clinical articles • management advice • practice profiles • technology reviews
PROMOTING EXCELLENCE IN ORTHODONTICS
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November/December 2013 – Vol 4 No 6
A golden opportunity for dentists: dental sleep medicine: part 2
BioDigital Orthodontics: part 6 Dr. Rohit C.L. Sachdeva
Dr. Harold F. Menchel
Practice profile Dr. Jack Fisher
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Pride Institute “Best of Class” special awards tribute
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The biology of orthodontic tooth movement: part 1
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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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Are you going to believe me or your own eyes? This is the “punchline” to an old joke where a wife catches her husband in the middle of an encounter with another woman. While our experience may tell us otherwise, we are asked to believe things in orthodontics that just may not ring true. Whether it is the use of a cephalometric analysis that is based on one case and not only is in the literature but has become the “normal” for many other analyses, or a pronouncement of a new technique with magical brackets and wires, we must at long last — think! We cannot agree on where “centric relation” is; or if it is important; or if the mandible can be advanced without doing damage; or if articulators are useful; or whether or not self-ligating brackets are better than traditional; or if they are, whether they should be “passive,” “active,” or interactive.” Many orthodontists have become experts at the mechanical part of tooth movement. But even in this area, we do not agree! Light forces, small light wires, heavy stainless steel wires? University studies have shown that lower incisors will move no matter what is done. Extraction or non-extraction, upright teeth stay within certain limits; lower incisors must be at specific angles — we decide whether to increase canine width or not. Yet even though these studies show that nothing works, we are given guidelines to follow. What does all of this rambling mean? There are 28 reasons for relapse. Do not violate these areas, and relapse will be very unusual. We must pay attention to the role of muscles in orthodontic tooth movement. What happens when muscles are not relaxed? What is the physiologic meaning for using stainless steel wires, titanium wires, filling the slot, or not? Does a light-force, small-diameter titanium wire move teeth any faster than a medium-force, large-diameter round wire? No! If we use a pre-adjusted appliance, why do we continue to make wire adjustments and/or change bracket positions? There are dozens of questions that should be asked, and if you do ask them, there are answers. Our specialty must, in my opinion, pay attention to anatomy, periodontal physiology, and neuromuscular physiology. By this I do not mean placing patients on a machine to find out about muscles. I do mean we need to be experts in knowing how muscles and periodontal fibers are affected by what we do to move teeth and jaws. It is critically important to understand what is happening physiologically during and after tooth movement. At this time in orthodontics, I believe some common philosophies of treatment are incredibly theoretical and wrong! We need to ask lots of questions!
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1 Orthodontic practice
Volume 4 Number 6
INTRODUCTION
November/December 2013 - Volume 4 Number 6
TABLE OF CONTENTS Orthodontic concepts BioDigital Orthodontics: Management of Class 1 non– extraction patient “Standard– Track”© – 9-month protocol:
Practice profile
6
part 6 Dr. Rohit C.L. Sachdeva, and Drs. Takao Kubota and Kazuo Hayashi, discuss a treatment for Class I nonextraction patients....................... 16
Dr. Jack Fisher: Changing smiles, changing lives This orthodontist employs both art and science to create great smiles.
Corporate profile
10
Planmeca®: innovative, upgradeable imaging technology This company delivers complete dental solutions based on integrated high-tech device and software options.
Special section Pride Institute “Best of Class” special award tribute .............. 28
ON THE COVER Cover photo courtesy of OraMetrix, Inc. Article begins on page 16.
OrthoAccel Technologies, Inc.
12
With a focus on developing, manufacturing, and marketing innovative technologies, this firm helps clinicians enhance dental care and orthodontic treatment.
2 Orthodontic practice
Volume 4 Number 6
Virtually everywhere
CS OrthoTrac Cloud
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Call 800.944.6365 or explore it here carestreamdental.com/cscloud © Carestream Health, Inc. 2013. OrthoTrac is a trademark of Carestream Health. iPad is a trademark of Apple, Inc., registered in the US and other countries. 9973 OR AD 1113
TABLE OF CONTENTS
38
Biology of bone
Continuing education
Practice management
The biology of orthodontic tooth movement part 1: Biology of
Growing the money tree William H. Black, Jr. discusses the financial advantages of having a good plan in place..................................52
Bone 101 Dr. Michael S. Stosich outlines the basic premises and biology of bone related to orthodontics .................38 A golden opportunity for dentists: dental sleep medicine: Part 2 Dr. Harold F. Menchel offers a wakeup call to clinicians to explore an evolving niche in dentistry .............42
Orthodontic insights More than one way — an issue related to invisible aligners Drs. Donald J. Rinchuse, Ethan Drake, Janet Robison, and Dara L. Rinchuse offer insights on the various forms of tooth movement..............46
Technology VELscope®...................................50
4 Orthodontic practice
Hard-piped filtered water system vs. self-contained bottled water system John Bednar helps avert problems coming down the pipe...................61
Product profile Dental technology gets a new look with Henry Schein’s augmented reality app ...................................54
Abstracts The latest in orthodontic research from around the world Dr. Shalin R. Shah presents the latest literature, keeping you up-to-date on the most relevant research from around the world...........................56
Legal matters Employment Law 101 Dr. Ali Oromchian discusses basic laws every orthodontist needs to know.............................................58
Book review Biomechanics in Orthodontics, 4th Edition Drs. Giorgio Fiorelli and Birte Melsen . .....................................................60
Practice development Four social media channels that drive new patient acquisition and retention Diana P. Friedman offers advice on cultivating a dynamic web presence . .....................................................62
Industry news ...........64 Materials & equipment .....................64 Volume 4 Number 6
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PRACTICE PROFILE
Dr. Jack Fisher Changing smiles, changing lives What can you tell us about your background?
Why did you decide to focus on orthodontics?
I grew up in Mayfield, a very small town in western Kentucky. After my undergraduate studies, I attended the University of Louisville School of Dentistry and then went on to residency at the Medical College of Georgia where I received a certificate in orthodontics. Upon completion of my formal education, I returned home to begin a practice limited to orthodontics. Realizing very quickly that the small community could not support a full-time specialist, I acquired a private pilot’s license and started another practice in a larger community where I could practice 2 days a week with an oral surgeon. Owning my own plane allowed me to raise a family in my hometown while also allowing me to expand my professional career and see more complex cases. It also gave me the opportunity to treat many surgical cases together with the oral surgeon. I was able to scrub in on many cases, which I greatly enjoyed. After our two boys graduated from high school, we were able to liquidate the practices and relocate to Memphis, Tennessee. I took a position with a corporate dental group to treat their orthodontic patients. This experience turned out to be beneficial because I began to realize that corporate dentistry did not fit my personality or meet the standard of care I wanted to provide my patients. So, at the age of 58, I started over again. In 2006, I was able to develop a temporary skeletal anchorage system (TSAD). This has afforded me the opportunity to be involved with several residency programs. For the past 7 years, I have conducted a cadaver course for the insertion and use of TSADs. The company conducting this course is Elite Ortho. I am also currently practicing orthodontics in Cordova, Tennessee, 14 days per month, and I am a faculty member at three residency programs. After 30-plus years in this great profession, I still enjoy going into the office every day, and I truly consider it a blessing to be able to teach and to help people smile.
My motto is, “Change a smile; change a life.” I enjoy orthodontics because it employs both art and science to create a great smile. I really feel that about 80% of what I do as an orthodontist is art. To be able to help patients achieve great smiles by altering their facial features, in conjunction with improving their oral form and function, is one of the most rewarding fields in healthcare. The demographics of most orthodontic practices are predominately teenagers. This age group is still early in its development, and most young people are very impressionable. We are privileged to be able to develop a relationship and spend time with them on a regular basis during the course of treatment. After the braces come off, which is a very exciting day in our office, we are then able to continue this relationship during the retention phase of treatment. This affords the orthodontist a distinct opportunity to be a positive influence for a significant amount of time in young people’s lives.
6 Orthodontic practice
How long have you been practicing, and what systems do you use? I have been practicing orthodontics for 30 years. I use a pre-adjusted fixed orthodontic appliance on more than 95% of my patients. Most of all our patients are treated with segmental mechanics initially and then are finished with continuous arch wires. Approximately 25% of our patients receive some type of a skeletal anchorage device. I do utilize DICOM imaging on approximately 80% of the cases.
Who has inspired you? I was inspired by a high school guidance counselor who asked me what I wanted to become. I responded by telling her that I wanted to become a dentist. When she laughed at me and told me that in her professional opinion, I would not be able to become a doctor, it drove and inspired me to prove her wrong. Her attitude toward my abilities, or lack thereof, has been a driving force for me for many years. I was also blessed to have parents that made sure I was surrounded by successful people during my formative years.
What is the most satisfying aspect of your practice? I enjoy the ability to help young people with their self-confidence by improving their smiles.
you
Professionally, what are you most proud of?
I attended the University of Louisville School of Dentistry where I received a DMD. I furthered my education at the Medical College of Georgia where I received a certificate in orthodontics.
What do you think is unique about your practice?
What training undertaken?
have
Being invited to teach residents and other orthodontists techniques that they had not been directly exposed to previously.
We have a therapeutic dog in our office that makes our patients and team members Volume 4 Number 6
PRACTICE PROFILE
feel comfortable with their treatment and our working atmosphere.
What has been your biggest challenge? Meeting my own expectations.
What would you have become if you had not become a dentist? A machinist, or perhaps a mechanical engineer, or a commercial airline pilot.
What is the future of orthodontics and dentistry? The future of the specialty of orthodontics is a big concern of mine. The fact that residents are finishing their residency with such a large amount of debt is a challenge. Can we really advise them to buy a million dollar practice with so much debt? Should we advise them to start a practice? This advice is difficult in most cases because of the market saturation. It leaves three options for the graduate: 1) to associate with an existing practice, 2) to take a job in the corporate dental atmosphere, or 3) to become employed by a pediatric dental group. The second option opens the door for a long discussion, depending on someone’s opinion of the business model for delivering dental services to the public. The more the corporate side of dentistry grows, the more it will keep the specialty side of dentistry in-house. The more these patients stay inside the corporate market, the fewer patients there will be for the private practice model to treat, whether it is for the private general practices or the private specialty practices. The market will become more limited for all private practices. Though there are fewer seats in first class, they are rarely empty. It does seem that there will always be a market for the high-end private practices, just a smaller version, which Volume 4 Number 6
makes it difficult for these practices to thrive. The dental industry has been a relatively low-risk venture with good profit margins. The corporate world now knows this and can also hire the new graduates who are desperate to pay off debt. Also, pediatric specialists have a ready-made orthodontic practice and are often eager to hire recent graduates as well. It seems that because orthodontic practices are able to be owned and operated in most states without the owner being an orthodontist (i.e., corporate dentistry, general practitioners, pediatric dentists, and so on), that we are beginning to see the erosion of the first, and in my opinion, the greatest specialty in dentistry. Another challenge facing the orthodontic specialty is the traditional education model for residency programs. The traditional learning experience has usually consisted of a department chair and one or two full-time faculty members. Of these faculty members, one usually focuses on research and the other serves as a clinical director. The program then has orthodontists from the surrounding community who donate 1 or 2 days of their time per month to treat cases with the residents. This model has served the residency programs very well for many years. However, with the technological advances in recent years, the learning curve for many practitioners is difficult to maintain. Two examples include 3D-imaging technology and treatment modalities using skeletal anchorage devices. Many practitioners are either unable or unwilling to keep pace with their changing specialty. This is alarming to many residents who are paying hundreds of thousands of dollars for their education and find out, after the fact, that they weren’t fully equipped. Also, the use of aligners by general practitioners is growing rapidly, and this further eats away
at the nature of the specialty. When we consider the shift to corporate dentistry, the debt load of newly graduated residents, the steep learning curve of the diagnostic tools and recent treatment modalities, the orthodontic specialty seems to be “dumbing down.” It seems this trend is in large part because residency programs are unable to keep up with the advances in the field. Many programs have also become seen as “cash cows” for financially strapped universities, and as a result, the gap between the standard of care delivered by clinicians who did not attend a residency and those who attended a 2- to 3-year program seems to be narrowing. I realize these comments could be offensive to some, and I do apologize if they are ill received. It is my opinion that we who choose to volunteer in residency programs have a responsibility to the future of the specialty, the residents we are teaching, and most of all, the patients we are treating to stay abreast of emerging diagnostic tools and treatment modalities. Otherwise, what will separate a recent graduate from an accredited orthodontic program and a GP who has taken a few weekend courses?
What are your top tips for maintaining a successful practice? Focus on the details. The practice will not run itself, so the owner must focus on the business details, or there will be no business to focus on. There isn’t any one marketing strategy; it’s all the little things together that add up to something great. You have to do a lot of little things well. Neglect the personal relationships, and the practice will go away. Building relationships is the key to any success, whether in business or in life.
Orthodontic practice 7
PRACTICE PROFILE
What advice would you give to budding orthodontists? Colleges, dental schools, and residency programs do not teach or emphasize, to any degree, the value in understanding personality types and understanding how to build solid relationships (at least I am not aware of any that do). Whether it is with a spouse, a child, a team member, a patient, or a referral source, to be successful in this era, it is vital to understand these principles. Any graduate from a CODAapproved program knows how to help patients improve their smiles. It is the rare graduate that understands the value or has been taught how to build relationships. My advice is to seek out a mentor who is trustworthy and possesses these skills. Then, learn and apply the wisdom offered by the mentor. Lastly, budding orthodontists need to understand that just because they graduated at the top of their class and attended a residency program, they are not entitled to anything. They still have to earn what they seek. Many budding orthodontists seem to have an entitlement attitude concerning what they want out of life, just because of their academic achievements. If they take a job position, they need to understand and accept that the position will pay only what the job is 8 Orthodontic practice
worth, not what they are worth. The market for the service they provide dictates to a large degree their earning potential. In their defense, I will say that I believe it is wrong for either a corporate office or private practice doctor to hire recent graduates and not pay them a significant percentage of what they earn for the practice. In this sense, I feel perhaps medicine has been a little more humanistic than we have been in dentistry. The recent graduates are not expendable and should be treated the way you would have wanted to be treated, if you were in their shoes graduating with such a significant debt load. Ten to 15 years ago, recent graduates could expect to start a de novo practice and to do well, or to find a senior doctor who valued their education and was looking for a partner or associate. Now, graduating residents are forced to work in a piecemeal fashion — a day per week here and a couple of days there — just to survive and to pay off student debt. We as a society of orthodontists must begin to address these issues in the very near future for the well-being and survival of our great profession.
What are your hobbies, and what do you do in your spare time? Teaching and flying. OP
Top Favorites In my opinion, I am a fairly boring person who is rarely wrong and never in doubt. I say this in jest, of course, but for those who do have an understanding of personality types, I have just revealed mine. I’m a true choleric or what’s known as a type D personality. Here is my list of top favorite things personally and in practice. • My relationship with God ranks first. • Family. I love investing time and money in family. • My friends. The relationships we develop with other orthodontists and peers have become invaluable. I love just hanging out with these friends, solving and debating the challenges life brings our way. I also love hanging around young adults in their 20s and 30s. • The use of DICOM imaging. We purchased a Midi Cone Beam, manufactured by Planmeca®, over a year ago, and I would feel handicapped without the use of DICOM imaging. • Skeletal anchorage. The anchorage system we use is the Securus system. It is a system I developed in 2005, but I presently do not have any financial interest in either of these products. • The most valuable asset in our practice is our team. We spend 8 hours per day together. You have to have people around you whom you enjoy and work well with. They all have strengths and weaknesses, as do I, and I cannot imagine working without them. • The greatest asset that I have been blessed with is Debbie, my wife of 37 years. She is my best friend, and she continues to make me complete. Volume 4 Number 6
CORPORATE PROFILE
Planmeca®: innovative, upgradeable imaging technology Company history Planmeca is the world’s largest privately held dental imaging company and one of the industry’s leading manufacturers of panoramic and cephalometric X-rays. Over the past four decades, it has expanded its sales network in more than 100 countries worldwide. Planmeca’s imaging units offer superior image quality, reduced radiation during routine procedures, easy upgradeability, and advanced, user-friendly imaging software. Planmeca has been a leader in digital imaging and advanced computer-integrated dental care concepts for years and remains in the forefront of technology as the field of dentistry evolves. Since the company’s establishment, Planmeca’s developers have worked closely with dentists and leading universities to anticipate future trends, using the data to design an advanced line of high-tech products. From the introduction of the first microprocessor-controlled chair, to the development of the ProMax™ line of imaging units with SCARA (Selectively Compliant Articulated Robotic Arm) technology, Planmeca has always led the way with new technology. The company’s goal is to supply dental professionals with the highest quality dental equipment that is uniquely designed for today’s modern, technologically advanced practice.
Patented SCARA technology What truly sets Planmeca apart from the competition is the company’s patented, exclusive SCARA technology. This robotic arm, which comes standard on all ProMax units, enables free geometry based on image formation and can produce any movement pattern required. The precise, free-flowing arm movements allow for a wide variety of imaging programs not possible with any other X-ray unit on the market; this allows the dental professional to take images based on diagnostic needs, not machine limitations.
Anatomically accurate extraoral bitewing program Planmeca’s ProMax S3, 3D, and 3D Mid imaging units offer an exclusive extraoral bitewing program, possible only with SCARA technology. This innovative program consistently opens interproximal contacts, eliminates patient 10 Orthodontic practice
positioning errors, and is more diagnostic than other intraoral modalities. ProMax extraoral bitewings are ideal for a number of patients, from the elderly and those requiring periodontal work to those with claustrophobia, sensitive gag reflexes, or those in pain. All of this comes in a true bitewing program that enhances clinical efficiency and takes less time and effort than a conventional intraoral bitewing.
Upgradeable innovation One of Planmeca’s greatest contributions to dental imaging is its innovative, upgradeable product platform — all based on exclusive, patented SCARA technology. Since it’s software-driven, SCARA technology enables limitless possibilities to upgrade existing equipment, allowing the new dentist on a smaller budget to grow while making only appropriate and necessary equipment investments. For example, Planmeca products can be upgraded from a 2D panoramic X-ray to a combination of pan/ceph capabilities, which can be further upgraded to accommodate 3D imaging needs. Whether it is the transformation of a film to a 3D unit, or the addition of a cephalometric arm, Planmeca offers solutions for every upgrade need. This single piece of technology makes the ProMax the most versatile all-in-one X-ray unit available on the market.
Reduced radiation procedures
for
safer
All Planmeca products are designed around the ALARA radiation principle (As Low As Reasonably Achievable). Through specially designed programs, such as horizontal and vertical segmenting, autofocus, and pediatric pans, dental professionals are able to provide their patients with excellent care without compromising their safety. Horizontal and vertical segmenting options limit the exposure to diagnostic areas of interest. By selecting these options, patient dosage can be reduced by up to 93%, which is highly advantageous when follow-up images are needed. Autofocus automatically positions the focal layer using a low-dose scout image of the patient’s central incisors, and uses landmarks within the patient’s anatomy to calculate placement. The result is a fast, diagnostic pan every time, which
“The company’s goal is to supply dental professionals with the highest quality dental equipment that is uniquely designed for today’s modern, technologically advanced practice.”
drastically reduces retakes caused by false positioning. Pediatric programs further lower the dose by automatically selecting the narrow focal layer of young patients, adjusting the collimator, and reducing the area of exposure from the top and the sides. This reduces the dosage area while still providing full diagnostic information.
Digital Perfection™: standard
the
new
Building on the well-established all-in-one idea of integration, Planmeca introduced the Digital Perfection concept in 2011. Seamless integration of dental equipment and software creates efficient diagnostic tools, optimized workflow, and advanced infection control methods that result in a treatment environment where all equipment shares an open interface. The company works worldwide with all aspects of the dental industry, including dental schools, dentists, and dental team members, as well as dealers, and uses the latest technologies to create the best products for dental offices and patients alike. As a forerunner in digital imaging technology, Planmeca delivers complete dental solutions based on integrated hightech device and software options with exquisite design. OP For more information, visit www.planmecausa.com This information Planmeca.
was
provided
by
Volume 4 Number 6
CORPORATE PROFILE
OrthoAccel® Technologies, Inc., developed AcceleDent® Aura, the first FDA-cleared clinical approach to safely accelerate orthodontic tooth movement by applying gentle SoftPulse Technology® as a complement to existing orthodontic treatment
“How long will I have to wear braces?” and “When do I get my braces off?” are inevitably two of the most frequently asked questions during orthodontic treatment consultation and actual treatment. Patients seek orthodontic treatment for a number of reasons, often so that they may be able to smile confidently at a special life event, such as a graduation or a wedding, while searching for new employment or working toward a career promotion. Today, advancements in technology allow patients to achieve a beautiful smile in far less time than ever before. 12 Orthodontic practice
AcceleDent®, a new device from OrthoAccel Technologies, Inc., offers a noninvasive, innovative solution that allows orthodontists and their patients to dramatically accelerate treatment. Available by prescription only, AcceleDent is a FDA-cleared, Class II medical device that exclusively uses SoftPulse Technology® to accelerate tooth movement up to 50% with just 20 minutes of daily use. This portable, lightweight, and hands-free device delivers gentle vibrations, or micropulses, to safely accelerate tooth movement as guided by orthodontists.
AcceleDent is offered worldwide by leading orthodontists who view accelerated treatment as a win-win situation for themselves, their patients, and their practices. With AcceleDent, patients may spend less time in braces, allowing orthodontists to potentially increase their practice efficiency. Orthodontists and their staff often hear comments and feedback from their patients, including “I cut my treatment time in half!” “I can hardly believe it!” and “AcceleDent is my best friend on adjustment day.”
Volume 4 Number 6
Research has demonstrated that pulsating forces increase the rate of bone remodeling compared to static forces. AcceleDent uses the application of pulsating forces to enhance orthodontics and moves teeth faster through accelerated bone remodeling. Rather than using only constant pressure, the device applies very light vibrations to the dentition. AcceleDent is a removable device and is comprised of an activator and mouthpiece. The activator and connected mouthpiece are used by patients to provide a gentle vibration to the teeth – the activator vibrates at a 25 grams force level and 30 Hz frequency for 20 minutes. The vibration is transmitted from the activator through the mouthpiece to patients’ teeth as they lightly bite down on the mouthpiece. This science has been applied in other parts of the body to increase the rate of fracture healing and bone density in long bones. The science has been validated in animals, and multiple U.S. clinical studies have demonstrated that AcceleDent can safely move teeth up to 50% faster. AcceleDent has been on the market in Europe and Australia since 2009. After receiving FDA clearance as a Class II medical device, AcceleDent was launched in the U.S. in 2012 and in Canada in early 2013. In just over 1-1/2 years, AcceleDent is already available in over 1,000 orthodontic practice locations across the U.S. and Canada. In September 2013, the product’s technology was issued a patent by the U.S. Department of Commerce’s United States Patent and Trademark Office, reinforcing OrthoAccel’s position as the industry’s leading supplier of an FDA-cleared device that accelerates orthodontic treatment.
Fast. Safe. Gentle. AcceleDent’s vibration is a reasonable and safe approach for accelerating tooth movement. In fact, the 25 grams of force applied to teeth with SoftPulse Technology is at least 200 times less than during ordinary chewing (5000 g). In addition to safely moving teeth at a rapid speed, AcceleDent’s gentle pulsing may help relieve the sensitivity and discomfort often associated with wearing braces. Orthodontists and patients repeatedly report that daily use of AcceleDent greatly reduces the discomfort associated with orthodontic treatment. Patients have also reported that their 20-minute AcceleDent routine helps relieve pain caused by Volume 4 Number 6
“In addition to moving teeth at a faster rate than expected, my AcceleDent patients report minimal sensitivity after each adjustment compared to other patients.” – Dr. Straty Righellis
AcceleDent Aura’s SoftPulse Technology can help teeth move up to 50% faster
bracket adjustment and tightening on the day of their orthodontic appointments.
Clinical results OrthoAccel® Technologies, Inc. has received positive feedback from leading orthodontists and consumers who tout AcceleDent for accelerating orthodontic treatment while gently enhancing movements directed by orthodontics. With AcceleDent, orthodontic treatment has been shortened significantly in some cases. Frederick Churbuck, the first U.S. patient to complete orthodontic treatment using AcceleDent, was originally predicted to undergo treatment for 18 months. However, by using AcceleDent, Mr. Churbuck was elated to complete his case in just 9 months. “My teeth are beautiful, and it only took 9 months,” said Churbuck after completing treatment. “It feels too good to be true. I am in a place so far beyond thrilled and am now an evangelist
for AcceleDent because of my results.” Shortly after the U.S. product launch, OrthoAccel Technologies, Inc. formed a Key Opinion Leadership (KOL) group comprised of a diverse group of world-class clinicians. Members present to their colleagues the scientific and clinical evidence behind AcceleDent’s groundbreaking technology, in addition to their own personal experiences, which include patient case studies that clinically substantiate AcceleDent’s acceleration of orthodontic treatment. “It’s important that we share the results of our case studies with our peers as it demonstrates that AcceleDent is a quality medical device that lives up to its claims,” said Dr. Robert Miller, who is a member of the KOL group and is also a worldwide, board-certified orthodontic lecturer as well as past president of the Virginia Association of Orthodontists. “Our evidence-based results are especially important since Orthodontic practice 13
CORPORATE PROFILE
AcceleDent’s history
CORPORATE PROFILE
AcceleDent is a leading medical device that enhances and accelerates orthodontic movements.” Miller recently presented a case study for a female patient who was in treatment to correct a Class II open bite and was projected to wear braces for 24 to 30 months. By using AcceleDent daily as prescribed, she completed treatment in 10 months and did not have to undergo surgery or extractions. Dr. Straty Righellis, Diplomate of the American Board of Orthodontics, prescribed AcceleDent to a 49-yearold female patient who then completed treatment 6 months early. Dr. Righellis’ patient was projected to wear braces for 18 months to eliminate spacing and to correct a functional crossbite, but completed treatment in just 12 months by using AcceleDent as prescribed. “I am recommending AcceleDent because I have seen in my patients that teeth move at a faster rate than I would normally expect,” said Dr. Righellis, who practices in Oakland, California. “In addition to moving teeth at a faster rate than expected, my AcceleDent patients report minimal sensitivity after each adjustment compared to other patients.”
Orthodontists and patients repeatedly report that daily use of AcceleDent greatly reduces the discomfort associated with orthodontic treatment.
AcceleDent Aura’s small, lightweight activator generates gentle micropulses and includes a USB interface which can be plugged directly into a computer to view usage history via the FastTrac Report. The mouthpiece, chosen specifically for each patient by an orthodontist, provides a comfortable fit and snaps easily on and off the activator for transport and cleaning
AcceleDent® Aura aligns with industry trends The orthodontic industry is in a growth phase driven by adults who are seeking orthodontic treatment either for the first time or to complement treatment received in adolescence. According to the American Association of Orthodontics, the number of adult patients has increased 23% in the past 20 years, with adults now comprising more than one in five orthodontic patients. These numbers are likely to continue rising as health and esthetic consciousness is at the forefront, and continues trending upward. Input from leading orthodontists and patients led to introduction of OrthoAccel Technologies’ newest device, AcceleDent Aura. Launched in May 2013, AcceleDent Aura houses a convenient USB port and includes an extension cable and power adapter. The USB port allows easy device charging and also offers orthodontists access to FastTrac, a patient usage 14 Orthodontic practice
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sports, cheerleading, acting, modeling, and playing a musical instrument. Jennifer Wammack of Houston, Texas, is the mother of 13-year-old aspiring actress, Hailey, who started using AcceleDent with her braces in January 2013 and is on track to have them removed in December 2013. “AcceleDent was a no-brainer choice for us. I remember wearing braces from middle school all the way through my senior year of high school, and I do not want Hailey or any of my children to have to endure that discomfort or any chance of teasing from classmates. We’re happy with the results so far, and I’m
“We’re proud that AcceleDent has been rapidly adopted by key influencers and mainstream orthodontic practices.” – Mike Lowe, OrthoAccel Technologies CEO
Michael K. Lowe, CEO, OrthoAccel Technologies, Inc.
already committed to making sure my other three children also use AcceleDent when it’s time for their orthodontic treatment,” said Ms. Wammack.
Commitment to orthodontic treatment
enhance
Mike Lowe, CEO of OrthoAccel Technologies, Inc., reports the company remains committed to supporting clinical trials that drive innovations for enhancing dental care and orthodontic treatment. An Investigator Initiated Research Program was recently launched by OrthoAccel Technologies to support independent research projects. The program awards unrestricted grants to orthodontists, clinical researchers, and basic scientists who are interested in studying AcceleDent’s efficacy in an academic or practice-based setting. “We’re proud that AcceleDent has been rapidly adopted by key influencers and mainstream orthodontic practices. To build upon that success, our Investigator Initiated Research Program will unveil additional product development opportunities for OrthoAccel Technologies as we strive to advance the area of accelerated orthodontics,” said Lowe. For more information or to schedule an in-office presentation, please call 1-866866-4919 or visit acceledent.com. OP About OrthoAccel Technologies, Inc. AcceleDent was developed by OrthoAccel Technologies, Inc., Houston, Texas, a privately held company that focuses on developing, manufacturing, and marketing innovative technologies to enhance dental care and orthodontic treatment. The first AcceleDent was launched in 2009 and has been recommended and prescribed to thousands of patients by orthodontists around the world. More information may be found at acceledent.com and acceledent.co.uk, or requested via info@orthoaccel.com. This information was provided OrthoAccel Technologies, Inc.
Volume 4 Number 6
by
Orthodontic practice 15
CORPORATE PROFILE
report that allows doctors to monitor their patients’ daily use to more accurately manage treatment. AcceleDent Aura’s sleek design is lightweight, accessible, and compact, making it simple for patients to use virtually anytime, anywhere. Parents of teens are pleased with AcceleDent Aura as it helps to alleviate concerns of prolonged wearing of braces and to help reduce pain and discomfort. Faster treatment is also the preferred choice for many students who may be self-conscious about their appearance in braces, or when participating in extracurricular activities, such as athletics,
ORTHODONTIC CONCEPTS
BioDigital Orthodontics: Management of Class 1 non–extraction patient “Standard–Track”© – 9-month protocol: part 6 Dr. Rohit C.L. Sachdeva, and Drs. Takao Kubota and Kazuo Hayashi, discuss a treatment for Class I non-extraction patients Introduction BioDigital Orthodontics is driven by a culture of high performance organizing.1-4 In a previous article,5 the ability to complete care of Class I patients requiring nonextraction treatment in 6 months or less was discussed. This is only possible if the practice is geared towards providing proactive and highly reliable care and if the patient, doctor, and care team are aligned in terms of the treatment objectives. The clinical pathway guideline for this Fast-Track approach to care was also discussed. In certain clinical situations, it may be difficult to implement a Fast-Track approach, especially when the practice is new or not ready to change its culture to that of a high performance organization. The purpose of this article is to describe an alternative clinical pathway guideline enabled by SureSmile technology that aids the clinician in providing timely care for Class I patients without losing quality of outcome. This protocol is termed the Standard-Track© 9-month protocol.
Rohit C.L. Sachdeva, BDS, M Dent Sc, is the cofounder 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 and 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. Takao Kubota, DDS, PhD, is in private practice in Yours Orthodontic Clinic in Yame City, Fukuoka, Japan, and is also associate professor, Department of Orthodontics, at Kanagawa Dental College, Yokosuka, Japan. Kazuo Hayashi, DDS, PhD, is associate professor, Division of Orthodontics and Dentofacial Orthopedics, Department of Oral Growth and Development, at the School of Dentistry, Health Sciences University of Hokkaido, Japan. Visit Dr. Sachdeva’s blog on http://drsachdeva-conference. blogspot.com. All doctors are invited to join the “Improving Orthodontic Care” discussion blog. Please contact improveortho@gmail.com for access information.
16 Orthodontic practice
Table 1: Clinical Pathway Guidelines developed by Sachdeva for “Standard-Track” care Protocol B for both users of .018” and .022” brackets systems
Class I Non-Extraction “Standard-Track” © Protocol B CPG, 9-Month Treatment (Sachdeva)
APPT I (Week 0)
• Initial consultation. • Diagnostic records. • Take supplementary impressions for auxiliary appliances such as quad helix if needed. • Diagnostic scan (OraScan or CBCT scan taken post bonding). • Bond teeth. • Place posterior molar turbos and check for height and balance. • Perform IPR prn. • Insert initial archwire. - .016” preformed SE NiTi Af 35ºC or .017” x .025” SE NiTi Af 35ºC if minimal crowding or torque control and deep bite correction needed. - Place auxiliary appliances, eg., tipback springs, ART springs, etc.
APPT 2 (Week 12)
• Place auxiliary devices such as quad helix if needed. • Remove posterior molar turbo. • Perform IPR prn. • Therapeutic scan (OraScan/CBCT). • Replace molar turbos.
• Review progress against Virtual Diagnostic Simulation (VDS). • Perform selective IPR prn. APPT 3 • Check turbo for height/balance. (Week 20) • Insert SureSmile Precision Archwire (SSPA) (full expression). SureSmile - Note: For .018” / .022” bracket, .017” x .025” SE NiTi Af 35ºC is used. Also, .019” x Therapeutic Phase .025” SE NiTi Af 35ºC may be used with the .022” bracket. • Check archwire placement against bracket archwire image.
APPT 4 (Week 28)
• Review progress against Virtual Therapeutic Simulation (VTS) • Make adjustments if necessary.
APPT 5 (Week 32)
• Review progress against VTS. • Make adjustments if necessary.
APPT 6 (Week 36)
• Debond. • Take final records for outcome evaluation.
Volume 4 Number 6
Figure 1: Patient III. A. “Standard-Track” presents with a Class I occlusion with moderate upper crowding and lower arch crowding with a crossbite tendency in the upper first molar and bicuspid area. A non-extraction approach to treatment was chosen. B. Initial cephalometric and panorex radiographs
Figure 2: Patient III. Virtual Diagnostic Model (VDM) derived by scanning plaster model of patient using the OraScanner® and is used for designing the initial treatment plan with Virtual Diagnostic Simulation (VDS)
Figure 3: Patient III. A. Simulation of correction of functional shift. Teeth in blue demonstrate post simulation of functional shift. Note a transverse shift was simulated. B. VDS superimposed on VDM. Note slight expansion planned in the maxillary first bicuspid and cuspid area. C. Virtual Diagnostic simulation (VDS). D. Planned recontouring of the mammelons on the upper incisors
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Orthodontic practice 17
ORTHODONTIC CONCEPTS
Patient III. “Standard-Track” Protocol B (9 months)
ORTHODONTIC CONCEPTS
Figure 4: Patient III. Maxillary quad-helix appliance inserted 4 weeks from the time initial records were taken
Figure 5: Patient III. Eight weeks post start of treatment. Upper 5-5 arch bonded with .018” bracket system. Upper .016” CuNiTi Af 35°C engaged. Upper right first bicuspid not engaged to minimize reactive intrusive displacement of the tooth. Bracket on upper left second bicuspid debonded during archwire engagement
Figure 6: Patient III. Twelve weeks post start of treatment. Lower 5-5 arch bonded with .018” bracket system. Lower 6’s, banded. Lower .016” CuNiTi Af 35°C engaged
Figure 7: Patient III. Sixteen weeks post start. Upper arch fully engaged. (Note upper right first bicuspid engaged)
Figure 8: Patient III. Twenty weeks post start. Upper and lower 6-6 alignment being achieved. Upper right buccal segment shows some intrusion despite the use of vertical check elastics
Figure 9: Patient III. A. Twenty-four weeks post start. Upper and lower 6-6 alignment substantially achieved. Upper right buccal segment open bite substantially closed with the use of vertical elastics. Quad helix removed in upper arch. Upper and lower second molars bonded. Therapeutic scan taken at this appointment with the OraScanner. B. Mid-treatment cephalometric and panorex radiograph 18 Orthodontic practice
Volume 4 Number 6
Š 2013 OraMetrix, Inc. All rights reserved. suresmile is a registered trademark of OraMetrix.
surezen.
After comes before. Dr. Scott Tyler Birmingham, MI
December 2011
August 2012
May 2013
Initial intraoral
Planned result
Actual result (Final)
For our most recent detailed suresmile case studies, please call 888.672.6387.
suresmile.com
to be sure.
ORTHODONTIC CONCEPTS
Figure 11: Patient III. The VTM of the upper jaw shows the cant in the anterior occlusal plane as a result of the intrusive reactive force felt in the right buccal segment as the upper right second premolar was extruded Figure 10: Patient III. Virtual Therapeutic Model (VTM)
Figure 13: Patient III. Virtual Therapeutic Simulation (VTS)
Figure 12: Patient III. SureSmile Virtual Prescription form completed with the Treatment Objectives. These are defined by “MACROS.” For this patient the following objectives were selected. Treat to the upper midline, lower archform, Class I occlusion, the upper and lower first premolars as reference teeth, upper functional occlusal plane, correct cant of the upper anterior occlusal plane
Figure 14: Patient III. SureSmile Precision Archwire (SSPA) Design evaluated against the Virtual Therapeutic Model (VTM)
Figure 15: Patient III. SureSmile Precision Archwire (SSPA) upper and lower archwires SE 0.17” x 0.25“ CuNiTi inserted 28 weeks from start of treatment and 4 weeks posttherapeutic scan
Figure 16: Patient III. Progress 32 weeks from start of treatment and 8 weeks posttherapeutic scan. Note: Up and down Class II elastics continued
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ORTHODONTIC CONCEPTS
Figure 17: Patient III. A. “Standard –Track”. Debonded 9 months from start of treatment. B. Final cephalometric and panorex X-rays. C. Virtual Final Models (VFM)
Patient IV. “Standard-Track” Protocol B (9 months)
Figure 18: Patient IV. A. “Standard-Track” presents with a Class I occlusion with minor upper and lower arch crowding with the upper midline shifted to the right of the lower midline. A nonextraction approach to treatment was chosen. B. Initial cephalometric and panorex radiographs
Figure 19: Patient IV. Virtual Diagnostic Model (VDM) derived by scanning plaster model of patient using the OraScanner and is used for designing the initial treatment plan with simulations
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Orthodontic practice 21
ORTHODONTIC CONCEPTS
Figure 20: Patient IV. A. Virtual Diagnostic Simulation (VDS) non-extraction, B. VDS superimposed on VDM
Figure 21: Patient IV. A. Twenty-four weeks post start of treatment. Upper and lower .018” bracket system was used. Only archwire used to this point for the upper and lower arch was .016” CuNiTi Af 35°C. From the start of treatment the patient was seen every month. The therapeutic scan was taken at this visit with the OraScanner. B. Mid-treatment panorex radiograph
Figure 22: Patient IV. Virtual Therapeutic Model (VTM)
Figure 23: Patient IV. SureSmile Virtual Prescription form completed with the Treatment Objectives. These are defined by “MACROS.” For this patient the following objectives were selected. Treat to the upper midline, lower archform, Class I occlusion, the upper and lower first premolars as reference teeth, upper functional occlusal plane. It was recognized that the patient would be treated with minimal overbite since she refused to have any IPR in order to retract the lower incisors to establish a better overjet-overbite relationship
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Volume 4 Number 6
ORTHODONTIC CONCEPTS
Figure 24: Patient IV. Virtual Therapeutic Simulation (VTS)
Figure 25: Patient IV. SureSmile Precision Archwire (SSPA) Design evaluated against the Virtual Therapeutic Model (VTM)
Figure 26: Patient IV. Eight weeks post SSPA insertion and 32 weeks from the start of treatment. The upper and lower SSPA used were SE 0.17” x 0.25” CuNiTi
24 Orthodontic practice
Volume 4 Number 6
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ORTHODONTIC CONCEPTS
Figure 27: Patient IV. A. “Standard –Track.” Debonded 9 months from start. B. Final cephalometric and panorex radiographs. C. Virtual Final Models (VFM)
Conclusions Both the “Fast-Track” protocol (discussed previously)1 and the “Standard-Track” protocol discussed currently using SureSmile offer substantial efficiencies in treating patients without any loss of quality.6-10 It should be noted that the SureSmile Therapeutic Phase for both protocols are similar. However, the “Fast-Track” protocol
developed by Sachdeva is distinctly faster than the “Standard-Track” protocol. Patient and practice characteristics play a significant role in determining the path chosen by the doctor. Future articles will systematically discuss the management of the additional spectrum of patients treated in the orthodontic practice.
Acknowledgments It is with the deepest sense of gratitude that the authors thank Dr. Sharan Aranha for her unconditional and enthusiastic support in the preparation of this manuscript. Without her efforts, it would be impossible to write and prepare this paper in a timely fashion. OP
References 5. Sachdeva R. BioDigital orthodontics: Planning care with SureSmile Technology: part 1. Orthodontic Practice US. 2013;4(1):18-23.
9. Groth C. Compare the quality of occlusal finish between SureSmile and conventional. Thesis at University of Michigan; 2012.
2. Sachdeva R. BioDigital orthodontics: Designing customized therapeutics and managing patient treatment with SureSmile technology: part 2. Orthodontic Practice US. 2013;4(2):18-26.
6. Alford TJ, Roberts WE, Hartsfield Jr JK, Eckert GJ, Snyder RJ. Clinical outcomes for patients finished with the SureSmile™ method compared with conventional fixed orthodontic therapy. The Angle Orthodontist. 2011;81(3):383-88.
10. Rangwala T. Treatment outcome assessment of SureSmile compared to conventional orthodontic treatment using the American Board of Orthodontics grading system. Thesis at Albert Einstein College of Medicine, Department of Dentistry-Orthodontics Bronx, New York; 2012.
3. Sachdeva R. BioDigital orthodontics: Diagnopeutics with SureSmile technology: part 3. Orthodontic Practice US. 2013;4(3):22-30.
7. Saxe AK, Louie LJ, Mah J. Efficiency and effectiveness of SureSmile. World J Orthod. 2010;11(1):16.
4. Sachdeva R. BioDigital orthodontics: Outcome evaluation with SureSmile technology: part 4. Orthodontic Practice US. 2013;4(5).
8. Sachdeva R, Aranha S, Egan ME, Gross HT, Sachdeva NS, Currier GF, et al. Treatment time: SureSmile vs conventional. Orthodontics. 2012;13(1):72.
1. Sachdeva R. BioDigital orthodontics-5. Management of Class 1 non–extraction patient with “Fast–Track”©– 6-month protocol. Orthodontic Practice US. 2013;5.
26 Orthodontic practice
Volume 4 Number 6
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Special Awards tribute from MedMark, llc and Pride Institute
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Letter from the Publisher Dear Readers: As publisher of three dental specialty magazines, I have spoken with many dentists and seen many dental products over the years. That is why I am thrilled to have the opportunity to spotlight Pride Institute’s ”Best of Class” Technology Award winners on behalf of Orthodontic Practice US, Implant Practice US, and Endodontic Practice US. The evolution of products with a meaningful impact on dentistry is vital to patient care and practice progress. These products and services have undergone scrutiny by Pride Institute’s knowledgeable panel of judges who invested a year of their time and effort to explore the attributes that made them stand out from the competition. From fledgling products to those that have already achieved name recognition, the winners represent an amazing array of categories from clinical to business applications. Since panelists who receive compensation from dental companies are prevented from voting in that company’s category, the result is an unbiased look at the products and their practical applications to dentistry, providing the dental professional with a product perspective untainted by manufacturer intervention. Pride Institute’s ”Best of Class” Technology awards debuted in 2009, and through print and digital media coverage have grown to impact approximately 150,000 dentists. At the ”Tech Expo” at the American Dental Association’s Annual Awards Session, held October 31 – November 3 in New Orleans, attendees will be able to interact face-to-face with the companies and participate in technology-centered education provided by members of the panel and esteemed consultants of Pride Institute. The Pride ”Best of Class” Awards were created and are organized by Dr. Lou Shuman, President of Pride Institute, who works tirelessly to maintain the rigorous standards of the selection process and its communication process through all its multimedia partners. The panel’s unrelenting pursuit to select technologies that provide continuous improvement for the dental community has resulted in a huge following, which continues to grow each year, culminating in the ADA Pride Tech Expo at the ADA Annual Session. Attendees have the opportunity to experience all the winners in one location for a hands-on experience, as well as are provided CERP presentations by all the expert panel members themselves. This year’s winners are: 3Shape TRIOS®
Isolite Systems Isodry®
ActionRun® Clinical Reactivation®
Kerr SonicFill™
Align Technology SmartTrack™
Lexicomp® Online™ for Dentistry featuring: VisualDX® Oral
DEXIS® Imaging Suite and DEXIS go®
Liptak Dental DDS Rescue™
Doxa Ceramir® Crown and Bridge
Orascoptic XV1
Gendex GXDP-700™ SRT™ Technology
SciCan STATIM G4
Glidewell Laboratories BruxZir® Shaded
Sesame Communications Sesame 24-7
Interactive Diagnostic Imaging Tru-Align®
Ultradent VALO®
Henry Schein Dental Viive™
LED Dental VELscope® Vx
i-CAT® FLX Cone Beam 3D
Enjoy this tribute to some very special products and services. We at MedMark hope that the insights you gain from reading these pages and the benefits that you reap from implementing the products will raise your practices to new levels of clinical excellence and business success. Thank you, and again, congratulations to the ”Best of Class” Technology Award winners for 2013!
Best regards, Lisa Moler Publisher MedMark, llc
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Letter from the founder of Pride “Best of Class” Technology Awards Dear Readers: The excitement and enthusiasm surrounding Pride Institute’s 2013 ”Best of Class” Technology Awards continue to invigorate the winning companies long after they are announced. This initiative culminates in the honorees’ participation in the ”Tech Expo” at the American Dental Association’s Annual Session — where attendees have a chance to interact and gain insight into the dynamic and technology-centric products and services that are impacting the contemporary dental practice. The ”Best of Class” Awards have attained a reputation of the highest integrity due to its rigorous and unbiased selection process and its distinguished panel of technology experts. The panel searches for companies that show initiative, and commit time, resources, and expertise in developing new technologies or improving existing ones. Their characteristics differentiate them in a compelling way, thus creating significant value for the clinician. I am very proud of the integrity of our unbiased and not-for-profit process. The thoughtful and many times heated debate, which is the hallmark of the panel’s decision-making process, takes place with absolute honesty and openness. Panel members must divulge all paid relationships with manufacturers, and as a result, are not allowed to vote in that specific category. Also, we are not tied down to have to choose a winner for every technology category in dentistry. If there is no clear differentiator in a category, there is no winner. The mission is to provide the dental community the benefit of having the opportunity to discover what our dental technology experts would choose to have in their own practices. As you read about these companies, know that they can provide a significant benefit in achieving the ultimate goal of the ”Best of Class” award process — selecting the technologies that allow us to provide the best possible care to our patients. Sincerely,
THE DISTINGUISHED PANEL
Dr. Lou Shuman President of Pride Institute
Lou Shuman, DMD, CAGS President of Pride Institute, Best of Class founder John Flucke, DDS Writer, speaker, and Technology Editor for Dental Products Report Marty Jablow, DMD Writer, speaker, technology consultant, and columnist for Dr. Bicuspid Paul Feuerstein, DMD Writer, speaker, and Technology Editor for Dental Economics Parag Kachalia, DDS Vice-Chair of Preclinical Education, Research and Technology, University of Pacific School of Dentistry Larry Emmott, DDS Writer, speaker, and Technology Editor for dentalcompare.com Titus Schleyer, DMD, PhD Associate Professor and Director, Center for Dental Informatics at the University of Pittsburgh, School of Dental Medicine
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DEXIS® IMAGING SUITE AND DEXIS GO® DEXIS® Imaging Suite is the latest software program in a long, dynamic history of bringing the best possible imaging solutions to general dentists and specialists alike. This innovative program has been rewritten on a next-generation code platform combining the image management capabilities of the award-winning DEXIS® 9 with a solid base for growth and exciting tools and applications. One such application is the new companion iPad app, DEXIS go® that provides a sleek, engaging new way for dental professionals to communicate with patients using an iPad®. It is designed to provide a great visual patient experience around image presentation in support of clinical findings and treatment recommendations. Like DEXIS Imaging Suite, DEXIS go functions as an imaging hub, displaying all radiographic and photographic images within a patient’s record. DEXIS users will find a comfortable familiarity with its simplicity and quad environment now infused with a modern iPadstyle flair and elegance.
i-CAT® FLX COMPLETE 3D TREATMENT SOLUTION
i-CAT® FLX is the complete 3D Treatment Solution. It optimizes clinical control over scan size, resolution, modality, and dose to help deliver optimum patient care, assist clinicians to quickly diagnose complex problems with less radiation, and aid in developing treatment plans more easily and accurately. Features include QuickScan+ for a full-dentition 3D scan at a lower dose than a 2D panoramic*; Visual iQuity™ technology for i-CAT’s clearest images*; SmartScan STUDIO’s touchscreen for easy selection of the appropriate scan size and resolution for each patient’s need; Tx STUDIO™ planning software with integrated tools for implant, surgical, and orthodontic applications; and i-PAN 2D panoramics. *Data on file
ISODRY® DENTAL ISOLATION SYSTEM The Isodry® dental isolation system is a proven, easy-touse alternative to traditional forms of dental isolation, such as the rubber dam or manual suction and retraction. The system aids in dental procedures by improving patient management and giving dental professionals unprecedented control of the oral environment: keeping the patient’s mouth open, improving visibility, controlling suction and oral humidity, and minimizing sources of contamination. The key to Isodry’s effectiveness are the Isolite Mouthpieces that work with the system. Morphologically correct Isolite Mouthpieces are available in five sizes and are designed to fit patients from pediatric to large adult. The wide range of mouthpieces means that it is now much easier to have effective isolation for every patient of every size. Isolite Mouthpieces also provide an added measure of safety during the dental procedure — protecting the patient from foreign body aspiration and shielding the tongue and cheek from injury by the handpiece or other dental instruments. For more information: www.isolitesystems.com
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BRUXZIR® SHADED RESTORATIONS BruxZir® Shaded restorations are made of monolithic zirconia with no porcelain overlay. Exhibiting classleading durability with up to 1465 MPa of flexural strength and high fracture toughness, they can be used in almost any clinical situation, but are ideal for demanding situations like bruxers, implant restorations, and areas with limited occlusal space. Because BruxZir zirconia is a monolithic material, it can be milled to a feather edge, for a more natural and hygienic emergence profile. BruxZir Shaded restorations display translucency and color similar to natural dentition, making them a more esthetic alternative to PFMs with metal occlusals/linguals or full-cast gold restorations. The BruxZir Shaded formulation offers complete color penetration all the way through the restorations, ensuring greater shade consistency and preventing any shade change after occlusal adjustment. For the second consecutive year, The Pride Institute recognizes BruxZir restorations as ”Best of Class.” BruxZir Shaded restorations are available nationwide at an Authorized™ BruxZir Laboratory near you. For more information: www.bruxzir.com
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VALO® AND VALO CORDLESS Ultradent created VALO in 2009 to address the many problems left unsolved by other curing lights on the market. Since its introduction, VALO has proven to be the most powerful light on the market, thanks to its multiwavelength light-emitting diode (LED) and optimally collimated beam capable of polymerizing any dental material, including porcelain and underlying resins. The ergonomic design of VALO’s wand-style body and large footprint of the curing head provides unprecedented access to the oral cavity where other curing lights simply cannot reach. Precision milled from a solid bar of high-grade, aircraft aluminum, VALO’s unique unibody construction ensures unsurpassed durability. The award-winning line of VALO curing lights now includes the original VALO, VALO Cordless, VALO Ortho, and VALO Ortho Cordless. Each one offers a unique combination of features that allows dental professionals to consistently deliver the right power in the right place. For more information: www.ultradent.com Call 1-800-552-5512
SESAME 24-7 CLOUD-BASED ONLINE PATIENT ENGAGEMENT MANAGEMENT SYSTEM Sesame 24-7 is a cloud-based online patient engagement management system that helps dental and orthodontic practices accelerate new patient acquisition, build patient loyalty, and transform the patient experience. Sesame 24-7 is an end-to-end system, which provides state-ofthe-art web design that optimizes viewing across any device, Search Engine Optimization (SEO), social network management, online sweepstakes and contests, and Search Engine Marketing (SEM) services. It also includes Dental Sesame, a robust patient engagement portal that helps practices maintain a loyal patient community that shows up for appointments, pays their bills on time, and refers friends to the practice. Sesame 24-7 delivers everything a dental practice needs to leverage the Internet to expand growth and profitability.
GENDEX GXDP-700™ SRT™ TECHNOLOGY VELSCOPE® VX SYSTEM Distributed by DenMat, Velscope® Vx is the industry’s leading adjunctive screening device used to discover oral mucosal abnormalities. When used in combination with standard examination procedures, Velscope Vx facilitates the early discovery and visualization of abnormal tissue, including oral cancer. A Velscope Vx examination is easy, painless to the patient, takes just one or two minutes to administer, and does not require additional rinses or stains. The portable Velscope Vx handpiece emits a safe blue light, which excites fluorophores from the surface tissue to the membrane where premalignant changes typically begin. The Velscope’s proprietary filter makes fluorescence visualization possible by blocking reflected blue light, and by enhancing the contrast between normal and abnormal tissue. The Velscope Vx system includes the handpiece, a charging station, and sanitary covers for the handpiece and lens. A digital camera accessory is also available to capture images of abnormal tissue.
SRT image optimization technology delivers 3D scans with higher clarity and detail around scatter-generating material. By using SRT Technology, clinicians are able to reduce artifacts caused by metal or radiopaque objects such as restorations, endodontic filling materials, and implant posts. When a scan is prescribed near a known area of scatter generating material, the user only needs to select the SRT button from the GXDP-700 touchscreen interface to utilize this new optimization technology. From endodontic to restorative and the post-surgical assessment of implant sites, SRT offers a significant improvement to image quality. Gendex’s design philosophy focuses on delivering awardwinning innovations with clinicians and patients in mind, and the addition of the SRT to the GXDP-700 platform aligns with that goal. The company’s strong history in continuing innovation, along with a deep dedication to deliver products that exceed the needs of dental professionals, have earned Gendex recognition as a global leader. For more information: www.gendex.com
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HENRY SCHEIN’S VIIVE™
STATIM G4
Henry Schein’s Viive (pronounced ”Vive”) is a clean and elegant new practice management system designed for the Apple Mac®. The system takes full advantage of the Mac’s simplicity and esthetics, allowing dentists to use the same robust features and tools they have come to love in the Mac . Because a group of dentists who are also Mac enthusiasts actually designed Viive, the system has a unique patient-centric workflow that helps dentists work the way they want to work using the tools they’re most comfortable using.
SciCan is proud to unveil the newest STATIM family member, the G4 series. The STATIM G4 is the same renowned and trusted autoclave it has been for over 20 years, but now boasts a new contemporary look and connectivity that is the first of its kind. The G4 technology will change the way you interact by providing a direct channel of communication through the Internet to you, or anyone you desire. Still powered by SciCan’s signature steam technology to provide sterilization and dryness at speeds faster than conventional chambered autoclaves, the STATIM has been drastically upgraded with a level of interactivity never seen before.
Right from startup, Viive focuses on the patient with a patient screen that gives team members fast and easy access to nearly every feature, function, and task associated with that patient. It boasts a design that makes most of these accessible with just a single click. Viive also includes integration with a variety of advanced services from trusted partners — including leading digital imaging solutions—to expand the capabilities of your modern digital practice. For more information: www.viive.com Call 855-Mac-Viive for a personal demo of Viive.
• Statim 2000 G4 cycles times: 6 minutes unwrapped – 14 minutes wrapped • Statim 5000 G4 cycle times: 9 minutes unwrapped – 17.5 minutes wrapped • A large 3.5” high-resolution touchscreen offers a vivid display of messages and current cycle information all with extraordinary clarity • SciCan’s STATIM G4 Technology offers a platform with endless possibilities. The product expansion and modes of communication will provide visibility from every facet, from usability to troubleshooting • Uses fresh steam distilled water with every cycle • Dri-Tec drying system for fast dry loads For more information: www.scicanusa.com Call 1-800-572-1211
3SHAPE TRIOS® COLOR NEXT-GENERATION INTRAORAL IMPRESSION SOLUTION 3Shape TRIOS® Color is a next-generation intraoral impression solution that is fast, accurate, and easy to use. TRIOS® Color is built on 3Shape’s Ultrafast Optical Sectioning™ technology, and its features include high accuracy capture in color, spray-and-powder-free scanning, clinical scan validation, intuitive Smart-Touch user interface and more. TRIOS® is optimized for a wide range of indications. Scanning is easy with 3Shape TRIOS® Color. There is no need to hold the scanner at a specific angle or distance, and dentists or assistants can even rest the scanner on the teeth for support as they scan. The system contains a broad array of smart tools that lets dentists edit their scans and easily rescan specific areas. The built-in Communicate™ software lets dentists and labs interact and exchange case information, 3D designs, 2D treatment previews, and comments. As an integral part of every TRIOS® system, 3Shape offers yearly software upgrades to keep the system ever-strong with new features and enhanced performance. For more information: www.3shapedental.com/trios Call 1-908-867-0144
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DOXA CERAMIR® TECHNOLOGY Ceramir is a revolutionary technology used to create a new class of unique materials called Nanostructurally Integrating Bioceramics (NIB). This Ceramir technology, which holds more than 100 patents, is the result of more than 25 years of extensive bioceramic research by Doxa. Ceramir Crown & Bridge permanent cement is the first product utilizing NIB technology, creating a resilient, more natural, biocompatible dental luting cement that integrates with natural tooth structure, is stable in the mouth, and exhibits tooth-like physical and mechanical properties. It is a self-sealing material that results in an alkaline seal for permanent acid resistance. Ceramir Crown & Bridge is indicated for PFM, zirconia, gold, metal and lithium disilicate fullcoverage crowns and bridges, as well as gold inlays and onlays, and metal pre-fab or cast metal posts. Ceramir is incredibly easy to use because it eliminates the need for bonding agents, conditioners, special cleaners, and primers. It also cleans up extremely easily, and the patients are thrilled because of no pain during placement, or post-op sensitivity. It’s a new way to think about cementation!
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SMARTTRACK™ ALIGNER MATERIAL Align Technology recently introduced SmartTrack – a new highly elastic aligner material that has been shown to improve control of tooth movements with Invisalign®. A study of 1,015 patients shows statistically significant improvement in the control of tooth movements such as rotation and extrusion (p<0.001). Percent of patients on track with treatment is also significantly higher at 5 months follow-up (p<0.001)* SmartTrack features: • More constant force over the two wear aligner wear to improve tracking SONICFILL™ SonicFill is the only easy to use, sonic-activated, Single-Fill™ dental posterior composite system for restorations that require no liner or additional capping layer. Proprietary sonic activation liquefies a highly-filled posterior composite, allowing it to flow into the cavity for effortless placement and superior adaptation. Along with low shrinkage stress and a high depth of cure, SonicFill lets you reliably place posterior cavities up to 5 mm in a single increment. It’s that fast, easy, and effective — greatly reducing procedure time. And with outstanding strength and Kerr’s patented 0.4 micron filler technology, restorations will last and look great.
• Higher elasticity to improve tracking
XV1 FROM ORASCOPTIC The new XV1 from Orascoptic is the first and only loupe with a built-in headlight. Traditional light systems employ an electrical cable that connects the headlight to a battery pack that is typically worn on a belt or in a pocket. These cables are notorious for breaking after getting caught on chairs, drawers, and doorknobs. By powering the headlight through circuitry embedded in the loupe frame itself, the XV1 eliminates the need for a separate battery pack, and consequently also eliminates the problematic cable. The XV1 delivers a powerful, shadow-less illumination in a compact, comfortable design. Innovative capacitive touch controls make it easy to operate, even with instruments in hand. Choose from five stylish colors, and magnification powers between 2.5x and 4.8x.
• More precise aligner fit to improve control of tooth movement and finishing
”The clinical results with SmartTrack have been excellent so far,” said Dr. Clark Colville, an orthodontist in Seguin, Texas and a participant in the SmartTrack study. ”The fit around the teeth from aligner to aligner is better than with any group of patients I have treated with Invisalign in my practice. Without a doubt, SmartTrack is the most exciting change in Invisalign technology among the many that have been introduced in recent years.” Due to advantages in performance, SmartTrack material is now the new standard Invisalign material for all Invisalign aligner products in North America and Europe, as well as other International markets.
For more information: www.orascoptic.com/xv1 for more product details. Call 1-800-369-3698 to schedule a product demonstration.
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LEXICOMP® ONLINE FOR DENTISTRY: COMPUTER ASSISTED DECISION SUPPORT FOR DRUG INTERACTIONS AND LESION DIAGNOSIS
TRU-ALIGN®, THE LASER-ALIGNING RECTANGULAR COLLIMATION SYSTEM FROM IDI
Lexicomp Online for Dentistry provides industry-leading reference information and screening tools to help answer prescribing, diagnosis, and treatment questions. Dental professionals can help enhance patient safety by accessing dental-specific pharmacology information on over 8,000 prescription drugs, OTCs, and natural products, plus decision support tools like VisualDx® Oral lesion diagnosis and an unsurpassed drug interactions screener. VisualDx® Oral is the new lesion identification tool designed to help dentists quickly develop a differential diagnosis and reduce diagnostic error. Available only through Lexicomp Online for Dentistry, dental professionals can have access to both VisualDx Oral’s specialist-level information and the top-rated dental-specific pharmacology information provided by Lexicomp – saving time in research and helping to enhance treatment safety. In addition to lesion diagnosis, Lexicomp Online for Dentistry is the only product that provides instant access to up-to-date, dental-specific pharmacology information and important clinical tools, such as drug interaction analysis and dental medication alerts. Lexicomp Online for Dentistry, enhanced with the revolutionary lesion diagnosis tool VisualDx Oral, will truly change how you practice dentistry, help save time in your office and help enhance treatment safety.
ACTIONRUN’S CLINICAL REACTIVATOR® Dormant patients need more than a generic reason to return. ActionRun’s Clinical Reactivator® service gives each GP’s patients clinically personalized reasons to come back. Many of these clinical reasons are tailored for specialties’ referrals including orthodontics, endodontics, and implants. Instead of simple, generic automated email or text solutions commonly offered by others, ActionRun is uniquely able to analyze each patient’s clinical record and compel dormant patients to return with clinical reasons specific to each patient - even without a treatment plan. Clinical Reactivator® is completely autonomous and requires no involvement from staff. Because it is cloud-based, there is no hardware or software to buy or maintain. By effectively reactivating GP’s dormant patients, ActionRun increases referrals to specialists and improves those patients’ health while boosting production for both GPs and specialists. Because it works so consistently well, ActionRun uniquely offers a performance guarantee based on production from reactivated patients. Clinical Reactivator® is part of a complete line of HIPPA-compliant patient communication solutions offered by ActionRun.
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Tru-Align®, the laser-aligning rectangular collimation system from IDI, lowers dental X-ray scatter radiation by as much as 60-70%, allaying patient fears and ensuring the safest and most beneficial dental office visit. TruAlign® technology, while reducing radiation exposure, also significantly reduces the need for X-ray retakes from the patented laser alignment system. Tru-Align® can be used with film, digital sensors, or phosphor plate (PSP) systems. Oral health professionals are ”bound” by the ALARA principle when it comes to taking X-rays. ALARA stands for ”As Low As Reasonably Achievable.” In other words, dentists are committed to minimizing radiation exposure. TruAlign®provides dentistry with a solution for complying with the ALARA principle and protecting their patients and staff from unnecessary dental radiation, in compliance with the most current FDA, ADA, and NCRP guidelines.
Congratulations to all of the 2013 Winners
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Leading the industry in targeting the niche specialties of dentistry
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CONTINUING EDUCATION
The biology of orthodontic tooth movement part 1: Biology of Bone 101 Dr. Michael S. Stosich outlines the basic premises and biology of bone related to orthodontics
T
he various influences of bone physiology underlying the phenomenon of orthodontic tooth movement need to be examined thoroughly for a true understanding of how we, as orthodontists, are capable of exerting orthodontic and orthopedic effects on the dentofacial complex. Long thought of as a static structure of the body used mainly to support and protect, bone has been shown to be a very dynamic system in constant modeling and remodeling to optimize its strength and mass. For such an optimization process to exist, sensor and feedback mechanisms must be present to sense changes in the state of the environment (loading forces) and send signals to an effector that can begin the process of optimizing bone.
Macroscopic anatomy of bone The structure of bone is best examined by first looking at the anatomy of a standard long bone such as the femur. The two ends
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 U.S. 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.
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Educational aims and objectives This article aims to discuss how the structure of bone affects the orthodontic process. Expected outcomes Correctly answering the questions on page 41, worth 2 hours of CE, will demonstrate the reader can: • Identify the macroscopic anatomy of bone. • Identify the microscopic anatomy of bone. • Recognize molecular pathways for orthodontic bone remodeling. • Recognize the three steps in the bone remodeling process.
of the bone, epiphyses, form joints with other bones and are covered with a layer of hyaline, or articular, cartilage. Between the two ends of the bone lies the diaphysis, or shaft of the bone. It contains many holes called nutrient foramina through which nerves and blood vessels enter into the bone. Enclosing the bone is a layer of tough, vascular covering of fibrous tissue called the periosteum. The periosteum is firmly attached to the bulk bone, and its fibers are continuous with the various tendons and ligaments connected to the bone. The periosteum is made of two main layers, the fibrous layer and osteogenic layer. The fibrous layer is made of dense connective tissue while the osteogenic layer contains osteoprogenitor cells that play important roles in the formation and repair of bone tissue1. Mineralized bone is composed of two main types. Cortical (or compact) bone is tissue that is very tightly packed resulting in a substance that is solid, strong, and resistant to bending. Cortical bone composes the walls of the diaphysis and also forms a thin wall around the epiphyses. The epiphyses, however, are mainly composed of cancellous, or spongy, bone. Spongy bone is composed of numerous branching bony plates called trabeculae. The trabeculae are arranged so that irregular interconnecting spaces occur between them, thus reducing the overall weight of the bone while also providing the needed strength. The spongy bone is densest in areas of the epiphyses, subjected to the largest forces of compression. In the larger bones, the diaphysis contains a
hollow tube down the center of the cortical bone called the medullary cavity. This area is lined with a thin membrane, called the endosteum, and filled with a specialized type of connective tissue called marrow, which is also continuous into the spongy bone of the epiphyses1.
Microscopic anatomy of bone Despite being seemingly static and inert, bone is a very dynamic tissue containing many active cells and processes at all times. Bone tissue itself is composed of bone tissue cells (osteocytes, osteoblasts, and osteoclasts) surrounded by insoluble extracellular matrix proteins. The protein matrix consists of both mineralized matrix to provide stiffness and strength, and collagen to provide flexible reinforcement for the mineral components. In cortical bone, bone matrix is deposited in thin layers called lamellae. The lamellae are arranged in concentric circles around tiny longitudinal tubes called Haversian canals. The Haversian canals contain mostly capillaries and nerves surrounded by loose connective tissue. Evenly spaced and trapped within the lamellae are osteocytes, also arranged in concentric patterns. The osteocytes themselves are located in pockets of fluid called lacunae. The osteocytes and lamellae together form a cylindrical-shaped unit called an osteon, which is the main structural unit of cortical bone (Figure 1). Each osteon is on the order of 200-250 μm in diameter1. Bone cells receive nutrients via blood vessels running through the Volume 4 Number 6
Haversian canals. The Haversian canals run longitudinally through bone tissue and are interconnected by transverse communicating canals called Volkmann’s canals. These canals contain larger blood vessels by which vessels in the Haversian canals communicate with the surface of the bone and medullary cavity. The Haversian and Volkmann canals are on the order 10 μm in diameter.1 Spongy bone is also composed of osteocytes in bone matrix. However, the bone cells are not arranged around Haversian canals. Instead, the cells are found within the trabeculae.1 Bone cells include the osteoblasts, osteoclasts, osteocytes, and bone lining cells. Osteoblasts are cuboidal-like cells that originate from mesenchymal stem cells; they are involved in bone formation by forming osteoid that they later mineralize by releasing alkaline phosphatase. Osteoclasts are multinucleated giant cells that originate from hematopoietic stem cells; they are involved in bone resorption. Bone lining cells are located on the periosteal surface and are osteoprogenitor cells that can differentiate into osteoblasts. Lastly, osteocytes are embedded in bone matrix and located in lacunae. Each osteocyte contains numerous cytoplasmic processes that extend outward and pass through fluid-filled tubes of bone called canaliculi, which are on the order of 100 nm in diameter. These cellular processes are attached to the membranes of neighboring cells by gap junctions and connect all osteocytes in the bone matrix as well as the bone lining cells at the periosteal surface, which are very important in cell signaling. Due to these processes, osteocytes are Volume 4 Number 6
Figure 2: Front view of the craniofacial skeleton without the supporting dentition
thought to be the main sensor cells of bone to mechanical forces.2
Molecular pathways for bone remodeling in orthodontics Remodeling of bone can be broken into three steps, each step involving many different cell types coming from different cell lineages. Something must first sense the mechanical force (shear stress) and signal osteoblasts, and osteoclasts to the remodeling area. The osteoclasts and osteoblasts must then migrate to the remodeling area via some sort of chemotactic signal. Finally, when the cells reach the damaged zone, they must begin the remodeling process.3 Osteocytes as sensor cells Fluid flow could occur at three different levels of the bone porosity. The Haversian and Volkmann canals that contain blood vessels and nerves are the first possibility but, being on the order of 10 μm, are too large to have an effective shear stress. The lacunar and canalicular network that contains the osteocytes is the second possibility. Being on the order of 0.1 μm, these networks correspond with the primary porosity scale associated with the relaxation of the excess pore pressure due to mechanical loading. The third possibility would be the movement of fluid through the collagen-hydroxyapatite matrix of the bone, which is on the order of 20-60 nm. Experiments have shown this to be unlikely because the crystals bind tightly to water and heavily restrict flow.4,5 By modeling the canalicular spaces as cell processes surrounded by a protein/ carbohydrate matrix called glycocalyx,
levels of shear stress from physiological levels of loading have been estimated between 8-30 dynes/cm.2,4 Even though exact values have not been measured in vivo, new techniques have been developed to show that increased flow through the lacunar and canalicular space does occur as a result of mechanical loading.6 Because of their location within the fluid-filled lacunae of bone, osteocytes have been proposed as the mechanical sensors that sense the fluid flow caused by mechanical loading and produce signals initiating bone remodeling and modeling. The processes can, therefore, sense the shear stress created by fluid flow, which can set off intracellular pathways. The processes of the osteocytes are used to communicate with other osteocytes of the bone as well as bone lining cells located on the bone surface. The osteocytes can, therefore, also send signals to other osteocytes as well as osteogenic bone lining cells about their mechanical state.7 How the fluid flow and shear stresses are sensed by the osteocytes is currently believed to be along two distinct pathways. Cytoskeletal changes with integrins being the mechanotransducer is one possibility. The activation of G-proteins that then trigger intracellular pathways is a second. Integrins are transmembrane, heterodimer receptor proteins located on almost every cell in the body. They are of extreme importance in cell adhesion and bind to extracellular proteins containing the RGD sequence. Integrins have the unique property of being able to bind extracellular proteins and being attached directly to the intracellular actin cytoskeleton via binding proteins. Because of this unique property, Orthodontic practice 39
CONTINUING EDUCATION
Figure 1: A. Microscopic anatomy of bone shows the osteon as the main structural unit of bone. The osteocytes are buried in the bone matrix and send processes outward that are used to communicate with other osteocytes as well as bone lining cells2. B. Exploded view of an osteocyte showing the many cell processes that extend to neighboring cells.
CONTINUING EDUCATION
Figure 3: Lateral view of the craniofacial skeleton without the supporting dentition
Figure 4: A. CBCT image of the frontal aspect of the cranofacial skeleton including the dentition B. CBCT image from the upper perspective of the cranofacial skeleton including the dentition C. Reconstructed 2D panorex including dentition
integrins are thought to be able to function as mechanotransducers by transmitting mechanical signals from the extracellular matrix to the cytoskeleton.8 Cyclic adenosine monophosphate (cAMP) is another second messenger that has been shown to increase in response to mechanical forces.9 Unlike the PKA pathway, cAMP production can be inhibited by use of indomethacin, suggesting a prostaglandin dependent pathway.9,10 The production of cAMP has been shown to inhibit ERK activation, and therefore, cAMP may play a negative regulatory function.10 Another important pathway stimulated by both G-proteins and integrins is production of nitric oxide (NO). Increases in intracellular Ca2+ activate nitric oxide synthase (NOS), particularly the isoform eNOS.11 The NO produced may also stimulate the production of more prostaglandins or may be a paracrine factor for osteoblasts.8
produce two possible paracrine factors, NO and prostaglandins (PGE2). Insulinlike growth factor (IGF) in the form IGF-1 has also shown to be a possible paracrine factor for the bone forming cells.12 It is also possible that PGE2 is an upstream regulator of IGF-1; inhibition of prostaglandin release using indomethacin has significantly inhibited IGF-1 (Chow, 2000). Recent work has shown that PGE2 may also act on the osteocytes as well. Jiang and Cheng13 demonstrated that PGE2 has a stimulatory effect on the formation of gap junctions among osteocytes in a parallel plate flow chamber model. They proposed that PGE2 stimulates the synthesis of connexin 43 (Cx43); the connexin involved in gap junctions between osteocytes, and formation of more functional gap junctions. By this method, greater numbers of signaling molecules can pass between osteocytes to increase the efficiency of cell signaling and ultimately bone remodeling. After the signal is received from the osteocytes, the osteoblasts begin the production of new bone. This process generally occurs about 72 hours after the mechanical stimulation and is evidenced by increases in osteocalcin (OCN) and collagen at the bone-forming surface,14 along with a measurable increase in mineral apposition rate8. The process has
Signaling osteoblasts Since the sensor-cell osteocytes are unable to directly make bone themselves, a paracrine factor must be released to stimulate bone formation, either by direct activation of osteoblasts or differentiation, and activation of bone lining cells. The intracellular pathways described above
been described on both the periosteal and endosteal sides of cortical bone as well as in trabecular bone.8 Endocrine factors such as parathyroid hormone (PTH) also appear to function as a signaling factor for osteoblasts. Instead of directly stimulating the osteoblasts to form bone, PTH seems to play a permissive role in the anabolic response of bone to mechanical loading and may play a key role in sensitizing the threshold of bone formation. Turner, et al.,15 hypothesize that PTH gives bone cells “memory” that allow them habituation to certain magnitudes of mechanical forces. Supporting this hypothesis is the fact that each bone in the body seems to have its own threshold for remodeling, with one example being long bones exhibiting different sensitivities to mechanical loading than craniofacial bones. Concluding remarks In this article, I have attempted to outline the basic premises and biology of bone as it relates to orthodontics in order to further delve into fundamental questions in orthodontics and dentofacial orthopedics. In the next issue, clinical questions will be posed and answered on the biology of tooth movement. OP
References 1. Hole JW Jr, Koos KA. Human Anatomy; 2nd ed.; Wm. C. Brown Publishers; Dubuque, Iowa; 1994; pp. 86-7, 122-8. 2. Smit TH, Burger EH, Huyghe JM. A case for straininduced fluid flow as a regulator of BMU-coupling and osteonal alignment. J Bone Mineral Res. 2002;17(11):20212029. 3. Tami AE, Nasser P, Verborgt O, Schaffler MB, Knothe Tate ML. The role of interstitial fluid flow in the remodeling response to fatigue loading; J Bone Mineral Res. 2002;17(11):2030-2037. 4. Weinbaum S, Cowin SC, Zeng Y. A model for the excitation of osteocytes by mechanical loading-induced bone fluid shear stresses. J Biomechanics. 1994;27(3):339360. 5. Burger EH, Klein-Nulend J. Mechanotransduction in bone – role of the lacuno-canlicular network. FASEB Journal. 1999;13(Suppl.),S101-S112.
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6. Mak AFT, L. Qin L, Hung LK, Cheng CW, Tin CF. A histomorphometric observation of flows in cortical bone under dynamic loading. Microvascular Res, 2000;59:290300.
11. McAllister TN, Frangos JA. Steady and transient fluid shear stress stimulate NO release in osteoblasts through distinct biochemical pathways. J Bone Mineral Res. 1999;14(6):930-936.
7. Pead MJ, Suswillo R, Skerry TM, Vedi S, Lanyon LE. Increased 3H-uridine levels in osteocytes following a single short period of dynamic bone loading in vivo. Calcified Tissue International. 1988;43(2):92-96.
12. Lean JM, Mackay AG, Chow JWM, Chambers TJ. Osteocytic expression of mRNA for c-fos and IGF-1: an immediate early gene response to an osteogenic stimulus. Amer J Physiology. 1996;270(6):E937-E945.
8. Bloomfield SA. Cellular and molecular mechanisms for the bone response to mechanical loading. International J Sport Nutrition Exercise Metabolism. 2001;11(S128-S136).
13. Jiang JX, Cheng B. Mechanical stimulation of gap junctions in bone osteocytes is mediated by prostaglandin E2. Cell Commun and Adhes. 2001;8(4-6):283-288.
9. Reich KM, Gay CV, Frangos JA. Fluid shear stress as a mediator of osteoblast cyclic adenosine monophosphate production. J Cell Physiol. 1990;143:100-104.
14. Chow JWM. Role of nitric oxide and prostaglandins in the bone formation response to mechanical loading. Exerc Sport Sci Rev. 2000;28(4):185-188.
10. Wadhwa S, Choudhary S, Voznesensky M, Epstein M, Raisz R, Pilbeam C. Fluid flow induces COX-2 expression in MC3T3-E1 osteoblasts via a PKA signaling pathway. Biochemical Biophysical Res Comm. 2002;297:46-51.
15. Turner CH, Owan I, Jacob DS, McClintock R, Peacock M. Effects of nitric oxide synthase inhibitors on bone formation in rats.” Bone. 1997;21:487-490.
Volume 4 Number 6
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The biology of orthodontic tooth movement part 1: Biology of Bone 101 1. Long thought of as a static structure of the body used mainly to support and protect, bone has been shown to be a very dynamic system in constant modeling and remodeling to optimize its ____. a. strength b. mass c. epiphysis d. both a and b 2. Enclosing the bone is a layer of tough, vascular covering of fibrous tissue called the _____. a. periosteum b. Haversian canals c. lamellae d. Volkmann canals 3. _______ (or compact) bone is tissue that is very tightly packed, resulting in a substance that is solid, strong, and resistant to bending. a. Spongy b. Cortical c. Endosseous d. Cancellous 4. In cortical bone, bone matrix is deposited in thin layers called ______. a. trabeculae
Volume 4 Number 6
b. lacunae c. lamellae d. mesenchymal layers 5. The Haversian canals contain mostly ______surrounded by loose connective tissue. a. trabeculae b. capillaries c. nerves d. both b and c 6. The osteocytes and lamellae together form a cylindrical-shaped unit called a(n) ____, which is the main structural unit of cortical bone. a. osteon b. osteoblast c. osteocyte d. collagen-hydroxyapatite matrix 7. _____ are multinucleated giant cells that originate from hematopoietic stem cells; they are involved in bone resorption. a. Osteoblasts b. Osteoclasts c. Integrins d. Actins
the body. a. Indomethacins b. Integrins c. Prostaglandins d. Adenosines 9. Since the sensor-cell osteocytes are unable to directly make bone themselves, _____must be released to stimulate bone formation, either by direct activation of osteoblasts or differentiation, and activation of bone lining cells. a. a paracrine factor b. nitric oxide synthase c. prostaglandin d. indomethacin 10. Endocrine factors such as ______also appear to function as a signaling factor for osteoblasts. a. G-proteins b. oxide synthase c. parathyroid hormone (PTH) d. osteocalcin (OCN)
8. ______ are transmembrane, heterodimer receptor proteins located on almost every cell in
Orthodontic practice 41
CE CREDITS
ORTHODONTIC PRACTICE CE
CONTINUING EDUCATION
A golden opportunity for dentists: dental sleep medicine Part 2: implementing sleep dentistry into your practice Dr. Harold F. Menchel offers a wake-up call to clinicians to explore an evolving niche in dentistry In last issue’s article, a general overview was presented on sleep dentistry. Part 2 will emphasize the practical aspects in implementing sleep dentistry in your practice. Discussed will be: • Your role coordinating treatment with the sleep physician • A flowchart for OSA patients with dental appliances • Discussion of specific sleep appliances and criteria for selection • Standard of care for examination and informed consent. Sleep dentistry can be introduced into your practice in two ways: 1. As a supplement to your traditional practice 2. Growing your practice with an emphasis on sleep dentistry. Choice 1 does not involve a significant financial or time commitment. In this case, you will be acting more as a technician for the sleep physician. You should consult with the sleep physician as to his/her preference for dental appliances as they may adjust them in the sleep lab. Choice 2 is more involved as will be discussed later in the article. Table 1 will describe the basic flow of patients in your practice. It may be difficult in many instances to get a follow-up split study due to lack of insurance coverage and patient compliance. There are dozens of dental sleep
Harold Menchel, DMD is a dentist in Coral Springs, Florida, who limits his practice to TMD, orofacial pain, and sleep disordered breathing. Dr. Menchel teaches undergraduate and graduate education in TMD and orofacial pain at Nova Southeastern School of Dental Medicine in Fort Lauderdale, Florida. He is the director of orofacial pain at Larkin Teaching Hospital in Miami, and lectures both nationally and internationally. He is a fellow of the American Academy of Orofacial Pain, a Diplomate of the American Board of Orofacial Pain, and a member of the American Academy of Dental Sleep Medicine.
42 Orthodontic practice
Educational aims and objectives This article aims to discuss some treatment methods for sleep disorders. Expected outcomes Correctly answering the questions on page 44, worth 2 hours of CE, will demonstrate the reader can: • Recognize some different types of sleep appliances and advantages and disadvantages. • Identify some devices that can help with the process. • Realize the need for interaction with a sleep physician and knowledge of state laws regarding the dentist’s role in sleep disorder treatment. • Realize the various aspects of informed consent on sleep appliances.
appliances on the market, all of which claim certain advantages. All dental sleep appliances do the same thing. They all advance the mandible to open the airway. In general the following guidelines may be useful: • No single type of sleep appliance will be appropriate for every patient. Depending on whether the patient has a full dentition, partially edentulous, or edentulous on one arch, different ones may be chosen. • The choice of materials is important also. The softer laminates are more comfortable for the patient than hard acrylic, but not as durable and adjustable if dental restorations change the tooth configuration. • Some appliances allow full mouth opening while others restrict it. Some sleep dentists assert that opening will tend to close the airway. • Tongue space is a strong consideration for many patients. The appliance should minimally constrict the tongue. • The more adjustable the appliance is and the ease of adjustment for the dentist, sleep physician, and patient are also important. Some dentists will allow the patient to adjust the appliance while others do not. • There are patients with significant limited openings and mandibular range of motion, due to arthritis, post radiation fibrosis of the muscles of mastication,
or autoimmune diseases such as scleroderma. Dental sleep appliances are contraindicated in these instances. • At this time, Medicare only allows reimbursement for Herbst and TAP appliances. There are devices that can aid you in taking protrusive bite records, e.g., George Gauge®, TAP gauge®, that are inexpensive and simple to use. A pulse oximeter may be helpful as a screening device that you should consider adding to your practice.1 (Review the limitations of PO as mentioned in Part 1. TMD issues, jaw lesions, and gross dental disease should be screened with a panoramic film.) TMD is not necessarily a contraindication for dental sleep appliances, but these patients have to be relatively pain free prior to treatment. In many instances, the mandibular advancement appliance can be therapeutic. Basic sleep dentistry courses are available to familiarize you with the more popular sleep appliances (e.g., TAP, Somnodent, Herbst, Kleerway, OASYS). There are even dental appliances available for partially edentulous patients. Patient selection will be presented as well as how to take a protrusive bite record. If this is the depth that you prefer to take sleep dentistry in your practice, it is important that you have a good relationship with a sleep physician to help you in titrating and evaluating the benefit Volume 4 Number 6
of the dental appliance. If you want to make sleep dentistry a significant part of your practice, it is necessary to have an indepth understanding of sleep anatomy and physiology, diagnosis, and management. You may consider prescribing your own home sleep studies for this as a screening method.3 Contact the AASM and AADSM for information on this. This can involve a significant investment in time and money. This is not discussed in this article. Dentists who make this choice need to have more advanced instrumentation, and, more importantly, may take the initial responsibility for titration and follow-up of their patients. Dental practice acts may vary greatly depending on the state you reside in, and it is imperative that you familiarize yourself with your state laws. Every state requires that only physicians diagnose sleep disorders, and that a physician reads the sleep study.
Informed consent appliances
for
dental
• All patients should be made aware that CPAP is still the gold standard for treating OSA, especially severe conditions, and that the dental appliance may not be as effective.4 • There have also been reports of dental sleep appliances causing permanent bite changes by advancing the Volume 4 Number 6
mandible, and creating posterior open bites due to lateral pterygoid shortening and condylar and eminence remodeling. Patients need to be informed of this possibility.5 • Any dental appliance can promote decay and periodontal inflammation if dental hygiene is neglected. • Sore teeth or minor tooth movement may occur with the dental appliance. • Rarely, the patient may develop jaw and or muscle pain.
Conclusions Adding sleep dentistry to your practice can be of great benefit to both you and your patients. Sleep physicians should be made aware that dentists are significant referrers. This is also a good motivation for your staff to learn a new and interesting facet in the practice of dentistry. There is no downside in introducing sleep dentistry into your practice. It can be done with minimal time and financial investment to you and grow as part of your practice as you decide. It is important to establish a good relationship with the sleep physicians in your community, and to let them know that you are available to make appliances for their patients as needed. Taking a good basic sleep course is essential. You must understand the physiology of sleep and pathophysiology of OSA, how to read a
PSG, how to do basic screening, and how to make, insert, and monitor dental appliances. Sleep dentistry is a wonderful new opportunity and should be strongly considered by all dentists.
Acknowledgements I would like to thank Drs. Barry Glassman, Don Malizia, and Steven Bender for their assistance with this article. It is greatly appreciated. OP References 1. Netzer N, Eliasson AH, Netzer C, Kristo DA. Overnight pulse oximetry for sleep-disordered breathing in adults: a review. Chest. 2001;120(2):625633. 2. de Almeida FR, Bittencourt LR, de Almeida CI, Tsuiki S, Lowe AA, Tufik S. Effects of mandibular posture on obstructive sleep apnea severity and the temporomandibular joint in patients fitted with an oral appliance. Sleep. 2002;25(5):507–513. 3. Gagnadoux F, Pelletier-Fleury N, Philippe C, Rakotonanahary D, Fleury B. Home unattended vs hospital telemonitored polysomnography in suspected obstructive sleep apnea syndrome: a randomized crossover trial. Chest. 2002;121(3):753758. 4. Ferguson KA, Ono T, Lowe AA, Keenan SP, Fleetham JA. A randomized crossover study of an oral appliance vs nasal-continuous positive airway pressure in the treatment of mild-moderate obstructive sleep apnea. Chest. 1996;109(5):1269– 1275. 5. Martínez-Gomis J, Willaert E, Nogues L, Pascual M, Somoza M, Monasterio C. Five years of sleep apnea treatment with a mandibular advancement device. Side effects and technical complications. Angle Orthod. 2010;80(1):30-36.
Orthodontic practice 43
CONTINUING EDUCATION
Table 1: This table is a recommended flow chart to be followed. It is important to note that a sleep physician has already examined the patient and a dental appliance prescribed. It may be difficult in many instances to get a followup split study due to lack of insurance coverage and patient compliance.
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ORTHODONTIC PRACTICE CE Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 12/1/2012 to 11/30/2016 Provider ID# 325231
REF: OP V4.6 MENCHEL
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A golden opportunity for dentists: dental sleep medicine: part 2 1. All dental sleep appliances do the same thing. They all advance the mandible ______. a. to open the airway b. to create biting force c. to stop tooth decay d. to decrease tongue space 2. No single type of sleep appliance will be appropriate for every patient. Depending on whether the patient has ______ different ones may be chosen. a. a full dentition b. partially edentulous c. edentulous on one arch d. all of the above 3. The softer laminates are more comfortable for the patient than hard acrylic, but _____if dental restorations change the tooth configuration. a. not as durable b. not as adjustable c. not as constricting d. both a and b 4. The appliance should minimally constrict _____. a. the edentulous arch b. the tongue
44 Orthodontic practice
c. the mandible d. the protrusive bite 5. There are patients with significant limited openings and mandibular range of motion, due to _____. Dental sleep appliances are contraindicated in these instances. a. arthritis b. post radiation fibrosis of the muscles of mastication c. autoimmune diseases such as scleroderma d. all of the above 6. All patients fitted with sleep appliances should have a ______as part of a TMD screening. a. TAP appliance b. cephalogram c. panoramic film d. EKG 7. ____ requires that only physicians diagnose sleep disorders, and that a physician reads the sleep study. a. No state b. Every state c. Some states d. The sleep association
8. All patients should be made aware that _____is still the gold standard for treating OSA, and that the dental appliance may not be as effective. a. TAP b. Herbst c. CPAP d. Kleerway 9. Any dental appliance can promote _______ if dental hygiene is neglected. a. malocclusion b. decay c. periodontal inflammation d. both b and c 10. You must understand the physiology of sleep and pathophysiology of OSA, how to read a PSG, how to do basic screening, and how to ______dental appliances. a. make b. insert c. monitor d. all of the above
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ORTHODONTIC INSIGHTS
More than one way — an issue related to invisible aligners Drs. Donald J. Rinchuse, Ethan Drake, Janet Robison, and Dara L. Rinchuse offer insights on the various forms of tooth movement
H
ooke’s Law for springs (and in orthodontics, springs act like beams) simply states, “The extension of (a spring), so the force.” Hooke’s Law applies to stainless steel wires (linear curve) and not for nickel-titanium wires (nonlinear curve) or rubber materials. For systems that obey Hooke’s Law, the extension produced is directly proportional to the load in an exponential manner. That is, the elongation of a bar is directly proportional to the tensile force and the length of the bar, and inversely proportional to the cross-sectional area and the modulus of elasticity. Figures 1-3 represent various labial and lingual wire configurations for Hawleytype removable appliances that can be used for minor tooth movement (Table 1). Two of the Hawley-type spring aligners pictured in these photos (Figures 1A-1B and 2A-2B) utilize stainless steel wire, with one having a double-helical loop (Figures 2A-2B), which would increase the force range as compared to the appliance in (Figures 1A-1B). Figure 3 represents an Inman Spring Aligner™, which utilizes pushand-pull NiTi coils that alter the force and range (increase) of the appliance. Table 1 represents forces (grams) of the labial, and labial and lingual (when the appliance is
Donald J. Rinchuse, DMD, MS, MDS, PhD, is Professor and Graduate Orthodontic Program Director at Seton Hill University Center for Orthodontics in Greensburg, Pennsylvania. Ethan Drake, DMD, MS, is a former orthodontic resident Seton Hill University Center for Orthodontics, presently in private orthodontic practice in Chambersburg, Pennsylvania. Janet Robison, PhD, DMD, MDS, is Assistant Professor of Orthodontics, University of Pittsburgh, Pennsylvania. Dara L. Rinchuse, DMD, is Clinical Faculty, Seton Hill University Center for Orthodontics in Greensburg, Pennsylvania and in private orthodontic practice in Belle Vernon, Pennsylvania.
46 Orthodontic practice
Figure 1A
Figure 1B
Figures 1A-1B: Appliance No. 3 (from Table 1), Modified Hawley spring aligner
Figure 2A
Figure 2B
Figures 2A-2B: Appliance No. 4 (from Table 1), Modified Hawley spring aligner with double-loop (helix) labial and lingual wires
made in a “spring aligner” fashion versus traditional Hawley), wire components of five Hawley-type appliances (Appliance No. 5 - Inman) when stretched 1/2 to 2 mm. Different wire configurations and types of wires can affect the force of various modified Hawley-type appliances as the data in Table 1 illustrates. Note that the forces for Appliance No. 4 and Appliance No. 5 are somewhat comparable. However, Appliance No. 4 is a Hawley-type spring aligner but with labial and lingual stainless steel 0.30-inch double-loop (helix) wire components, while Appliance No. 5 is an Inman Spring Aligner utilizing NiTi coils. Certainly, the force and range of each appliance must be ascertained when deciding on a treatment approach. Forces for invisible aligners are not so easily obtained for a number of reasons; one reason is the practicality of actually utilizing/placing a “gauging” system for measurements. In deciding on an appliance and/or
approach to resolve minor to moderate crowding, there are certainly many ways other than the use of vacuum-formed thermoplastic aligners. Nonetheless, the results of Invisalign® (Align Technologies Inc.) treatments have generally been good1,2 (Figures 4A-4C), but there have also been some mixed reviews.3-8 For sure, the resolution of minor crowding can involve the use of a host of different appliances, such as Hawley spring aligners, Inman aligner, clear braces, and so forth. And, it is possible to use more than one type of appliance, one following the other, for particular cases. There is also the possibility that some cases that are treatment planned for orthodontics are best resolved with cosmetic dentistry (Figures 5A and 5B), and vice versa. The advantage of cosmetic dentistry over orthodontics in certain situations is that cosmetic dentistry can alter the size, shape, and color of teeth (Figures 5A and 5B), which is clearly Volume 4 Number 6
Figure 4A1 Figures 4A1-4A2: Pre-treatment photos
Figure 4B: Use of clear vacuum-formed aligner for orthodontic treatment
Figure 4C1 Figure 4C2 Figures 4C1-4C2: Final results of treatment with vacuum-formed aligner
Figure 5A: Pre-treatment
Figure 5B: Post-treatment
Figures 5A-5B: Case treated with cosmetic dentistry> 4 maxillary incisor veneers.
not possible with orthodontic treatment. For middle-aged and older adults, a recommendation of cosmetic dentistry may be a prudent choice. Patients in this age range typically have worn teeth and possibly “dark triangular gingival spaces” due to tooth recession, which can be addressed with dental cosmetic and restorative treatments, i.e., veneers or crowns. In addition, the stability of the results with cosmetic dentistry (orthodontic relapse) is better since the pre-restored teeth are in a somewhat stable position. Of course, there are cases that require both orthodontics and cosmetic dentistry. When a patient has no rotated or angulated teeth, a Hawley spring aligner may be the appliance of choice. Removable appliances with finger springs can also be used (Figures 6A-6C). For other patients, the choice may be clear brackets (Figure 7), and, it makes sense in certain situations to start with clear fixed appliances for 4-6 weeks, and then finish with either vacuumformed clear aligners or a spring aligner Volume 4 Number 6
(Figures 8A-8E). For patients where the decision is to start with fixed appliances for 4-6 weeks, several wire changes can be made in this time frame. One of the advantages of starting with “braces” and then finishing with a removable appliance(s) is that leveling/aligning/uprighting can be achieved prior to the use of removable appliances. The other advantage is that the teeth are typically “loose” and easier to move after using “braces” — and at the time the vacuum-formed aligner(s) (or spring) is (are) placed. The modern paradigm for correction of minor to moderate crowding should not be limited to one treatment technique, i.e., vacuum-formed aligners. Just as there are various types of malocclusions and types of crowding, so should there be different treatment approaches, including orthodontic and non-orthodontic. As previously mentioned, there are times when a concomitant orthodontic approach makes sense, and fixed appliances can be initially used followed by vacuum-formed
ORTHODONTIC INSIGHTS
Figure 3: Appliance No. 5 (from Table 1), Inman spring aligner push-and-pull NiTi coils
Figure 4A2
aligner(s). There are some caveats for treating patients with minor crowding. Although the amount of tooth movement may be minor, these types of cases should be viewed as difficult from a patient satisfaction perspective. There may actually be more complaints from this group of patients than those coming from patients/families with severe and handicapping malocclusion, because even when severe cases do not finish ideally, the patients/families are typically very satisfied considering where they “came from.” On the other hand, if a case is not “that bad” to start, the expectations for a perfect result are higher. Another consideration is that patients/ families expect that a “perfect finish” will stay that way forever. Be reminded, many of these minor tooth movement cases (now typically referred to as “Invisalign” cases) are individuals who had had braces before (and usually full braces), and their teeth have relapse. So this may be a situation where the orthodontist has a lifetime commitment to these patients. The future of vacuum-formed thermoplastic aligners will inevitably lead to the use of “shape memory polymers.” This technology would be somewhat comparable to the advance in orthodontic wire technology going from stainless steel to nickel-titanium. With shape memory technology, it will be possible to fabricate one aligner (“shape memory”) for each Orthodontic practice 47
ORTHODONTIC INSIGHT
Figure 6A1
Figure 6A2
Figures 6A1–6A2, 6B, 6C1–6C2: Case with anterior crossbite (6A1–6A2) where a removable Hawley appliance with a finger spring was utilized (6B) to correct the anterior crossbite (6C1–6C2)
Figure 6B
Figure 7: Clear, fixed appliances used to mitigate mild to moderate crowding. Figure 6C1
Figure 6C2
Table 1: Labial and lingual wire components of Hawley type appliances stretched 1/2, 1, 1-1/2, and 2 mm. Force of stretched labial and lingual wires obtained in grams.
APPLIANCE
1/2 mm stretch**
1 mm stretch
1-1/2 mm stretch
2 mm stretch
-Labial wire*
100g
250g
400g
No measurement
-Lingual wire
No lingual wire
No lingual wire
No lingual wire
No lingual wire
80g
120g
150g
250g
No lingual wire
No lingual wire
No lingual wire
No lingual wire
-Labial wire
100g
250g
400g
No measurement
-Lingual wire
91g
249g
390g
475g
80g
120g
150g
250g
60g
80g
120g
250g
-Labial wire
55g
150g
240g
No measurement
-Lingual wire
80g
130g
150g
190g
No. 1 Traditional Hawley
No. 2 Hawley with double-loop labial bow -Labial wire -Lingual wire No. 3 Hawley spring
No. 4 Hawley spring with double loop -Labial wire -Lingual wire No. 5 Inman spring aligner
*Maxillary Removable Hawley Type Appliances No. 1, No. 2, No. 3, No. 4 (Labial bow wire size: 0.30 inches) ** Stretch force obtained by the use of Halden AB Strain Gauge; Sweden (Jonard Ind. Corp., Bronx NY 104630)
48 Orthodontic practice
Volume 4 Number 6
ORTHODONTIC INSIGHTS
Figure 8A1 Figure 8A2 Figures 8A1-8A2: Case with moderate mandibular anterior crowding (post orthodontic treated case that relapsed)
Figure 8C1
Figure 8B2
Figure 8B1
Figure 8C2
Figures 8B1-8B2: Case was started with mandibular clear, fixed appliances for 6 weeks
Figures 8C1-8C2: Treatment result after the use of clear, fixed appliances.
Figure 8D1 Figures 8D1-8D2: Case now with mandibular spring aligner
Figure 8D2
Figure 8E1
Figure 8E2
Figures 8E1-8E2: Final result
patient that will be capable of being deformed (by light or heat, etc.) as it being placed over a crowded arch and then have the ability to slowly return to its original shape once activated again. The activation could be by means of light, heat, or other sources. The single shape memory aligner is fabricated after a “tooth setup” of the patient’s crooked teeth/arch is made into an ideal tooth position. In addition, laser scans can be done directly in the mouth without the need for traditional impressions to produce 3D images of the teeth that can be seamlessly integrated to produce computer models.6,9 OP Volume 4 Number 6
References
Dentofacial Orthop.2005;128(3):292-298.
1. Boyd RL. Complex orthodontic treatment using a new protocol for Invisalign appliance. J Clin Orthod. 2007;41(9):525-547.
5. Kuncio D, Maganzini A, Shelton C, Freeman K. Invisalign and traditional orthodontic treatment postretention outcomes compared using the American Board of Orthodontics objective grading system. Angle Orthod. 2007;77(5):864-869.
2. Miller KB, McGorray SP, Womack R, Quintero JC, Perelmuter M, Gibson J, Dolan TA, Wheeler TT. A comparison of treatment impacts between Invisalign aligner and fixed appliance therapy during the first week of treatment. Am J Orthod Dentofacial Orthop. 2007;131(3):302. 3. Lagravere MO, Flores-Mir C. The treatment effects of Invisalign orthodontic aligners: A systematic review. J Am Dent Assoc. 2005;136:1724-1729. 4. Djeu G, Shelton C, Maganzini A. Outcome assessment of Invisalign and traditional orthodontic treatment compared with the American Board of Orthodontics objective grading system. Am J Orthod
6. Ackerman JL, Proffit WR. What price progress? Am J Orthod Dentofacial Orthop. 2002;121(3):243. 7. Rinchuse DJ, Rinchuse DJ. Orthodontics and the general practitioner. J Am Dent Assoc. 2002;133:1160-1164. 8. Miller RJ, Duong TT, Derakhshan M. Lower incisor extraction treatment with Invisalign system. J Clin Orthod. 2002;36(2):95-102. 9. Keim RG. Intraoral scanners have arrived. J Clin Orthod. 2013;47(6):341-342.
Orthodontic practice 49
TECHNOLOGY
T
he VELscope Vx is LED Dental Inc.’s latest model release of the VELscope system. The VELscope Vx is the most powerful FDA- and Health Canadaapproved tool to screen for oral cancer, a growing health-care issue around the world. It is used by dentists to detect early stage oral cancer and pre-cancer, as well as other oral abnormalities such as viral, fungal, and bacterial infections that might otherwise go unseen. The technology is the first to offer both cordless convenience and an optional digital camera and customized bracket that make it easy for dentists to photo-document suspicious lesions. The VELscope Vx is: • cordless • compact • affordable – even for multiple operatories. The VELscope’s distinctive bluespectrum light causes the soft tissues of the mouth to naturally fluoresce. Healthy tissues fluoresce in distinctive patterns — patterns that are visibly disrupted by trauma or disease. Using the VELscope, a wide variety of oral abnormalities can be discovered — often before they’re visible to the unassisted eye. Discovering soft tissue abnormalities is particularly important in the fight against oral cancer. Because the VELscope Vx assists in early detection, cancer can be caught before it has time to spread, potentially saving lives through less invasive, more effective treatment. Used on a regular basis, the VELscope Vx helps dental professionals find a wide variety of soft-tissue abnormalities, allowing practices to aspire to an advanced level of patient care. The VELscope Vx is: • completely safe • simple to use • no unpleasant rinses or stains • entire exam in about 2 minutes. Occasionally, the VELscope system plays a crucial role in saving lives. OP
The VELscope Vx is the most powerful FDA- and Health Canada-approved tool to screen for oral cancer, a growing health-care issue around the world.
This information was provided by LED Dental Inc. 50 Orthodontic practice
Volume 4 Number 6
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Orthodontic Practice US is a peer-reviewed, bimonthly publication containing articles by leading authors from around the world. Orthodontic Practice US is designed to be read by specialists in Orthodontics, Periodontics, Oral Surgery, and Prosthodontics.
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Orthodontic practice 51
PRACTICE MANAGEMENT
Growing the money tree William H. Black, Jr. discusses the financial advantages of having a good plan in place
Y
our practice is established. You have a good reputation and a good management team in place. Gone are the days of building the practice and putting all profit back toward growth. That’s the good part! But success creates other questions and concerns. When clients first come to us they typically have the same refrain: “I am paying salaries, sick pay, vacation pay, major medical, matching Social Security and Medicare, paying into unemployment and Workman’s Comp. I have to pay a lot of money in income taxes…How do I keep more of what I make? No one has any solutions for me!” What I’ve found clients really mean is they want an idea that is not “outside the box,” that won’t increase their audit profile, an idea that won’t get them in trouble with Internal Revenue. The simple answer is to consider a custom-designed qualified plan! In other words, consider a form of a pension plan (known as “qualified” because the contribution qualifies for an income tax deduction). Think about it this way: there is not a company on the New York Stock Exchange, a union, or government agency that doesn’t have a pension plan. So using the rules that are on the books to create a custom-designed plan for the closely held professional practice may be the answer.
• Plan assets grow tax deferred • Plan assets are protected from judgment creditor claims1 • Plan assets are eligible for tax-free rollover to one’s IRA account • Qualified plans receive up-front approval from Internal Revenue in the form of a Favorable Determination Letter Let me clear up a few myths straightaway. These plans are not about retirement; they are about the tax benefits and asset accumulation features, i.e., your money tree. Who’s worried about retirement? It’s the employees putting $25 a week into their 401(k) plan. More power to those employees, but we, as business owners, are past that. Look at a plan as a way to pay yourself on a tax-favored basis! Here is how to look at the merits. Assume a 39% federal income tax rate and assume a 6% state income tax rate. So, for brevity, we will assume an overall tax rate of 45%. Since there is no requirement to have a plan, what does it look like without one? For every $10,000 in taxable income, what does it look like with a plan or without one? (We use $10,000 in this analysis because it is scalable. Want to know what $50,000 would do? Multiply by 5. $75,000? Multiply by 7.5, etc.) Here is where it gets interesting. On one hand you have $10,000 working for
Consider the benefits: • Contributions are income tax deductible
William H. Black, Jr. has been in the pension administration business for 34 years. The firm Pension Services, Inc. administers both defined contribution and defined benefit plans, employs an ERISA attorney, an Enrolled Actuary, and complete clerical staff. Mr. Black is qualified to give continuing education to CPAs in 47 different states. He has spoken nationally and internationally on retirement plans, has been quoted in USA Today, written articles for several industry journals and has appeared on many financial radio shows discussing the topic of retirement and financial matters. He may be contacted at bill@pensionsite.org.
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you; on the other, you have $5,500. The tax benefits alone give you 81% more (10,000 ÷ 5,500) right out of the gate. Now, consider the plan’s assets grow tax deferred while the non-plan grows taxably. Add it all together, and you can see the benefits growing with every passing year! Many believe, initially, that the plan will cause all employees to come in, with contributions for all, and any employee is entitled to take his/her contribution out immediately. While plans like that do exist, they are not well designed or well thought out. ERISA, the Employee Retirement Income Security Act of 1974, gives us 39 years of instruction on how to design a plan. In other words, these plans are black and white, really no gray area. Now the question becomes how to design a plan to benefit the rainmaker? That is the easy part! Many different options exist, hence the need for customization. Many “cookie cutter” plans are out there, a one-size-fitsall approach. These are commonly referred to as “bundled” plans. While those plan designs have their place, they cannot be all things to all people. What to do? Start with a checklist of basic questions. What is the annual budget for the contribution? How is the business set up, as a Corporation either
Without a Plan
With a Plan
Taxable Income
$10,000
$10,000
Tax at 45%
$4,500
$0
After-tax Balance
$5,500
$10,000
Comments on graph: • No tax on the “with a plan” column as the contribution is income tax deductible. • After-tax balance is as of the present day. In the future, monies coming out of an IRA or qualified plan are subject to ordinary income taxes. • The chart does not take into account asset protection benefits. • This is scalable. Considering a $50,000 contribution? The values are five times as much, etc.
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us they typically have the same refrain: “I am paying salaries, sick pay, vacation pay, major medical, matching Social Security and Medicare, paying into unemployment and Workman’s Comp. I have to pay a lot of money in income taxes…How do I keep more of what I make?”
S or C, as an LLC, LLP, PA, Partnership, or Sole Proprietor? How many employees? Are there existing plans in place now? How is the ownership structured, all in the hands of one person, or two or more? With the above, and an employee census, i.e., employee names, dates of birth and dates of hire, job titles and annual salaries, a projection can be created that will show, in black and white, what the benefits and detriments are. Look at it in conjunction with your CPA and make a
business decision on what is right for your situation. OP This discussion is not intended as tax advice. The determination of how the tax laws affect a taxpayer is dependent on the taxpayer’s particular situation. A taxpayer may be affected by exceptions to the general rules and by other laws not discussed here. Taxpayers are encouraged to seek help from a competent tax professional for advice
about the proper application of the laws to their situation.
References 1. Patterson v. Schumate (http:// financial-dictionary.thefreedictionary.com/ Patterson+v.+Shumate)
Volume 4 Number 6 Orthodontic practice 53
PRACTICE MANAGEMENT
When clients first come to
PRODUCT PROFILE
Dental technology gets a new look with Henry Schein’s augmented reality app
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ome technologies have become so routine to our daily lives that it’s hard to believe they didn’t exist 20 years ago. Online banking first launched in 1994. Amazon opened its virtual doors in 1995. Text messaging became mainstream in 2001. Smartphones gained momentum and exploded in popularity with the introduction of the first Apple iPhone® in 2007. In just two decades, inventions that seemed impossibly futuristic have become practical, widely used tools. One of the newest technologies still in its infancy, but already making a major impact, is augmented reality. Henry Schein has long been an innovator and early adopter of cutting-edge technology, and once again, they lead the way and are embracing this exciting development. Henry Schein Dental’s first interactive Equipment and Technology Catalog using augmented reality technology was released in October, and it literally changes the way doctors and their teams view dental products and services.
What is augmented reality? Augmented reality projects a virtual layer of interactive features on top of an actual physical environment, when viewed on the screen of a mobile phone or tablet. Henry Schein’s catalog and other brochures give readers another world of options — a digital world — that is interconnected to the printed page they are reading. Viewing the page through their device’s camera, they can launch interactive product descriptions and specifications, training videos, current promotional offers, and one-click buttons that connect them quickly to a sales representative. It’s all done just by hovering over an augmented reality enhanced page with an iPad®, iPhone® or Android™ device loaded with the Henry Schein Xtra app. Augmented reality can be difficult to explain in words, and its benefits can’t be grasped fully unless you see the technology yourself. You will be amazed at how powerful and applicable it can be to your dental practice.
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Test drive Henry Schein’s augmented reality app — It’s quite a ride If you have a mobile device, you can try augmented reality right now by scanning the page right next to this article. Just go to the Apple App Store or Google Play and download the free augmented reality mobile app called Henry Schein Xtra. Next, open the Henry Schein Xtra app and hover over the page with your device, being sure the entire page is displayed on your screen. Your device will “scan” the page to find the augmented reality features, and then watch the ad come to life with an on-screen button that launches a video. As you’ll see, augmented reality puts you in control of your browsing experience because you engage with items that matter most to you in an informative new way. Plus augmented reality gives Henry Schein the
opportunity to constantly update materials with new information, promotions, videos, and more so you always have the latest news at your fingertips. Thanks to this new innovation, Henry Schein’s printed catalogs and brochures can remain a doctor’s go-to resource for what’s new in dental technology today, tomorrow and months from now. Search for Henry Schein Xtra in the Apple App Store or Google Play to give augmented reality a try today. OP This information was provided by Henry Schein Dental.
Download the Henry Schein Xtra App
Watch the Video Volume 4 Number 6
Customized Practice Solutions for ORTHODONTISTS
Scan this page with the Henry Schein Xtra App for an interactive experience!
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Office Design & Consultation
From the Front Office to the Treatment Room and every touchpoint in between, Henry Schein has the solutions you need to connect all of your practice technologies to maximize the digital workflow resulting in greater efficiencies. With your success in mind, let us help you determine which products and technologies will enhance patient care within your practice. Our specialists have the experience and knowledge to assist and guide you in all of your equipment and technology choices.
Service, Repair & Installation
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1-800-645-6594 prompt #1 www.henryscheindental.com
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Contact your Henry Schein Sales Consultant to ask about equipment and technology to advance patient care in your practice.
ABSTRACTS
The latest in orthodontic research from around the world Dr. Shalin R. Shah presents the latest literature, keeping you up-to-date on the most relevant research from around the world Pulp vitality and histologic changes in human dental pulp after the application of moderate and severe intrusive orthodontic forces Han G, Hu M, Zhang Y, Jiang H. American Journal of Orthodontics and Dentofacial Orthopedics (2013) 144:518-22. Abstract Aims: Orthodontic forces produce a series of changes in dental pulp. However, no one has attempted to investigate the incidence of pulp necrosis after orthodontic therapy in the clinic. In this study, we aimed to investigate pulp vitality and histologic changes after the application of moderate and severe intrusive forces. Materials and Methods: Twenty-seven adolescent patients were assigned to one of three groups: the control group of three subjects; the moderate-force group, with 12 subjects who received a 50-g force to the first premolars bilaterally; and the severeforce group, with 12 subjects who received a 300-g force. The forces were applied for 1, 4, 8, or 12 weeks. An electric pulp tester was used to test for vitality, and teeth that did not respond to the electric pulp tester were subsequently tested thermally with a stick of heated gutta percha. Results: The teeth with a negative response to the electric pulp tester still responded to the thermal test. We found odontoblast disruption, vacuolization, and moderate vascular congestion in both force groups, but no necrosis was observed. Pulp stones were formed only in the severe-force group.
Shalin Raj Shah, DMD, MS, received his Certificate of Orthodontics and Masters of Science in Oral Biology from the University of Pennsylvania and is a Diplomate of the American Board of Orthodontics. He is also a graduate of the University of Pennsylvania College of Arts and Sciences and School of Dental Medicine. Currently, Dr. Shah is Clinical Associate of Orthodontics at the University of Pennsylvania and is in private practice (Center for Orthodontic Excellence) in Princeton Junction, New Jersey, and Philadelphia, Pennsylvania.
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Conclusions: Dental pulp still has vitality after intrusive treatment with different forces. These data provide new insights into the effects of intrusive orthodontic forces. Biofilm formation on stainless steel and gold wires for bonded retainers in vitro and in vivo, and their susceptibility to oral antimicrobials Jongsma MA, Pelser FDH, van der Mei H, Atema-Smit J, van de Belt-Gritter B, Busscher HJ, Ren Y. Clin Oral Investig (2013) 17:1209-18.
Abstract Aims: Bonded retainers are used in orthodontics to maintain treatment result. Retention wires are prone to biofilm formation and cause gingival recession, bleeding on probing, and increased pocket depths near bonded retainers. In this study, we compare in vitro and in vivo biofilm formation on different wires used for bonded retainers and the susceptibility of in vitro biofilms to oral antimicrobials. Materials and Methods: Orthodontic wires were exposed to saliva, and in vitro biofilm formation was evaluated using plate counting and live/dead staining, together Volume 4 Number 6
Development of labial gingival recessions in orthodontically treated patients Renkema AM, Fudalej PS, Renkema A, Kiekens R, Katsaros C. American Journal of Orthodontics and Dentofacial Orthopedics (2013) 143:206-12. Abstract Aims: Our aim was to assess the prevalence of gingival recessions in patients before, immediately after, and 2 and 5 years after orthodontic treatment. Materials and Methods: Labial gingival recessions in all teeth were scored (yes or no) by two raters on initial, end-of-treatment, and post-treatment (2 and 5 years) plaster models of 302 orthodontic patients (38.7% male; 61.3% female) selected from a posttreatment archive. Their mean ages were 13.6 years (SD, 3.6; range, 9.5-32.7 years) at the initial assessment, 16.2 years (SD, 3.5; range, 11.7-35.1 years) at the end Volume 4 Number 6
of treatment, 18.6 years (SD, 3.6; range, 13.7-37.2 years) at 2 years post treatment, and 21.6 (SD, 3.5; range, 16.6-40.2 years) at 5 years post treatment. A recession was noted (scored â&#x20AC;&#x153;yesâ&#x20AC;?) if the labial cementoenamel junction was exposed. All patients had a fixed retainer bonded to either the mandibular canines only (Type I) or all six mandibular front teeth (Type II). Results: There was a continuous increase in gingival recessions after treatment from 7% at end of treatment to 20% at 2 years post treatment, and to 38% at 5 years post treatment. Patients less than 16 years of age at the end of treatment were less likely to develop recessions than patients more than 16 years at the end of treatment (P = 0.013). The prevalence of recessions was not associated with sex (P = 0.462) or extraction treatment (P = 0.32). The type of fixed retainer did not influence the development of recessions in the mandibular front region (P = 0.231). Conclusions: The prevalence of gingival recessions steadily increases after orthodontic treatment. The recessions are more prevalent in older than in younger patients. No variable, except for age at the end of treatment, seems to be associated with the development of gingival recessions. Evaluation of optimal length and insertion torque for miniscrews Suzuki M, Deguchi T, Watanabe H, Seiryu M, Iikubo M, Sasano T, Fujiyama K, Takano-Yamamoto T. American Journal of Orthodontics and Dentofacial Orthopedics (2013) 144:251-9. Abstract Aims: The purpose of this article was to test the theory that short miniscrews will decrease the possibility of damaging the root, but the failure rate will increase. Materials and Methods: One hundred eighty-six miniscrews (diameter, 1.3 Ă&#x2014; 5 mm, n = 63; 6 mm, n = 62; 7 mm, n = 61) were placed in 105 consecutive patients. Multi-slice computed tomography and cone beam computed tomography scans were taken before and after miniscrew placement. Insertion torque was measured at miniscrew placement. Results: The success rate of the miniscrews in the maxilla (93.4%) was higher than that in the mandible (70.3%). A significantly lower success rate with 5 mm miniscrews was observed compared
with 6 mm and 7 mm miniscrews in the mandible. Miniscrews placed in less than approximately 3.8 mm of bone and those within 1.4 mm of the root had significantly higher failure rates. Miniscrews placed with insertion torque greater than 10 N-cm had a tendency for a lower success rate. Conclusions: The optimum lengths of miniscrews of a diameter of 1.3 mm are 5 mm in the maxilla and 6 mm in the mandible. They should be placed at a distance from the root with insertion torque less than 10 N-cm for safe orthodontic anchorage without failure. Effect of piezopuncture on tooth movement and bone remodeling in dogs Kim Y-S, Kim S-J, Yoon H-J, Lee PJ, Moon W, Park Y-G. American Journal of Orthodontics and Dentofacial Orthopedics (2013) 144:23-31. Abstract Aims: The aim of the study was to elucidate whether a newly developed, minimally invasive procedure, piezopuncture, would be a logical modification for accelerating tooth movement in the maxilla and the mandible. Materials and Methods: Ten beagle dogs were divided into two groups. Traditional orthodontic tooth movement was performed in the control group. In the experimental group, a piezotome was used to make cortical punctures penetrating the gingiva around the moving tooth. Measurements were made in weeks 1 through 6. Tooth movement and bone apposition rates from the histomorphometric analyses were evaluated by independent t tests. Results: The cumulative tooth movement distance was greater in the piezopuncture group than in the control group: 3.26-fold in the maxilla and 2.45-fold in the mandible. Piezopuncture significantly accelerated the tooth movements at all observation times, and the acceleration was greatest during the first 2 weeks for the maxilla and the second week for the mandible. Anabolic activity was also increased by piezopuncture: 2.55-fold in the maxilla and 2.35-fold in the mandible. Conclusions: Based on the different effects of piezopuncture on the maxilla and the mandible, the results of a clinical trial of piezopuncture with optimized protocols might give orthodontists a therapeutic benefit for reducing treatment duration. OP Orthodontic practice 57
ABSTRACTS
with effects of exposure to toothpaste slurry alone or followed by antimicrobial mouth rinse application. Wires were also placed intraorally for 72 hours in human volunteers, and undisturbed biofilm formation was compared by plate counting and live/dead staining, as well as by denaturing gradient gel electrophoresis for compositional differences in biofilms. Results: Single-strand wires attracted only slightly less biofilm in vitro than multistrand wires. Biofilms on stainless steel single-strand wires, however, were much more susceptible to antimicrobials from toothpaste slurries and mouth rinses than on single-strand gold wires and biofilms on multi-strand wires. Also, in vivo significantly less biofilm was found on single-strand than on multi-strand wires. Microbial composition of biofilms was more dependent on the volunteer involved than on wire type. Conclusions: Biofilms on single-strand stainless steel wires attract less biofilm in vitro and are more susceptible to antimicrobials than on multi-strand wires. Also in vivo, single-strand wires attract less biofilm than multi-strand ones. Clinical Significance: Use of singlestrand wires is preferred over multi-strand wires, not because they attract less biofilm, but because biofilms on single-strand wires are not protected against antimicrobials as in crevices and niches as on multi-strand wires.
LEGAL MATTERS
Employment Law 101 Dr. Ali Oromchian discusses basic laws every orthodontist needs to know
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ne of the most dreaded aspects of business for any entrepreneur, especially the dental entrepreneur, is employee management. Employees are vital to any successful business, and particularly in an orthodontic office where personal relationships and communication ensure loyal and happy patients. However, in our litigious society, orthodontists need to take extra care to guarantee that they are compliant with all applicable federal, state, and local employment laws. This article will discuss the most common traps including overtime pay, lunch, and other breaks, last paychecks for terminated employees, HIPPA, and employment handbooks.
Overtime pay The United States Department of Labor oversees compliance with laws for overtime pay for employees at the national level. Overtime pay is regulated by the Fair Labor Standards Act (FLSA), which prescribes standards for minimum wage and overtime pay for both private and public employment. The FLSA requires employers to pay employees at least the federal minimum wage plus overtime pay of one and a half times the regular rate of pay for their work. Unless specifically exempted, employers must pay overtime pay to employees for hours worked in excess of 40 hours in a workweek. There is no limit in the FLSA to the amount of overtime hours an employee can work. Importantly, the overtime requirement may not be waived by agreement between
Ali Oromchian, JD, LL.M, is the founding attorney of the Dental & Medical Counsel, PC law firm and is renowned for his expertise in legal matters pertaining to dentists. Mr. Oromchian has served as a key opinion leader and legal authority in the dental industry with dental CPAs, consultants, banks, insurance brokers, and dental supplies and equipment companies. He serves as a legal consultant for numerous dental practice management firms who rely on his expertise for their client’s businesses. He is also recognized as an exceptional speaker and educator who simplifies complex legal topics and has lectured extensively throughout the United States.
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the employer and employee, and any announcement by an employer that no overtime work will be permitted or that overtime work will not be paid for unless authorized in advance does not impair an employee’s right to compensation for the overtime worked. Some states, such as California, have overtime laws. In cases where an employee is subject to both the state and federal overtime laws, the employee is entitled to overtime according to the higher standard (i.e., the standard that will provide the higher overtime pay). Some typical pitfalls that occur include (a) paying a fixed sum for a varying amount of overtime; (b) creating a fixed salary for an employee for a regular work week that the federal or state overtime laws; and (c) trying to convince the employee to waive overtime.
Lunch and break laws Federal law does not require meal or other breaks from work. Meal breaks are not compensable, but other breaks, typically short breaks lasting 5 to 20 minutes, are compensable under federal law. If an employer decides to offer a short break of some sort, then it is included in the sum of hours worked during the workweek, and it is considered when determining overtime pay. Many states have their own lunch/ break requirements, which must be adhered to strictly; however if the state does not have specific laws pertaining to lunch/breaks then the federal law applies. One frequent violation in orthodontic offices occurs when the employees are interrupted and required to work at any point in their lunch break. This can be as simple as answering phone calls or checking insurance coverage.
Last paycheck Under federal law, employers are not required to give former employees their final paycheck immediately upon termination of employment. However, some states require immediate payment. One such state is California, where discharged
employees or employees who quit are due their final paycheck upon termination of employment. There are significant penalties, which accrue as soon the final paycheck is not paid. Additionally, it is illegal in many states to withhold a final paycheck to persuade an employee to return uniforms, laptops, pay back money, or return any other item.
HIPAA The Health Insurance Portability and Accountability Act of 1996 (HIPAA) legislates certain privacy protections that apply to health care providers, including orthodontists. The law is designed to help patients keep as much of their personal information private as possible. The law protects from unauthorized disclosure of any personally identifiable health information (protected health information, or PHI) that pertains to a consumer of health care services. Health information is personally identifiable if it relates to an individual specifically and includes the following: • Health care claims or health care encounter information, such as documentation of doctor’s visits and notes made by physicians and other provider staff; • Health care payment and remittance advice; • Referral certifications and authorization. Covered entities, including orthodontists, must adopt written PHI privacy procedures; designate a privacy officer, require their business associates to sign agreements respecting the confidentiality of PHI; train all of their employees in privacy rule requirements; give patients written notice of the covered entities’ privacy practices and access to their medical records; give patients a chance to request modifications to the records; give patients a chance to request restrictions on the use or disclosure of their information; give patients a chance to request an accounting of any use to which the PHI has been put, and give patients a chance to request alternative methods of communicating information. They must Volume 4 Number 6
litigious society, orthodontists need to take extra care to guarantee that they are compliant with all applicable federal, state, and local employment laws.
also establish a process for patients to use in filing complaints and for dealing with complaints. Under HIPAA, patient authorization is not necessary if a disclosure is made for purposes of treatment, securing payment, or in accordance with the operations of a health care provider. However, if PHI is to be disclosed for any other purpose, the patient’s written authorization is necessary.
Employee handbooks Employee handbooks are a useful tool for communication between an employer and employee about many aspects of the employer-employee relationship. An employee handbook should describe the legal obligations of an employer and the employee’s rights. An employee handbook should include a section with Volume 4 Number 6
anti-discrimination policies and sections explaining compensation to the employee, the employer’s policies regarding work hours and schedules, standards of conduct, safety and security, employee benefits, and leaves policies. The absence of an employee handbook, or a poorly drafted one, puts you at a disadvantage when defending a claim brought against you by a current or former employee. At the very least, your employment manual should define who is covered by the handbook, review existing policies and practices, draft consistent, understandable and legally permissible employment policies, review the handbook with management prior to implementation to obtain feedback, and submit the draft handbook to experienced labor law counsel for review.
Solutions Employee management and legal compliance is usually the weakest link within any orthodontic practice because the owner-dentist had to manually manage records, and ensure proper time keeping and performance reviews. HR for Health is a SAAS-based employee management system that ensures legal compliance with federal and state documents, performance improvements through metrics, increases employee satisfaction, and provides insights into your employees that allow you to turn their weaknesses into strenghts. The risks are high and the responsiblities important, but with powerful strategic tools such as HR for Health, all orthodontic offices can be compliant with complicated employment laws. OP Orthodontic practice 59
LEGAL MATTERS
...in our
BOOK REVIEW
Biomechanics in Orthodontics, 4th Edition Drs. Giorgio Fiorelli and Birte Melsen
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hen I interviewed Drs. Melsen and Fiorelli 17 years ago upon the publication of the 1st edition of Biomechanics in Orthodontics, I asked them what they intended as an encore to their epoch-making publication that used a CD-ROM with computer hypertexts and multimedia resources. They promised to make periodic upgrades to the material, and have they ever with this 4th edition. Without doubt, Biomechanics in Orthodontics has been the quintessential reference for orthodontists regarding the mechanics of tooth movement for many years. But this new edition, which is completely cloud-based, brings a new dimension to orthodontic learning. The information is no longer dependent upon any particular operating system or computer. Rather now, users can access it with any computer or tablet, which makes it universal in application. The same subjects are covered as in previous editions, but there are more clinical examples with vastly improved photographic and image quality. Also, improvements in techniques, such as TADs, bracket-free fixed orthodontics, and lingual orthodontics, are now included. Another new feature illustrated nicely in anchorage preservation is TriadÂŽ Gel posterior occlusal additions that lock in the reactive parts of the dentition during space closures. The accompanying videos are superbly done and do much to illustrate many of the concepts presented. Extensive and up-to-date bibliographies add an important component and afford readers with a rich resource for references. The authors have made every effort to afford this information to the orthodontic public, e.g., reduced prices for those who purchased the 3rd edition, 1-month rentals of the entire book, and 1-month free trials for a single chapter. Those wishing to purchase or request a free chapter can visit the website at http://www.orthobiomechanics.com/en/. The authors also encourage readers to visit their Facebook page â&#x20AC;¨https://www.facebook.com/ OrthodonticBiomechanicsSummerSchool. Biomechanics in Orthodontics is the reference for their International Orthodontic 60 Orthodontic practice
This new edition, which is completely cloud-based, brings a new dimension to orthodontic learning. The information is no longer dependent upon any particular operating system or computer. Rather now, users can access it with any computer or tablet, which makes it universal in application.
Biomechanics Summer School, which lasts 5 weeks in Tuscany, Italy. No other single source for orthodontic biomechanics exceeds what Drs. Melsen and Fiorelli have collected and presented in this 4th edition of Biomechanics in Orthodontics, and in my opinion, any professional library will be incomplete without this publication.
1,000 pages, 3,000 photos and illustrations Review by Larry White, DDS, MSD For more information on this book, visit http://www.ortho-biomechanics.com/en OP
Volume 4 Number 6
John Bednar helps avert problems coming down the pipe
I
f your office currently has a hard-piped filtered water system, and you are strictly practicing orthodontics, now is a good time to consider if and when you should change to a self-contained bottled water system. A hard-piped filtered water system is a system that has a copper water line connected to a water filter that is usually located within the equipment room. The copper water line is typically installed under the concrete floor and either runs towards the front of the office, and then branch lines run to each treatment room, or individual lines run from the equipment room to each treatment room. There are a few issues in having the hard-piped filtered water system. One issue is where the hard-piped filtered copper water line terminates within the treatment area. It usually requires a 3/8” compression fitting to be installed on the line so that the DCI water handpiece hose can be connected. The point of this connection often fails, and if an equipment control panel is not being utilized, then the water is constantly running. If the failure occurs after hours, then the doctor and staff arrive the following morning to find that the office has flooded. Another issue that is standard practice is that building departments and/ or city inspectors are requiring that a backflow preventer be installed on every line where a handpiece or another piece of equipment is connected. So, a backflow preventer is beginning to be a requirement in the individual treatment areas, in addition to within the equipment room or wherever the main water source enters the suite. A backflow preventer will cost anywhere from $800 to $1,000 and will require annual testing.
John Bednar currently serves as the construction project manager at OrthoSynetics and has been with the company since 2002. Mr. Bednar works with the entire project team from the initial space-planning, concept through the architectural and engineering phase, ultimately working with and overseeing the construction of the office until the office is open. He also helps in expansions and remodels and assists in facility management. John has over 17 years of experience in the construction of orthodontic and pediatric dental facilities.
Volume 4 Number 6
If your office did not to have to meet these requirements at the time it was built, then you can expect for these requirements to be imposed on you some time in the near future as more local jurisdictions are starting to perform inspections to check on items such as these. Keep in mind that after the backflow preventer installation is complete, it then must be tested on an annual basis by a company that is certified to do so. The reason for this requirement is to prevent any contaminated water from backing up and finding its way back into the city’s main domestic water supply. If your office currently has this hard-piped filtered water system, then you may want to make sure you have an equipment control panel or another way to shut off this water line when you leave for the day or for an extended period of time. The equipment control panel has switches and/ or buttons to control the turning on and off of the hard-piped filtered water system, the vacuum pump, and the air compressor. This equipment control panel should be conveniently located so that staff can easily turn the filtered water, air compressor, and vacuum pump on upon arrival and then turn if off before leaving for the day. Turning the filtered water off at the end of the day will prevent the office from flooding if a failure should occur since the only water that will leak from the system will be the minimal amount of water still within the line. As an alternative, you could install a self-contained bottled water system. This system comes with different-sized bottles depending on your needs. The cost of these bottles ranges between $200 and $400 per bottle. The bottle can mount inside a cabinet if rear delivery is used or inside a chairside mobile or stationary cart. The bottle can also attach directly to the chair or to the pivot arm if an over-thepatient delivery is desired. The bottle is pressurized directly off of the air line. The 3/8” compression fitting installed on the air line may possibly need to be replaced with a double 3/8” compression fitting depending on the exact system to be used. Since an orthodontist uses very little water, filling the bottles with domestic water has
become more of the norm, although an independent countertop filtering system can be utilized to fill the bottles without the worries of backflow prevention. The old hard-piped filtered water line in the treatment areas would simply be capped since it would no longer be in use, and the same would apply within the equipment room or wherever the main water source may be. When you consider updating your hard-piped water system, it is important to evaluate the cost of the modifications that need to be made and implemented in an effort to prevent failure, as well as the cost of the inspections to meet your city’s building requirements. While doing so, you should also evaluate the potential costs for a self-contained water system considering the versatility, and if such system meets your needs. It is important to address this issue as we are coming across more cities and jurisdictions that are changing their requirements. You will also be making an effort to protect yourself against the potential of a flooded office. Please keep in mind that different cities and jurisdictions will have different building requirements, and it is important to educate yourself on these, as well as surround yourself with people who understand the issues and requirements associated with such projects. OP
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PRACTICE MANAGEMENT
Hard-piped filtered water system vs. self-contained bottled water system
PRACTICE DEVELOPMENT
Four social media channels that drive new patient acquisition and retention Diana P. Friedman offers advice on cultivating a dynamic web presence Facebook, Twitter, and other online sites have become not just wildly popular but significant parts of their users’ daily lives — for instance, the average Facebook user spends 55 minutes a day there! For many consumers — including your current and prospective patients — these channels have also become a go-to resource for buying decisions. In fact, 74% of consumers rely on online resources to guide purchase decisions, while consumers are 71% more likely to make a purchase based on online referrals. By cultivating a comprehensive, active, and well-branded online presence, your practice can make the most of these opportunities to acquire new patients and strengthen loyalty with current ones. Here are four online social media channels on which to focus.
Facebook Facebook is one of the most businessfriendly social media sites. Businesses can create branded, customized Facebook pages and effectively drive traffic to their page using multiple inexpensive marketing tactics, including a broad spectrum of practice patient-directed communications as well as search engine-targeted ads. The practice can leverage its Facebook channel to post a wide variety of multimedia content to engage and educate visitors. Don’t forget Facebook’s Page Insights analytics feature, which allows you to measure your page’s reach, engagement, and other key performance data.
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, she served as a recognized practice management consultant, author, and speaker. She holds an MA in Sociology and an MBA from Arizona State University.
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Why it’s worth your time Your existing and prospective patients are there…Over one billion users…that’s nearly one-sixth of the world’s population! But more to the point, a staggering 93% of all U.S. adult Internet users are on Facebook. …And they’re engaged — We already know Facebook users spend a lot of time there. They participate, too: More than 2.7 billion “Likes” and comments occur on Facebook each day.
YouTube YouTube, the popular video-sharing site, allows you to easily upload videos up to 15 minutes long. These can be shared with your YouTube community as well as leveraged in other practice web channels such as posted on social media pages and embedded in your website. Why it’s worth your time Your existing and prospective patients are there — YouTube stats show that 6-plus billion videos are watched every day, and
that 1-plus billion unique users visit the site each month. This is the perfect place to feature patient testimonials. Testimonials — especially in video format — act as very strong influencers: 90% of consumers trust peer recommendations. This channel can also be leveraged effectively to educate the community through short presentations by the orthodontist as well as provide an effective introduction to the practice. It’s great for SEO — Did you know YouTube is technically the world’s secondlargest search engine? And according to Forrester research, videos are 50 times more likely to rank on the first page of search engines.
Google+ Google+, Google’s foray into social networking, shares many features with sites like Facebook. Google+ is businessfriendly: It allows you to create brandfocused pages for your practice, “circle” other users (their version of “friending” someone), share videos, pictures, and status updates, and much more.
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1. Leonard, H. This is what an average user does on Facebook. Business Insider. http://www. businessinsider.com/what-does-an-averagefacebook-user-do-2013-3. Published March 6, 2013. Accessed November 5, 2013.
These very important online channels can help your orthodontic practice accelerate new patient acquisition. The best thing you can do for your practice is to get started. Why it’s worth your time Your existing and prospective patients are there — Google+ has exploded in the last year: It now has more than 500 million users, and recently passed Twitter to become the world’s second-largest social network. Google+ has moved beyond a niche network and is now essential for any practice trying to attract patients through social media. Most importantly, as an orthodontic practice you serve a local community, and Google+ is all about targeting that local audience.
Twitter Twitter is an interactive stream of messages — each message is limited to 140 characters. These messages (“tweets”) post on your Twitter page, and automatically stream to users who “follow” you. With Twitter, it takes just seconds to create a tweet that reaches thousands of potential patients. Why it’s worth your time Your existing and prospective patients are there — Twitter has 200-plus million active members. Twitter is widely regarded as a powerful marketing tool that can be used to share quick and focused updates, connect
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with patients, learn from customers’ past experiences, and connect with professional peers. And they’re using it to inform potential buying decisions — 42% of all active Twitter users learn about products and services via Twitter, and 88% follow brands or companies.
Final thoughts These very important online channels can help your orthodontic practice accelerate new patient acquisition. The best thing you can do for your practice is to get started. If you haven’t already, start by setting up a Facebook Business page — Facebook is so popular that not having a page in 2013 looks nearly as bad as not having an upto-date practice website. Next, evaluate how you can fold these other channels into your online marketing mix and strategy. Once your practice gets started with these channels, it’s important to keep them updated, fresh, and relevant. It’s worth your time to consider getting some help from a proven online dental marketing company — just make sure they are focused on orthodontics and have a track record of success in helping practices grow through these channels. OP
2. Nelson, A. 20 stats about how social media influences purchasing decisions. Salesforce marketing cloud. http://www. salesforcemarketingcloud.com/blog/2012/11/20stats-about-how-social-media-influencespurchasing-decisions/. Published Nov. 21, 2012. Accessed November 5, 2013. 3. Teen and Young Adult Internet Use. Pew Research Center. http://www.pewresearch.org/ millennials/teen-internet-use-graphic/. Published February, 2010. Accessed November 5, 2013. 4. Kern, E. Facebook is collecting your data — 500 terabytes a day. Gigaom. http://gigaom. com/2012/08/22/facebook-is-collecting-yourdata-500-terabytes-a-day/. Published August 22, 2012. Accessed November 5, 2013. 5. YouTube. Press room. http://www.youtube. com/yt/press/. Accessed November 5, 2013. 6. Qualman, E. 39 Social Media Statistics to Start 2012. Socialnomics. http://www.socialnomics. net/2012/01/04/39-social-media-statistics-tostart-2012. Published January 2012. Accessed November 5, 2013. 7. Christensen. A. 12 valuable tips for SEO beginners. Search Engine Watch. http:// searchenginewatch.com/article/2234885/12Valuable-Tips-for-Video-SEO-Beginners. Published January 9, 2013. Accessed November 5, 2013. 8. Watkins, T. Suddenly, Google Plus is outpacing Twitter to become the world’s second largest social network. Business Insider. http:// www.businessinsider.com/google-plus-isoutpacing-twitter-2013-5. Published May 1, 2013. Accessed November 5, 2013. 9. Wickre, K. Celebrating #Twitter7. Blogs. https://blog.twitter.com/2013/celebratingtwitter7. Published March 21, 2013. Accessed November 5, 2013. 10. Baer, J. 7 surprising statistics about Twitter in America. Convince&Convert. http://www. convinceandconvert.com/twitter/7-surprisingstatistics-about-twitter-in-america/. Accessed November 5, 2013. 11. Baer, J. 7 surprising statistics about Twitter in America. Convince&Convert. http://www. convinceandconvert.com/twitter/7-surprisingstatistics-about-twitter-in-america/. Accessed November 5, 2013.
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PRACTICE DEVELOPMENT
References
INDUSTRY NEWS
Carestream Dental’s CS 8100 digital panoramic imaging system receives 2013 International Medical Design Excellence Award Carestream Dental announced its CS 8100 digital panoramic imaging system has been selected as the Bronze Winner in the Dental Instruments, Equipment, and Supplies category of the 2013 Medical Design Excellence Awards (MDEA) competition. Presented by UBM Canon and Medical Device and Diagnostic Industry (MD+DI) magazine, the MDEA program recognizes the achievements of medical device manufacturers, their suppliers, and the many people behind the scenes (engineers, scientists, designers, and clinicians) in the areas of product innovation, design and engineering achievement, end-user benefit, and cost-effectiveness in manufacturing and healthcare delivery. The CS 8100 digital panoramic imaging system offers the latest imaging technology to obtain highly detailed and optimally contrasted panoramic images. The CS 8100 also comes with exclusive 2D+ technology that enables practitioners to create slices at regular intervals along the jaw to focus on one area of interest and visualize more details than standard 2D images reveal. It’s a cost-effective solution that overcomes some of the limitations of standard panoramic imaging such as structure overlap. The patient-centric design and transparent patient support features of the CS 8100 also help practitioners obtain high-quality images effortlessly. Integrated handgrips help patients remain stationary, while the face-to-face positioning aids with patient alignment. Images are captured in as little as 10 seconds, reducing the period of exposure while also minimizing the risk of patient movement and need for retakes. The CS 8100’s open design accommodates patients of all shapes and sizes, including those in wheelchairs. For more information about the CS 8100, call 800-944-6365 or visit www.carestreamdental.com/CS8100.
6th Annual Ethics and Legal Aspects of Dentistry Conference The 6th Annual Ethics and Legal Aspects of Dentistry Conference sponsored by the American College of Legal Medicine will be held Friday and Saturday, February 28 – March 1, 2014, at the Westin Galleria in Dallas, Texas. Dentists attending the conference will be able to learn more about legal issues in dentistry and understand the government’s role and the role of dental education, describe ethical, moral, and diagnostic issues as they relate to the dental practice; evaluate risk management considerations; and identify issues relating to patient care, access to care and dental healthcare coverage, electronic record keeping, licensure issues, the current landscape for malpractice, and more. For further information and registration, visit the ACLM website at www.aclm.org or contact Wendy Weiser at wendy@wjw.com or Dr. Bruce Seidberg at bseidbergddsjd@me.com.
MATERIALS & EQUIPMENT OrthoEssentials OrthoEssentials, of Mount Holly, New Jersey is now an authorized distributor for Select Defense Enamel Surface Sealant. It comes in two convenient sizes and will provide an 86% reduction in enamel demineralization around orthodontic brackets. This product also contains Selenium which will greatly reduce plaque buildup around orthodontic brackets. Select Defense is the only surface sealant on the market with Selenium. For more information, email info@orthoessentials.net or call 866-517-3257 or 215-396-3803.
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Volume 4 Number 6
PLANMECA ProMax® S3 Pan/Ceph
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ORTHOPHOS XG 3D The right solution for your diagnostic needs.
Implantologists Endodontists
Orthodontists will benefit from highquality pan and ceph images for optimized therapy planning.
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will appreciate the seamless clinical workflow from initial diagnostics, to treatment planning, to ordering surgical guides and final implant placement.
The advantages of 2D & 3D in one comprehensive unit
General Practitioners will achieve greater diagnostic accuracy for routine cases.
ORTHOPHOS XG 3D
ORTHOPHOS XG 3D is a hybrid system that provides clinical workflow advantages, along with the lowest possible effective dose for the patient. Its 3D function provides diagnostic accuracy when you need it most: for implants, surgical procedures and volumetric imaging of the jaws, sinuses and other dental anatomy. For standard 2D images, it offers the most comprehensive selection of pan and ceph programs to meet virtually all needs, from standard panoramic programs for adults and children, to extraoral bitewing, sinus, TMJ options and many more.
Automatic patient positioning The new Auto-Positioner measures the exact tilt of the patientâ&#x20AC;&#x2122;s occlusal plane and automatically adjusts the height for an optimal panoramic image within the sharp layer, thereby preventing incorrect positioning and reducing re-takes.
For more information, visit www.Sirona3D.com or call Sirona at: 800.659.5977
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