final shaping of the smile and teeth are done, and seeing the patients so happy with their new smiles.

Professionally, what are you most proud of?

System to streamline our workflow and eliminate PVS impressions, which has helped us enhance the patient experience and make our practice a state-of-the-art digital environment for efficient treatment.

I love teaching, especially love to teach the residents at UOP in the orthodontic department. I am also very proud of being able to teach other orthodontists how to be better at using the Damon System and share what I have learned over the past 13 years.

What has been your biggest challenge?

What do you think is unique about your practice?

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

Our practice treats about 50 percent adults. We pride ourselves on communicating with them. Additionally, we are now using Ormco’s Lythos™ Digital Impression

I would have become a plastic surgeon. I love helping others make positive changes in their lives, and I could have enjoyed that.

The biggest challenge in practice is the business side of orthodontics. Also, working with staff members and assembling the right team players and keeping them motivated to succeed.

Volume 5 Number 2

I still believe that the future of dentistry as a whole is bright. The future of orthodontics lies in technology. Patients are willing to pay for technology, and they recognize the practices that continually are striving to keep up on the latest advances in orthodontics.

What are your top tips for maintaining a successful practice? The most important tip for maintaining a successful practice is patient care. Not just being good at straightening teeth, but taking care of the patient from the initial phone call to the day the braces come off.

What advice would you give to budding orthodontists? I would encourage young budding orthodontists to ask themselves three questions. What kind of an orthodontist do you want to be? What kind of orthodontics do you want to do? Where do you want to be in 5 years? Write it down!

What are your hobbies, and what do you do in your spare time? I enjoy going to the lake and wake surfing. I love to golf, ride mountain bikes, and motorcycles. In my spare time, I like to watch football. OP

Top Ten Favorites 1. Beautiful smiles 2. Damon™ Q brackets 3. i-CAT® cone beam 3D imaging 4. Lythos™ Digital Impression System 5. G25 Nautique wakeboard boat 6. Cancun 7. First-class seat 8. Titleist ProV1x™ golf balls 9. Mexican food 10. Oversized recliner Volume 5 Number 2

Orthodontic practice 7

PRACTICE PROFILE

What is the future of orthodontics and dentistry?

ORTHODONTIC CONCEPTS

Management of Class 2 non-extraction patients: part 8 Drs. Rohit C.L. Sachdeva, Steve Moravec, and Takao Kubota discuss the application of SureSmile® technology in the management of patients presenting with Class 2 malocclusions Introduction The Class 2 malocclusion does not simply manifest itself as a sagittal problem of the craniofacial complex. Its etiology and manifestation is a result of a blending of a complex of elements that also have a temporal and functional component. Careful dissection, planning, and management of the contributing factors, and the three-dimensional recognition of the morphological and spatial components of the presenting malocclusion play a significant role in the efficient and effective care of these patients. Table 1 provides a list of high-level factors that need to be considered in formulating a plan of care for a Class 2 patient. The focus of this paper is limited to discussing the application of SureSmile® technology1-10 in the management of patients presenting with Class 2 malocclusions by discussing specific patient histories.

Table 1: Considerations in the management of Class 2 patient treatment

II. Application of SureSmile in treatment of patients with Class 2 malocclusion In general, SureSmile technology provides five major functionalities in aiding the orthodontist in managing the care of Class 2 patients (Sachdeva). These are:

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. Visit Dr. Sachdeva’s blog on http://drsachdevaconference.blogspot.com. All doctors are invited to join the “Improving Orthodontic Care” discussion blog. Please contact improveortho@gmail.com for access information.

8 Orthodontic practice

Table 2: Strategies for using SureSmile targeted precision therapeutics to manage the correction of a Class 2 condition in a patient (Sachdeva)

A. Decision support with 3D simulations These simulations provide a visual interface for the orthodontist to understand the severity of the presenting a problem in 3D. Furthermore, it augments the doctor’s ability to plan the nature of Class 2 correction. This may be orthopedic and or dentoalveolar in nature. The magnitude of

the correction designed in the simulation is based upon the doctor’s mental model, reality, research findings, patient’s expectations, and expected participation in care, and also the doctor’s skills. Recognition of the contributory factors that potentially aid in the correction of the malocclusion and the directionality of Volume 5 Number 2

B. Communication The visual interface provides an extremely valuable and persuasive approach to enhance the learning experience of the patient with regard to her affliction and also discusses the virtual plan in an interprofessional environment.

Figure 1: Gives an overview of the two most common Clinical Pathway Guidelines – Protocol A and Protocol B developed by Sachdeva

Figure 3: Patient BK. An example of Protocol B using a lower hybrid SureSmile archwire. Patient presents with a Class 2 subdivision 1 left. 3A. Initial intraoral photographs. 3B. An initial .017” x. 025” NiTi hybrid lower SureSmile archwire has been designed. It is active anteriorly to correct the crowding and passive in the buccal segments to hold them stable. A Forsus™ spring is being used unilaterally on the left to correct the Class 2. Similar to the lower archwire, the upper archwire is also designed as a hybrid archwire Volume 5 Number 2

C. Patient management The visual plan also provides the patient, the doctor, and the staff with a useful approach to track and manage the progress of patient care and, most importantly, to motivate the patient through the course of care.

Figures 2A-2C: Patient PK is an example of Protocol A for Class 2 correction. 2A. Initial 2B. Class 2 correction is initially achieved using conventional mechanics with the Forsus™ spring. Note the distal movement of the upper first molar to correct the Class 2 molar relationship is achieved prior to engaging SureSmile technology. Once the correction is achieved, a mid-treatment scan is taken, and a SureSmile archwire is designed to correct the residual malocclusion

Figure 4: Patient SK. 4A. Initial intraoral records show that patient presents with a Class 2 Div 1 Subdivision right. 4B. Initial panoramic radiograph

Orthodontic practice 9

ORTHODONTIC CONCEPTS

their displacement supports the clinician’s decision in selecting and designing the appropriate appliance and therapeutic approach in managing care. Additionally, various treatment scenarios may be planned, and the optimal design selected.

ORTHODONTIC CONCEPTS

5A: Patient SK. A. Virtual Diagnostic Model (VDM). (Note: The model was scanned a few months post initial photographs. The patient shows a more severe Class II relationship in the right buccal segment than is reflected In the intraoral images.)

5C: VDS shows post orthopedic correction

5B: VDM (blue) vs. VDS (white) are shown. The initial step in the Virtual Diagnostic Simulation (VDS) entailed simulating asymmetric orthopedic changes to partially correct the Class 2 on the right side while maintaining the Class 1 relationship on the left. Also, in the inset table, one notes the amount of corrective displacement required to achieve the desired orthopedic effect

5D: VDM (blue) and VDS with dentoalveolar and orthopedic changes (white). The next step in the simulation involves dentoalveolar correction of the Class 2 malocclusion. Also, note the slight archwidth changes planned to accommodate for the new mandibular position

5E: VDS shows post orthopedic and dentoalveolar correction 5F: Shows the nature and magnitude of displacements of the dentition to correct the â&#x20AC;&#x153;dental portionâ&#x20AC;? of the malocclusion

D. Targeted precision therapeutics SureSmile targeted precision appliances may be used in six different ways (Sachdeva) (Table 2) to manage the correction of the Class 2 malocclusion. E. Outcome evaluation SureSmile visual tools may also be used very effectively to measure treatment outcome and implement the findings into a continuous quality improvement initiative in the practice.

II. Clinical Pathway Guidelines for managing patients with Class 2 malocclusion Figures 6A-6C: Patient SK. 6A. Virtual diagnostic model. 6B. Shows correction of midline of VDM through orthopedic simulation 6C. The archwidths were corrected through dental movement as a continuum of orthopedic simulation 10 Orthodontic practice

Effective use of SureSmile technology mandates the management of a patient Volume 5 Number 2

In the bend resides wisdom. Dr. Eric Howard Landcaster, PA

June 2012

July 2012

August 2013

Initial intraoral.

Planned result. Upper arch treated lingually.

Final result.

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ORTHODONTIC CONCEPTS

Figures 7A-7F: Patient SK. Shows the clipping plane in different segments to show the archwidth changes in the VDS with orthopedic correction and VDS with dentoalveolar and orthopedic changes. 7A and 7D. Clipping plane at the second bicuspid level. 7B and 7E. Clipping plane at the first molar level. 7C and 7F. Clipping plane at the second molar level

by following processes that are defined by Clinical Pathway Guidelines (CPG). Exceptions to CPG occur to suit individual’s needs; however, in most situations, they provide a reasonable approach to navigate the care of a patient in a systematic and progressive manner. Common to all Clinical Pathway Guidelines (CPG) to manage patients with Class 2 malocclusion is the use of the decision support system to plan care at the onset of treatment. The type and timing in use of SureSmile precision archwires varies and is driven by the dictates of the plan (Figure 1). Class 2 Clinical Pathway Guidelines (Sachdeva) broadly fall under two categories: namely, a Protocol A and Protocol B. These are shown in Figure 1.

Figure 8: Patient SK. Shows staged linear movements used to monitor the patient’s overjet, crowding, midline correction, and archwidth changes. This is also a useful tool for the patient to monitor progress of care

Figures 9A-9B: Patient SK. 9A. Mid-treatment intraoral photos at the time of Therapeutic scan. 9B. Mid-treatment X-rays. (Note: Correction achieved with use of asymmetric Forsus™ appliance.) 12 Orthodontic practice

Volume 5 Number 2

ORTHODONTIC CONCEPTS Figures 10A-10E: Patient SK. 10A. Virtual Therapeutic Model (VTM). 10B. VTM (white) was compared with the initial VDS (green) with dentoalveolar and orthopedic changes. Both the upper and lower arch widths were expanded slightly more than planned. Note: All objectives were met as initially planned. 10C. Virtual Therapeutic Simulation (VTS) with prescription archwire designed. 10D. Prescription archwire viewed against VTS. 10E. Displacement values for VTS

Figures 11A-11C: Patient SK. 11A. Final intraoral photos at debond. 11B. Virtual Final Model (VFM). 11C. Final panoramic radiograph

Volume 5 Number 2

Orthodontic practice 13

ORTHODONTIC CONCEPTS

Figures 12A-12B: Patient SK. Outcome Evaluation. 12A. VFM (green) superimposed on the Initial VDS (white). Note: The final result is quite similar to the proactively planned treatment. 12B. VDM (green) compared with the VFM (white). Note: The asymmetric change in the mandible achieved with the unilateral use of Forsus™ helped correct the asymmetry in the buccal occlusion as well as the midline

Figures 13A-13F: Patient SK. Outcome Evaluation. 13A and 13D. Clipping plane at the second bicuspid level. 13B and 13E. Clipping plane at the first molar level. 13C and 13F. Clipping plane at the second molar level. 13A-13C. VTM (white) vs. VDS (green) and 13D-13F. VFM (white) vs. VDS (green). Note upper left segment is minimally tipped. The left side is tipped and expanded buccally more than the right side

III. Patient SK history — Protocol A The following is a description of the management of a patient presenting with a Class 2 Div 1 Subdivision right using Protocol A. Patient SK presented as a 12-year-old male pre-peak velocity. The initial records of the patient are shown in Figure 4. The SureSmile decision support system was used to design a 3D treatment plan for the patient. The plan, as shown in Figure 5, considered both orthopedic and dentoalveolar displacements. Figure 6 shows a close-up view of the midline correction and the archwidth changes as a result of both orthopedic and dentoalveolar movements. In deciding the amount of archwidth changes, one needs to consider the buccolingual axial inclinations of the molar and premolars in the buccal segments shown in Figure 7. An additional aspect in planning the care for patient SK involved developing incremental milestones to evaluate the progress of care as shown in Figure 8.

References 1. White L, Sachdeva R. Transforming orthodontics-Part 1 of a conversation with Dr. Rohit Sachdeva, Co-founder and Chief Clinical Officer of Orametrix Inc. by Dr. Larry White. Orthodontic Practice US. 2012;3(1):10-14. 2. White L, Sachdeva R. Transforming orthodontics-Part 2 of a conversation with Dr. Rohit Sachdeva, Co-founder and Chief Clinical Officer of Orametrix Inc. by Dr. Larry White. Orthodontic Practice US. 2012;3(2):6-10. 3. White L, Sachdeva R. Transforming orthodontics-Part 3 of a conversation with Dr. Rohit Sachdeva, Co-founder and Chief Clinical Officer of Orametrix Inc. by Dr. Larry White. Orthodontic Practice US. 2012;3(3):6-9.

14 Orthodontic practice

The initial treatment of the patient began with the use of a unilateral Forsus™ appliance on the patient’s right side on a near full sized .017” x .025”, Af 27ºC NiTi both in the upper and lower arch with a .018” bracket. The Class 2 correction was achieved over a period of 7 months. At this time, records were taken to initiate the SureSmile process (Figure 9). The patient was scanned for the Virtual Therapeutic Model (VTM), and a Virtual Therapeutic Setup (VTS) was designed (Figure 10). Both upper and lower .017” x .025”, Af 35ºC NiTi SureSmile prescriptive archwires were installed 8-weeks post Therapeutic scan and backed up with light Class 2 elastic wear. (The wire should have been installed a month earlier, but this was not possible because the patient missed an appointment.) The SureSmile active treatment phase lasted 3 months, and the patient was debonded 4 months from the initial installation of the SureSmile archwires. An outcome evaluation for the patient was performed by superimposing the

4. 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. 5. 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. 6. Sachdeva R, Kubota T, Hayashi K. BioDigital orthodontics: Management of space closure in Class I extraction patients with SureSmile: Part 7. Orthodontic Practice US. 2014;5(1):14-23. 7. Sachdeva R. BioDigital orthodontics: Designing customized therapeutics and managing patient treatment

models representing different shown in Figures 12 and 13.

stages

Conclusions Effective management of Class 2 correction requires careful planning and execution. SureSmile technology provides a valuable technology platform to extend the skill sets of an orthodontist to accomplish these goals. Future papers will discuss a spectrum of patient histories showing the versatility of using SureSmile technology in treating patients with Class 2 malocclusions governed by the philosophy and principles of BioDigital Orthodontics.

Acknowledgments The authors thank both Dr. Sharan Aranha and Maya Sachdeva for the preparation of this manuscript. The authors are also grateful to Peter Kierl, DDS, MS, Ortho (Edmond, Oklahoma); and Darrell Schmidt, DDS, MS, Ortho (Rhinelander, Wisconsin) for sharing some of their patient records. OP

with SureSmile technology: part 2. Orthodontic Practice US. 2013;4(2):18-26. 8. Sachdeva R. BioDigital orthodontics: Diagnopeutics with SureSmile technology: part 3. Orthodontic Practice US. 2013;4(3). 2013;4(3):22-30. 9. Sachdeva R. BioDigital orthodontics: Outcome evaluation with SureSmile technology: Part 4. Orthodontic Practice US. 2013;4(4):28-33. 10. Sachdeva R. BioDigital orthodontics: Planning care with SureSmile Technology: Part 1. Orthodontic Practice US. 2013;4(1):18-23.

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CLINICAL

Posterior occlusal guides Drs. Larry W. White and Kim Fretty discuss simple, inexpensive, and patient-friendly supplements to the Class II corrector armamentarium Posterior occlusal guides Abstract Class II malocclusions make up a large part of the difficult orthodontic maladies that clinicians must correct. Traditional techniques, such as elastics, headgears, and removable functional appliances, have recently been supplanted with so-called noncompliant appliances that are fixed in the mouth, requiring patients to use them 24 hours per day. While these fixed appliances have had remarkable success, the non-acceptance by many patients, the frequent breakage, and considerable cost have discouraged many orthodontists from routinely using them. Posterior occlusal guides (POGs) offer a simple, inexpensive, and patient-friendly supplement to the Class II corrector armamentarium.

Introduction For several decades, European orthodontists successfully used removable functional appliances far more extensively than their American counterparts for the treatment of Class II malocclusions. This was probably due to the fixed appliances that appealed more to early leaders in American orthodontics, such as E.H. Angle and Calvin Case. Over the past 4 decades, European clinicians have endorsed fixed appliances far more than in the past.

Larry W. White, DDS, MSD, graduated from Baylor Dental College and then served for 2 years in the U.S. Air Force Dental Corps. He returned to Baylor Dental College and received a graduate degree in orthodontics, and then practiced in Hobbs, New Mexico, for 31 years. He was the first director of the University of Texas Health Science Center in San Antonio’s orthodontic residency program. Dr. White has published more than 100 professional articles, authored several books about orthodontics, and edited numerous professional publications. He is a Diplomate of the American Board of Orthodontists and a Fellow in the American College of Dentists. Dr. White has authored over 100 clinical articles, lectured in 35 countries, and was editor of the Journal of Clinical Orthodontics for 17 years. Kim Fretty, DDS, is a senior resident at Texas A&M University, Baylor College of Dentistry, Dallas, Texas.

18 Orthodontic practice

Figure 1: Note the clear Triad occlusal overlay on the mandibular premolar that reinforces posterior anchorage during space closure

Figure 2: Schematic of original Class II subdivision malocclusion with midline deviation

Figure 3: Posterior teeth with Triad Gel templates that advance the mandible unilaterally and correct the midline, overjet, and overbite

Figure 4: Left occlusal template removed to allow dentoalveolar adaptation

Figure 5: Right occlusal template removed when midline and occlusion stabilize

Figure 6: Triad Gel

Although removable functional appliances have seemingly lost much of their appeal throughout the world, those of the fixed variety enjoy remarkable popularity, e.g., Herbst1, MARA2, MPA3, Forsus4, and so on. The fixed functional appliances’ large allure rests upon their cemented attachments that must remain in the mouth. Doctors have enjoyed using these since they obligate patients to wear them until corrections take place. Because of this feature, they have acquired the cognomen of noncompliant appliances. However, anyone who has treated orthodontic patients for a minimum of time knows that

a high level of compliance is needed for patient acceptance of the noncompliant mechanisms. There is nothing a clinician can put in patients’ mouths that they cannot remove — one way or another. Although many patients have used these noncompliant apparatuses successfully, there are large numbers that have refused to use them or have succeeded in developing into “serial destroyers.” These latter patients break so many appliances that it finally results in doctors seeking alternate therapies. Several features of noncompliant appliances bear responsibility for patient non-acceptance: Volume 5 Number 2

CLINICAL

Figure 7: Triad leaf

Figure 8: Original Class II subdivision with a midline discrepancy

Figure 9: Class II subdivision with midline, overjet, and overbite corrected and Triad Gel added to the occlusal surfaces of the mandibular left posterior teeth

Figure 10: Completed therapy with corrected midline, overjet, overbite, and Class I occlusion on both sides

Figure 11: Typical Class II mixed dentition

Figure 12: Maxillary primary second molar removed to accommodate mandibular template

Figure 13: Maxillary primary second molar sliced to accommodate mandibular template

Figure 14: Mixed dentition malocclusion

Figure 15: Left side with primary molar removed and template in place

• the size and bulk of the appliances • the connection that keeps the maxillary and mandibular irretrievably connected • the interference with normal chewing for several weeks • the unnatural and therapeutic bite it forces on the patient • parental objections regarding the restricted movements of the appliances Even with their recent popularity among orthodontists, these Class II appliances have a number of negative features that discourage doctors’ use: • cost of the appliances • need of a laboratory procedure • patient and parental complaints • patient refusal to wear after placement • patient breakage of the appliances • anterior displacement of the mandibular

dentition Clearly, an alternative to the current fixed functional appliances that is more patient friendly and easier for the orthodontic clinician to apply would be welcome. As with many discoveries in life, a serendipitous development has opened new and effective possibilities for Class II corrections that can be used both unilaterally and bilaterally.

reposition the mandible and correct slight midline deviations, overjet and overbite discrepancies along with Class II subdivisions by building up the posterior teeth with Triad Gel while holding the mandible in the new position that corrected the midline, overbite, and overjet (Figures 2-7). Light-cure Triad Gel is supplied in a tube with a variety of colors, but many who use this technique prefer a more viscous product. Other clinicians express a preference for the Triad material that comes as a sheet and is commonly used to make Hawley retainers or splints. The sheet’s viscosity prevents it from spreading uncontrolled and gives the operator more time to review its placement before curing with the light. Either of these Triad materials

20 Orthodontic practice

Theory, technique, and therapeutic examples Dr. Birte Melsen and Dr. Giorgio Fiorelli5 were using Triad® Gel (Dentsply) to augment anchorage by increasing occlusal pressure on the anchor or reactive part of the orthodontic appliance (Figure 1) when Dr. Fiorelli6 discovered he could

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1. Data on file. 2. Initial treatment plan and first refinement, if needed.

CLINICAL

Figure 16: Occlusal view of clear Triad Gel templates

Figure 17: Maxillary occlusal view showing sliced primary molar

POG technique and application The following Class II subdivision patient will illustrate one technique for applying POGs (Figures 18-21).

Figure 18: Self-etching sealant used for a shallow etch. A deep etch makes the removal of Triad more difficult

Figure 19: Self-etching sealant mixture for application to the occlusal surfaces of the mandibular posterior teeth

Figure 22: Patient with a Class II subdivision malocclusion and an anterior crossbite of tooth 2.2

will form a useful occlusal guide, and the selection will depend on the clinician’s experience and choice. Other materials, such as bonding composites, glass ionomer cements, and others, can also serve successfully for POGs. The posterior occlusal guides, which Dr. Fiorelli fortuitously developed, act somewhat akin to fixed functional appliances that can cause temporomandibular fossae and dentoalveolar remodeling7-9. He reveals this strategy with the following images of patient therapy (Figures 8-10). 22 Orthodontic practice

Figure 20: Curing of Triad Gel. Note the anterior incisal wax bite to hold corrected bite steady during the light cure

Figure 21: Cured Triad Gel on the mandibular molar occlusal surface. Note the maxillary molar indentations of the altered bite

Figure 23:. Before treatment, cephalometric tracing and the Visualized Treatment Objective (VTO) illustrates the needed incisor positioning (cross-hatched teeth). Maxillary incisors are exactly on the A Line and need only slight torquing to achieve an ideal position and a slight extrusion. The mandibular incisors need a slight protraction and intrusion for ideal incisal position

Interestingly, a colleague of Dr. Fiorelli, Dr. Paola Merlo6, expanded on this idea of posterior occlusal guides and came up with a brilliant idea for intercepting Class II malocclusions in the mixed dentition. She either removes or slices the distal portion of the maxillary second primary molar, which allows her to build up a template of Triad Gel on the lower dentition that encourages the mandible to slide forward. Figures 1117 illustrate how she guides these patients into Class I occlusion.

Patient therapy The images shown in this article display a sequence of photos during the orthodontic therapy for a Class II subdivision patient using Posterior Occlusal Guides (POGs). The patient’s models display a firm Class I occlusion on the right side, a Class II occlusion on the left side, a lingually displaced maxillary left lateral incisor in crossbite, and a maxillary midline deviation to the left. The patient used .022 Insignia™ brackets supplied by Ormco™. Ostensibly, the Insignia formula builds first, second, and third order Volume 5 Number 2

CLINICAL

Figure 24: Models of Class II subdivision patient

Figure 25: Patient at treatment initiation with Triad POGs

Figure 26: Patient with POGs after 1 month of therapy

Figure 27: Patient with POGs after 2 months of therapy

Figure 28: Patient with POGs after 3 months of therapy

Figure 29: Patient with POGs after 4 months of therapy. No elastics have been used

movements within the brackets and also supplies customized arch wires for the patient. Figure 22 illustrates the original malocclusion, while Figure 23 displays the initial cephalometric tracing combined with the Visualized Treatment Objective (VTO). The VTO shows that the maxillary incisors lie exactly on the A Line10 and need no facial or lingual movement with only a slight amount of torque to correctly position the roots and crowns; and they need only slight extrusion. The lips have contours that closely conform to the Holdaway ideals.11,12 The mandibular incisors can move facially a slight amount with minimum intrusion. Figures 24-31 show a series of photos from the initiation of treatment through completion of therapy. It took 4 months for the Class II side to correct into a Class I. No typical Class II mechanics, e.g., elastics, 24 Orthodontic practice

functional appliances, or headgears were used during this first phase of treatment. The patient used light Class II elastics on the left side for a couple of months near the end of therapy, but no other Class II mechanics were used at any point. Figures 32A and 32B illustrate the after cephalometric tracing and the superimposition of the before treatment and after treatment cephalometric tracings. The superimpositions were made by superimposing on the line S-N at the most anterior part of the sella turcica as suggested by Melsen.5 Some mandibular terminal growth is expressed by a downward and forward movement. The maxillary incisors extruded and essentially stayed in place anteriorly-posteriorly. The mandibular incisors intruded but stayed in place anteriorly-posteriorly. The maxillary molars moved forward slightly but did

not extrude, while the mandibular molars showed little movement at all. Although the maxillary and mandibular incisors moved more than the VTO forecast, the extrusion and position of the maxillary incisors were the movements indicated by the prediction as was the slight amount of crown inclination. The mandibular incisors did not display the slight forward movement forecast by the VTO, but they did intrude as needed. The lips remained essentially unchanged and conform to the Holdaway norms for Caucasian females.

Discussion and conclusion These therapies show the potential and effectiveness of posterior occlusal guides, and their ease of application should soon result in their adaptation by many orthodontic clinicians. Compared with any of the available functional Class II correctors Volume 5 Number 2

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CLINICAL

Figure 30. Final photos of corrected Class II subdivision malocclusion

Figure 32A: After treatment cephalometric tracing

Figure 32B: Before and after treatement cephalometric superimpositions

or other Class II therapies, POGs offer several advantages such as the following: • ease of application • avoidance of impressions and a subsequent lab technique • relatively low cost of application • less interference with mastication • their fixed nature that does not rely on patient compliance • durability and resistance to breakage • no restrictive mechanistic connection between the maxilla and mandible • lack of mandibular restriction • lack of bulky gadgetry • less breakage and fewer patient complaints • greater patient acceptance • simple repairs, alterations, and removals Although its disadvantages seem few, here are the most notable: • their need to be replenished and supplemented as the mandible retracts • their need of occlusion to function • their lack of constant pressure as provided by many functional appliances The limited and isolated therapies displayed in this paper don’t provide ironclad affirmation for their inclusion in the orthodontic armamentarium. But it is difficult to avoid the conclusion that difficult problems seem to resolve with their use. 26 Orthodontic practice

Figure 31: Before and after photos of patient treated with POGs

At this time, no collection of treated patients exists. Without such a reservoir of POG therapies, their effects will require conjecture and some extrapolation. Specifically, we need to know if they anteriorly displace the mandibular dentition, retract the maxillary molars, change the occlusal plane, extrude the maxillary incisors, bend the mandible, or remodel condyles among other inquiries.13 In all probability, they should function much as other noncompliant Class II correctors, i.e., primarily by dentoalveolar changes. Recently, a published study on Class II subdivision malocclusions found that these rather common orthodontic challenges do have significant skeletal and dental discrepancies between the Class I and Class II sides, but that two-thirds of the asymmetry is dentoalveolar.14 This suggests that POGs will work primarily by rearranging the dentition through dentoalveolar remodeling with these malocclusions. Fortunately, the POGs represent the least invasive Class II corrector in existence. Patient acceptance is excellent, and none has reported any discomfort. Since they are bonded to mandibular posterior teeth, they work 24 hours a day, which accounts for their efficiency and effectiveness. Any breakage repairs quickly and easily. Just as with other functional appliances, POGs need additions occasionally as they affect their changes. But the added Triad bonds easily to the original by simply priming the cured material with a bonding sealant before light curing — but only after reassuring the overbite, overjet, and midline. Upon removal, the occlusal spaces once occupied by the POGs quickly resolve by the subsequent eruption of the involved posterior teeth. Compared with other Class II

correctors, they seem to have few disadvantages, but this is early into their introduction, and it will take more experience with more clinicians to discover their limitations and specific applications. OP

References 1. Pancherz H. Treatment of class II malocclusions by jumping the bite with the Herbst appliance. A cephalometric investigation. Am J Orthod. 1979;76(4):423-442. 2. Eckhart JE, White, L.W. Functional Nonextraction Treatment. Clinical Impressions. 2009;17(1):32-34. 3. Coelho Filho CM. Mandibular protraction appliances IV. J Clin Orthod. 2001;35(1):18-24. 4. Jones G, Buschang PH, Kim KB, Oliver DR. Class II non-extraction patients treated with the Forsus Fatigue Resistant Device versus intermaxillary elastics. Angle Orthod. 2008;78(2):332-338. 5. Melsen B, Fiorelli G. Biomechanics in Orthodontics. Denmark: Aarhus; 2013. 6. White LW. Orthodontic Pearls, A Clinician’s Guide. Dallas, TX: Taylor Publishing Co.; 2012. 7. Voudouris JC, Woodside DG, Altuna G, Kuftinec MM, Angelopoulos G, Bourque PJ. Condyle-fossa modifications and muscle interactions during herbst treatment, part 1. New technological methods. Am J Orthod Dentofacial Orthop. 2003;123(6):604-613. 8. Woodside DG, Altuna G, Harvold E, Herbert M, Metaxas A. Primate experiments in malocclusion and bone induction. Am J Orthod. 1983;83(6):460-468. 9. Woodside DG, Metaxas A, Altuna G. The influence of functional appliance therapy on glenoid fossa remodeling. Am J Orthod Dentofacial Orthop. 1987;92(3):181-198. 10. Alvarez A. The A line: a new guide for diagnosis and treatment planning. J Clin Orthod. 2001;35(9):556-569. 11. Holdaway RA. A soft-tissue cephalometric analysis and its use in orthodontic treatment planning. Part I. Am J Orthod. 1983;84(1):1-28. 12. Holdaway RA. A soft-tissue cephalometric analysis and its use in orthodontic treatment planning. Part II. Am J Orthod. 1984;85(4):279-293. 13. Cozza P, Baccetti T, Franchi L, De Toffol L, McNamara JA Jr. Mandibular changes produced by functional appliances in Class II malocclusion: a systematic review. Am J Orthod Dentofacial Orthop. 2006;129(5):599, e1-12, e1-6. 14. Minich CM, Araújo EA, Behrents RG, Buschang PH, Tanaka OM, Kim KB. Evaluation of skeletal and dental asymmetries in Angle Class II subdivision malocclusions with cone-beam computed tomography. Am J Orthod Dentofacial Orthop. 2013;144(1):57-66.

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RESEARCH

Evaluating the diagnostic value of lateral cephalogram radiographs Drs. Jay V. Patel, Harold Slutsky, Jeffrey Godel, Jie Yang, and James J. Sciote study the necessity of lateral cephalograms for orthodontic diagnosis Abstract Introduction: There remains a discord among orthodontists regarding the usefulness of a lateral cephalogram radiograph as a part of diagnostic records for treatment planning. Today, orthodontists take diagnostic lateral cephalograms largely based on a personal preference, rather than following any evidence-based approach for determining whether taking the radiograph will affect treatment planning. The aim of this study is to identify patients with the type of malocclusion for which the availability of a lateral cephalometric radiograph will affect the treatment plan. This would prevent patients whose treatment plan would not benefit from a diagnostic lateral cephalogram from receiving unnecessary ionizing radiation. Methods: The data for this study were obtained from responses to two questionnaires, conducted 5 weeks apart, to 5 orthodontists with clinical experience. Primarily, the orthodontists were required to treatment plan 20 cases, twice, once with full diagnostic records, including a lateral cephalometric radiograph, and once without. Results: Based on the data, it was found that for about 67% of patients who had a

Jay V. Patel, DMD, MS, is in private practice in Atlanta, Georgia. Dr. Patel conducted this project for fulfillment of the Masterâ&#x20AC;&#x2122;s Degree in Oral Biology at Temple University Graduate School during his orthodontic residency last year. Harold Slutsky, DMD, is an Adjunct Clinical Professor of Orthodontics at the Kornberg School of Dentistry, Temple University, Philadelphia, Pennsylvania. Jeffrey Godel, DDS, is Interim Chair of Orthodontics, Department of Orthodontics, Kornberg School of Dentistry, Temple University. Jie Yang, DMD, MS, is Chair of Oral and Maxillofacial Radiology, Kornberg School of Dentistry, Temple University. James J. Sciote, DDS, MS, PhD, is Professor of Orthodontics, Kornberg School of Dentistry, Temple University.

28 Orthodontic practice

lateral cephalometric radiograph taken that this X-ray does affect the treatment plan. These patients presented with bilateral, sagittal dental malocclusions, matching significant soft-tissue profile disharmony and at least one arch with a moderate arch length discrepancy. Conclusions: A larger follow-up study is suggested to further investigate the relationship between malocclusion, lateral cephalometric radiographs, and treatment planning.

Introduction and literature review The American Association of Orthodontists has provided a set of clinical practice guidelines that include a recommendation for which pretreatment diagnostic records should be taken prior to comprehensive orthodontic treatment. This â&#x20AC;&#x153;gold standardâ&#x20AC;? for diagnostic records consists of intraoral and extraoral photographs, dental casts, intraoral and/or panoramic radiographs, and cephalometric radiographs and/ or cone beam computed tomography (CBCT).1 However, some studies have demonstrated that the efficacy of diagnostic cephalometric radiographs to treatment plan orthodontic cases is not proven.2,3 While some suggest that lateral cephalograms provide useful diagnostic information for certain types of malocclusions, there is no evidence that routine use on all patients is necessary.4 At present, there is no basis for a cost-benefit analysis for the routine use of cephalometric radiographs with regard to their effect on quality of treatment or predictability of results.5 Therefore, there is a large degree of uncertainty among orthodontists as to when cephalometric radiographs are needed. Questions that surround the efficacy of clinical diagnosis and treatment may be answered by epidemiological studies, but such research has not been conducted for orthodontics. There is a lack of evidence to support the routine acquisition of lateral cephalograms, even though they appear to be diagnostically critical in certain cases.4 Dental X-rays comprise the most

Yes Total

100

80% of the time needed

100

67% of the time needed

Table 1: Need for cephalogram for diagnosis 20 cases reviewed by five orthodontists T1 = cephalogram available T2 = no cephalogram 5 weeks later

frequent artificial source of ionizing radiation to people living in the United States.6 Ionizing radiation causes the production of micronucleated cells, which have been linked with an increased risk of cancer.7 Any given dose of ionizing radiation may cause cancerous changes, and no dose threshold exists below which radiation is known to be predictably safe.8 Exposure to ionizing radiation is the most consistent environmental risk factor currently known for meningioma, and dental radiographs could be associated with an elevated risk to develop intracranial meningioma, especially in young patients on whom X-rays are taken frequently.6 It is difficult to demonstrate a clear cause-and-effect relationship between dental X-rays and malignancy due to the extended latent period, which can extend from 10 to 20 years.1 There is, however, a general consensus that clinicians should be selective as to which radiographs they take on patients. Each X-ray provides information that benefits the diagnosis and treatment plan.8,9,10 These considerations are all the more poignant with increased public attention on the potential danger of dental radiographs. Such is the case in recent years with a highly publicized article in The New York Times and research that links dental radiographs with meningioma.7 Our purpose of this study is to determine the necessity of lateral cephalograms for orthodontic diagnosis. We surveyed five orthodontists on the need for a lateral cephalogram to determine diagnosis and treatment plan. Volume 5 Number 2

Methods and materials Twenty patients were selected from the orthodontic private practice of Harold Slutsky, DMD. For a period of several months, Dr. Slutsky evaluated the orthodontic records of new patients to determine, in his opinion, if a lateral cephalogram was necessary for diagnosis and treatment. Patients were classified into two groups, either in need of the radiograph or not. From this list, 20 random patients were selected for study, with 10 from each group. Subjects selected for this study ranged in age from 9-26 years, had full permanent dentitions, and were treatment planned for comprehensive fixed orthodontic therapy. Diagnostic records consisted of the following: 1. plaster cast orthodontic study models trimmed to the American Board of Orthodontics specifications 2. photographs, which included five intraoral photographs, including left, center, and right intraoral views, as well as maxillary and mandibular occlusal views; and three extraoral photographs, which included facial profile, full face smile, and full face somber 3. panoramic radiograph 4. lateral cephalogram that was traced and had a digitized cephalometric analysis The plaster casts were scanned to produce a virtual copy. All records were stored in digital formats for diagnostic evaluations in the study. Five orthodontists from private practice with a minimum of 5 years of clinical practice experience were chosen to participate in the study. These practitioners had different educational backgrounds and years of experience to represent a cross section of orthodontists. University Institutional Review Board approval and informed consent from the orthodontists for their participation as study subjects were obtained. After consent, each orthodontist was sent the de-identified record sets of the 20 patients and asked to complete a few diagnostic questions for each patient (Table 1). After a period of 5 weeks, the orthodontists were asked the same questions; however, at the second time point, the lateral cephalogram and digitized cephalometric analysis were omitted. For the second evaluation, the order of the 20-subject record sets was scrambled.

RESEARCH

This approach helped us identify certain types of malocclusions for which this radiograph was not needed.

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Statistical analysis A McNemar test was used to determine if there was a significant change in the perceived need for a cephalogram between T1 and T2. A nested, random effects model was used to determine if there is any significant change in treatment plan, controlling for the availability of a cephalogram

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

10243 OR DI AD 0114

Orthodontic practice 29

Volume 5 Number 2 8765_Bundle ad-Ortho-3.8x10.7_02.indd 2

1/2/14 2:39 PM

orthodontist decision

RESEARCH

T1 1 2 3 4 5

1 y y y n y

2 y y y y y

3 y y y y y

4 n y y n y

5 n y y y y

6 y y y y y

7 n n y y y

8 y y y n y

9 y y y y y

T2 1 2 3 4 5

1 n n y n y

2 y y y y y

3 y y y y y

4 n n y n n

5 n n n y y

6 y y y y y

7 n n y n y

8 y n y y y

9 n y y y y

Patient Number 10 11 12 n y y y y y y y y y y y y y y 10 n n y y y

11 y y y n y

12 y y y y y

13 n n n n y

14 n y y y y

15 y y y y y

16 n y n y n

17 n y n n y

18 y y y y y

19 y y y y y

20 n y n y y

13 n n y n y

14 n y y y y

15 y y y y y

16 n n n n n

17 n n n n n

18 y y y y y

19 y y y y y

20 n y y y y

Table 2: Need for cephalogram at T1 or T2

Figure 1: Pretreatment composite photographs for Patient 12. 12-year 3-month Hispanic, Skeletal Class II, dental Class II

Figure 2: Pretreatment composite photographs for Patient 18. 10-year 11-month Hispanic, Skeletal Class I, dental Class III

Figure 3: Pretreatment composite photographs of Patient 17. 10-year 10-month Hispanic, Skeletal Class II, dental Class I

between T1 and T2. Chi-square analysis and an inter-class correlation coefficient were used to show any statistically significant difference in treatment plan between orthodontists.

grams were always needed are illustrated by patients number 12 and 18. Patient 12 was diagnosed with a Class II malocclusion due to a retrognathic mandible. In addition, the vertical dimension expressed a short lower face height, which creates a palataly impinging overbite with pronounced mandibular incisor crowding (Figure 1). Patient 18 was diagnosed with a Class III malocclusion with an anterior crossbite and impacted maxillary right canine (Figure 2). An example of where a cephalogram was not needed is illustrated by patient number 17. He was diagnosed with a Class I malocclusion with maxillary diastema, mild mandibular incisor crowding, and mild mandibular posterior spacing (Figure 3).

was not necessary for treatment planning when it was not part of diagnostic records. The orthodontists we surveyed decided that cephalograms were usually necessary to make diagnostic decisions for patients who had Class II and Class III malocclusions (Figures 1 and 2). Class I malocclusions with minor dental irregularities were most often identified to not need a cephalogram for diagnosis (Figure 3). Since only five orthodontists were surveyed, no definitive conclusions can be drawn without larger sample sizes. However, the data do suggest that there are characteristic presentations of malocclusions for which cephalometric diagnostic information is not necessary to arrive at a treatment plan. It is important to extend this study to include larger patient numbers and orthodontic participants to address the question of when cephalometric radiographs are necessary, given the potential biologic risk inherent in ionizing radiation. From epidemiologic surveys conducted on the incidence of malocclusion, it is known that approximately 60% of malocclusions are Class I.11 If we can identify the facial and dental characteristics of malocclusions that do not require cephalometric radiographs, we can reduce radiation exposure and risk for ionizing radiation in some patients. In

Results The orthodontists made decisions regarding diagnosis and treatment with (T1) and without (T2) lateral cephalograms and tracings. We compared differences in their opinions regarding the necessity of lateral cephalograms and tracings to formulate treatment plans at the two time points. At T1, 80% of the time cephalograms were considered necessary, and at T2, 67% of the time cephalograms were necessary (Table 1). A McNemar test determined that there was a significant change (chi-square = 9.00, p = 0.002) in the perceived need for a cephalogram between T1 and T2. At T2, when cephalograms were not available, there was slightly greater perception that the radiographs were not necessary. Patterns emerged in the responses at the two time points. For some of the patients, cephalograms were always necessary at T1 and T2, while for others patients, cephalograms were often not necessary at T1 and never necessary at T2 (Table 2). Examples of patients where cephalo30 Orthodontic practice

Discussion A survey of five orthodontists at two time points with 20 sets of records for orthodontic treatment demonstrated that the majority of diagnosis and treatment planning decisions require the use of a lateral cephalogram. However, 20% to 33% of the time, cephalograms were not necessary. There was also a significant difference in the need for cephalograms if present, or absent, at the time of clinical decision making. Orthodontists were more inclined to feel that a lateral cephalogram

Volume 5 Number 2

RESEARCH

order to estimate the number of patients that could be included in this group, future studies should have a distribution of malocclusion classifications that is representative of malocclusion incidence in the general population. A continued interest in research similar to this study will be of great benefit to the well-being of orthodontic patients and may help change orthodontists’ misconceptions about when and why to take lateral cephalograms. It is believed that a large number of orthodontists routinely take these radiographs on all patients as a type of defensive medicine. For these orthodontists, the lateral cephalogram is taken so that, in case of a medical malpractice claim, they will not be accused of failing to meet the standard of care. Unfortunately, since it is not taken for medical necessity, trusting patients are exposed to ionizing radiation for the wrong reasons.

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Conclusions • Cephalograms are needed for orthodontic diagnosis and treatment in a majority of cases. • Up to 33% of patients did not require cephalograms for diagnosis and were characterized with Class I malocclusions and minor dental irregularities. • A larger follow-up study is needed to further investigate the relationship between malocclusion, lateral cephalogram radiographs, and treatment planning. • In the future, it should be possible to identify a group of subjects for whom lateral cephalograms will not be necessary, which will decrease the risk of ionizing radiation.

Acknowledgments We gratefully acknowledge the five orthodontists who participated in this study and research assistant, Damian Mariano, who assisted in all aspects of this study in its entirety. The authors have no financial, economic, or professional interests that have influenced positions presented in this article. OP

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References 1. American Association of Orthodontists. Clinical Practice Guidelines for Orthodontics and Dentofacial Orthopedics. St. Louis, MO: American Association of Orthodontists. 2008. 2. Bruks A, Enberg K, Nordqvist I, Hansson AS, Jansson L, Svenson B. Radiographic examinations as an aid to orthodontic diagnosis and treatment planning. Swed Dent J. 1999;23(2-3):77-85. 3. 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(3):212-219. 4. Devereux L, Moles D, Cunningham SJ, McKnight M. How important are lateral cephalometric radiographs in orthodontic treatment planning? Am J Orthod Dentofacial Orthop. 2011;139(2):e175-181. 5. Nijkamp PG, Habets LL, Aartman IH, Zentner A. The influence of cephalometrics on orthodontic treatment planning. Eur J Orthod. 2008;30(6):630-635. 6. Claus EB, Calvocoressi L, Bondy ML, Schildkraut JM, Wiemels JL, Wrensch M. Dental x-rays and risk of meningioma. Cancer. 2012;15;118(18):4530-7. 7. Angelieri F, Carlin V, Saez DM, Pozzi R, Ribeiro DA. Mutagenicity and cytotoxicity assessment in patients undergoing orthodontic radiographs. Dentomaxillofac Radiol. 2010;39(7):437-440. 8. Abbott P. Are dental radiographs safe? Aust Dent J. 2000;45(3):208-213. 9. White SC, Mallya SM. Update on the biological effects of ionizing radiation, relative dose factors and radiation hygiene. Aust Dent J. 2012;57(suppl 1):2-8. 10. White SC, Mallya SM. Update on the biological effects of ionizing radiation, relative dose factors and radiation hygiene. Aust Dent J. 2012;57(suppl 1):2-8. 11. Emrich RE, Brodie AG, Blayney JR. Prevalence of Class I, Class II and Class III malocclusions (Angle) in an urban population; an epidemiological study. J Dent Res.1965;44(5):947-953.

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Orthodontic practice 31

Volume 5 Number 2 8765_Bundle ad-Ortho-3.8x10.7_02.indd 1

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RESEARCH

Occlusal philosophy: investigating the reasons orthodontists have for occlusion preference Drs. Colin M. Webb and Donald J. Rinchuse delve into functional occlusal schemes Abstract Objective: The aim of this study was to survey orthodontists to investigate if and why they preferred certain functional occlusal schemes. Methods: An email invitation from the American Association of Orthodontists, AAO Partners in Education, was sent to a random sample of the AAO members in the United States and Canada (n = 2,300), requesting participation in a 14-question online survey (Survey Monkey). There was a total of 111 orthodontists who participated in the survey. Results: It was found that 68% of orthodontists do not believe that there is one functional occlusal scheme that is ideal for all patients. The majority (71%) of orthodontists disagree or strongly disagree that occlusion is the primary cause of temporomandibular disorders (TMD). The overwhelming majority (94%) of orthodontists believe that TMD and genetics, plus psychosocial factors, were either strongly correlated or moderately correlated. The vast majority (82%) of orthodontists believe that if they did not share the same occlusal philosophy as their referring dentists, then the referring dentist would be less likely to refer patients to them. Conclusions: This survey demonstrated that the majority of orthodontists believe that there is no functional occlusal scheme that is more ideal than another, and that referring dentists do play a role in orthodontists’ decisions on occlusion.

Introduction There is much controversy in the orthodontic community as to which

Colin M. Webb, DDS, MS, MBA, is a Private Practice orthodontist in Charlotte, North Carolina. Donald J. Rinchuse, DMD, MS, MDS, PhD, is Professor and Program Director, Seton Hill University Center for Orthodontics, Greensburg, Pennsylvania.

32 Orthodontic practice

functional occlusal scheme is optimal for patients. When determining which scheme to use, there are many different factors that practitioners can consider. Esthetically, orthodontists can examine the facial type (mesofacial, brachyfacial, dolichofacial) and soft tissue (smile arc) to determine which occlusal scheme appears to have the most harmonious form with the face.1 Functionally, orthodontists can examine the chewing kinematics to determine which functional occlusal scheme a patient would most benefit from.1 Historically, the orthodontic profession has taken an approach that believed any occlusion that deviated away from the “ideal” mesiobuccal cusp of the maxillary first molar in the buccal groove of the mandibular first molar, minimal overjet and overbite, and canine protected occlusion to be considered nonoptimal or “diseased.”2,3 Many graduating dentists are taught that canine protected occlusion is the ideal functional occlusal scheme, and that all patients should possess this occlusal scheme.4 In 1958, D’Amico5 found that when canines were in contact, there was an immediate interruption of the tension of the temporal and masseter muscles, and therefore, the magnitude of force was reduced. In 1985, Schneikert6 found what he believed was evidence that canine teeth are designed to be “guardian teeth.” He cited their corner position, their large size, the length of their roots, and the fact that they are the last primary tooth lost as evidence proving that they were designed to guard the rest of the occlusion.6 Similar to D’Amico5, Schneikert6 also found that because the canine is located far away from the “hinge” of the temporomandibular joint (TMJ), the canine is in a more favorable position to bear lateral forces. The argument for group function tends to be that distributing lateral force through three or more teeth lessens the amount of force on any one tooth and avoids subjecting the canine to the entire brunt of the force.1 In studies performed by O’Leary, Shanley, and Drake7 and McAdam,8 it was found that teeth in

group function showed less mobility than teeth in canine protected occlusion. In the 1970s, Isaacson9 introduced a biological concept of occlusion that focused on determining what types of occlusions were most beneficial to individual patients — i.e., patients with anterior teeth that were periodontally compromised would benefit best from an occlusion that removed forces from these teeth. So, based on Issacson’s9 view, patients with periodontally compromised canines should probably not be set up to have canines protect their occlusion. Historically, the balanced occlusion scheme has had much less support in the dental community, although this may not be true today. While most would agree that balancing side interferences can be detrimental to the dentition and the TMJs, all balancing side contacts do not have to be interferences. According to Ash10, “A balancing side contact is not a balancing side interference if it does not interfere with function nor cause dysfunction … or … injury to any of the components of the masticatory system.” There seems to be no concrete evidence that indicates that a balanced occlusal scheme without interferences is not suitable for most people.11,12 Some researchers have even found that the balanced occlusal scheme may give an advantage to TMD patients.13 In 1990, Minagi13 evaluated 430 dental students and observed a highly significant correlation between the absence of contacts on the non-working side and the increase of joint sounds with age. There are even epidemiological data that have demonstrated that balanced occlusion may be the most prevalent functional occlusal scheme in Class I normal occlusions.19-31 The orthodontic literature is equivocal with regard to which functional occlusion predominates in nature. D’Amico,5 Ismail and Guevara,14 and Scaife and Holt15 all found that canine protected occlusion (CPO) was more common, while MacMillan,11 Shuyler,16 Alexander,17 and Beyron18 found predominance of group function occlusion. However, the natural occurrence of Volume 5 Number 2

Topic

Results

One ideal functional occlusion?

68.47% no; 18.02% neutral; 13.51% yes

Is CPO optimal?

57.66% yes; 27.93% neutral; 14.41% no

Group function could be optimal?

88.29% yes; 6.31% neutral; 5.41% no

Balanced occlusion could be optimal?

56.76% yes; 27.93% neutral; 15.32% no

Are maxillary premolars = canines?

79.28% yes; 12.61% neutral; 8.11% no

Does occlusion cause TMD?

39.64% disagree; 31.53% strongly disagree; 19.82% neutral; 8.11% agree; 0.90% strongly agree

How correlated are occlusion and TMD?

45.05% minimally correlated; 32.43% moderately correlated; 9.91% neutral; 8.11% not correlated; 4.50% strongly correlated

How correlated are genetics plus psychosocial factors and TMD?

57.66% moderately correlated; 36.94% strongly correlated; 3.60% neutral; minimally correlated 1.80%; 0% not correlated

Exact centric relation is important in diagnoses?

31.53% agree; 22.52% neutral; 17.12% strongly agree; 17.12% disagree; 11.71% strongly disagree

10 Your dentist prefers you treat to spec FO?

Loss of referral if didn’t agree with general practitioner?

43.24% to some extent; 39.64% no; 17.12% yes 62.16% agree; 19.82% strongly agree; 11.71% neutral; 6.31% disagree; 0% strongly disagree

12 Type of practitioner

79.28% private practice; 17.12% private plus academia; 1.80% academia; 1.80% other; 0% resident

13 How long practicing?

67.57% > 10 years; 16.22% 2-5 years; 14.41% 5-10 years; 1.80% 0-2 years

CE/institutes that favor one spec functional occlusion?

balanced occlusion (i.e. with nonworking contacts) was found by: Weinberg,19 Yuodelis and Mann,20 Ingervall,21 Gazit and Lieberman,22 Sadowsky and BeGole,23 Sadowsky and Polson,24 Rinchuse and Sassouni,25 Shefter and McFall,26 de Laat and van Steenberghe,27 Ahlgren and Posselt,28 and Egermark-Eriksson.29 If there was one functional occlusion scheme that clearly predominated in nature, then this made lead us to believe that humans were meant to function optimally in that occlusion, but that is not the case. One of the main problems with the current functional occlusion paradigm is the recordings and criteria used to classify the type of functional occlusion. In 2001, Clark and Evans32 stated, “The criteria Volume 5 Number 2

64.86% none; 18.92% Roth-Williams; 13.51% Pankey; 13.51% other; 8.11% Dawson; 4.50% OBI; 0.90% LVI

that denote an ideal functional occlusion have not been conclusively established.” It is very difficult to study and test different occlusal schemes when the criteria and standards for testing are not universal and agreed upon. Many CPO studies examine tooth contact in one single lateral position (edge-to-edge) after a lateral movement.32 However, this does not adequately reflect the natural pattern of lateral movement performed by individual patients. Studies of this nature do not evaluate the functional zone between centric and the extreme lateral edge-to-edge position. In normal function, most individuals do not even make the extreme lateral edge-toedge movement.2 Even in parafunction, the edge-to-edge purely laterotrusive

movement is rarely used; most often there is a protrusive and lateral component to parafunctional shifting of the mandible.1 It’s been shown that 99% of all people lack cuspid protected occlusion in protrusion5, which implies that CPO does nothing to protect from protrusive parafunction. In 1987, Yaffe, et al.,33 found that only one of 69 subjects (with Class I occlusions) demonstrated pure CPO at the first stage of lateral movement. Yaffe, et al.,33 also found that the lateral glide movement is a complex movement in which the nature of tooth contact changes in location, direction, and number of teeth participating. It has also been found, using basic principles of engineering mechanics, that widely held notions of tooth loading during excursions are no longer valid, and this includes the notion that CPO can reduce or eliminate harmful lateral forces during excursions.34 When orthodontists attempt to consider which occlusal scheme would be best for chewing function, they must also consider individual variation. Not including the different chewing-pattern differences between children and adults, there are about seven different adult chewing patterns that are believed to be gender specific and related to craniofacial morphology.1 The characteristics of the shape of the masticatory cycle are completed in the 2nd year of life when the primary dentition reaches full occlusion and does not vary much throughout life.2 Subjects with normal occlusions tend to have more simple elliptical movements. It is possible that an individual with a more vertical chewing-pattern shape may adapt better to CPO, while another individual with a more horizontal chewing-pattern shape may function best with group function or a balanced occlusion (without interferences).1 Perhaps most importantly, esthetics of these different schemes must also be considered. As a profession we have begun to strive for a consonant smile arc. This can be easily achieved with a group function or balanced occlusion scheme. However, in the presence of pure canine protected occlusion, the canines must be extruded enough to disocclude the posterior segments in most patients.1 This extrusion of the canines could preclude a consonant smile arc and give patients a “vampire” teeth look. The aim of this study was to gather information of the general consensus among orthodontists with regard to functional occlusion. This investigation Orthodontic practice 33

RESEARCH

Table 1: Functional occlusion survey summary results

RESEARCH also sought to understand the reasoning behind their preferred occlusal scheme and whether or not orthodontists’ referring dentists play a role.

Materials and methods A 14-question survey was emailed to a random sample of orthodontists across the United States via email through the American Association of Orthodontics (AAO). Orthodontic residents and faculty from Seton Hill University worked concomitantly to develop the 14-question survey. The original survey was comprised of 20 questions. It was first sent to the mentors of this project and other faculty to be evaluated, and then four questions were eliminated. The existing 16-question survey was pre-tested with fellow residents and two more questions were eliminated. After the pre-test, the language in some of the questions was also modified. In the finalized 14-question survey, the first 11 questions focused on the beliefs of the orthodontist, and the last three were respondent demographic questions. A finalized copy of the 14-question survey was then entered into a template using Survey Monkey. The survey was then sent to the AAO for distribution to a random sample of 2,300 orthodontists who were members of the AAO. The survey was first available to the participants on July 9, 2013. Parenthetically, the AAO sends research surveys to only a percentage of their members so that all of the members aren’t receiving weekly emails soliciting their participation in a research study, and the response rate is expected to be no more than 10%. A motivational tool to encourage response rate was the opportunity to win a raffle prize upon completion of the survey. On August 9, 2013, a reminder was sent to all participants in an attempt to increase the response rate. A total of 111 orthodontists participated in the survey. All data were tabulated and analyzed within the survey instrument (Survey Monkey) or hand tabulated via an Excel spreadsheet.

Results Of 2,300 emails sent to a random sample of orthodontists who are members of the American Association of Orthodontics, 111 participated in the survey; there were 109 responses after the first mailing and two additional responses after the reminder email. The survey was completely anonymous. The important findings from the survey are shown in Table 1: Functional 34 Orthodontic practice

occlusion survey summary results. Some of the more important findings were that 68% of orthodontists do not believe that there is one functional occlusal that is ideal for all patients. The vast majority (88%) of orthodontists believe that a group function occlusal scheme could be ideal for some patients. The vast majority (79%) of orthodontists believe that maxillary first premolars could function similarly as maxillary canines in cases with agenesis of canines, extraction of canines, or canine substitution. The vast majority (71%) of orthodontists disagree or strongly disagree that occlusion is the primary cause of TMD. The majority (63%) of orthodontists believe that occlusion and TMD were either not correlated, minimally correlated, or neutral. The overwhelming majority (94%) of orthodontists believe that TMD and genetics, plus psychosocial factors, were either strongly correlated or moderately correlated. The majority (60%) of orthodontists reported that most of their referring dentists prefer that they treat patients they have referred to a certain functional occlusal scheme, at least to some extent. The vast majority (82%) of orthodontists believe that if they did not share the same occlusal philosophy as their referring dentists, then that dentist would be less likely to refer to them in the future. Respondents who indicated that they had completed a continuing education course that emphasized a certain occlusal scheme were more likely to believe that CPO was the ideal occlusion for all patients than respondents who did not complete such CE courses (26.7% compared to 9.7%). The respondents who completed these courses were also more likely to indicate that they believed occlusion to be the primary cause of TMD with 16.6% reporting that they agree or strongly agree compared to 6.9%. Lastly, 56.6% of these respondents that had completed a continuing education course that emphasized a certain occlusal scheme indicated that they agree or strongly agree that an understanding of the exact position of centric relation was important in diagnosing and treating their orthodontic patients. All (100%) respondents who indicated that they were mainly involved in “academia” indicated that they disagree or strongly disagree that occlusion was the primary cause of TMD, and that occlusion and TMD were minimally correlated. With regard to how long the respondents

have been practicing, there was very little difference in the response percentages.

Discussion Because no similar studies exist, the results of this study could not be compared to the results of other survey studies investigating similar questions. Therefore, the results of this study were compared to the current literature on the topic of functional occlusion. The first result to be discussed is that the majority (68%) of orthodontists agree that there is not one functional occlusion scheme that is optimal for every patient. It seems that orthodontists understand that each individual is unique, and therefore, has his or her own unique optimal occlusal scheme. This may mean that while some patients will function best in a canine protected occlusion, others would benefit most from a group function occlusal scheme. This correlates well with what Isaacson9 found decades ago when he introduced his “biologic concept of occlusion.” CPO as the optimal type of functional occlusion is a claim that is unsupported by the majority of the high-level evidence.1 Based on the literature, CPO could be one possible occlusal scheme for patients, but there are several others that orthodontists could treat patients toward as well.1 Group function and balanced occlusion with no interferences appear to be perfectly acceptable functional occlusion schemes, and in some cases, depending on unique patient characteristics, it could be argued that they are superior.1,7,13 When orthodontists consider a patient’s chewing cycle kinematics, craniofacial morphology, static occlusion type, current oral health status, and parafunctional habits, important and relevant information concerning the most suitable functional occlusal scheme for each patient may be gleaned.1 Orthodontists must always remember that the type of occlusion a patient possesses is not nearly as important as how he or she uses the occlusion.1 The same functional occlusion scheme could be very different between a patient with parafunctional habits and a patient without parafunctional habits.1 Subjects with perfect occlusion have TMD, and subjects with awful occlusion are TMD-free.1,13,27 The arbitrary selection of one functional occlusal scheme for all patients ignores the value and importance of the variation between individual patients. Each person has a unique stomatognathic Volume 5 Number 2

RESEARCH and neuromuscular functional status, and orthodontists must continually consider this while diagnosing, treatment planning, and treating their patients.1 Another result of this survey was that most orthodontists believed occlusion to be TMD-neutral, or not correlated at all. In fact, the overwhelming percentage of orthodontists (94%) believed genetic and psychosocial factors to be moderately or strongly correlated with TMD. While occlusion cannot be ruled out completely, there is little to no evidence that demonstrates that it is the primary cause of TMD.1 TMD is a generic disorder with six subclasses, and each of those subclasses has its very own multifactorial etiology,1 and most orthodontists seem to understand this. With regard to referring dentists, 82% of orthodontists believe that if they didn’t share the same occlusal philosophy as one of their referring dentists, then they would lose that referrer. This should be very troubling. This could lead to orthodontists treating patients in ways not supported by the best evidence to simply keep a referring dentist happy. With the increasingly overwhelming pressure to produce revenue put on by the burden of student loans, new practitioners could be succumbing to the pressure from referring dentists in order to keep their new patient numbers high. Another finding of this survey was that respondents who indicated that they had completed a continuing education course that emphasized a certain occlusal scheme were more likely to believe that CPO was the optimal occlusion for all patients than respondents who did not complete such CE courses (26.7% compared to 9.7%). The respondents that completed these courses were also more likely to indicate that they believed occlusion to be the primary cause of TMD with 16.6% reporting that they agree or strongly agree compared to 6.9%. Questions that these data raised follow: Did these respondents trust the CE course lecturer so much that they did not refer to the evidence for themselves? Do these respondents consider the beliefs of these courses to be “above” the evidence? Do orthodontists understand what evidencebased clinical orthodontics is, and how they should apply it to their practice? There were several limitations of this survey study. The data from this study were based on the assumption that answers were an accurate and 36 Orthodontic practice

honest representation of orthodontists across the United States and Canada. As noted earlier, the survey results were based on the responses of 111 of 2,300 orthodontists surveyed. Per the AAO, this response rate was somewhat expected. In retrospect, it may have been beneficial to have a more attractive title to intrigue and motivate orthodontists to respond to the questionnaire. Another possibility would be to offer the questionnaire in a different way. The researcher could have brought the questionnaire to an AAO meeting or other orthodontic conference and had the questionnaire completed by orthodontists onsite. The next course of action in regard to research could be having this study repeated, but comparing the responses of ABO-Boarded versus non-Boarded orthodontists. Another study could survey dentists rather than orthodontists and see how they respond to similar questions.

Conclusions Despite the almost certain diversity in educational experiences within the sample group, responses were consistent with current literature concerning functional occlusion and TMD. However, with historical philosophies still being taught in dental schools, residencies, and continuing education, orthodontists still fear they are at the mercy of their referring dentist. • 68% of orthodontists do not believe that there is one functional occlusal scheme that is ideal for all patients. • 79% of orthodontists believe that maxillary first premolars could function similarly as maxillary canines in cases with agenesis of canines, extraction of canines, or canine substitution. • 71% of orthodontists disagree or strongly disagree that occlusion is the primary cause of TMD. • 63% of orthodontists believe that occlusion and TMD were either not correlated, minimally correlated, or neutral. • 94% of orthodontists believe that TMD and genetics, plus psychosocial factors, were either strongly correlated or moderately correlated. • 82% of orthodontists believe that if they did not share the same occlusal philosophy as their referring dentists, then that dentist would be less likely to refer to them in the future. • Respondents who completed a continuing education course that

emphasized a certain occlusal scheme were more likely to believe that CPO was the ideal scheme and that occlusion was more strongly correlated with TMD. OP

References 1. Rinchuse DJ1, Kandasamy S, Sciote J. A contemporary and evidence-based view of canine protected occlusion. Am J Orthod Dentofacial Orthop. 2007;132(1):90-102. 2. Ackerman MB. The myth of Janus: Orthodontic progress faces orthodontic history. Am J Orthod Dentofacial Orthop. 2003;123(6):594-596. 3. Angle EH. Classification of malocclusion. Dent Cosmos. 1899;41(2):246-264. 4. Klasser GD, Greene CS. Predoctoral teaching of temporomandibular disorders: a survey of U.S. and Canadian dental schools. J Am Dent Assoc. 2007;138(2):231-237. 5. D’Amico A. The canine teeth: normal functional relation of the natural teeth of man. J Calif Dent Assoc. 1958;26:6-23. 6. Schneikert EO. Occlusion and articulation. Quintessence Intern. 1985;8:567-570. 7. O’Leary TJ, Shanley DB, Drake RB. Tooth mobility in cuspid-protected and group-function occlusions. J Prosthet Dent. 1972;27(1):21-25. 8. McAdam DB. Tooth loading and cuspal guidance in canine and group-function occlusions. J Prosthet Dent. 1976;35(3):283290. 9. Isaacson D. A biologic concept of occlusion. J Prevent Dent. 1976;3:12-16. 10. Ash MM, Ramjford S. Occlusion. 4th ed. Philadelphia, PA: Saunders; 1996. 11. MacMillan HW. Unilateral vs bilateral balanced occlusion. J Am Dent Assoc. 1930;17:1207-1220. 12. McLean DW. Physiologic vs pathologic occlusion. J Am Dent Assoc. 1938;25:1583-1594. 13. Minagi S, Watanabe H, Sato T, Tsuru H. Relationship between balancing-side occlusal contactbalancing patterns and temporomandibularjoint sounds in humans; proposition of the concept of balancing-side protection. J Craniomandib Disord. 1990;4(4):251-256. 14. Ismail J, Guevara P. Personal communications of unpublished data. 1974. 15. Scaife RR Jr, Holt JE. Natural occurrence of cuspid guidance. J Prosthet Dent. 1969;22(2):225-229. 16. Schuyler CH. Factors contributing to traumatic occlusion. J Prosthet Dent. 1961;11:708-716. 17. Alexander PC. Analysis of the cuspid protected occlusion. J Prosthet Dent. 1963;13:309-317. 18. Beyron H. Occlusal relation and mastication in Australian aborigines. Acta Odontol Scand. 1964;22:597-608. 19. Weinberg LA. The prevalence of tooth contact in eccentric movements of the jaw: its clinical implications. J Am Dent Assoc. 1961;62:402-406. 20. Yuodelis RA, Mann WV Jr. The prevalence and possible role of nonworking contacts in periodontal disease. Periodontics. 1965;3(5):219-223. 21. Ingervall B. Tooth contacts of the functional and nonfunctional side in children and young adults. Arch Oral Biol. 1972;17(1):191-200. 22. Gazit E, Lieberman MA. Occlusal contacts following orthodontic treatment. Measured by a photocclusion technique. Angle Orthod. 1985;55(4):316-320. 23. Sadowsky C, BeGole EA. Long-term status of temporomandibular joint function and functional occlusion after orthodontic treatment. Am J Orthod. 1980;78(2):201-212. 24. Sadowsky C, Polson AM. Temporomandibular disorders and functional occlusion after orthodontic treatment: results of two long-term studies. Am J Orthod. 1984;86(5):386-390. 25. Rinchuse DJ, Sassouni V. An evaluation of functional occlusal interferences in orthodontically treated and untreated subjects. Angle Orthod. 1983;53(2):122-130. 26. Shefter GJ, McFall WT Jr. Occlusal relationships and periodontal status in human adults. J Periodontol. 1984;55:368374. 27. de Laat A, van Steenberghe D. Occlusal relationships and temporomandibular joint dysfunction. Part I: Epidemiologic findings. J Prosthet Dent. 1985;54(6):835-842. 28. Ahlgren J, Posselt U. Need of functional analysis and selective grinding in orthodontics. a clinical and electromyographic study. Acta Odontol Scand. 1963;21:187226. 29. Egermark-Eriksson I, Carlsson GE, Magnusson T. A longterm epidemiologic study of the relationship between occlusal factors and mandibular dysfunction in children and adolescents. J Dent Res. 1987;66(1):67-71. 30. Woda A, Vigneron P, Kay D. Non-functional and functional occlusal contacts: a review of the literature. J Prosthet Dent. 1979;42(3):335-341. 31. Tipton RT, Rinchuse DJ. The relationship between static occlusion and functional occlusion in a dental school population. Angle Orthod. 1991;61(1):57-66. 32. Clark JR, Evans RD. Functional occlusion: I. A review. J Orthod. 2001;28:76-81. 33. Yaffe A, Ehrlich J. The functional range of tooth contact in lateral gliding movements. J Prosthet Dent. 1987;57(6):730-733. 34. Katona TR. An engineering analysis of dental occlusion principles. Am J Orthod Dentofacial Orthop. 2009;135(6):696697, e1-8.

Volume 5 Number 2

Dr. Colin Gibson presents a case that previously would need fixed-appliance therapy

32-year-old female presented with Class I impinging deep bite and moderate to severe crowding. The crowding existed in the maxillary and mandibular anterior segments and was the cause of a maxillary anterior occlusal cant that bothered the patient esthetically (Figures 1-9). Due to her deep bite and grinding habits, she had generalized wear facets anteriorly and posteriorly. Her periodontal status was that of mild and localized recession and bone loss. She had future plans with her dentist for restoration of tooth No. 19. This case presented several challenges functionally and esthetically. Impinging deep bite cases are challenging enough with fixed appliances, but our patient was very insistent on clear aligner therapy, specifically ClearCorrect™. We advised her that choosing clear aligner therapy would require consistent cooperation and compliance in order to achieve our lofty goals. She agreed and was eager to begin her correction and achieve the outcomes that we described in our consultation. This case shows practitioners that fairly dramatic outcomes can be achieved with ClearCorrect clear aligner therapy. The amount of esthetic improvement, crowding resolution, and bite correction achieved could previously be accomplished only with fixed-appliance therapy (Figures 1017).

Colin Gibson, DDS, MS, holds the following degrees from the University of Nebraska and the University of Nebraska Medical Center — Bachelor’s of Science in Biological Sciences, Doctor of Dental Surgery, and Masters of Science in Advanced Oral Biology. He is an active member of the American Association of Orthodontists, Metropolitan Denver Dental Society, American Dental Association, Colorado Dental Association, Rocky Mountain Society of Orthodontists, Alpha Alpha Chapter of the Omicron Kappa Upsilon National Dental Honors Society; and he is a BoardEligible Orthodontist by the American Board of Orthodontics.

Volume 5 Number 2

Figure 1

Figure 2

Figure 3

Figure 4

Figure 5

Figure 6

Figure 7

Figure 8

Treatment sequence and detail

while wearing the aligners. The patient was treatment planned for 17 total aligners, over 12 months of treatment time, and 12 total appointments. ClearCorrect delivers aligners in “phases” which is four sets of aligners at a time (e.g., 1A, 1B, 1C, 1D; 2A,

We delivered her Phase 0 aligners and asked the patient to wear them for 3 weeks. The purpose of the Phase 0 aligners is to ensure proper fit and allow the patient to experience everyday life

Orthodontic practice 37

CASE STUDY

ClearCorrect™ correction of a Class I impinging deep bite with crowding

CASE STUDY

Figure 9

Figure 10

Figure 11

Figure 12

Figure 13

Figure 14

Figure 15

Figure 16

Figure 17

2B, 2C, 2D, and so forth). This is beneficial if a patient isn’t compliant, or if the teeth just aren’t tracking as anticipated. You can easily call and halt the production of the subsequent aligners, send in new impressions, and reboot the case from there. This means no wasted aligners, and no added cost for the orthodontist or the patient. So we anticipated receiving five phases, with a total of 17 aligners. We performed interproximal reduction (IPR) with both double- and singled-sided rotary discs and hand-held finishing strips when necessary. At appointment Nos. 2, 4, and 5, we performed 0.3 mm total IPR, and at appointment Nos. 3 and 6, we performed 0.6 mm total IPR. Engagers were placed on teeth Nos. 21, 24, and 28 prior to delivery of 1C. These engagers were used for distal tipping and distal translation of tooth No. 21. In addition, they aided in lingual torque, extrusion, and facial translation of No. 24, and anchorage on No. 28. Engagers were also placed on teeth Nos. 5, 11, and 12 prior

to appointment 2A. These engagers were used for distal rotation and facial translation of tooth No. 5, anchorage on tooth No. 11, and distal tipping and faciodistal translation of tooth No. 12. We placed our engagers using products, including Flow-Tain™ and Enhance™ (Reliance Orthodontic Products, Inc.). At each visit, we ensured that all contact points were correct using floss and that all engagers were not damaged and were still present.

patient with in-office fabricated vacuumformed retainers that were slightly thicker and adjusted to her occlusion due to her grinding habits. She was asked to wear her retainers at night only and to return for a new mandibular retainer after her permanent crown on tooth No. 19 was completed (Figures 11-18).

38 Orthodontic practice

Finishing and retention Although this case presented difficulties, no aligner refinements were needed to achieve the desired results. The treatment finished on time (12 months) and with only the 12 projected appointments, which included records, Phase 0, and the first retention visit. We performed a minimal amount of enameloplasty to correct and mask the wear facets that occurred due to her crowding and bite. We provided this

Summary The patient was very pleased with the esthetic improvements in her smile. Her dentist was pleased with the occlusal changes and preparation for temporary and permanent crown restoration of tooth No. 19. The correction of her overcrowded teeth and deep bite will improve her periodontal health and wear of her occlusion over time. This patient has referred several other ClearCorrect patients due to her happiness and satisfaction with her treatment. OP

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BANDING TOGETHER

Thu’s story After 2 decades, a postcard from a former patient proves to Dr. Jerry Clark that changing a smile also changes a life

ver 20 years ago, a young lady appeared in our office to discuss the possibility of orthodontic treatment. Her name was Thu. She was a foster child, and I had provided orthodontic care for one of the other children in the family. Thu had a severe crowding problem in both arches with high maxillary canines and very crowded lower incisors. Thu was a beautiful young lady but was very self-conscious about her teeth and would not smile. She was very shy and unsure of herself. Her foster parents were very kind and loving people but were not in a financial position to pay for Thu’s orthodontic care. After discussing the crowding problem, which would require extraction of four bicuspids and the need for orthodontic treatment to realign the teeth, we began to discuss how that correction could be achieved. We got in touch with an oral surgeon friend who agreed to remove Thu’s bicuspids at no charge, and we told her we would provide her orthodontic care at no monetary cost to her or her foster family. Thu was so excited! Thu’s case is not unusual. Many times over the years, patients who did not have the financial resources to pay for treatment have sought treatment in our office for a variety of orthodontic problems. Our policy from day 1 has always been the same. We will work with everyone who is in need of orthodontic care to make treatment as affordable as possible, and for those who could not afford treatment, we would work out some arrangement whereby they could receive orthodontic care. Sometimes that meant having them show me their report cards to “earn” their treatment by getting good grades in school. Sometimes it might be having them pay a very small portion of the total normal treatment fee. Our practice will always work out something for any patient who truly desires and needs orthodontic care. In Thu’s case, we had her

Jerry Clark, DDS, MS, is a board-certified orthodontist who maintains a full-time practice in Greensboro, North Carolina. He received his BS and DDS from the University of North Carolina and his MS in orthodontics from St. Louis University in Missouri. He is also a partner in Bentson Clark and Copple, a company that specializes in the sale and transition of orthodontic practices.

40 Orthodontic practice

The unique profession of orthodontics, where we are privileged to see patients over an extended period of time, gives us the opportunity to make an impact in their lives far beyond the beautiful smiles and the perfect occlusions that we are able to produce.

bring in her report cards, and her “payment” for treatment was the good grades that she received in school. Thu was an excellent student and made straight A’s. After approximately 2 years, we completed Thu’s treatment, and due to her excellent cooperation, we were able to achieve outstanding results. Everyone in the office cried the day she got her braces off. Over the 2 years of treatment, we were

privileged to witness the metamorphosis of Thu from a shy and uncertain young adolescent into a beautiful self-confident young lady with a beautiful, engaging smile. During the retention phase of treatment, we followed Thu for 2 additional years and watched her continue to grow and mature. The last time I saw her, she was applying to college and was interested in possibly becoming a teacher. Volume 5 Number 2

Volume 5 Number 2

to become part of their lives. The unique profession of orthodontics, where we are privileged to see patients over an extended period of time, gives us the opportunity to make an impact in their lives far beyond the beautiful smiles and the perfect occlusions that we are able to produce. Our profession is about relationships, and I for one am honored and privileged every day to try to make an impact on the lives of our patients that we treat. I encourage all of my colleagues to take the opportunity that is often presented to us. Try to make a positive impact on everyone you encounter. Give back to your community in some way. And one way you can do this is by offering treatment to patients who otherwise could not afford orthodontic care. You can do this on an individual basis, or you can get involved

with organizations like Smile for a Lifetime. Started by Dr. Ben Burris in 2008, this foundation’s mission is “to create selfconfidence, inspire hope, and change the lives of children in our communities in a dramatic way. The gift of a smile can do all this for a deserving, underserved individual who, in turn, can use this gift to better themselves and their community.” Smile for a Lifetime is a charitable non-profit organization that provides orthodontic treatment (free braces) to individuals 11-18 years old, who may not have the opportunity to acquire assistance any other way. I would encourage anyone who is interested in getting involved to visit the Smile for a Lifetime website at www.s4l.org. OP

Orthodontic practice 41

BANDING TOGETHER

Fast-forward 20 years. One day in 2009, out of the blue I received the letter from Thu that is reproduced in this article. Also enclosed was a picture of Thu and her daughter. This is undoubtedly the nicest thank you letter I have ever received because it was truly from Thu’s heart. What a wonderful gift she gave to me that day with this note of thanks, letting me know that I had had impacted her life and her future. As orthodontists, what a blessing we experience every day when we have the opportunity to spend our time with the patients whom we are so honored to treat. We never really know the full impact we are having on our patients’ lives. Sometimes it is the results we achieve, but more importantly, it is the time we are able to spend with our patients who allow us

PRODUCT PROFILE

New innovations from Ormco Corporation

ou said you wanted the Damon™ System available in more prescriptions. The Ormco team heard you. Now, the Damon™ System is available in an all new prescription — yours! With the introduction of Damon™ Custom this spring, you can order the exact prescription values* needed to best treat each individual patient. An industry first, Damon Custom allows orthodontists to order their own prescription value for every upper and lower 5-5 Damon Custom bracket. Here’s how it works: • Stock your Rx — Order multiple kits of a popular Rx, modify an existing Rx, or create your own OR • Order per patient — Order the Rx you deem necessary to best treat each individual case

Damon™ Custom facts Harnessing the power of Ormco’s patented technology, Damon Custom is conveniently packaged in completely individualized prescription single patent kits. The bracket features and benefits include:

Personalizing and simplifying treatment With Damon Custom, ordering is easy! No digital software to learn, no hoops to jump through — ordering will be available through a simple online form on our website, www.ormco.com. Due to high demand for Damon Custom, doctors interested in participating in the limited, pre-launch this spring are encouraged to visit www.ormco.com to complete an interest form. Be sure to visit Ormco booth No. 1805 at the AAO 2014 Annual Session to learn more about Damon Custom, and place your pre-launch order! * Within manufacturing limitations.

Insignia™ Ai Here at Ormco, we’re excited to take digital orthodontics to the next level with the launch of Insignia™ Ai. The newly introduced Insignia platform features a dramatically updated approver interface that is both user-friendly and visually appealing.

Meet the new approver interface

Damon Custom pad • 80-gauge mesh for superior bonding • Damon™ 3MX rhomboid pad with vertical scribe line for easy placement 90-degree, horizontal slot drop-in hooks • Easily fits in the horizontal slot for treatment versatility • Increased distance from the gingival tissue allows for greater patient comfort Upper and lower brackets open to the occlusal • Patented SpinTek™ slide technology facilitates ease of opening for comfortable, easy wire changes and adjustments 42 Orthodontic practice

Insignia Ai’s clean, sleek design creates a more intuitive experience and now includes a Wizard that navigates users through the suggested approval process step by step to provide an added level of case support. Not sure what step is next or the best way to make a critical adjustment? Just let the Wizard guide you! For a clearer visual of the smile transformation, a movie can be created that will superimpose the tooth movement from initial malocclusion to the final design of the patient’s smile. This visual is a great tool to help patients better understand the treatment process and build excitement for the final results. Insignia Ai has combined two occlusion tools into a simultaneous function that allows you to interact with the patient’s occlusion from multiple angles. Now you have access to an unprecedented level of interactive visualization to achieve both the esthetics and occlusion you prefer. In creating Insignia Ai, Ormco partnered with Dr. Dwight Damon to integrate Damon™ System treatment

mechanics. Clinicians now have the option to select the Damon™ archform as the basis of their patient’s archform design. When selected, geometric algorithms based on the Damon archform will drive the design of the case. The clinician will also be able to view a virtual Damon ruler — an exact digital replica of the Damon™ Arch Symmetry Template.

Experience Insignia Ai With so many new features, we’ve developed a comprehensive, interactive online tutorial to ensure you can explore the new software. Please visit the website, http://ai.ormco.com, and check out the videos below: • What Is Insignia™? — discover the unique features of Insignia as a newer user • Check Out the New Approver Interface — tutorial for experienced users to learn about the updates to Insignia • Watch Insignia Ai in Action — watch how the Wizard can assist in completing a case from start to finish If you’re heading to the AAO 2014 Annual Session in New Orleans, be sure to visit Ormco at booth No. 1805 for a handson demo! To learn more about Insignia Ai and Damon Custom, visit www.ormco.com. OP This information was provided by Ormco.

Volume 5 Number 2

Drs. Lindsay E. Grosso, Morgan Rutledge, Donald J. Rinchuse, Doug Smith, and Thomas Zullo investigate buccolingual inclinations of patients with dolichofacial, brachyfacial, and mesofacial vertical facial growth patterns Abstract Objective: The purpose of this observational study was to investigate whether the buccolingual inclinations of pretreatment orthodontic patients’ occlusions vary for the maxillary and mandibular first molars in accordance with facial patterns (i.e., dolichofacial, brachyfacial, or mesofacial). Materials and Methods: Records of 30 pretreatment orthodontic patients were taken from a population of 523 and divided into three groups of 10 according to vertical facial patterns (dolichofacial, mesofacial, and brachyfacial) based on cephalometric analysis. Pre-existing CBCT images were used to take the following angle measurements relative to the occlusal plane: 1-2) long axis of the maxillary right first molar and maxillary left first molar 3-4) long axis of the mandibular right first molar and mandibular left first molar 5-6) buccal surface of the maxillary right first molar and maxillary left first molar 7-8) buccal surface of the mandibular right first molar and mandibular left first molar

Lindsay E Grosso, DMD, MBA, is a graduate of Seton Hill University Center for Orthodontics, Greensburg, Pennsylvania. Morgan Rutledge, DMD, MS, is a graduate of Seton Hill University Center for Orthodontics, Greensburg, Pennsylvania. Donald J Rinchuse, DMD, MS, MDS, PhD, is Professor and Program Director, Seton Hill University Center for Orthodontics, Greensburg, Pennsylvania. Doug Smith, DMD, MDS, is Clinical faculty, Seton Hill University Center for Orthodontics, Greensburg, Pennsylvania. Thomas Zullo, PhD is Adjunct Professor, Seton Hill University Center for Orthodontics, Greensburg, Pennsylvania.

Volume 5 Number 2

Educational aims and objectives The aim of this article is to discover whether the buccolingual inclinations of pretreatment orthodontic patients’ occlusions vary for the maxillary and mandibular first molars in accordance with facial patterns (i.e., dolichofacial, brachyfacial, or mesofacial). Expected outcomes Correctly answering the questions on page 49, worth 2 hours of CE, will demonstrate the reader can: • Review some of Andrews’ “The Six Keys to Normal Occlusion.” • Compare differences in buccolingual inclinations of maxillary and mandibular first molars in pretreatment patients with dolichofacial, brachyfacial, and mesofacial vertical facial growth patterns. • Recognize if orthodontists may need to implement bracket prescriptions for dolichofacial patients with greater mandibular buccal crown torque and, subsequently, greater maxillary buccal crown torque to keep cuspal heights of molars more even. • Realize the various concepts that are in use regarding tooth and arch parameters related to facial type. • Identify the American Board of Orthodontics’ measuring gauge that scores the buccolingual inclinations of maxillary and mandibular first molars.

Three additional measurements were analyzed at a separate time: 1-2) the right angle of the mandible and the left angle of the mandible, and 3) the buccolingual cuspal height differences of the mandibular first molars. Results: Multivariate analysis of variance (MANOVA) indicated statistical significant differences (p = .019) between the buccolingual cuspal height differences of the mandibular first molars (known as buccolingual inclinations of the mandibular molars to the American Board of Orthodontics) relative to the occlusal plane. The pretreatment orthodontic patients with a dolichofacial vertical pattern showed greater lingual crown inclination with respect to the mandibular molars than brachyfacial and mesofacial types. Conclusions: If the American Board of Orthodontics (ABO) is correct in its assessment of the buccolingual inclination of molars, orthodontists may need to implement bracket prescriptions for dolichofacial patients with greater mandibular buccal crown torque and,

subsequently, greater maxillary buccal crown torque to keep cuspal heights of molars more even.

Introduction For years orthodontists have tried to mainstream clinical practice while maintaining the quality and long-term stability of treatment. One development that revolutionized orthodontics was the straight-wire appliance. In 1972, Dr. Lawrence Andrews published his classic article entitled “The Six Keys to Normal Occlusion,” in which he described the results of his static occlusion study of 120 non-orthodontic dental casts with “normal” untreated occlusion, juxtaposed with 1,150 posttreatment American Board of Orthodontics’ dental casts.1 His study was an effort to discern what characteristics were common among the 120 naturally occurring optimal occlusions (no orthodontic treatment), as compared to very successfully treated orthodontic case occlusions. Subsequently, Andrews’ “Six Keys” findings led to the development of the straight-wire appliance. Andrews’ third of his six keys discussed standards for crown inclination Orthodontic practice 43

CONTINUING EDUCATION

Buccolingual inclinations of maxillary and mandibular first molars in relation to facial pattern

CONTINUING EDUCATION

Measurement

Dolichofacial

Brachyfacial

Mesofacial

FMA (MP-FH) (°)

22.9 - 31.8

2.4 - 14.1

19.2 - 28.9

Palatal-Mand Angle (PP-MP) (°)

25.4 - 40.8

7.5 - 23.8

26.1 - 36.6

Gonial/Jaw Angle (Ar-Go-Me) (°)

116.7 - 149.7

109.8 - 130.7

119.1 - 133.2

P-A Face Height (S-Go/N-Me) (%)

56.5 - 64.5

68.8 - 81.2

59.5 - 68.2

RH/LFH (ArGo/ANSMe) (%)

62.2 - 84.1

80.7 - 111.0

66.0 - 85.2

Table 1: Range of cephalometric values for the 10 patients in each facial pattern group

Group

Males

Females

Average Age

Dolichofacial

13.76

Brachyfacial

15.79

Mesofacial

15.31

Table 2: Number of males and females, and average ages for each group

in “optimal” occlusions, and as he noted, the maxillary and mandibular posterior crowns were lingually inclined, albeit to varying degrees.1 Recall, Andrews-judged inclination, or facial-lingual “slanting” of the teeth, from the crowns of the teeth, not the long axis through the roots of the teeth as can be gleaned from radiographic imaging. Lingual inclination of the maxillary posterior teeth from canine to molar was found to be relatively constant with slightly more inclination in the molars, while inclination of the mandibular molars progressively increased from the canine to second molar.1 A question in search of an answer is whether the same buccolingual inclination is appropriate for most patients, considering variation in facial/skeletal types and alveolar bone structure in a given patient population. More specifically, each bracket prescription is manufactured to position teeth with specified inclinations, assuming that brackets are bonded to ideal position on each tooth with little to no variability in facial surface contours for those teeth, and 44 Orthodontic practice

that clinicians use full-size wires. Controversy has existed for years regarding tooth and arch parameters related to facial type. It is widely accepted that dolichofacial patients have narrower arches, higher-arched palates, and more tendency toward open bite and significantly smaller maximum biting force, while brachyfacial patients tend toward deep bites and have much stronger maximum biting force.2,3 Some authors have suggested that patients with long lower anterior face heights (i.e., dolichofacial) have molars that are more upright buccolingually, whereas patients with short lower anterior face heights (i.e., brachyfacial) have molars that are more lingually inclined.4,5 Janson, et al.,6 found that when dental casts from patients with different facial patterns were studied, “maxillary posterior teeth in subjects with vertical growth patterns (dolichofacial) [had] a statistically significantly greater buccal inclination as compared with those with horizontal growth patterns (brachyfacial).” They did not find any statistically significant differences in inclination of mandibular

posterior teeth between the groups. Janson, et al.,6 takes this concept further and argues that because there tends to be greater palatal inclination in upper molars of brachyfacial patients, they can withstand more palatal expansion since a common collateral effect of rapid palatal expansion is buccal tipping of molars. This implies that greater expansion and potential buccal tipping could be carried out for brachyfacial patients without causing harm to the molars that have been tipped. However, the brachyfacial patients are typically the ones with wider arches who are less likely to need expansion. Conversely, Ross, et al.,7 found that there were no statistically different buccolingual inclinations of maxillary or mandibular molars between different vertical growth patterns when dental casts were used to evaluate crown inclinations. Furthermore, Tsunori4 argues that patients with long-face patterns have comparatively more narrow arches yet have tongue sizes similar to those patients with shortface patterns. The more narrowed arches allows the tongue to have a greater effect on the buccolingual inclination of the teeth by placing force on the molars and uprighting the teeth.4 Additionally, some conjecture that the weaker musculature of the dolichofacial pattern8,9,10 could prevent tipping of the molars or at least provide less resistance to the forces from the tongue.4 To this end, many “non-extractionists” believe that if the mandibular molars are lingually inclined, there is a need to upright these teeth and expand the dental arches, regardless of natural variations in inclination that may not yet be known.11 It should be mentioned that the final inclination of the posterior teeth is not solely dependent on prescription; final tooth position also depends on variables including appliance slot size, archwire size, anterior tooth inclination, arch width, Curve of Wilson, and so on. Nonetheless, further investigations are needed to determine whether certain aspects of treatment — such as inclination — can be standardized, while other aspects must continue to be prescribed for each individual patient. The purpose of this study was to investigate whether the buccolingual inclinations of maxillary and mandibular first molars in pretreatment orthodontic patients vary according to patients’ vertical facial patterns (i.e., brachyfacial, mesofacial, or dolichofacial). The null hypothesis was that there are no statistically significant Volume 5 Number 2

differences in the buccolingual inclinations of mandibular or maxillary first molars relative to vertical facial patterns.

Materials and methods After receiving Institutional Review Board (IRB) approval, 30 patient records were selected by a single examiner (M.R.) from a total of 523 patients with pre-existing i-CAT速 (Imaging Sciences International) cone beam computed tomography (CBCT) images available at a private practice in Pennsylvania. These 30 patient records were chosen because they highly characterized the three facial types, i.e., brachyfacial, mesofacial, or dolichofacial. The sample consisted of Caucasian patients with pretreatment CBCT images available, a fully erupted permanent dentition, no missing or impacted teeth with the exception of third molars, no significant molar rotations, no posterior crossbite and no previous orthodontic treatment. All pretreatment lateral cephalometric images were traced by one examiner (D.S.) using Dolphin Imaging 11.7 software (Dolphin Imaging & Management Solutions, a Patterson Technology). A separate cephalometric analysis was created in Dolphin Imaging to evaluate and categorize the vertical facial pattern of each patient and included FMA (MP-FH), palatal mandibular angle (PPMP), gonial/jaw Angle (Ar-Go-Me), P-A face height (S-Go/N-Me) expressed as a percentage and RH/LFH (ArGo/ANSMe) expressed as a percentage (Table 1). Volume 5 Number 2

Using these cephalometric measurements, 10 subjects out of the 523 who could be best characterized to represent each facial type (i.e., brachyfacial, mesofacial, or dolichofacial) were selected for a total of 30 subjects. When possible, those selected for the brachyfacial and dolichofacial groups had cephalometric measurements that were two standard deviations beyond the corresponding normal values (Table 1). The mesofacial group included subjects with values within the normal range for at least two measurements, and no values more than one standard deviation away from normal (Table 1). The subjects were between the ages of 11 and 20 years. The group consisted of 15 males and 15 females; six males and four females in the dolichofacial and brachyfacial groups, and three males and seven females in the mesofacial group (Table 2). Existing cone beam images were retrieved for each patient; extraneous portions of the images were removed; and a slice was taken to bisect the maxillary and mandibular first molars. The image was positioned with the occlusal plane perpendicular to the floor and rotated to view the first molars from the distal (Figure 1). The occlusal plane was established by drawing a line to connect the buccal cusp tips of the mandibular molars. CBCT images were used to take the following angle measurements relative to the occlusal plane (Figure 2,1-2) long axis of the maxillary right first molar and maxillary

left first molar 3-4) long axis of the mandibular right first molar and mandibular left first molar 5-6) buccal surface of the maxillary right first molar and maxillary left first molar 7-8) buccal surface of the mandibular right first molar and mandibular left first molar The first four angles measured were the inner angles formed by the long axes of the four first molars (including crown and root). The other four measurements consisted of four inner angles formed between the occlusal surface and lines tangent to the buccal surface of the clinical crowns of each first molar. The CBCT images were also used to take three additional measurements relative to the occlusal plane that were analyzed at a separate time from the aforementioned measurements: (9-10) the right angle of the mandible and the left angle of the mandible, and 11) the buccolingual cuspal height differences of the mandibular first molars (Figure 3). The right and left angles of the mandible were measured by using the inside angle of a line drawn to bisect the mandible on both sides and the established occlusal plane. The buccolingual cuspal height differences of the mandibular first molars (known as buccolingual inclinations of the mandibular molars to the American Board of Orthodontics) was established for each subject by drawing a line from the buccal cusp of the left mandibular first molar to the buccal cusp of the right mandibular first Orthodontic practice 45

CONTINUING EDUCATION

Figure 1: Sample CBCT of the angle measurement of the buccolingual cuspal height differences of the mandibular first molars. The measurement was established by drawing a line from the buccal cusp of the left mandibular first molar to the buccal cusp of the right mandibular first molar and a line from the lingual cusp of the left mandibular first molar to the lingual cusp of the right mandibular first molar, and then measuring the vertical distance between the two lines at the center

Figure 2: Schematic of measurement taken on CBCT images. 1-2) Example of long axis of the maxillary right first molar and maxillary left first molar, 3-4) long axis of the mandibular right first molar and mandibular left first molar, 5-6) buccal surface of the maxillary right first molar and maxillary left first molar, 7-8) buccal surface of the mandibular right first molar and mandibular left first molar

Figure 3: Schematic of measurement taken on CBCT images. 9-10) Example of angle measured from the occlusal plane to a line bisecting the mandible on right and left sides. 11) Milimeter measurement found by drawing a line from the buccal cusp of the left mandibular first molar to the buccal cusp of the right mandibular first molar and a line from the lingual cusp of the left mandibular first molar to the lingual cusp of the right mandibular first molar, and then measuring the vertical distance between the two lines at the center

CONTINUING EDUCATION

Facial Type

UR6

UL6

B UR6

B UL6

LR6

LL6

B LR6

B LL6

Mean

Std. Deviation

DOLICHOFACIAL

87.000

5.5638

BRACHYFACIAL

89.490

54.384

MESOFACIAL

88.990

5.4204

Total

88.493

5.3945

DOLICHOFACIAL

82.960

6.9451

BRACHYFACIAL

86.950

6.2179

MESOFACIAL

84.440

4.4410

Total

84.783

5.9912

DOLICHOFACIAL

89.350

4.9417

BRACHYFACIAL

94.600

10.9191

MESOFACIAL

96.250

8.8862

Total

90.203

12.7814

DOLICHOFACIAL

86.560

13.4257

BRACHYFACIAL

94.020

8.9674

MESOFACIAL

94.030

15.3190

Total

90.203

12.7814

DOLICHOFACIAL

105.420

6.2833

BRACHYFACIAL

102.900

2.7793

MESOFACIAL

102.570

2.8956

Total

103.630

4.3506

DOLICHOFACIAL

104.650

7.1581

BRACHYFACIAL

105.550

5.6086

MESIOFACIAL

105.550

5.6086

Total

104.247

5.4387

DOLICHOFACIAL

124.920

5.8719

BRACHYFACIAL

125.790

12.4512

MESOFACIAL

126.160

12.0418

Total

125.623

10.2027

DOLICHOFACIAL

130.090

13.7909

BRACHYFACIAL

131.010

7.9442

MESOFACIAL

131.330

10.4192

Total

130.810

10.6107

F Value Between Subjects

0.579

1.145

1.750

0.846

Results

1.312

0.796

0.036

0.034

Table 3: Descriptive Statistics for molar inclination measurements All findings were Insignificant. F = .933 for the MANOVA. Code: UR6 = Maxillary Right 1st Molar, UL6 = Maxillary Left 1st Molar, B UR6 = Buccal Surface of Maxillary Right 1st Molar, B UL6 = Buccal Surface of Maxillary Left 1st Molar, LR6 = Mandibular Right 1st Molar, LL6 = Mandibular Left 1st Molar, B LR6 = Buccal Surface of Mandibular Right 1st Molar, B LL6 = Buccal Surface of Mandibular Left 1st Molar

46 Orthodontic practice

molar and a line from the lingual cusp of the left mandibular first molar to the lingual cusp of the right mandibular first molar, and then measuring the vertical distance between the two lines at the center. In total there were 11 measurements taken using the CBCT images. All measurements were taken by the same examiner (M.R.). Standard descriptive statistics were calculated for each measurement, which included the mean and standard deviation for each variable analyzed. A multivariate analysis of variance (MANOVA) was first used to test for differences in angles formed by the long axes and buccal surfaces of the teeth across the three facial types, as measured in the first eight measurements. A separate MANOVA was used to test for differences in angles for the right and left sides of the mandible, and the buccolingual cuspal height differences of mandibular molars. A Bonferroni (post hoc) test was also used done to account for multiple comparisons. The data were analyzed with IBM SPSS v.19 software.

Regarding the first set of data, the largest mean angles measured for the long axis of the maxillary first molars were found in the brachyfacial type, with mean measurements of 89.490째 for the maxillary right first molar (UR6) and 86.950째 for the maxillary left first molar (UL6). The highest mean angles measured for the line tangent to the buccal surfaces of the maxillary first molars were found in the mesofacial group, with means of 96.250째 (B UR6) and 94.030째 (B UL6). For the long axis measurements of the mandibular arch, no facial type consistently had the largest or smallest angles, and it should be noted that there is very little difference among the mean values for the three facial types for these two measurements (Table 3). For the second set of data, the highest mean measured for the buccolingual cuspal height differences of the mandibular molars was found in the dolichofacial group, with a mean of 2.010 mm. The brachyfacial group again had the smallest measurement for buccolingual inclinations, with a mean of 1.030. Although the mesofacial group fell in the middle with a mean of 1.100, this measurement is very close to the mean brachyfacial measurement, and both are almost half of the dolichofacial group mean (Table 4). Volume 5 Number 2

Discussion The results of the present study demonstrated that in this particular population of pretreatment orthodontic patients, there was only a statistically significant difference with respect to buccolingual cuspal heights of the mandibular first molars among facial types. The dolichofacial group demonstrated more lingual crown inclination of mandibular molars leading to greater cuspal height differences as compared to the brachyfacial and mesofacial groups. The null hypothesis was therefore rejected. Isaacson, et al.,12 argued that patients with vertical facial patterns had narrower maxillae and were therefore more likely to be in posterior crossbite. This argument further supports the results of this study showing that buccolingual cuspal height differences should be greater for dolichofacial patients due to the narrow maxilla and other facial aspects that go along with the vertical pattern. Conversely, Janson et al.,6 found that when dental casts from patients with different facial patterns were measured, “maxillary posterior teeth in subjects with vertical growth patterns [had] a statistically significantly greater buccal inclination as compared with those with horizontal growth patterns.” They did not find any statistically significant differences in inclination of mandibular teeth between the groups. The results of the present study Volume 5 Number 2

Facial Type

Mean

Std. Deviation

DOLICHOFACIAL

111.62

5.1865

BRACHYFACIAL

106.13

4.8208

R Md °

1.283 MESOFACIAL

108.04

11.4642

Total

108.597

7.8553

DOLICHOFACIAL

111.25

5.7504

BRACHYFACIAL

105.02

4.4758

MESIOFACIAL

108.26

6.5554

Total

108.117

6.0425

DOLICHOFACIAL

2.01

0.6740

BRACHYFACIAL

1.03

0.7646

MESIOFACIAL

1.100

0.6342

Total

1.380

0.8083

3.032

L Md°

Cuspal

6.222*

Height Diff. (mm)

F Value

Table 4: Descriptive Statistics for mandibular measurements Data revealed statistically significant differences among the facial types for the set of three variables for the MANOVA (F = 2.812, p = .019). Code: R Md° = Right mandibular angle, L Md° = Left mandibular angle, CHD of Md molars = Cuspal Height Difference of mandibular molars

support Janson’s6 findings that there were no significant differences in the buccal inclinations of the maxillary teeth of any facial type. However, the present study demonstrates significant differences were found in the buccolingual cuspal height differences of the mandibular first molars among facial types, while Janson’s6 study did not study this particular variable. The findings of the present study are clinically relevant with respect to the American Board of Orthodontics grading system of clinical treatment outcomes for board certification. As previously mentioned, the buccolingual cuspal height differences of the mandibular first molars (known as the buccolingual inclination of the mandibular molars according to American Board of Orthodontics)13 were measured in the present study by drawing a line from the buccal cusp of the left mandibular first molar to the buccal cusp of the right mandibular first molar and a line from the lingual cusp of the left

mandibular first molar to the lingual cusp of the right mandibular first molar, and then measuring the vertical distance between the two lines at the center. Currently, the American Board of Orthodontics utilizes a measuring gauge to score the buccolingual inclinations of maxillary and mandibular first molars.13 According to the model grading system, the gauge is placed on the occlusal surface of the right and left posterior teeth and should contact the buccal cusps of the mandibular first molars. With the gauge in place, the lingual cusp should be within 1 mm of the surface of the straight edge. If the mandibular lingual cusps are between 1 mm and 2 mm from the straight-edge surface, 1 point will be scored for that tooth; and if it is more than 2 mm from the straight edge surface, 2 points will be scored for that tooth. High scores on individual segments or combinations of segments can lead to a failure from the Board.13 The ABO states in the model grading system, “The buccolingual inclination is used to Orthodontic practice 47

CONTINUING EDUCATION

Although some patterns were noted in the measurements of the first set of data, results of the MANOVA analysis revealed no statistically significant differences among the three facial types for any of the first eight angles measured (F = .933, p = .540) (Table 3). The MANOVA analysis for the second set of data revealed statistically significant differences among the facial types for the set of three variables (F = 2.812, p = .019) (Table 4). The tests of between subjects effects further revealed a statistically significant difference among the buccolingual cuspal height differences of the mandibular molar measurements for the three facial types. The Bonferroni (post hoc) test showed the buccolingual cuspal height differences of the dolichofacial group to be significantly larger, indicating more lingual crown torque of mandibular first molars, than the brachyfacial (p = .012) and mesofacial (p = .020) groups with no statistically significant differences between the brachyfacial and mesofacial groups.

CONTINUING EDUCATION assess the buccolingual angulation of the posterior teeth. In order to establish proper occlusion in maximum intercuspation and avoid balancing interferences, there should not be a significant difference between the heights of the buccal and lingual cusps of maxillary and mandibular molars and premolars.”14 However, due to differing schools of thought on occlusal intercuspation and balancing interferences, the stance taken by the Board is equivocal and not supported by high quality evidence.15 If in fact the ABO is correct in its assessment of buccolingual inclination of molars, orthodontists may need to properly diagnose dolichofacial patients and implement bracket systems for these patients that would achieve more buccal crown torque. This would allow for less cuspal height differences of maxillary and mandibular molars, avoid balancing interferences due to plunging lingual cusps, and permit practitioners to achieve treatment results in line with standards set by the ABO. However, another thought could be that the ABO may need to look into revising the grading system with respect to the buccolingual inclinations of the mandibular first molars in patients with dolichofacial vertical patterns, since this view is not unequivocally supported by evidence. Currently in orthodontics, a straightwire appliance with one prescription for buccolingual inclination of maxillary and

mandibular first molars is usually used, irrespective of vertical facial pattern. However, according to the present study’s findings, there were statistically significant differences in the initial buccolingual cuspal height differences of mandibular first molars for dolichofacial patterns. It can be argued that if only one prescription is being utilized, buccolingual cuspal height differences of mandibular molars in patients with true dolichofacial patterns may result in balancing interferences with maxillary molar cusps posttreatment unlike their brachyfacial and mesofacial counterparts. There were several limitations of this study. Ideally, a larger sample of subjects in each of the three facial types would have been preferred. However, the method in the present study allowed the researchers to select the best characterized 30 subjects from the total of 523 patients in a private practice office. While additional subjects could have been included in this study from the 523 study population, they would not have represented the facial type’s groupings as well. Next, researchers have been recently working to develop standards for evaluating and measuring CBCT.16,17 Thus far, no standards are universally accepted among the orthodontic community regarding orientation and reference planes for CBCT images. Nonetheless, even with the lack of subjects in each sample group, statistical significance was still found in

the buccolingual cuspal height differences of mandibular molars among the three facial types. The dolichofacial group was found to be significantly larger than the brachyfacial and mesofacial groups. Future investigations are still needed to test additional angles and measurements in an effort to discern any existing relationships. Perhaps determination of a common method for selecting patients for facial pattern would increase reliability and validity.

Conclusions The present study compared differences in buccolingual inclinations of maxillary and mandibular first molars in pretreatment patients with dolichofacial, brachyfacial, and mesofacial vertical facial growth patterns. The results indicate that there were statistically significant differences in the buccolingual cuspal height differences of the mandibular first molars (known as the buccolingual inclination of the molars according to the ABO) among the three facial types. The dolichofacial patients in a group of pretreatment orthodontic patients demonstrated greater cuspal height differences and more lingual crown inclination of mandibular, and subsequently maxillary molars than the mesofacial or brachyfacial patients. OP

References 1. Andrews LF. The six keys to normal occlusion. Am J Orthod. 1972;62(3):296-309. 2. Pepicelli A, Woods M, Briggs C. The mandibular muscles and their importance in orthodontics: a contemporary review. Am J Orthod Dentofacial Orthop. 2005;128(6):774-780. 3. Proffit WR, Fields HW Jr. Contemporary Orthodontics. 2nd ed. Saint Louis: Mosby; 1992.

7. Ross VA, Isaacson RJ, Germane N, Rubenstein LK. Influence of vertical growth pattern on faciolingual inclinations and treatment mechanics. Am J Orthod Dentofacial Orthop. 1990;98(5):422-429. 8. Proffit WR, Fields HW. Occlusal forces in normal- and long-face children. J Dent Res. 1983;62(5):571-574. 9. Ingervall B, Helkimo E. Masticatory muscle force and facial morphology in man. Arch Oral Biol. 1978;23(3):203-206.

4. Tsunori M, Mashita M, Kasai K. Relationship between facial types and tooth and bone characteristics of the mandible obtained by CT scanning. Angle Orthod. 1998;68(6):557-562.

10. Proffit WR, Fields HW, Nixon WI. Occlusal forces in normal- and long-face adults. J Dent Res. 1983;62(5):566-570.

5. Okada N, Kasai K. Relationship between mandibular tooth inclination and maxillofacial morphology using CT scanning [in Japanese]. Nihon Univ J Oral Sci. 1996;22:381-392.

11. Rinchuse DJ, Kandasamy S. Implications of the inclination of the mandibular first molars in the extractionist versus expansionist debate. World J Orthod. 2008;9(4):383-390.

6. Janson G, Bombonatti R, Cruz KS, Hassunuma CY, Del Santo M Jr. Buccolingual inclinations of posterior teeth in subjects with different facial patterns. Am J Orthod Dentofacial Orthop. 2004;125(3):316-322.

12. Isaacson JR, Isaacson RJ, Speidel TM, Worms FW. Extreme variation in vertical facial growth and associated variation in skeletal and dental relations. Angle Orthod. 1971;41(3):219-229.

48 Orthodontic practice

13. American Board of Orthodontics. Grading System for Dental Casts and Panoramic Radiographs. St. Louis, MO; 2012. 14. Casko JS, Vaden JL, Kokich VG, Damone J, James RD, Cangialosi TJ, Riolo ML, Owens SE Jr, Bills ED. Objective Grading System for Dental Casts and Panoramic Radiographs. American Board of Orthodontics. Am J Orthod Dentofacial Orthop. 1998;114(5):589-599. 15. Rinchuse DJ, Kandasamy S, Sciote J. A contemporary and evidence-based view of canine protected occlusion. Am J Orthod Dentofacial Orthop.2007;132(1):90-102. 16. Tong H, Enciso R, Van Elslande D, Major PW, Sameshima GT. A new method to measure mesiodistal angulation and faciolingual inclination of each whole tooth with volumetric cone-beam computed tomography images. Am J Orthod Dentofacial Orthop. 2012;142(1):133-143. 17. Miner RM, Al Qabandi S, Rigali PH, Will LA. Conebeam computed tomography transverse analysis. Part 1: Normative data. Am J Orthod Dentofacial Orthop. 2012;142(3):300-307.

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Buccolingual inclinations of maxillary and mandibular first molars in relation to facial pattern

The biology of orthodontic tooth movement part 3: the importance of magnitude

GROSSO 1. In 1972, _______ published his classic article entitled “The Six Keys to Normal Occlusion,” in which he described the results of his static occlusion study of 120 non-orthodontic dental casts with “normal” untreated occlusion, juxtaposed with 1,150 posttreatment American Board of Orthodontics’ dental casts. a. Dr. Lawrence Andrews b. Dr. Edward H. Angle c. Dr. C.C. Steiner d. Dr. R.M. Ricketts 2. It is widely accepted that dolichofacial patients have ______ and significantly smaller maximum biting force, while brachyfacial patients tend toward deep bites and have much stronger maximum biting force. a. narrower arches b. higher-arched palates c. more tendency toward open bite d. all of the above 3. Janson, et al., found that when dental casts from patients with different facial patterns were studied, “maxillary posterior teeth in subjects with vertical growth patterns (dolichofacial) [had] a statistically ______ buccal inclination as compared with those with horizontal growth patterns (brachyfacial).” a. significantly lower b. significantly greater c. equal d. slightly lower 4. Conversely, Ross, et al., found that there were ______buccolingual inclinations of maxillary or mandibular molars between different vertical growth patterns when dental casts were used to evaluate crown inclinations. a. statistically different b. extremely diverse c. no statistically different d. extremely damaging 5. Furthermore, Tsunori argues that patients with long-face patterns have comparatively ______ yet have tongue sizes similar to those patients with short face patterns. a. more narrow arches b. wider arches

Volume 5 Number 2

c. d.

large teeth small teeth

6. To this end, many “non-extractionists” believe that if the mandibular molars are lingually inclined, there is a need to _____, regardless of natural variations in inclination that may not yet be known. a. upright these teeth b. expand the dental arches c. use a smaller archwire d. both a and b 7. Isaacson, et al., argued that patients with vertical facial patterns had _____ and were therefore more likely to be in posterior crossbite. a. wider maxillae b. buccolingual height differences c. narrower maxillae d. cuspal height differences 8. (Regarding the American Board of Orthodontics’ measuring gauge to score the buccolingual inclinations of maxillary and mandibular first molars) With the gauge in place, the lingual cusp should be within _____ of the surface of the straight edge. a. about .5 mm b. within 1 mm c. 2 mm d. 3 mm 9. The ABO states in the model grading system, “The buccolingual inclination is used to assess the buccolingual angulation of ____.” a. the posterior teeth b. the anterior teeth c. all dolichofacial patients d. all brachyfacial patients 10. The dolichofacial patients in a group of pretreatment orthodontic patients demonstrated _____than the mesofacial or brachyfacial patients. a. greater cuspal height differences b. more lingual crown inclination of mandibular, and subsequently maxillary, molars c. greater need for extractions d. both a and b

STOSICH 1. A commonly thought negative sequela of _____ is root resorption. a. light force b. craniofacial malformation c. heavy force d. gram forces

6. Bodily movement, on the other hand, requires minimum forces of ____. a. 35-60g b. 75-120g c. 125g-130g d. 140g-150g

2. Owman-Moll, et al., studied the effects of applying twice the amount of force magnitude, 50g versus 100g, related to tooth movement and root resorption and found the degree of root resorption ______ with the doubled force. a. did not differ significantly b. differed significantly c. had no impact at all d. resulted in many clinical consequences

7. This is in conflict to Tanne, et al., where it was found that ____ times the force is needed for bodily tooth movement. a. two b. three c. four d. five

3. They (the Gonzales, et al. study) found increased rates of tooth movement at the lightest force of ____ and more root resorption with heavier forces. a. 2.5g b. 5g c. 10g d. 15 4. ______ is fundamental, whether it be with light force or heavy force. a. Using optimal force b. Using springs c. Controlling direction d. Tipping forces 5. For instance, tipping, being the mechanically easiest of tooth movements, responds to forces as low as ____. a. 5-10g b. 15-20g c. 25-30g d. 35-60g

8. McGuiness, et al., found the net force felt on the PDL to tipping forces varies not only in magnitude, but the _____ as well. a. craniofacial structure b. force c. initial arch d. type of tooth 9. In reviewing the vast available studies, it is reasonable to posit that the magnitude of the force is as important as ______ of the force, with the goal of reducing the amount of time the tooth is under traumatic force (either light or heavy). a. the direction b. the duration c. mitigation d. both a and b 10 . Yet a safe and fundamental principle, with the goal of proper clinical magnitude selection, is the ______ from various force application. a. maintenance of maximum force b. minimization of errors c. reduced patient trauma d. both b and c

Orthodontic practice 49

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The biology of orthodontic tooth movement part 3: the importance of magnitude Dr. Michael S. Stosich delves into the clinical consequences of force magnitude Introduction How important is magnitude in orthodontic tooth movement? What is a “heavy force,” and what is a “light force” in orthodontics? What does it mean at the biological level? Though much work has been done advocating light forces for orthodontic tooth movement, with entire systems and philosophies built around it, what really is to be considered heavy force, and how much does it matter? At the most fundamental level, the minimum amount of force needed is enough to trigger the process of bone remodeling around the tooth, and the maximum is below the threshold of hyalinization and occlusion of vascular structures in the periodontal ligament. In this article, I will present views grounded in scientific research, that present various evidence that one type of force magnitude is better and or equal than the other, and what clinical consequences or side effects can result from its application.

Root resorption A commonly thought negative sequela of heavy force is root resorption. The etiology of root resorption is multifactorial, and importantly, no definitive evidence links

Educational aims and objectives This article aims to discuss force magnitude and its possible side effects. Expected outcomes Correctly answering the questions on page 49, worth 2 hours of CE, will demonstrate the reader can: • Realize the importance of magnitude in orthodontic tooth movement. • Define the meaning of “heavy” and “light” force in orthodontics. • Examine risk factors regarding root resorption. • Translate some of these concepts into clinical practice.

heavy orthodontic forces to root resorption. Root resorption risk factors include the severity of the presenting malocclusion, genetics, systemic health, initial root morphology, density of alveolar bone, previous endodontic treatment, patient age and sex, history of asthma or allergies, length of treatment, the proximity of roots to the cortical plate, extractions, duration of force, and constant force.1,2 Owman-Moll, et al.,3 studied the effects of applying twice the amount of force magnitude, 50g versus 100g, related to tooth movement and root resorption and found the degree of root resorption did not differ significantly with the doubled force. Furthermore, tooth movement did not differ significantly over a period of 7 weeks.

Light force/heavy force 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

50 Orthodontic practice

From the light force perspective, Gonzales, et al.,4 studied four different mesial force applications of 10, 25, 50, and 100g on rat maxillary first molars. The study sought to examine the effects of varying forces on tooth movement and root resorption. They found increased rates of tooth movement at the lightest force of 10g and more root resorption with heavier forces. To translate this into the human craniofacial structure in terms of actual gram force was not, unfortunately, elicited. From a contrasting perspective, Yee, et al.5, compared orthodontic tooth movement under heavy (300g) and light (50g) continuous forces in canine retraction and found that during initial tooth movement, force magnitudes were unrelated, but at later periods, higher rates

Figure 1: Finite model of an incisor and force distribution11

of tooth movement were produced with heavy forces. The caveat to this was a loss of retraction control, or magnitude direction, in this study. Due to a loss of anchorage and canine rotation, the increased rate of tooth movement was effectively cancelled out. Controlling direction is fundamental, whether it be with light force or heavy force. Indeed, the type of desired tooth movement calls for different minimum level of force magnitude levels. For instance, tipping, being the mechanically easiest of tooth movements, responds to forces as low as 35-60g.6 Bodily movement, on the other hand, requires minimum forces of 75-120g. This is in conflict to Tanne, et al.,7 where it was found that 4 times the force is needed for bodily tooth movement. McGuiness, et al.,8 found the net force felt on the PDL to tipping forces varies not only in magnitude, but the type of tooth as well. As can be seen, even deciding on the minimum force level needed for certain types of tooth movement is unclear.

Contrasting views in the literature A thorough review of the literature shows hundreds of contrasting articles in various Volume 5 Number 2

CONTINUING EDUCATION

Figure 2: .012, .014, .016 NiTi wires

animal species and various human clinical studies. Further variation appeared in the type of tooth movement, the magnitude, and the direction. Additionally, what is classified as a heavy force (100g, 150g, 200g, etc.) in humans or a light force (10g, 20g, 30g, and so on) is not entirely clear. There is wide variability in the literature suggesting the benefits of light forces or heavy forces. Each tooth in an individual patient may require a certain “optimal” force,6 which clinically cannot currently be known. In reviewing the vast available studies, it is reasonable to posit that the magnitude of the force is as important as the direction and duration of the force, with the goal of reducing the amount of time the tooth is under traumatic force (either light or heavy).

Figure 3: Root resorption in maxillary incisors12

malocclusions, bracket slot size, and many others, I will not seek to address it here. However, the selection of the type of initial arch wire can be discussed based on a recent report. A comprehensive 2013 Cochrane Review examining nine randomized controlled clinical trials with 571 participants over a period of 60 years, published in the 2013 Cochrane Database sought to answer which initial arch wires were most effective for tooth alignment during orthodontic treatment.9 Wires examined were multi-stranded stainless steel, conventional (stabilized) NiTi, superelastic NiTi, copper NiTi, and thermo-elastic NiTi initial arch wires. Notably, no reliable evidence was found in favor of a specific arch wire material and its effect on pain, speed of alignment, or root resorption.

Summary Webster’s Dictionary defines a drug as a substance intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease.10 Based on a consensus of the various studies, the optimum level of magnitude that is best for orthodontic tooth movement remains unclear. Yet a safe and fundamental principle, with the goal of proper clinical magnitude selection, is the minimization of errors and reduced patient trauma from various force applications. It is important to remember that each wire we install on the patient is a prescription drug delivery mechanism with a known rate of force magnitude that potentially can deliver a desired, or an undesired clinical consequence, underlying the importance of each wire and its clinical application. OP

How does this translate into clinical practice? In clinical practice, one example is the cross-sectional wire diameter and the wire’s material composition. The orthodontist must decide which type of wire(s) to employ for a given patient, where numerous options are available, each touting perceived advantages over the next, and where each clinician has a slightly biased preference. This begs the question, Under what science is this wire being chosen? Is it best to begin everyone on a .012 or .014 NiTi (nickel-titanium) wire and progress upwards to .016NiTi, .018NiTi, then rectangular wires, then steel wire, and so on? Since that question is plagued with various clinical variables and presenting Volume 5 Number 2

References 1. Topkara A, Karaman AI, Kau CH. Apical root resorption caused by orthodontic forces: A brief review and a long-term observation. Eur J Dent. 2012;6(4):445-453. 2. Sameshima GT, Sinclair PM. Predicting and preventing root resorption: Part 1. Diagnostic factors. Am J Orthod Dentofacial Orthop. 2001;119(5):505-510. 3. Owman-Moll P, Kurol J, Lundgren D. Effects of a doubled orthodontic force magnitude on tooth movement and root resorptions. An inter-individual study in adolescents. Eur J Orthod. 1996;18(2):141-150. 4. Gonzales C, Hotokezaka H, Yoshimatsu M, Yozgatian JH, Darendeliler MA, Yoshida N. Force magnitude and duration effects on amount of tooth movement and root resorption in the rat molar. Angle Orthod. 2008;78(3):502-509. 5. Yee JA, Türk T, Elekdağ-Türk S, Cheng LL, Darendeliler MA. Rate of tooth movement under heavy and light continuous orthodontic forces. Am J Orthod Dentofacial Orthop. 2009;136(2):150-151, e1-9. 6. Proffit WR, Fields HW. Contemporary Orthodontics. 3rd ed. St. Louis, MO: Mosby; 2000: 296.

7. Tanne K, Sakuda M, Burstone CJ. Three-dimensional finite element analysis for stress in the periodontal tissue by orthodontic forces. Am J Orthod Dentofac Orthop. 1987;92(6):499-505. 8. McGuinness NJ, Wilson AN, Jones ML, Middleton J. A stress analysis of the periodontal ligament under various orthodontic loadings. Eur J Orthod. 1991;13(3):231-242. 9. Jian F, Lai W, Furness S, McIntyre GT, Millett DT, Hickman J, Wang Y. Initial arch wires for tooth alignment during orthodontic treatment with fixed appliances. Cochrane Database Syst Rev. 2013;4:CD007859. 10. “drug”. Merriam-Webster.com. 2011. http://www.merriamwebster.com/dictionary/drug. Retrieved May 8, 2011. 11. Hemanth M, Lodaya SD. Orthodontic force distribution: a three-dimensional finite element analysis. World Journal of Dentistry. 2010;1(3):159-162. 12. Leach HA, Ireland AJ, Whaites EJ. Radiographic diagnosis of root resorption in relation to orthodontics. Br Dent J. 2001;190(1):16-22.

Orthodontic practice 51

PRODUCT INSIGHT

The use of Propel to increase the rate of aligner progression Dr. Thomas S. Shipley discusses increasing the bone remodeling rate for more rapid aligner progression

he use of clear aligners has gained broad acceptance as an alternative way to orthodontically move the dentition. As the orthodontic community becomes more familiar with this modality of treatment, questions arise as to best clinical practices to achieve optimal results. One area of interest is how often to change aligners. The Invisalign® System suggests the optimal time to change from one aligner to the next, with good patient compliance, is 2 weeks. The aligner system and the amount of movement prescribed in each aligner determine how frequently the patient is required to change aligners in the sequence. Changing aligners at a faster rate than the velocity of tooth movement would be one cause of aligners not “tracking” over time. This rate of aligner change is a limiting factor in the overall case completion time. In more difficult cases, the number of aligners prescribed may reach as many as 40 to 60 aligners, with even more in the most difficult cases. To the patient, who can quickly do the math, and to the clinician, who knows “refinement” or “auxiliary treatment” has not even been accounted for yet, the future of the orthodontic treatment becomes daunting. In these cases, or with any case, where increased velocity of tooth movement

Thomas Shipley, DMD, MS, received his Bachelor of Science degree in Business Management from Brigham Young University and went on to earn his doctorate from the University of Kentucky College of Dentistry. Dr. Shipley completed a master’s program in orthodontics at West Virginia University. He maintains a full-time private practice in Peoria, Arizona, and is an Adjunct Professor at Arizona School of Dentistry, Department of Orthodontics in Mesa, Arizona. Dr. Shipley maintains membership in numerous professional organizations, such as the American Dental Association, the Arizona Dental Association, the American Association of Orthodontics, the Pacific Coast Society of Orthodontists, the Comprehensive Care Continuum Study Club; and he is the coordinator of the International Dental Ed Continuing Education Study Group for the Northwest Phoenix area. He is board certified by the American Board of Orthodontics.

52 Orthodontic practice

is desired, a way to change aligners at a more rapid pace becomes attractive. The rate of tooth movement is dependent on the rate of the physiologic process of bone remodeling.1,2 If this rate of bone remodeling is increased, then the rate at which aligners should be changed increases also. Failing to change the aligners fast enough to coincide with the velocity of tooth movement would be equivalent to placing intermittent orthodontic forces on the dentition, which could actually slow the overall progress of the movement.

Increasing the rate of bone remodeling is the key to being able to change aligners at a more rapid pace, therefore, decreasing overall treatment time. A female patient presented at age 21 with a mild Class II, Division 2 malocclusion. Moderate upper and lower dental crowding existed with a 60% deep bite and negatively inclined upper incisors. The patient’s chief concern was the rotation of the upper left lateral incisor. The CBCT showed good root parallelism and normal development of the dentition (Figures 1-7).

Figure 1

Figure 2

Figure 3

Figure 4

Figure 5

Volume 5 Number 2

Figure 6

PRODUCT INSIGHT

The treatment plan was developed to use clear aligners in conjunction with Class II elastics to resolve the dental crowding, slightly procline the upper and lower incisors, correct the deep bite, and improve the Class II dental relationship. Once the treatment plan was finalized, the resultant prescription for aligners was 43 upper and lower aligners. The aligners consisted of 43 active maxillary aligners, and 23 active lower aligners, followed by 20 lower passive aligners (Figures 8-9). Cuts were made in the upper aligners near the maxillary canines to create hooks for Class II elastics and cutouts in the lower aligners in the buccogingival area of the lower second molars to allow for Class II button hooks to be bonded (Figure 14). No interproximal reduction was prescribed. The patient desired to finish treatment faster than 86 weeks! The clinician was concerned that this treatment did not allow much time for refinements and detailing which may be needed. Both agreed that Propel would be an appropriate way to speed the orthodontic treatment. Propel is a technique performed with the patented FDA Registered Class 1 5(10k)-exempt disposable medical device that creates Micro-Osteoperforations (MOPs). These MOPs stimulate a cytokine response in the patient’s alveolar bone during orthodontic treatment (Figures 1011).3 MOPs reduce overall orthodontic treatment time by harnessing the body’s own biology to increase the rate of tooth movement and release challenging movements.4 This in-office technique can be performed chairside in minutes during a patient’s regularly scheduled office visit and can be used in conjunction with any type of fixed or removable orthodontic appliance. Micro-Osteoperforations with Propel can be used to advance the treatment of any malocclusions, including, but not limited to, crowding, space closures, molar uprighting, rotations, intrusions, and extrusions. Aligners 1 and 2 were delivered at the initial appointment. The patient was told to wear each aligner for 2 weeks and return in 4 weeks for placement of attachments. At the 4-week return appointment, aligner 3 was delivered, attachments were placed, and Class II elastics commenced. No Propel was used for the first 6 weeks of treatment. A regular tray progression of 2 weeks per tray was used. There are several advantages to starting at this pace. The patient has ample time to adapt to wearing the trays and to learn how to be compliant.

Figure 7

Figure 8

Figure 9

Treatment progressed at a slower pace, not to overburden the patient with learning to wear the trays, having attachments placed, beginning elastic wear, and Propel all at the same time. In addition, the clinician is given an opportunity to gauge patient compliance before beginning Propel. The

enhanced cytokine response with the MOPs would be of little benefit without good patient compliance. Six weeks into treatment, Propel was initiated. The use of local infiltration anesthesia (2% Lidocaine with 1:100,000 epinephrine) was employed. “Profound”

Figure 10

Figure 11

Figure 12

Figure 13

Figure 14

Figure 15 Orthodontic practice 53

PRODUCT INSIGHT topical anesthesia may instead be used. The patient rinsed twice with chlorhexidine gluconate and expectorated. MOPs were placed inter-radicularly using the Propel device as follows: Three MOPs mesial and distal of the maxillary lateral incisors, and two MOPs mesial and distal of the lower incisors (Figures 12-13). She stated that there was little discomfort of the procedure other than

mild pressure between the teeth in a few areas. A post-Propel CBCT was taken, which shows the location of the maxillary left MOPs (see image). The patient rinsed again with chlorhexidine gluconate after the procedure and was asked to wear the aligners at a progression of 3 days each. With such a rapid pace of aligner progression, close monitoring by the clinician is needed to ensure patient

compliance and good aligner “tracking.” If the rate of aligner progression exceeds actual tooth movement, it will be apparent due to poor aligner fit. Aligner progression may be slowed, if needed, based on how the patient presents on follow-up visits. The patient was seen 2 weeks later and was now beginning aligner 9. As shown in the photos, the aligners were fitting the dentition perfectly (good “tracking”). This

Figure 16

Figure 17

Figure 18

Figure 19

Figure 20

indicated that the progression at 3 days per aligner was appropriate for this patient (Figures 16-18). In addition, the soft tissue had completely healed with no signs of trauma at 2 weeks (Figures 19-20). The patient was seen again 2 weeks later (4 weeks post-Propel). At this time, she was just beginning tray 14, and a CBCT was taken that shows the MOPs slightly smaller, but still present (Figure 21). Again, the “tracking” of the aligners was still excellent. A 4-week interval was now chosen, continuing at 3 days per aligner. Four weeks later, the patient was wearing the 23rd aligners. The aligners were Figure 21

Figure 22

54 Orthodontic practice

Figure 23

Figure 24

Volume 5 Number 2

PRODUCT INSIGHT

still â&#x20AC;&#x153;trackingâ&#x20AC;? perfectly, and treatment was completed on the lower arch. Complete resolution of the lower dental crowding was achieved as prescribed using 23 aligners over a period of 14 weeks. No refinement or detailing was needed for the lower arch. More aligners were delivered, and Class II elastics were continued. The patient returned every 4 weeks forward until completion of treatment of the maxillary orthodontic treatment. The aligner progression continued at 3 days per aligner. The patient continued to change the lower passive aligners at the same pace. At 23 weeks, treatment was completed on the upper dentition after the use of 43 upper aligners. No refinement aligners were needed. Attachments were removed, and retainers with similar Class II elastic hooks and cutouts were fabricated. The bonded buccal hooks on the lower 2nd molars were left for 6 months, for the continued use of class II elastics for 12 hours per night as part of the retention protocol. Otherwise, the clear removable retainers were worn according to the clinicianâ&#x20AC;&#x2122;s normal retention protocol. Evaluation of the final records shows adequate inclination of the upper and lower incisors to allow for better anterior guidance, which was achieved by upper anterior labial crown torque and lower

Figure 25

Volume 5 Number 2

Orthodontic practice 55

PRODUCT INSIGHT incisor proclination aided by the use of Class II elastics. In addition, the overbite was corrected to an appropriate 30%. The patientâ&#x20AC;&#x2122;s chief concern of the rotated upper left lateral incisor was completely corrected to her satisfaction, along with complete resolution of the remaining upper and lower dental rotations. The post-treatment CBCT, taken 6 months post-Propel, shows the MOPs almost complete healed (Figure 25). The final results show that Propel is a good approach to increasing the rate of clear aligner progression by increasing the rate of bone remodeling. Treatment time was reduced over 70% in this case as compared to a typical 2 week interval aligner case. The overall amount of appointments were reduced from 20+ to 8. More research is needed to gain a better understanding of the exact rate of tray progression that should be used. A clinician new to this treatment modality should consider starting at a slower progression than that shown with this case, such as 7 days per aligner. Close monitoring should be employed, and adjustments may be made to the rate of progression based on the clinical results for each patient. OP

Table 1: Treatment progression References 1. Henneman S, Von den Hoff JW, Maltha JC. Mechanobiology of tooth movement. Eur J Orthod. 2008;30(3):299-306. 2. Krishnan V, Davidovitch Z. On a path to unfolding the biological mechanisms of orthodontic tooth movement. J Dent Res. 2009;88(7):597-608. 3. Teixeira CC1, Khoo E, Tran J, Chartres I, Liu Y, Thant LM, Khabensky I, Gart LP, Cisneros G, Alikhani M. Cytokine expression and accelerated tooth movement. J Dent Res. 2010;89(10):11351141. 4. Khoo E, Tran J, Raptis M, Teixeira CC, Alikhani M, Abey M. Accelerated Orthodontic Treatment [research paper]. New York: New York University; 2011.

56 Orthodontic practice

Volume 5 Number 2

A faster way to deliver orthodontic success As a practitioner, the most important thing is achieving the best clinical outcome. Propelâ&#x20AC;&#x2122;s chairside technique can be done in minutes in conjunction with any orthodontic modality. Our patented, disposable device is redefining treatment protocol without sacrificing patient comfort or the desired finish.

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SERVICE PROFILE

Who is ”minding the store” of your practice?

he actual practicing of orthodontics is just one of the items that require the orthodontist’s time. This also pertains to attracting new patients, improving case acceptance, working smarter, completing treatment on time, keeping current with technology, and maintaining profitability. The orthodontist’s ability (and availability) to manage the business of the practice while simultaneously serving as practitioner can be overwhelming. There never seems to be enough hours in the day even though “minding the store” is crucial to the practice’s success. With the demands of day-to-day operations, it’s easy to neglect the business of information. And when you don’t have the information you need, you can’t identify problems or make decisions to alter your course. This accountability piece, the information to measure the health of the practice, is only as important as the action that follows in order to foster real growth. Gaidge provides a unique solution to solve both sides of this equation: instant access to critical orthodontic practice information, as well as the insight to know what issues require what solutions. Gaidge, a web-based software platform, is equal parts “practice performance monitor” and “orthodontic practice management tool.” By bridging directly to most orthodontic management software, Gaidge automatically generates accurate, daily assessments of the practice’s “health.” Using industry standard benchmarks, Gaidge alerts the practice to specific areas or departments that are lagging, providing guidance to understand and remedy the “blip” before it becomes a trend. Consider, as an example of what Gaidge provides to the practice, the means by which you attain similar metrics, and how you would seek remedy: • Is the phone ringing? Are new patients continuing to call our office? Are we engaging them in a way that assures they will attend the exam? Are we converting patients who have had treatment recommended into starts? • What is our case acceptance rate, and how does it compare with the same month over the past 5 years? How does it 58 Orthodontic practice

Gaidge provides a unique solution to solve both sides of this equation: instant access to critical orthodontic practice information as well as the insight to know what issues require what solutions.

compare with other similar practices in my region? • Can we set and track both short-term and long-term goals for achievement levels on a daily basis? The Gaidge “Leader Board” tool does exactly this. • Do we suffer from costly interruptions to my schedule (forcing me to work more days and lose profitability), and to what extent? o Are there a high number of noshows? o Are there excessive emergency repair visits? o Are there too many retention visits? o What is the real expense of having too many patients go over their estimated completion date (the most costly issue there is to your practice)? The above is not meant to send

you into a panic attack. The point is that having immediate, daily access to this information, as well as a tool set to manage any “blips,” can be a gamechanger for the orthodontist, the team, and their consultant. While most orthodontic management platforms can produce a myriad of “two-dimensional” reports, the process of gathering and assembling them into accurate, actionable elements would require a full-time statistician with significant orthodontic prowess. Gaidge makes the ability to “mind your store” vastly easier, faster, and more manageable. Your “store” does not have to be so overwhelming. To discover how Gaidge can assist your practice in moving to the next level, visit www.gaidge.com or call (800) 2873396 to schedule a demonstration for you and your team. OP This information OrthoBanc.

was

provided

Volume 5 Number 2

MATERIALS lllllllllllll & lllllllllllll EQUIPMENT DENTSPLY Raintree Essix announces the launch of MTM® Clear•Aligner DENTSPLY Raintree Essix, a division of DENTSPLY International, has announced the U.S. market launch of its new clear aligner service center treatment, MTM® (Minor Tooth Movement) Clear•Aligner. The treatment is backed by more than a decade of development and clinical testing and combines proven chairside techniques with advanced digital modeling to provide clinicians with a streamlined solution for treating minor anterior misalignments. MTM® Clear•Aligner is uniquely engineered to deliver the space and force needed to accomplish tooth movement. It utilizes a proprietary “open pathway” architecture that allows teeth to move easily into the desired positions. And unlike many other aligner systems, MTM® Clear•Aligner does not require the clinician to bond unsightly attachments to the patient’s teeth to accomplish movement. Instead, it uses integrated “force points” in the aligner to provide a greater range of tooth movements, while making aligner placement and removal easy for the patient. For more information, visit www.essix.com.

tops Software Releases topsOrtho™ 6.0 D7 Matrix™ Analytics allows doctors to pinpoint every patient tops Software has released the latest version of its practice management software. topsOrtho 6.0 comes with several new features, including topsChecklist (which allows a practice to create customized checklists) and a new backup mechanism that automatically saves practice data each hour. It also includes redesigned treatment notes. topsOrtho 6.0 also marks the debut of D7 Matrix™ analytics. With D7 Matrix, orthodontists can view statistics such as the following, all in one place: • Where each patient is in his or her treatment (for example, how many patients are in active treatment, and how many are in retention) • Profitability by type of treatment • Conversion rates, broken down in various ways (such as during a specific time frame or by treatment coordinator) • Treatment times, depending on treatment method or type of patient. For more information, visit www.topsOrtho.com or call 770-627-2527.

Volume 5 Number 2

3Shape’s new Splint Designer™ CAD software opens new business opportunities for dental labs 3Shape recently released a groundbreaking software tool for CAD design of common dental appliances, such as splints, night guards, and protectors, all ready for output using 3D manufacturing machines and materials. 3Shape is offering this attractive tool to Dental System™ Premium subscribers for free. 3Shape Splint Designer overview: • CAD design of splints, night guards, protectors, and similar dental appliances. • Splints and appliances can be ordered directly through the Dental System™ order form. • An intuitive workflow guides users through the design steps: open the bite with a virtual articulator, create a shell, add a bar profile on top, combine both parts, and optionally “cut” the design with the antagonist in the included virtual articulators. • Option to engrave ID tags in the appliance for patient identification or branding of the lab. • Included free of charge for all 3Shape Dental System™ Premium subscriptions. Please contact your local 3Shape supplier, or visit www.3shapedental.com.

Carestream Dental signs integration agreement with Intuit Demandforce Carestream Dental, provider of industry-leading imaging, CAD/ CAM, software, and practice management solutions for dental and oral health professionals, announced an integration agreement with Intuit Demandforce. Under the terms of the agreement Carestream Dental will develop integration for Demandforce services in its CS OrthoTrac, CS WinOMS, and Windent practice management software products. In addition, Carestream Dental will provide technical assistance to Intuit Demandforce for their existing CS SoftDent and CS PracticeWorks practice management software integrations. For more information, call 800-944-6365 or visit www.carestreamdental.com. For more information on Demandforce, call 800-210-0355 or visit www.demandforce.com.

Ortho Classic, Inc. teams-up with OrthoVOICE Ortho Classic, Inc. has teamed-up with OrthoVOICE and will be holding their annual H4 Forum during the days prior to the opening party for OrthoVOICE. Both events will take place at the Planet Hollywood Resort and Casino in Las Vegas, Nevada. The H4 Forum will run on September 17 and 18 and lead directly into OrthoVOICE and their opening party on the evening of September 18. OrthoVOICE will then continue on September 19 and 20 with the opening of their exhibit hall and group of seminars. For more information, call Ortho Classic at 866-752-0065 or visit www.orthoclassic.com.

Orthodontic practice 59

PRACTICE MANAGEMENT

3 reasons you need to re-evaluate your digital marketing strategy Diana Friedman discusses ways to keep online marketing strategies fresh

s a successful orthodontist, you understand that the processes and procedures used to treat your patients are under a constant state of evolution. You realize that many of the treatment approaches that worked so well just a few years ago are no longer considered state of the art. As a result, you routinely evaluate the latest advancements in your field to find new and innovative ways to offer superior treatment.

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, Friedman served as a recognized practice management consultant, author, and speaker. She holds an MA in Sociology and an MBA from Arizona State University.

60 Orthodontic practice

Have you ever considered this same line of reasoning holds true for your digital marketing strategy? In a study conducted by Sesame Communications, 93% of patients stated it was more convenient to find answers online compared to calling the office.1 Given this preference and the rapidly evolving Internet technologies (e.g., smartphone and tablet adoption) and options for finding orthodontists outside Google searches, it’s likely that the online marketing strategies your practice deployed even 12 months ago may be outdated. Here are three reasons it’s time to re-evaluate your digital marketing strategy:

1. Mobile is taking over A recent study by Pew Internet showed smartphone adoption increased an astounding 21% from May 2011 to 2013.2

Another study found 90% of mobile phone searches result in a purchase or a visit.3 All you have to do is look in your practice reception area to see this trend in action. With this pattern of mobile adoption, re-evaluating your website, patient communications, and social media channels to ensure they are optimized for mobile viewing is more important than ever. There are really two ways to accomplish this. In terms of website, it is imperative that your website render optimally on any mobile device. This can be accomplished by building a separate mobile site that identifies the device and presents an alternate website that will work with a limited set of devices. However, the optimal way to accomplish this is to update your website to what’s known as “responsive design.” In this scenario, your website is built on a Volume 5 Number 2

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PRACTICE MANAGEMENT state-of-the-art platform that automatically adapts the design and content to screens of any size to ensure an optimal patient experience on virtually any device. In terms of patient communications, it is imperative your patient engagement platform (often referred to as a patient portal) is mobile optimized. This means your patients would be able to view their accounts, pay bills, confirm appointments, and access their records from any device. If you consider 57% of users won’t recommend a business with a poorly designed mobile site, making sure your patients have a great mobile experience with your patient portal should be a top priority on your list of digital marketing initiatives.

friends to your practice, they also expect more from the online relationship. The days of adding a Facebook, Twitter, or Google+ account and expecting it to act like a billboard for your practice are over. To ensure your social media efforts pay dividends, your practice needs to plan to keep all its sites up-to-date, providing relevant and patient-directed content of interest, or to invest in a service that specializes in social engagement for dental care providers.

3. Topical search sites are on the rise Google is no doubt what comes to mind when the word “search” is mentioned. However, due to the immense amount of

To ensure your social media efforts pay dividends, your practice needs to plan to keep all its sites up-todate, providing relevant and patient-directed content of interest, or to invest in a service that specializes in social engagement for dental care providers.

2. We live in a “social” world Just last year 72% of Internet users ages 30 to 49 were active on social media — and by all accounts that number continues to rise. Even more interesting, 47% of Americans say Facebook is their number one influencer of purchases (up from 24% in 2011).5 Social media, when done correctly, will drive new patients to your practice from referrals and foster loyalty with your existing patient community. However, as consumers rely more on social media to make decisions and refer

content on the larger search engines, there has been a rise in what’s known as vertical search or topical sites. Basically, these are websites that cater to a specific topic or area of interest. In the last half of 2012, topical sites had an 8% increase in search traffic while major search engine traffic decreased by 3% over the same period.6 Examples for successful topical sites in the consumer world include websites such as WebMD, Amazon, and eBay. In the world of dental care, the best example for this is healthgrades.com.

References 1. Sesame Communications Member Survey, 2010

mobile-search-statistics-showing-past-and-predictingfuture. Accessed February 11, 2014.

2. Pew Internet & American Life Project. Smartphone ownership 2013.http://pewinternet.org/Reports/2013/ Smartphone-Ownership-2013/Findings.aspx. Verified February 11, 2014.

4. Vizibility. 13 Mobile Stats Your Competitors Already Know. http://vizibility.net/blog/13-mobile-stats-yourcompetitors-already-know-infographic/. Accessed February 11., 2014.

3. Social Media Today. 10 Mobile Search Statistics: Showing the Past and Predicting the Future. http:// socialmediatoday.com/stuartwainstock/2031461/10-

5. Bullas J. 22 Social Media Facts and Statistics You Should Know in 2014. Jeff Bullas blog. http://www. jeffbullas.com/2014/01/17/20-social-media-facts-

62 Orthodontic practice

Today more than 20 million prospective patients search healthgrades.com for a new dental care provider in their local area, and more than half will schedule an appointment when a “click-to-request an appointment” feature is present.7 Topical search sites like healthgrades.com can help your orthodontic practice in a couple of important ways. First, it will provide increased practice exposure to highly qualified prospective patients and drive more of them to your practice. Second, it will also provide additional exposure on the more traditional search engines. A listing on a well-trafficked vertical search site in many cases will appear above your practice website on the regular search results. This obviously increases the opportunity for prospective patients to engage with you online. Focus your attention on those topical sites that have an area dedicated to dental care providers. Given the impact this can have on new case starts, you would do well to capitalize on the evolution in this particular area of digital marketing.

Final thoughts Technology is in a constant state of change; you realize this when it comes to caring for your patients. You want to ensure that you’re always looking for the latest advancements to improve outcomes. You understand this approach improves not only the experience your patient has with your practice, but also the results of the treatment. If you adopt this same approach for your digital marketing strategy, you will fortify the engagement with your patients, drive new case starts, improve production, and ensure sustained growth and profitability for your practice. A complete review of your current digital marketing strategy and its relevance, given ongoing technology advancements, is a great way to start. Make sure you consider the evolution of mobile, patient portal, social, and topical searches as you plan your go-forward strategy. OP

and-statistics-you-should-know-in-2014/. Accessed February 11, 2014. 6. ComScore, 2013 U.S. Digital Future in Focus. http:// www.comscore.com/Insights/Press_Releases/2013/2/ comScore_Releases_the_2013_U.S._Digital_Future_in_ Focus_Report. Accessed Februrary 11, 2014. 7. Healthgrades Use Study, 2013, http://articles. healthgrades.com/about/healthgrades-solutions-foradvertisers.

Volume 5 Number 2

INDUSTRY NEWS

ith first patients enrolled, OrthoAccel Technologies, Inc., announced the start of a groundbreaking clinical trial that evaluates the effect of AcceleDent on orthodontic tooth movement with aligners. Manufactured by OrthoAccel, AcceleDent is the only FDA-cleared, Class II medical device that speeds up orthodontic treatment by as much as 50 percent. Conducted at the University of Florida College of Dentistry, the prospective randomized controlled trial follows patients for 12 weeks during their clear aligner treatment with AcceleDent. The trial’s principal investigator, Timothy Wheeler, DMD, PhD, is a distinguished researcher of orthodontic treatment with clear aligners. “The purpose of this clinical trial is to evaluate how pulsatile forces produced through AcceleDent’s SoftPulse Technology® enable teeth to move faster,” said Wheeler, who is a professor at the University of Florida College of Dentistry. “AcceleDent is such a groundbreaking innovation that there’s a lot of interest in this study among orthodontists who want clinical evidence showing the product’s potential benefits when used with clear aligners — faster tooth movement and reduced pain.” First introduced in the United States in 2012, AcceleDent’s technology was developed in part by Dr. Jeremy Mao, co-director of the Center for Craniofacial Regeneration at Columbia University College of Dental Medicine in New York. Mao’s pioneering work in the early 2000s, which was initially conducted while he was a faculty member at the University of Illinois, Chicago, was paramount in establishing the therapeutic effect of pulsatile forces in accelerating bone modeling and remodeling in the craniofacial region. With many of the nation’s leading orthodontists prescribing AcceleDent to their patients, AcceleDent is now available in over 1,000 orthodontic locations throughout the U.S. “As the sole provider of a noninvasive, 64 Orthodontic practice

FDA-cleared medical device that speeds up orthodontic treatment, we recognize our responsibility to support orthodontists by continuing to provide clinical evidence confirming AcceleDent’s claims of accelerating orthodontic tooth movement safely and gently,” said Michael K. Lowe, president and CEO of OrthoAccel. Orthodontists and staff members interested in learning more about AcceleDent, or how to offer the technology at their practice, can locate an OrthoAccel sales representative at AcceleDent.com/ orthodontists or call 866-866-4919.

Technologies, Inc., is a privately owned medical device company engaged in the development, manufacturing, and marketing of products to enhance dental care and orthodontic treatment. OrthoAccel developed and sells AcceleDent, the first FDA-cleared clinical approach to safely accelerate orthodontic tooth movement by applying gentle micropulses via SoftPulse Technology as a complement to existing orthodontic treatment. More information can be found at acceledent.com and acceledent.co.uk or requested via info@ orthoaccel.com. OP

About OrthoAccel Technologies, Inc.

This information was provided OrthoAccel Technologies, Inc.

Based in Houston, Texas, OrthoAccel Volume 5 Number 2

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