Orthodontic Practice US May/June 2019 Vol 10 No 3 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews May/June 2019 – Vol 10 No 3 • orthopracticeus.com

PROMOTING EXCELLENCE IN ORTHODONTICS Treating mixed dentition cases with clear aligner therapy and low pulsatile forces

A concept and approach for correcting posterior crossbites Dr. Suhail A. Khouri

Alveolar-focused orthodontics Dr. Jeffrey Miller

Taking control of aligner planning Dr. Tim Dumore

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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 Bradford N. Edgren, DDS, MS, FACD 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 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

rthodontic Practice US is the one orthodontic publication that I thoroughly enjoy reading from cover to cover. It continues to be a most valuable asset for our practice because of its practicality and innovation. We have tried, in a small way, to keep up the Orthodontic Practice US tradition of innovation by way of manuscripts that have covered some of the most pressing current orthodontic unknowns, in our opinion. We started with the historical difficulty of reliable transverse diagnosis;1 then on to improved transverse diagnosis;2,3 proposed a new approach to help resolve anterior open bite (AOB);4 proposed a new approach to help resolve impacted canines without surgery;5 and suggested an approach for improving the chances for new research discovery.6 Two themes run through these manuscripts: 1) treat the etiology to help resolve the malocclusion and 2) treat early enough with a new innovative Phase I regimen. We agree with the late great Dr. Allan G. Brodie: “It should be apparent by this time that my own answer to the question of when a malocclusion should be treated would be the same as for almost any other abnormal condition or disease, namely, when it is first seen.”7 Thirty-five years ago during the first week of my orthodontic residency, it was disheartening to see a pie chart in our assigned text that revealed that only 5% of malocclusions were of known cause; 60% were of unknown cause; 35% of the public had no malocclusion. If one were to believe the chart, orthodontists were treating most cases without knowing the cause of that which they were treating. That moment started our lifelong investigation into the etiologies of malocclusion. New orthodontic inventions can be important; however, new inventions likely do not address etiology — the root cause of a condition. The hope is that a better understanding of the etiology of malocclusion will yield better final treatment results, results that will be easier to attain and longer lasting; patients deserve no less: “The ideal treatment approach for any disease is identifying the etiology, understanding the pathophysiology, and removing the etiology.”8 By the late 1980s, we had proposed a new etiology theory along with a new Phase I regimen. A 10-year study of “early Phase I only — no braces care” followed a successful pilot study. In the past 30 years, we have treated thousands of Phase I patients successfully by attempting to address the etiology of their malocclusions. We have found that some patients have not needed Phase II care; however, most patients do require some Phase II care; case complexity is remarkably improved; formerly impacted canines become de-impacted; anterior open bites are usually resolved by the time for braces; CL II cases usually resolve — without relapse by time for braces. Post-orthodontic relapse is essentially a non-issue (for example, formerly CL II patients corrected to CL I remain CL I (we use only removable retainers). Our referenced manuscripts suggest how to treat the etiology of malocclusion in any practice by following a new Phase I treatment plan regimen. The measured skeletal deformity that contributes to the etiology of malocclusion can be determined and corrected.1-5 There is more good news: Treating the etiology of many malocclusions also helps some medical maladies that have an airway component. Two birds with one stone. Dr. John L. Hayes

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-inchief 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

© FMC 2019. All rights reserved. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Orthodontic Practice US or the publisher.

REFERENCES 1. Hayes JL. In search of improved skeletal transverse diagnosis. Part I: traditional measurement techniques. Orthodontic Practice US. 2010;1(3):34-39. 2. Hayes JL. In search of improved skeletal transverse diagnosis. Part II: a new measurement technique used on 114 consecutive untreated patients. Orthodontic Practice US. 2010;1(4): 34-39. 3. Hayes JL. Proposed clinical skeletal transverse measurement technique –palpation adjacent to the molars. Orthodontic Practice US. 2011;2(2): 28-29. 4. Hayes JL. A new regimen of Phase I care applied to anterior open bite—10 case studies: an etiology proposed by the strategy of triangulation. Orthodontic Practice US. 2012;3(3): 118-26. 5. Hayes JL. A new regimen of Phase I care applied to potential canine impactions. Orthodontic Practice US. 2013;4(3): 44-51. 6. Hayes JL. In search of the etiology of malocclusions—a common discovery technique is proposed. Orthodontic Practice US. 2018;9(5):60-64. 7. Brodie AG. The Fourth Dimension in Orthodontics. Angle Orthod. 1954;24(1):15-30. 8. Kim KB. How has our interest in the airway changed in the last 100 years. Am J Orthod Dentofacial Orthop. 2015;148: 740-747.

John L. Hayes, DMD, MBA, received his dental degree from the Boston University, H.M. Goldman School of Graduate Dentistry and his orthodontic certificate from the University of Pennsylvania, School of Dental Medicine, Orthodontic Department where he is a Clinical Associate. He continues to research and lecture on the advantages of early interceptive treatment and on the etiology of malocclusions. Dr. Hayes is in private practice in Williamsport, Pennsylvania, with his wife, Sharon, who is also an orthodontist. He can be reached at jhayesortho@comcast.net.

ISSN number 2372-8396

Volume 10 Number 3

Orthodontic practice 1

INTRODUCTION

In search of …

TABLE OF CONTENTS

Orthodontic concepts Alveolar-focused orthodontics

Dr. Jeffrey Miller discusses the importance of considering the position of the roots within the alveolar housing

Publisherâ&#x20AC;&#x2122;s perspective Taking a stand for success .........................................................6

Research Thermoplastic aligners with dimples and relief areas for minor tooth movements Drs. Tara M. Kraisinger, Daniel J. Rinchuse, Thomas Zullo, and Jennifer L. Giltner discuss a predictable and cost-effective way to prevent relapse ....................................................... 18

Controlling incisor position to optimize horizontal chin expression in Class II subjects treated with the MARA (Mandibular Anterior Repositioning Appliance)

Technique 14 Next-generation treatment planning Dr. Adam Schulhof discusses how combination treatment plans can yield greater efficacy for patients

Drs. James E. Eckhart and Thikriat AlJewair study the relationship between incisor movements and horizontal versus vertical expression of the mandibular growth...........................24

ON THE COVER Inset cover photos courtesy of Dr. Jeffrey Miller. Article begins on page 8.

2 Orthodontic practice

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TABLE OF CONTENTS

Continuing education A concept and approach for correcting posterior crossbites Dr. Suhail A. Khouri discusses a technique that facilitates the correction of crossbites and Class III malocclusions...................................36

Continuing education

Treating mixed dentition cases with clear aligner therapy and low pulsatile forces

Drs. Jasmine Gorton and Sona Bekmezian discuss a viable treatment option for mixed dentition cases

Practice development Technology Taking control of aligner planning Dr. Tim Dumore outlines the steps for an easy and efficient aligner workflow ....................................................... 44

Five ways to differentiate your orthodontic practice Rich Carnahan discusses ideas to set a practice apart from the competition... 50

Product profiles

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www.orthopracticeus.com READ the latest industry news and business WATCH DocTalk Dental video interviews with KOLs LEARN through live and archived webinars RECEIVE news and event updates in your inbox by registering for our eNewsletter

CONNECT with us on social media Connect. Be Seen. Grow. Succeed. | www.medmarkmedia.com

4 Orthodontic practice

Volume 10 Number 3

PUBLISHER’S PERSPECTIVE

Taking a stand for success

t a recent seminar on growing business practices, one particularly meaningful session started with the speaker asking people to stand if their business has lasted 1 to 5 years. After that group sat down, next, the 5- to 10-year group was asked to rise. When recognizing people in the 10- to 15-year category, I looked around to see very few in that category standing in this large room. I was surprised and humbled, and also very proud that after 1½ decades, I was still standing — both literally and figuratively. With the ever-changing business climate we are currently living in, it is often difficult to keep track of all of the details needed to keep your business in the public eye while staying laser-focused on expansion and growth. While general dentists Lisa Moler and specialists alike need to concentrate on all of the techFounder/Publisher, MedMark Media nology and techniques that lead to better patient care, you also must remember, and already may be painfully aware of, the vital importance of understanding how to keep your business side booming. From social media to networking with colleagues, to methods for hiring and retaining employees who will have your back and your practice’s best interests in their minds, both entrepreneurs and dentists have to find a work-life balance between our personal and business lives. In our upcoming issues, my column will offer tips on how to be a successful entrepreneur while being a caring business owner and running a profitable business! As a woman entrepreneur, I understand the frustrations and triumphs of tackling the world of business with all of its complexities and the competition of others who are also chasing success. It’s a massively competitive world we are living in! As always, this issue’s articles discuss topics to help your orthodontic practice expand both clinically and professionally. Rich Carnahan outlines five ways to differentiate your practice and make it more memorable to patients — he notes that you shouldn’t be afraid to be creative as long as the marketing makes sense for your individual style and practice. Dr. Suhail A. Khouri discusses a technique for correction of crossbites and Class III malocclusions. Through his personal experience and case reports, this article shows his diagnostic rationale for his V-bend technique. Also, Drs. James E. Eckhart and Thikriat Al-Jewair discuss a mandibular anterior repositioning device to explore the relationship between incisor movements and horizontal versus vertical expression of the mandibular growth. These two articles demonstrate the authors’ inventiveness and eagerness to be a part of solutions for common orthodontic challenges. Regarding the subject of clear aligners, Drs. Jasmine Gorton and Sona Bekmezian discuss treating mixed dentition patients with clear aligner therapy and low pulsatile forces, while doctors from Seton Hill University Advanced Education Program in Orthodontics and Dentofacial Orthopedics offer their study on thermoplastic aligners for maintaining orthodontic alignment and preventing relapse. In his Orthodontic Concepts article, Dr. Jeffrey Miller addresses the importance of considering root position within the alveolar housing using “the game-changing power” of 3D CBCT technology. We hope that through articles such as these, we shine a light on varying methods and solutions for treatment of orthodontic patients. Through my future columns, I hope to connect with you not just as dental specialists, but business people and entrepreneurs. At Orthodontic Practice US, we care about your stress AND success, and the often challenging and even painful journey to achieving your goals. After 15 years, I’m still standing — proud of the hard work that it took to get here, proud of my amazing, unwavering team that constantly has my back, and looking forward to all of the exhilaration of embracing and conquering business speed bumps and hurdles, while still learning with every step. I’m still standing. My goal is for you all to stand with me in the coming years, with our fierce entrepreneurial spirits — tackling life, propelling us upward, and pushing us forward to unlimited success in both your business and personal aspirations! To your best success! Lisa Moler Founder/Publisher MedMark Media 6 Orthodontic practice

Published by

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Volume 10 Number 3

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ORTHODONTIC CONCEPTS

Alveolar-focused orthodontics Dr. Jeffrey Miller discusses the importance of considering the position of the roots within the alveolar housing

fter 34 years of orthodontic practice, I have seen and participated in my share of “fads.” I remember getting so excited about using functional appliances only to later find out the mechanism of correction was not due to increased skeletal growth. In today’s highly competitive orthodontic arena and with the pressure to stay current on new and evolving technologies, orthodontic specialists often feel obligated to implement new trends into their practices before they are fully comfortable, resulting in decreased focus on areas that could be very helpful to patients’ treatment. For example, long-term case stability is not even a part of the conversation among some orthodontic Facebook groups. I still believe that orthodontists provide a service that requires specialty training. However, for some types of patients, the rationale for keeping orthodontic treatment in the specialty arena has been vague at best. Consider a Class I patient with 3 mm-4 mm of dental crowding in each arch. Can you explain what an orthodontist is going to do differently than the “Do It Yourself Aligner Shop” around the corner for this case? Unfortunately, orthodontics for some has been reduced to the alignment of only the clinical crowns, forgetting about the roots, supporting bone, and long-term stability. One of the major differentiators is how the roots are positioned within the supporting bone. A successful orthodontic result must consider the position of the roots within the alveolar housing. Figure 1 shows lower incisors from two different patients with similar malocclusions. Alveolar Focused Orthodontics (AFO) asks the following question: “Should the anatomy of the alveolar housing be a consideration in Jeffrey C. Miller, DDS, received a Bachelor of Science degree in Biology from Towson State University, and his dental degree from University of Maryland Dental School. He has a Certificate in Orthodontics from the State University of New York at SUNY Buffalo and is a Diplomate of the American Board of Orthodontics. He has been in private practice since 1984 and currently practices in the Baltimore, Maryland area. Please email Dr. Miller if you are interested in joining the Alveolar-Focused Orthodontic Facebook group, drmiller@orthodonticassoc.com. Disclosure: Dr. Miller has been a speaker in conjunction with 3M Unitek and Carestream.

8 Orthodontic practice

Figure 1: Lower incisors from two different patients with similar malocclusions. (Image captured on Carestream 9300)

our orthodontic treatment strategy?” Obviously, the patient on the left has a significantly more robust alveolar housing than the patient on the right. If you consider the alveolar housing anatomy, and believe the best position for the root should be centered within the housing, then you would conclude that the patient on the right would require more precise tooth movement because of the limited housing. So, how do we get this information? Answer: CBCT. Without CBCT, it would be impossible to determine the limitations of orthodontic tooth movement. It is also becoming clearer via CBCT post-active orthodontic treatment studies that the alveolar housing does not modify significantly regardless of the bracket/ wire system used. Although there is some controversy regarding the accuracy of CBCT in its ability to measure very thin bone, the quality of these images has increased over the past several years, making root dehiscence images more reliable. I believe that it is the ability to view individual teeth and their supporting bone that will move orthodontics away from the “clinical crown jockeys” and back to a specialty discipline of dentistry. In a 2016 article by Drs. Hoang, Nelson, Hatcher, and Oberoi titled, “Evaluation of mandibular anterior alveolus in different skeletal patterns,”1 the authors found that highangle patients seem to have the thinnest buccal lingual alveolar housing width, therefore limiting the amount of orthodontic expansion or constriction. Notice how the lower incisor has been pushed out of the alveolar housing after orthodontic treatment in Figure 2. In the following case examples, I hope to explain why it is “mission critical” to consider

Figure 2: Notice how the lower incisor has been pushed out of the alveolar housing after orthodontic treatment

Figure 3: Consider the anatomy of alveolar housing in the orthodontic treatment of a19-year-old female patient with several conditions

Figure 4: Based on a cephalometric analysis, an orthodontist would likely suggest one of four treatment approaches. (Image captured on Carestream 9300)

the anatomy of the alveolar housing when providing orthodontic treatment. Let’s take a look at this 19-year-old female patient (Figure 3) with the following conditions: • Poor lip competency • Hyperdivergent skeletal pattern • Skeletal open bite • Slightly gummy smile • Class I dental relationship • Class II skeletal relationship • Retrognathic mandible • Bimaxillary Protrusion Volume 10 Number 3

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acceledent.com © 2019 OrthoAccel Technologies, Inc. 1 Based on doctor testimonials on file. 2 Based on company-sponsored, randomized-controlled, blinded clinical trials. One study results showed the AcceleDent group was significantly faster than the sham control group in moving teeth in the ITT and PP groups by 50% (p=0.0496) and 38% (p=0.0234), respectively. Gakunga, P., Anthony, R. OA-02 Effect of Cyclic Loading (Vibration) on Orthodontic Tooth Movement. 2011. Unpublished study used for FDA clearance. Another study ITT analysis showed an average monthly rate of tooth movement in the AcceleDent group was 1.16 mm/month (95% CI: 0.86-1.46; 48.1 ± 7.1% faster) compared to 0.79 mm/month (95% CI: 0.49-1.09) in the control group, with a mean difference of 0.37 mm/month (95% CI: 0.07-0.81, P = 0.05), while the PP analysis showed significantly faster movement of the retracting cuspids when vibration was applied (P = 0.02). Typodonts with mounted mini screws and bonded brackets were used during this study for measuring error relating to tooth movement. Pavlin, D., Anthony, R., Raj, V., Gakunga, P.T. Cyclic loading (vibration) accelerates tooth movement in orthodontic patients: a double-blind, randomized controlled trial. Semin Orthod. 2015;21:187–194. 3 Accelerated tooth movement does not necessarily correlate to shorter duration of treatment. Individual results may vary. 4 Based on a randomized, controlled and parallel group clinical trial conducted during a four-month period. Because of possible unwanted treatment effects of bite wafers on pain reporting, the authors chose not to use a sham device that may have a bite wafer effect. Therefore, this study cannot dismiss the possibility that a placebo effect from AcceleDent may have influenced the results. Lobre, W.D., Callegari, B.J., Gardner, G., Marh, C.M., Bush, A.C., and Dunn, W.J. Pain Control in Orthodontics Using a Micropulse Vibration Device: A Randomized Clinical Trial. The Angle Orthodontist, 2015.

ORTHODONTIC CONCEPTS

Figure 5: The same 19-year-old female patient with a clearer view of the central incisors and the supporting alveolar housing. (Image captured on Carestream 9300)

Figure 7: CBCT images of this same patient tell a different story regarding the complexity of orthodontically repositioning this patient’s lower incisor. (Image captured on i-CAT™ FLX)

• Slight tongue thrust • Slight crowding in both arches Based on a cephalometric analysis (Figure 4), an orthodontist would likely suggest one of the following treatment approaches: 1. Extract lower first bicuspids, interproximal reduction of upper anterior teeth, and orthognathic surgery 2. Extract all first bicuspids, intrude the molars (in an effort to close bite) 3. Non-extraction treatment with interproximal reduction of both upper and lower anterior teeth, molar intrusion 4. Non-extraction with upper and lower interproximal reduction and orthognathic surgery Of course, no treatment also is always an option. I would suggest that, based on a cephalometric analysis, the ideal treatment approach would be treatment number 1 followed by 2. However, if you were to consider the size and shape of the alveolar housing via CBCT, the treatment decision could change. Figure 5 shows this same patient with a clearer view of the central incisors and the supporting alveolar housing. Notice the extremely thin alveolar housing associated with the lower central incisors. Extraction and retraction may not be in this 10 Orthodontic practice

Figure 6: Demonstration of what appears to be a straightforward retreatment case

Figure 7A: Two different patients, both showing the lower incisor dehisced through the buccal cortical plate

Figure 8: An adult female patient with a Class I dental occlusion and a Class II skeletal relationship

Figure 7B: This patient before and after root recapture (Incognito™ lingual appliance, 3M). (Image captured on i-CAT FLX)

patient’s best interest since dehiscence would likely result. Therefore, based on the CBCT review, plan number 4 followed by 3 maybe a better treatment approach. Keep in mind that it is nearly impossible to assess the alveolar housing anatomy with traditional two-dimesional images (panoramic and cephalometric radiographs). Orthodontic retreatments offer additional challenges due to “more” limiting size of the alveolar housings and the more advanced age of this patient population. Figure 6 demonstrates what appears to be a straightforward retreatment case. CBCT images (Figure 7) of this same patient tell a different story regarding the complexity of orthodontically repositioning this patient’s lower incisor. Figure 7A shows two different patients, both showing the lower incisor dehisced through the buccal cortical plate. The patient on the left still has a fairly robust alveolar housing, which could reaccept the lower

Figure 9: The lower right central incisor (0.02 mm sagittal slice). Note: The minimal width of the alveolar housing, and the procumbence of both the lower incisor and the alveolar housing that supports it. (Image captured on i-CAT FLX)

incisor root. Figure 7B shows this patient before and after root recapture (Incognito™ lingual appliance, 3M). The patient on the right (Figure 7A) is not as fortunate; the alveolar housing has resorbed, making root recapture very difficult without surgical intervention to augment the alveolar width. I find it helpful to simulate multiple treatment options to determine which plan results in the best tooth/root/alveolus relationship. For example, Figure 8 shows an adult female Volume 10 Number 3

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ORTHODONTIC CONCEPTS patient with a Class I dental occlusion and a Class II skeletal relationship. Obviously, there are dental compensations of the lower incisors to accommodate the Class II skeletal pattern (lower incisors flared, pre-orthodontic treatment). Figure 9 shows the lower right central incisor (0.02 mm sagittal slice). Notice two things: 1. The minimal width of the alveolar housing 2. The procumbence of both the lower incisor and the alveolar housing that supports it Achieving average clinical crown torque for these lower incisors would dictate uprighting of the roots (Figure 10). This “average” clinical crown torque would not comport with the underlying bone anatomy, therefore possibly orthodontically dehiscing the incisor roots through the cortical plate as seen in the SureSmile® treatment simulation in Figure 11. Using SureSmile software, different treatment approaches can be simulated. This simulation is based on the pretreatment CBCT (Figure 12). SureSmile creates a three-dimensional reconstruction that can be manipulated to simulate different treatment approaches. Figure 13 shows the simulation with a lower incisor extraction and upper interproximal reduction (cuspid to cuspid). Although the bone modeling is accurate within 0.20 mm, it shows the cortical plates as “static boundaries.” Because the changes to the shape and size of the alveolar housing are minimal when considering orthodontic tooth movement, the simulations should not be taken as the holy grail but rather as a general indicator for the root/alveolar housing relationship. Figure 14 shows two different treatment simulations for the same patient and the resulting effects to the lower incisor root/ alveolar housing relationship. I believe a better treatment approach would be to attempt to keep the lower incisor roots in a position that maintains the root “reasonably” within the alveolar housing.

Figure 11: This “average” clinical crown torque would not comport with the underlying bone anatomy, therefore possibly orthodontically dehiscing the incisor roots through the cortical plate as seen in the SureSmile treatment simulation Figure 10: Achieving average clinical crown torque for these lower incisors would dictate uprighting of the roots. (Image captured on i-CAT FLX)

Figure 13: The SureSmile treatment simulation with a lower incisor extraction and upper interproximal reduction (cuspid to cuspid)

Figure 12: Using SureSmile software, different treatment approaches can be simulated. This simulation is based on the pretreatment CBCT. (Image captured on i-CAT FLX)

Figure 14: Two different treatment simulations for the same patient and the resulting effects to the lower incisor root/ alveolar housing relationship

Figure 16: The pretreatment and 12-month post active orthodontic treatment sagittal slice (0.20 mm) of the lower central incisor. Note: The resulting clinical crown torque is in alignment with the alveolar housing. (Image captured on i-CAT FLX) 12 Orthodontic practice

Figure 15: Twelve-month post-active orthodontic treatment photos of this patient

Figure 17: Comparision of the SureSmile treatment simulation with the actual posttreatment CBCT 3D reconstruction Volume 10 Number 3

Figure 15 shows 12-month post-active orthodontic treatment photos of this patient. Figure 16 shows the pretreatment and 12-month post-active orthodontic treatment sagittal slice (0.20 mm) of the lower central incisor. Notice that the resulting clinical crown torque is in alignment with the alveolar housing. Figure 17 compares the SureSmile treatment simulation with the actual post treatment CBCT 3D reconstruction. Figure 18 compares two different postactive orthodontic treatment axial view slices (0.20 mm) contrasting Patient A (above case example) and Patient B’s post-active orthodontic axial views of the lower incisors. Notice that Patient A’s roots are properly within the alveolar housing where Patient B’s roots were orthodontically dehisced through the facial cortical plate (CBCT taken 3 years post-active orthodontic treatment). I do not pretend to have all the answers. We are largely still figuring out the significance of these images. For example, Figure 19 shows a rotated lower right central incisor. Proper alignment would create increased dehiscence on both the buccal and lingual since the alveolar housing is not wide enough to accept the properly aligned root. Is this an indication for preorthodontic alveolar augmentation? Do we take a chance and hope the dehiscence

Figure 19: A rotated lower right central incisor. (Image captured on PreXion)

A successful orthodontic result must consider the position of the roots within the alveolar housing. will not manifest in a gingival problem? I am optimistic that our esteemed profession will have the answers to these questions in the next decade. In a 1972 study, “The Six Keys to Normal Occlusion,”2 Dr. Lawrence F. Andrews described the position of the teeth in patients with no history of orthodontic treatment and reasonably good alignment and occlusion. In other words, he described where Mother Nature places the teeth for folks who are fortunate enough not to need our services. As far as I know, there has never been a reasonable scientific contradiction to this 47-year-old study. Yet think about how many claims are made suggesting that there is a new and improved position for the clinical crowns that provides superior orthodontic results without a single shred of scientific support. It reminds me of the kid on the playground who likes to make up the rules as the game is played. In conclusion, I believe, as orthodontic specialists, we need to become more mindful

of the underlying bone anatomy. Unfortunately, the underlying bone anatomy cannot be properly visualized using panoramic and cephalometric radiographs. Cone beam computed tomography allows for the alveolar housing to play a more “appropriate” role in our orthodontic diagnosis and treatment planning. Our specialty is at a pivotal point; we can continue with the non-evidencebased fads that are so recklessly promoted, or we can recognize the game-changing power of CBCT. In this author’s humble opinion, CBCT is no longer an option; it is an obligation.

Acknowledgment Dr. Miller extends his gratitude to Dr. Kelly Wray for her assistance in editing this article. OP

REFERENCES 1. Hoang N, Nelson G, Hatcher D, Oberoi S. Evaluation of mandibular anterior alveolus in different skeletal patterns. Prog Orthod. 2016;17(1):22. 2. Andrews LF. The six keys to normal occlusion. Am J Orthod. 1972;62(3):296-309.

Stay Connected Between Issues Like us on Facebook at facebook.com/OrthodonticPracticeUS Watch our DocTalk Dental videos at doctalkdental.com Check out our Webinars at orthopracticeus.com/webinars Connect. Be Seen. Grow. Succeed. www.medmarkmedia.com Volume 10 Number 3

Orthodontic practice 13

ORTHODONTIC CONCEPTS

Figure 18: Comparision of two different post-active orthodontic treatment axial view slices — Patient A and Patient B. (Image captured on i-CAT FLX/i-CAT Next Generation)

TECHNIQUE

Next-generation treatment planning Dr. Adam Schulhof discusses how combination treatment plans can yield greater efficacy for patients

uring their education, orthodontic students are often taught to approach their work using a specific method or philosophy. Orthodontists tend to remain on that track throughout the entirety of their career without crossing over or combining methods. A newer way of thinking about esthetic orthodontics by creating hybrid treatment plans has potential to impact practices and the effectiveness of treatment for patients. Combining two or more philosophies can prove to be much more successful for patients. At Columbia University College of Dental Medicine, we weren’t taught one way over the other, so I was able to learn how to use different methods for the individual and mixing when necessary. From a biomechanical perspective, hybrid orthodontic treatments allow us to utilize the right tool at the right time. But we are also business owners and have to satisfy our patients with the treatment method that suits them without sacrificing efficiency and effectiveness.

Identifying suitable cases Knowing when to utilize a hybrid treatment starts by opening a discussion with

patients. I have my patients rate factors such as cost, time, looks, comfort, and lifestyle based on which is most important. As the orthodontist, I rate the appliance options. I conduct treatment planning from a different angle without separating brackets, lingual, or aligners into silos. From this perspective, I can approach appliances like menu options, mixing and matching in a way that will meet the terms the patient cares about most, and what I, as the clinician, consider will be most effective. A recent combination case I treated was for a patient who had lifestyle and appearance concerns. This particular patient is a teenager and an actress who had an impacted canine, but there was never perfect timing to get her treatment going because of her demanding work schedule. We determined the best method for her by thinking of the appliances chronologically, starting with lingual on top to correct the canine and aligners fitted on the bottom. Once the canine was brought in, we finished with aligners on the top as well. Embracing the advantages of different appliances and using them in conjunction ensured not only great results, but also met the needs of her lifestyle and timing.

Achieving predictable results Predictable outcomes are all about communication. Patient compliance is one of the big concerns with aligner therapy since they are not stuck to the tooth like fixed appliances. Of course, compliance issues exist with elastic bands and brushing, but compliance is a bigger challenge with aligners. A lot of practices downplay the compliance because they don’t have the backup lingual option for esthetics. When a practice has limited tools that is what they are going to sell. When you have every tool, you can be a better orthodontist and guide the patient to make a more educated decision. Some patients dislike the idea of attachments, so practices skip attachments altogether. Unfortunately, forgoing aligner attachments can result in extended treatment and less predictable results. In my practice, if the patient is turned off by having attachments, then we do lingual. We can’t bend to a patient’s will to the point where I compromise treatment. Recently, I treated a patient that came to me after seeking treatment from other orthodontists. She wanted clear aligners but was told that her crowded bottom teeth

Orthodontist Adam Schulhof, DMD, graduated with high honors from the University of Medicine and Dentistry of New Jersey and received his specialty training from Columbia University. His early interest in lingual orthodontics has led to him becoming the top provider for Incognito™ in the United States and the world. Dr. Schulhof has presented lectures on lingual orthodontics throughout the world. He’s currently developing a lingual orthodontic curriculum for Columbia University residents and is in practice at The Schulhof Center in New York and New Jersey. Disclosure: Dr. Schulhof was part of the LingualCare Clinical Advisory Board and is now a key opinion leader for 3M™ and Incognito™.

Figure 1: Initial photographs — actress on prime-time television with impacted canine on top 14 Orthodontic practice

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TECHNIQUE eliminated her as a candidate for aligners, and that her treatment would take 2 years. Our solution was to use clear brackets on the bottom teeth with clear aligners on top. This method was efficient from the get-go and didn’t stretch out the timeline

of treatment. It was a successful case of giving the patient the esthetic look and appliances she desired, while utilizing a method I knew would work and have the outcome I wanted to achieve. No one had given her that option before, and I was

Figure 2: Progress photographs — impacted canine on top treated with Incognito™ system while lower treated with aligners

thrilled to be able to find the combination that worked for her.

Practical impacts Previously, a large drawback to prescribing a hybrid treatment was the cost. A combo case that only needed upper aligners would incur a fee for the full set, and those costs were often a barrier for patients. I use 3M™ Clarity™ Aligners because they have a much different model — you only pay for what you use. This is where the clinical part meets the small business aspect of what we do. With Clarity Aligners, I have lower overhead for the case and don’t pass along inflated fees to the patient. It’s easy to have tunnel vision for the kind of treatment we are used to and thus categorize patients. Conducting combo treatments is a new way of thinking, but it’s fitting in the new world of orthodontics we have entered. Modern procedures are not bound by brackets on the front of teeth — there are lingual, clear aligners, clear brackets, and more. Exploring the possibility of using each appliance for its strengths simultaneously can delivery greater efficacy for your patients’ treatment, as well as setting your practice apart. Ultimately, any way you can differentiate your business and better serve patients is a great combo. OP

Figure 3: Final photographs — canine in position, all accomplished completely invisibly with Incognito and Clarity Aligners 16 Orthodontic practice

Volume 10 Number 3

RESEARCH

Thermoplastic aligners with dimples and relief areas for minor tooth movements Drs. Tara M. Kraisinger, Daniel J. Rinchuse, Thomas Zullo, and Jennifer L. Giltner discuss a predictable and cost-effective way to prevent relapse

etention, the final phase of orthodontic treatment, aims to control corrected tooth positions. Maintaining orthodontic alignment and preventing relapse is one of the most challenging aspects of orthodontics. The misconception that well-aligned teeth will remain straight for a lifetime is a misunderstood professional and public perception.1 Little and colleagues found the results of orthodontic treatment are more likely to be unstable rather than stable, and the only way to ensure satisfactory alignment is lifetime retention.1 The limited scientific evidence on retention protocol is conflicting. The most predictable and cost-effective way to prevent relapse is lifetime retainer wear which requires patient compliance.2,3 Patient compliance has been shown to decrease as treatment progresses and after it is complete, which can therefore negatively affect compliance with retention protocols causing relapse.4 In addition to poor compliance with retainer wear, there are many other factors responsible for relapse. Due to tension in the periodontal fibers, teeth have a tendency to return toward their initial positions.5 However, changes in skeletal and soft tissue as growth continues throughout life may have a more profound impact on the probability of relapse.6 Arch length and width from canine to canine decreases over time, which also affects the long-term stability of the mandibular incisors.7

Tara M. Kraisinger, DDS, is a Resident at Seton Hill University Advanced Education Program in Orthodontics and Dentofacial Orthopedics. Daniel J. Rinchuse, DMD, MS, MDS, PhD, is a Professor and Program Director at Seton Hill University Advanced Education Program in Orthodontics and Dentofacial Orthopedics. Thomas Zullo, PHD, is an Adjunct Professor in Biostatistics — Seton Hill University Advanced Education Program in Orthodontics and Dentofacial Orthopedics. Jennifer L. Giltner, DMD, is a Resident at Seton Hill University Advanced Education Program in Orthodontics and Dentofacial Orthopedics.

18 Orthodontic practice

Figure 1: Application of the Triad Gel on the tooth surface to create space for tooth movement lingually and placement of the dimple on the active side. The dimple was marked with black to assist with visualization of the dimple

Over 30 years ago, Sheridan and colleagues8 described a technique for using Essix thermoplastic aligners with divots and windows for minor tooth movement. The windows were created for a relief area for the teeth to move into, whereas the divots created the pressure to move teeth. However, since the divot is placed after the aligner is vacuum-formed, it thins the material out so that it collapses and is no longer effective. If a Type “A” material is used, Triad® Gel (Dentsply International Inc.) can be used to reinforce the divot. However, this also makes the divot more rigid and less desirable for tooth movement. Here is described and demonstrated an alternative method, dimple and relief system (DRS), for minor tooth movement that can be done in the office, which is applicable for minor tooth movement for initial orthodontic treatment or to correct some relapse problems after orthodontic treatment. The null hypothesis was that thermoplastic aligners with dimples and relief system (DRS) do not significantly improve tooth alignment as measured by the Little Irregularity Index4 from time 1 (T1) to time 2 (T2), 4 weeks later.

Methodology After IRB approval from Seton Hill University, 19 patients consecutively treated on retention recall with minor mandibular anterior relapse who met the inclusion criteria were asked to participate in the study by the

principle investigator (TK). The subjects were recruited at Seton Hill Center for Orthodontics and from an affiliate faculty members’ private practice. The patients consisted of males and females between the ages of 15-40 with minor relapse of a permanent lower incisor. All patients must have undergone previous comprehensive treatment with fixed appliances. Exclusion criteria were patients taking bisphosphonates, estrogens, chronic use of NSAIDs, and other analgesics since agents like these have a pharmacologic effect on tooth movement.9.10.11 A mandibular impression was taken to obtain a working model at T1. Little Irregularity (II) Index4 was used to measure the summed displacement of adjacent anatomic contact points of six mandibular teeth to the hundredth of a millimeter on the stone model from lower canine to canine using D-type IP67 waterproof digital calipers obtained from Moore & Wright Europe as a quantification of relapse. The Little Irregularity Index was recorded for T1 by a blinded second investigator (JG). Miles, et al., used the (II) and demonstrated the reliability of this method.12,13 On the model, a relief area for tooth correction to move into was created with Triad Gel, which has a desired viscosity so that a smooth finish can be achieved with little to no modification with a bur (Figure 1). The application of the Triad Gel to the model was done with a microbrush. Next, dimples were made in the model on the pressure Volume 10 Number 3

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RESEARCH side with a No. 4 Brasseler round bur on a straight handpiece (Figure 1). The location of the dimple depended on the type of movement needed. If the relapsed tooth required only labial or lingual movement, the dimple was placed in the center of the active side (Figure 1). However, if the tooth needed both mesial rotation and labial/lingual movement, the dimple was placed more toward the mesial on the active side. Finally, the aligner was vacuum-formed with Essix® Plus™ Plastic (0.040ʺ/1 mm thickness, Dentsply Raintree Essix) thermoplastic material using a Drufomat (Dentsply Sirona). Essix Plus is a Type “C” material, which is more flexible and more rubbery than the more rigid and less flexible Type “A” material. Details regarding the composition and properties of the various thermoplastic materials have been described previously by Rinchuse, et al.,15,16 Pendleton, et al.,17 Karam and Rinchuse,18 and Rinchuse, et al.19,20 Interproximal reduction was done as needed using a lightning strip, obtained from Benco Dental, until contact between the teeth was completely broken and dental floss was passive. This created adequate space for tooth movement. Subjects were instructed to wear the aligner at least 20-22 hours per day for 4 weeks, only removing to eat and brush. Subjects were asked to keep a daily journal to track the number of hours the aligner was worn since compliance is the single most important factor contributing to the amount of tooth movement achieved.21 After 4 weeks, a second mandibular impression was taken at T2. The Little Irregularity Index was recorded for T2 by a blinded second investigator (JG) using the same method as previously described for T1. As described by Little, measurements were obtained directly from a mandibular cast rather than intraorally, since consistent accuracy of measurements are dependent upon proper positioning of the caliper.4 This also assisted in proper blinding of (JG). Using dental casts rather than digitized models also reduced bias when measuring (II).22 PICO P – Orthodontic patients that experienced minor mandibular anterior relapse I – Dimple and relief aligner C – Comparison of pretreatment (T1) and (T2) Irregularity Index Outcome – Irregularity Index (measured on the model by a blinded rater)

the Irregularity Index at T1 and T2 was 0.70 mm (0.36, SD) and is statistically significant (t=7.75, p<0.0004) (Table 2). The largest difference between T1 and T2 was 1.34 mm. All subjects’ Irregularity Indexes decreased from T1 to T2 indicating better incisor alignment after treatment with the aligner (Figures 3-5). Through journal logs, patients reported an average of 17-22 hours of aligner wear. Aligner companies recommend 20-22 hours of aligner wear per day for best results.23

Discussion Retention is one of the most challenging aspects in orthodontics.24 Incisor malalignment is a specific concern due to the esthetic

Figure 2: Measurements were obtained to the hundredth of a millimeter on the stone model for T1 and T2 using Little’s Irregularity Index using the protocol described by Miles, et al.13

Table 1: Mean and standard deviation values for Little’s Irregularity Index at T1 and T2

Pair 1

Mean

Std. Deviation

Std. Error Mean

Little’s Index T1

2.6569

1.24778

.31195

Little’s Index T2

1.9600

1.16286

.29072

Table 2: Paired t-test showing the difference between Little’s Irregularity Index at T1 and T2 Paired Difference Mean

Pair 1

.69688

Std. Deviation

Std. Error Mean

.35961

.08990

95% Confidence Interval t of the Difference Lower

Upper

.50525

.88850

7.752

Sig. (2-tailed)

.000

Results The mean Irregularity Index was 2.66 mm (1.25, SD) at T1 and 1.96 mm (1.16, SD) at T2 (Table 1). The difference between 20 Orthodontic practice

Figure 3: T1 (left) and T2 (right). The lower right lateral incisor was moved buccally Volume 10 Number 3

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RESEARCH concerns with this type of relapse.25 Sheridan and colleagues9 showed four case reports describing a technique for minor tooth movements using windows and divots in an Essix aligner. We have modified this technique to placing the dimple in the model prior to fabrication of the aligner. Placing the dimple after the aligner is made thins the material, and the dimple collapses, whereas, placing the dimple in the model before vacuum-forming makes it more robust. If more tooth movement is required, this allows the opportunity to enhance the dimple with a dimple instrument (OrthoPli, #077-ID1, 1 mm dimple instrument) without needing to remake an impression and aligner. This method is particularly useful for minor relapse after orthodontic treatment. Robbins and colleagues26 defined patient centricity as â&#x20AC;&#x153;a dynamic process through which the patient regulates the flow of information to and from him/her via multiple pathways to exercise choices consistent with his/her preference, values, and beliefs.â&#x20AC;? To incorporate patient centricity in clinical trials, endpoints and objectives should be in the interest of the patient community. Simplifying clinical trials makes it easier for patients to comply with research designs. RCT study designs create concerns of complexity, treatment time, and posttreatment follow-up.27 In order to lessen the burden on the patients having to make a visit every 1-2 weeks, the interval was increased to 4 weeks and only one follow-up appointment. In addition to the contact points of the tooth undergoing active movement with the dimple, it was a trend to see a decrease in the Irregularity Index of the remaining contact points lower canine to canine. All subjects had a decrease in (II) indicating improvement in incisor alignment. Since the plastic was not thinned to initially create the dimple, the dimple was able to be enhanced with a dimple instrument. Half of the subjects required enhancement of the dimple. These subjects presented with a higher irregularity index requiring increased tooth movement to correct relapse. Additional tooth movement and correction of relapse was observed after enhancement of the dimple. Per-protocol analysis was used, and three dropouts were eliminated from statistical analysis.28 Mandibular incisors become more crowded and irregular after removal of retainers.29 Therefore, it can be assumed malalignment of subjects left untreated would worsen overtime. It is important to note that subjects qualified for this study through their own non-compliance with retainer wear following 22 Orthodontic practice

Figure 4: T1 (left) and T2 (right). The lower right lateral incisor was moved buccally

With the increasing prevalence of clear aligners, as orthodontists, it is important to be able to offer our patients an alternative clear aligner solution to correct minor relapse of an esthetically sensitive area.

Figure 5: T1 (left) and T2 (right). The central incisors were moved lingually. Aligner required enhancement with divoter to achieve more lingual movement Volume 10 Number 3

Clinical implications and relevance to orthodontic dentistry With the increasing prevalence of clear aligners, as orthodontists, it is important to be able to offer our patients an alternative clear aligner solution to correct minor relapse of an esthetically sensitive area. This method allows the practitioner to correct minor incisor relapse with minimal cost to the patient and doctor. An average of 30 minutes of laboratory time was needed from impression-making to the delivery of the aligner, and an average of 10 minutes of chair time was used. OP

Little RM. The irregularity index: a quantitative score of mandibular anterior alignment. Am J Orthod. 1975;68(5):554-563.

R ichter DD, Nanda RS, Sinha PK, Smith DW, Currier GF. Effect of behavior modification on patient compliance in orthodontics. Angle Orthod. 1998;68(2):123-132.

ohnston CD, Littlewood SJ. Retention in Orthodontics. Br J Dent. J. 2015;218(3):119-122.

elrose C, Millett DT. Toward a perspective on orthM odontic retention? Am J Orthod Dentofacial Orthop. 1998;113(5):507-514.

ittle RM, Riedel RA, Stein A. Mandibular arch length L increase during the mixed dentition: postretention evaluation of stability and relapse. Am J Orthod Dentofacial Orthop. 1990;97(5):393-404. heridan JJ, Ledoux W, McMinn R. Essix appliances: minor S tooth movement with divots and windows. J Clin Orthod. 1994;28(11):659-663.

10. B artzela T, Türp JC, Motschall E, Maltha JC. Medication effects on the rate of orthodontic tooth movement: a systematic literature review. Am J Orthod Dentofacial Orthop. 2009;135(1):16-26. 11. P atel A, Burden DJ, Sandler J. Medical disorders and orthodontics. J Orthod. 2009;36(suppl):1-21. 12. G ameiro GH, Pereira-Neto JS, Magnani MB, Nouer DF. The influence of drugs and systemic factors on orthodontic tooth movement. J Clin Orthod. 2007;41(2):74-78. 13. Miles PG, Weyant RJ, Rustveld L. A clinical trial of Damon 2 vs conventional twin brackets during initial alignment. Angle Orthod. 2006;76(3):480-485. 14. Taner TU, Haydar B, Kavuklu I, Korkmaz A. Short-term effects of fiberotomy on relapse of anterior crowding. Am J Orthod Dentofacial Orthop. 2000;118(6):617-623.

REFERENCES 1.

Vanarsdall RL, White RP Jr. Relapse and retention: professional and public attitudes. Am J Orthod Dentofacial Orthop. 1990;98(2):184.

Parker WS: Retention — retainers may be forever. Am J Orthod Dentofacial Orthop. 1989;95(6):505-513.

Rinchuse DJ, Miles PM, Sheridan JJ. Orthodontic retention and stability. A clinical perspective. J Clin Orthod. 2007;41(3):125-132.

15. Rinchuse DJ, Miles PM, Sheridan JJ. Orthodontic retention and stability: a clinical perspective. J Clin Orthod. 2007;41(3):125-132. 16. Rinchuse DJ, Miles PM, Sheridan JJ: Chapter 12 Orthodontic retention and stability. In: Miles PM, Rinchuse DJ, Rinchuse DJ: Evidence-based clinical orthodontics. Quintessence Publishing: Chicago, 2012. 17. Pendleton R, Rinchuse DJ, Robison JM, Close JM, Marangoni R. Attachment bond strengths of thermoplastic

retainer materials using two acrylic bonding resins. J Clin Orthod. 2008;42(4):215-219. 18. Karam J, Rinchuse DJ. Dental amalgam corrosion in vacuum-formed retainers. Orthodontics (Chic.). 2011;12(1):70-74. 19. Rinchuse DJ, Rinchuse DJ. Active tooth movement with Essix-based appliances. J Clin Orthod. 1997;31(2):109-112. 20. Rinchuse DJ, Rinchuse DJ, Dinsmore C. Elastic traction with Essix-based anchorage. J Clin Orthod. 2002;36(1):46-48. 21. Chisari JR, McGorray SP, Nair M, Wheeler TT. Variables affecting orthodontic tooth movement with clear aligners. Am J Orthod Dentofacial Orthop. 2014;145(suppl 4):S82S91. 22. Russell CM. Reliability and validity of a computer-based Little irregularity index. Am J Orthod Dentofacial Orthop. 2003;124(2):13A-14A. 23. Living with Invisalign® clear aligners. Web site https://www. invisalign.com/how-invisalign-works/living-with-invisalign. Accessed March 12, 2019. 24. Melrose C, Millett DT. Toward a perspective on orthodontic retention? Am J Orthod Dentofacial Orthop. 1998; 113(5): 507-514. 25. Fudalej P, Bollen AM, Hujoel IA. Relapse of mandibular incisor alignment is not associated with the total posttreatment mandibular rotation. Am J Orthod Dentofacial Orthop. 2010;138(4):392.e1-392.e7. 26. Robbins DA, Curro FA, Fox CH. Defining patient-centricity: opportunities, challenges, and implications for clinical care and research. Ther Innov Regul Sci. 2013;47(3):349-355. 27. Mulimani PS: Evidence-based practice and the evidence pyramid: A 21st century orthodontic odyssey. Am J Orthod Dentofacial Orthop. 2017;152(1):1-8. 28. Pandis N. Sources of bias in clinical trials. Am J Orthod Dentofacial Orthop. 2011;140(4):595-596. 29. Myser SA, Campbell PM, Boley J, Buschang PH. Longterm stability: postretention changes of the mandibular anterior teeth. Am J Orthod Dentofacial Orthop. 2013;144(3):420-429. 30. Forde K, Storey M, Littlewood SJ, et al. Bonded versus vacuum-formed retainers: a randomized control trial. Part 1: stability, retainer survival, and patient satisfaction outcomes after 12 months. Eur J Orthod. 2017;40(4):387-398.

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Volume 10 Number 3

Orthodontic practice 23

RESEARCH

comprehensive treatment.5 It has been shown that bonded mandibular retainers are more effective at preventing relapse than vacuum formed retainers.30 Therefore, a bonded retainer should be considered for patients who have a history of non-compliance.

RESEARCH

Controlling incisor position to optimize horizontal chin expression in Class II subjects treated with the MARA (Mandibular Anterior Repositioning Appliance) Drs. James E. Eckhart and Thikriat Al-Jewair study the relationship between incisor movements and horizontal versus vertical expression of the mandibular growth Abstract Objectives To compare the mandibular growth rate of pubertal MARA-treated boys and girls to untreated controls, and to study the relationship between incisor movements and horizontal versus vertical expression of the mandibular growth. Materials and Methods This retrospective study evaluated head films approximately 1-year apart from pubertal MARA-treated deep bite Class II boys and girls. Changes in incisor position and Gnathion were measured for vertical and horizontal components and were compared to similar-age boy and girl controls. The movements of the incisor incisal edges were then combined, and that sum was graphed against the ratio of the Gnathion horizontal or vertical movement vector to the Gnathion overall movement vector. Results The boy MARA patients grew the mandible 5.7 mm in 14.2 months (a treatment effect increase of 1.7 mm over controls), and the girl MARA patients grew the mandible 3.7 mm in 12.5 months (a treatment effect increase of 1.5 mm over controls). There was a strong linear correlation between the total of incisor movements

and the percent Gnathion horizontal or vertical movement in boys (p < 0.05) and girls (p < 0.05). Conclusion MARA boys grew the mandible radially 43% more than controls, and the horizontal expression of that growth was 81% more than for controls. MARA girls grew the mandible radially 64% more than controls, and the horizontal expression of that growth was 82% more than for controls. The sum of growth movements of the incisors is related approximately linearly to the percentage horizontal or vertical growth changes in Gnathion.

Introduction It is possible to enhance mandibular growth compared to what would have occurred in untreated controls using mandibular advancers, provided that the treatment occurs during puberty and provided that the treatment period would be long enough.1,2,3,4 This study examines how much more chin growth (compared to controls) can be achieved using the MARA during treatment intervals of a little more than a year, separately for boys and girls, during gender-appropriate ages of pubertal mandibular growth. It has been published that the pubertal period for both sexes averages 30 months, during

James E. Eckhart, DDS, attended dental school at the University of Southern California where he was valedictorian and graduated in 1970. After practicing general dentistry for 2 years, he attended the orthodontic program at University of California at San Francisco and obtained his certificate in orthodontics in 1974. He has practiced orthodontics in Manhattan Beach, California, since 1975. After using the Herbst appliance for some years, Dr. Eckhart, along with Dr. Douglas Toll, started developing the Mandibular Anterior Repositioning Appliance (MARA), and obtained a patent for it in l996. Dr. Eckhart can be reached at jameseeckhart@earthlink.net. Thikriat Al-Jewair, BDS, MBA, MSc, MS, FRCDC, ABO Dip, is an Associate Professor and the Director of the Advanced Education Program in Orthodontics and Dentofacial Orthopedics at the University of Missouri-Kansas City. She obtained her MS and a Certificate in Orthodontics from the University at Buffalo. She has also completed a Masters in Dental Public Health from the University of Toronto and a 1-year Certificate program in Clinical Research from Harvard Medical School. Furthermore, she is a Diplomate of the American Board of Orthodontics and a Fellow of the Royal College of Dentists of Canada in both Orthodontics and Dental Public Health.

24 Orthodontic practice

which the unassisted mandibular growth rate averages 59% higher for boys and 34% higher for girls than the pre-puberty average of 2.4-2.1 mm per year.5 A recent study6 found that pubertal boy controls grew the mandible 4.0 mm in 14.2 months (0.27 mm/month), and pubertal girl controls grew the mandible 2.3 mm in 12.5 months (0.18 mm/month). Enhancing the ratio of the mandibular horizontal growth vector to the overall mandibular growth vector is also discussed in this paper. Drawings6 of the mechanics of mandibular growth illustrate that the horizontal and vertical components of Gnathion growth largely relate to how the upper and lower incisors are handled (specifically in deep bites) because extrusion and retraction of the upper incisor â&#x20AC;&#x201D; whether by orthodontic movement within the maxilla or by orthopedic movement of the maxilla or both â&#x20AC;&#x201D; causes downward vertical rotation and slight backward rotation of the chin, and extrusion and protraction orthodontic movement of the lower incisor promotes downward and slight backward rotation of the growing chin. In the present study, it was determined to open any deep bite with braces and intrusion arches and bite turbos prior to advancing the mandible, allowing the chin to be advanced without requiring it to be dropped vertically due to incisal guidance (Figure 1).

Materials and methods Two Class II study groups were selected for MARA treatment, one each of pubertal boys and girls. Each group was compared to age-matched Class II controls from Bolton and Michigan.6,7 If the beginning occlusion was a severely deep bite, the MARA was sometimes postponed until after bite opening. If the preliminary bite opening took longer than 6 months, a new T1 film was Volume 10 Number 3

Volume 10 Number 3

RESEARCH

taken prior to placement of the MARA. The fact that girls start puberty as early as they do sometimes required us to place braces on deciduous teeth while opening the bite. We took a T2 film immediately after removal of the MARA so as to assess accurately the MARA changes. If the T2 film was not taken within 6 months of removal of the MARA, that patient was excluded from this study. There were three time points chosen for selection of head films. T0 was before any treatment. If the MARA was placed within 6 months of the T0 film, that film was used for the beginning measurements. T1 was after bite-opening braces, if any, before MARA, if the beginning braces took 6 months or longer. T2 was immediately after MARA removal. (This time was chosen deliberately so as not to dilute the growth per month experienced by the MARA patients, which would have seemed to be if we used the T3 film taken after all active treatment was used, since the T2-T3 interval was often another 12 months.) There were 21 boys with an average beginning age of 13.2 years, and 11 girls with an average age of 11.5 years. The head films were chosen to represent accurately the time the MARA was in place (Table 1). The decision of what age to start the MARA treatment for each study participant was guided by the discussion in Mellion, et al.,5 regarding pubertal chronological age, statural growth, and mandibular growth. The MARA boys started at an average age of 13.2 years, with a range of 11.9-14.3 years, and the MARA girls started at an average age of 11.5 years, with a range of 10.25 years to 12.5 years. To study the effects of the treatments on incisor positions and chin growth, we made measurements in PowerPoint. (Figure 2). All our films had embedded rulers for standardized enlargements. In both MARA groups, lines were drawn on the T1 film for SN, S-A, S-U1, S-Gn, palatal plane, and functional occlusal plane. Also, the incisal tip of L1 was marked, and three dots circumscribe Sella (Figure 2A). These points were chosen because they are easy midline structures to identify accurately. Although many published studies measured Co-Gn, or Ar-Gn to assess mandibular length, it was found to be easier to see S-Gn when comparing two films. This method had a small error of overlooking fossa growth, which we ignored due to its small magnitude and due to the short T1-T2 intervals. Mandibular radius was approximated to be from Sella to Gnathion for both T1 and T2,

Figures 1A-1D: 1A. Deep bite class II before treatment; 1B. = deep bite Class II moved forward to Class I, showing posterior bite opening, and new Gnathion position with vertical increase; 1C. = deep bite Class II showing lower incisor intrusion before advancing mandible; 1D. = bite-opened class II moved forward to Class I, showing no posterior bite opening, and new Gnathion position with less vertical change

Table 1: Beginning age (yrs) for MARA for boys and girls Boys

Film Interval

# of Patients

Age Range

T0-T2

T1-T2 Total # in study

Girls

Film Interval

# of Patients

Age Range

11.9-13.9

T0-T2

10.3-12.5

12.3-14.3

T1-T2

12.4

13.2

11.5

Total # in study

T0 or T1 age = age of patient in years at time point 1 within 6 months prior to placing MARA T2 = age of patient within 6 months of removal of MARA

Figures 2A-2C: 2A. T1 film with reference lines and dots. 2B. T1 grouped lines and dots ready to transfer. 2C. T2 film with T1 lines and dots superimposed on SN at S, and new dots for U1 (upper incisor dot), L1 (lower incisor dot), and Gn (Gnathion dot) Orthodontic practice 25

RESEARCH because only the change in Gnathion was being examined. Next, the lines and dots were grouped, copied, and pasted (Figure 2B), and transferred to the T2 film and superimposed on SN at S (Figure 2C). Sometimes the T2 film had to be rotated in PowerPoint so the grouped lines would superimpose correctly on SN, depending on the variation in tip angle of the head between T1 and T2. The T2 A pt, U1, L1, and Gn were then marked and grouped onto the T2 film (Figure 2C). Next, the ΔU1, ΔL1, and ΔGn were measured in their X and Y distances from the T1 U1, L1, and Gn, using the T1 occlusal plane as the reference X axis (Figure 3). The Δ measurements were made by viewing the films at 200% to increase accuracy, and then correcting the tables to 100% in Excel. The measurements are compiled in Table 2.

Results Table 3 shows the average movements of the incisors and Gnathion separately for MARA boys and girls. Table 4 shows the comparison of incisor movements and Gnathion movements between MARA and controls for boys and girls. The MARA boys moved the upper incisor backward 0.74 mm in 14.2 months compared to controls, a retraction of 43%. The MARA boys moved the lower incisor forward 0.53 mm compared to controls, an increase of 230%. The MARA boys had a small 15% increase in downward movement of the upper incisor, but a large 120% increase in downward movement of the lower incisor, which can be explained by the deliberate bite opening mechanics prior to MARA placement. The MARA boys increased the vertical component of chin growth only 21% compared to controls, but increased the horizontal component of chin growth by 81% compared to controls, nearly a 2 mm increase. The MARA girls moved the upper incisor backward 2.58 mm in 12.5 months compared to controls, a retraction of 163%. The MARA girls moved the lower incisor forward 0.95 mm compared to controls, an increase of 271%. The MARA girls had a significant 135% increase in downward movement of the upper incisor, and a large 286% increase in downward movement of the lower incisor. The MARA girls increased the vertical component of chin growth only 44% compared to controls, but increased the horizontal component of chin growth 26 Orthodontic practice

Figures 3A-3C: From T1-T2, registered on SN at Sella, relative to T1 occlusal plane as the X axis. 3A. Upper incisor changes; how far the upper incisor tip moved forward and downward from Sella, T2U1 = Time 2 Upper incisor, T1U1 = Time 1 Upper incisor, ∆U1X = movement of Upper incisor parallel to T1 occlusal plane, ∆U1Y = movement of Upper incisor perpendicular to T1 occlusal plane. 3B. Lower incisor changes; how far the lower incisor tip moved forward and downward relative to Gnathion, T2L1 = Time 2 Lower incisor, T1L1 = Time 1 Lower incisor, T2L1X = distance of T2 Lower incisor from T2 Gnathion parallel to T1 occlusal plane, T1L1X = distance of T1 Lower incisor from T1 Gnathion parallel to T1 occlusal plane, T2L1Y = distance of T2 Lower incisor from T2 Gnathion perpendicular to T1 occlusal plane, T1L1Y = distance of T1 Lower incisor from T1 Gnathion perpendicular to T1 occlusal plane, Δ (change in) L1X = T2L1X - T1L1X, Δ (change in) L1Y = T2L1Y - T1L1Y. 3C. Gnathion changes, how far Gnathion moved forward and downward relative to Sella, T2Gn = Time 2 Gnathion, T1Gn = Time 1 Gnathion, ∆GnX = change in Gnathion from T1-T2, parallel to T1 occlusal plane, ∆GnY = change in Gnathion from T1-T2, perpendicular to T1 occlusal plane

by 82% compared to controls, nearly a 1.3 mm increase. MARA girls had more retraction and extrusion of the upper incisor than boys did. Both boys and girls showed a large increase in Gnathion horizontal growth, and slight increase in Gnathion vertical growth. Figure 4 shows that compared to controls, for 21 MARA boys in 14.2 months, the upper incisor moved slightly down and back. The lower incisor moved slightly forward and intruded nearly 2 mm. Gnathion nearly doubled its forward movement, and slightly increased its vertical movement. The mandible increased in length an average of 0.40 mm per month, compared to 0.27 mm per month for controls. This shows an increase in boys’ radial mandibular growth rate with the MARA of 43%. Compared to controls, for 12 MARA girls in 12.5 months, the upper incisor moved down over 1.5 mm and backward 2.5 mm. The lower incisor moved slightly forward and intruded nearly 2 mm. Gnathion significantly increased its forward movement, and slightly increased its vertical movement, and the mandible increased in length an average of 0.30 mm per month, compared to 0.18 mm per month for Controls. This shows an increase in girls’ radial mandibular growth rate with the MARA of 61%. Using the data in Table 2, it is possible to plot a scatter graph showing the

relationship between total incisor movements and percentage of horizontal chin change (Figure 5).

Statistics For control and MARA boys and girls, the sum of the upper incisor X and Y movements, minus the sum of the lower incisor X and Y movements, was related linearly to the proportion of chin growth that was horizontal and to the proportion of chin growth that was vertical. For control boys, the Pearson correlation coefficient was r = 0.8262, and the probability factor was p = < 0.00001. The result is significant at p < 0.05. For control girls, the Pearson correlation coefficient was r = 0.8081, and the probability factor was p = 0.000267. The result is significant at p < 0.05. For MARA boys, the Pearson correlation coefficient was r = 0.8297, and the probability factor was p = < 0.00001. The result is significant at p < 0.05. For MARA girls, the Pearson correlation coefficient was r = 0.83092, and the probability factor was p = 0.00059. The result is significant at p < 0.05.

Discussion Both control boys and girls and MARA boys and girls showed a significant relationship between incisor vector changes and horizontal and vertical chin change. There is no doubt that the direction of chin Volume 10 Number 3

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RESEARCH Table 2: MARA boys and girls upper incisor, lower incisor, and Gnathion changes MARA Boys Excluding Open Bites Name

T0 or T1 AGE (Mos)

∆ U1X

∆ U1Y

∆ L1X

∆ L1Y

∆ GnX

∆ GnY

∆ Gn

∆GnX/ ∆Gn

∆GnY/ ∆Gn

∑∆ U1X -∆ L1

148

-1.5

-2.5

2.0

-2.5

3.8

3.0

4.8

0.8

0.6

-4.5

163

-0.5

-1.3

0.0

-3.3

4.0

1.3

4.2

1.0

0.3

-5.0

170

0.5

-0.5

2.0

0.0

1.5

3.8

4.0

0.4

0.9

2.0

152

1.0

-0.5

0.3

6.3

2.0

6.6

1.0

0.3

1.8

153

0.0

-1.5

-4.0

4.5

1.3

4.7

1.0

0.3

-5.5

159

1.5

-1.5

1.0

-1.0

5.5

0.0

5.5

1.0

0.0

160

-0.8

-4.5

1.0

-0.5

1.5

8.5

8.6

0.2

1.0

-4.8

150

4.5

-1.5

-2.5

0.5

11.0

4.0

11.7

0.9

0.3

1.0

153

5.0

0.5

2.0

1.5

5.3

1.5

5.5

1.0

0.3

9.0

EthW

157

0.8

-1.5

0.8

-0.5

2.5

5.5

6.0

0.4

0.9

-0.5

163

4.3

-2.0

1.0

0.0

5.0

2.0

5.4

0.9

0.4

3.3

168

0.0

-4.0

-1.5

0.0

3.8

2.5

4.5

0.8

0.6

-5.5

147

-1.3

-1.0

0.0

2.8

3.9

0.7

-2.3

165

3.0

-1.5

-2.0

2.5

8.0

7.0

10.6

0.8

0.7

2.0

167

-0.8

2.5

-1.0

2.5

5.0

5.6

0.4

0.9

0.0

143

2.5

-2.5

-1.5

1.5

7.0

6.8

9.7

0.7

0.0

159

-1.5

-6.5

-1.5

-0.5

3.0

8.0

8.5

0.4

0.9

-10.0

153

0.0

-1.8

0.0

-2.5

2.8

2.5

3.7

0.7

-4.3

152

-1.5

2.5

1.0

1.5

5.5

5.7

0.3

1.0

0.5

161

3.5

-1.0

0.8

0.0

4.3

1.0

4.4

1.0

0.2

3.3

171

1.8

0.0

1.0

2.5

5.0

4.0

6.4

0.8

0.6

5.3

MARA Girls Who Showed Chin Growth During MARA Time SieD

123

-3.0

-2.5

0.0

-4.0

5.0

3.5

6.1

0.8

0.6

-9.5

KKee

133

-3.0

-4.0

0.0

-1.5

5.0

5.2

-0.3

1.0

-7.0

134

-2.3

-2.5

0.0

-3.0

3.5

0.0

3.5

1.0

0.0

-7.8

150

-3.5

-4.0

1.0

-2.0

3.3

3.5

4.8

0.7

-8.5

134

1.0

-2.0

1.0

-0.8

1.3

1.5

2.0

0.6

0.8

-0.8

127

2.8

-2.5

0.0

3.5

4.5

5.5

7.1

0.6

0.8

3.8

147

0.5

0.0

1.0

4.3

2.5

4.9

0.9

0.5

2.5

149

0.0

-1.5

-2.0

3.8

0.0

3.8

1.0

0.0

-5.0

149

-2.5

-5.0

2.5

-4.3

3.0

0.8

3.1

1.0

0.2

-9.3

131

1.0

-0.3

0.0

-0.5

2.3

0.5

2.3

1.0

0.2

0.3

144

-1.5

-6.5

3.0

-3.5

1.0

5.0

5.1

0.2

1.0

-8.5

NAME = MARA patient ID T0 orT1 AGE = age of patient in months at time point 1 within 6 months prior to placing MARA ET = number of months between film 1 and film 2 ∆U1X = change of upper incisor position between films, parallel to T1 occlusal plane, films superimposed on Sella-Nasion at Sella (SN at S) ∆U1Y = change of upper incisor position between films, perpendicular toT1 occlusal plane, films superimposed on SN at S ∆L1X = change of lower incisor distance from its own Gnathion between films, parallel to T1 occlusal plane ∆L1Y = change of lower incisor distance from its own Gnathion between films, perpendicular to T1 occlusal plane ∆GnX = change of Gnathion position between films, parallel to T1 occlusal plane, films superimposed on SN at S ∆GnY = change of Gnathion position between films, perpendicular to T1 occlusal plane, films superimposed on SN at S ∆Gn = vector distance of change of Gnathion position between films, films superimposed on SN at S ∆GnX/∆Gn = percent of Gnathion change between films which is parallel to T1 occlusal plane ∆GnY/∆Gn = percent of Gnathion change between films which is perpendicular to T1 occlusal plane ∑ = “the sum of” ∑∆U1 -∆L1 = ∑(∆U1X + ∆U1Y - ∆L1X - ∆L1Y) 28 Orthodontic practice

growth is influenced by how the incisors are handled. It should be repeated that this study uses T2 films that were taken shortly after removal of the MARA prior to final braces removal, and this fact may distinguish this study from other published reports. As a safeguard to prevent artificial anterior displacement of the mandible, tomograms were taken prior to MARA removal to assure that the condyles were centered in the fossa. This study does not mix boys and girls. If data becomes available regarding the chin growth vector amounts and ratios for intermaxillary push-pull Class II correctors, it may prove that the use of the MARA produces superior chin changes, albeit small, compared to those devices that are suspected of increasing the vertical vector of chin growth, particularly any which extrude the lower molars. It appears that the MARA minimally advances the lower dentition compared to controls, which may not be true of other intermaxillary Class II correctors. Larger MARA horizontal chin changes might be attempted by deliberately retracting lower incisors, such as by removing lower bicuspids, and leaving the MARA in during a longer portion of puberty, creating a Class III molar relation in order to double the horizontal chin increase. Especially for boys, the MARA increase in monthly growth rate of the mandible over controls might be even greater if the advancement of the mandible is greater, and the total mandibular growth might more than double if the MARA is left in twice as long. By carefully selecting the optimum treatment age, recognizing that girls need to start 2 years earlier than boys, and by controlling the effect of incisor position on hinging of the growing mandible, it can be shown that chin prominence can be enhanced. A similar study might be done with other Class II corrector cases to see how they affect chin radial growth and the ratio between chin horizontal growth and chin radial growth.

Conclusions Movements of the upper and lower incisors are related to horizontal and vertical chin change in both control and MARA deep-bite boys and girls. There was a 43% increase in overall growth of the mandible comparing MARA boys to control boys, and a 61% increase in overall growth of the mandible comparing MARA girls to control girls. Volume 10 Number 3

REFERENCES 1. Freeman DC, McNamara JA Jr, Baccetti T, Franchi L, Fränkel C Long-term treatment effects of the FR-2 appliance of Fränkel. Am J Orthod Dentofacial Orthop. 2009;135(5):570. 2. Rabie AR, She TT, Hägg U. Functional appliance therapy accelerates and enhances condylar growth. Am J Orthod Dentofacial Orthop. 2003;123(1):40-48. 3. Malta LA, Baccetti T, Franchi L, Faltin K Jr, McNamara JA. Long-term dentoskeletal effects induced by bionator therapy. Angle Orthod. 2010;80(1):10-17. 4. Franchi L, Pavoni C, Faltin K Jr, McNamara JA, Cozza P. Long-term skeletal and dental effects and treatment timing for functional appliances in class II malocclusion. Angle Orthod. 2013;83(2):334-340. 5. Mellion ZJ, Behrents RE, Johnston LE Jr. The pattern of facial skeletal growth and its relationship to various common indexes of maturation. Am J Orthod Dentofacial Orthop. 2013;143(6):845-854. 6. Eckhart JE, Al-Jewair T, Magnitude of monthly pubertal mandibular growth in untreated Class II teens, and the relationship between upper and lower incisor movements and horizontal versus vertical expression of chin growth, Orthodontic Practice US, Jan-Feb 2019, 10:1, (16-26)

Table 3: Average MARA boys and girls upper incisor, lower incisor, and Gnathion changes MARA Boys Averages

STD

Range

MARA Girls Averages

STD

Range

AVG AGE MOS

158

8.0

143>171

AVG AGE MOS

138

9.8

123>150

AVG ET MARA MOS

14.2

3.7

10>23

AVG ET MARA MOS

12.5

1.9

9>17

AVG ∆U1X MM

0.98

2.1

-1.5>+5.0

AVG ∆U1X MM

-1.00

2.2

-3.5>+3.0

AVG ∆U1Y MM

-1.63

1.7

-6.5>+1.0

AVG ∆U1Y MM

-2.80

2.0

-6.5>+0.0

AVG ∆L1X MM

0.26

1.5

-2.5>+2.5

AVG ∆L1X MM

0.60

1.1

-1.5>+2.5

AVG ∆L1Y MM

-0.29

1.7

-4.0>+2.5

AVG ∆L1Y MM

-1.30

2.3

-4.3>+3.5

AVG ∆GnX MM

4.35

2.3

+1.5>+11.0

AVG ∆GnX MM

2.80

1.9

-1.5>+5.0

AVG ∆GnY MM

3.70

2.4

+0.0>8.5

AVG ∆GnY MM

2.60

2.2

+0.0>+6.0

AVG ∆Gn MM

5.71

2.3

+3.7>11.7

AVG ∆Gn MM

3.80

1.6

+2.2>+7.5

AVG ∆GnX/∆Gn

0.76

0.3

+0.2>+1.0

AVG ∆GnX/∆Gn

0.73

0.4

-0.3>+1.0

AVG ∆GnY/∆Gn

0.65

0.3

+0.2>+1.0

AVG ∆GnY/∆Gn

0.68

0.4

+0.0>+1.0

AVG ∆GnX/∆GnY

1.17

AVG ∆GnX/∆GnY

1.07

AVG ∆GnX/MO = 0.31 MM

AVG ∆GnX/MO = 0.22 MM

AVG ∆GnY/MO = 0.26 MM

AVG ∆GnY/MO = 0.21 MM

AVG ∆Gn/MO = 0.40 MM

AVG ∆Gn/MO = 0.30 MM

Footnotes: (see Table 2)

Table 4: Incisor and Gnathion changes comparing controls and MARA patients (mm) Boys 14.2 Mos

Controls

MARA

Δ (MARA -Controls)

% Change

Girls 12.5 Mos

Controls

MARA

Δ (MARA -Controls)

% Change

∆U1X

1.74

1.00

-0.74

-43

∆U1X

1.58

-1.00

-2.58

-163

∆U1Y

-1.39

-1.60

-0.21

∆U1Y

-1.19

-2.80

-1.61

135

∆L1X

-0.23

0.30

0.53

-230

∆L1X

-0.35

0.60

0.95

-271

∆L1Y

1.51

-0.30

-1.81

-120

∆L1Y

0.70

-1.30

-2.00

-286

∆GnX

2.38

4.30

1.92

∆GnX

1.54

2.80

1.26

∆GnY

3.07

3.70

0.63

∆GnY

1.80

2.60

0.80

Footnotes: (see Table 2)

7. AAOF Legacy Collection, http://www.aaoflegacycollection. org/aaof_home.html

Figure 4: Vector diagram of boys and girls control changes (solid) versus boys and girls MARA changes (dashed) Volume 10 Number 3

Figures 5A-5B: (Upper incisor and Gnathion movements are superimposed on SN at S, with the X axis being the T1 occlusal plane). (Lower incisor movements are relative to Gnathion, with the x axis being the T1 occlusal plane) 5A. Graph of relationship between MARA boys and girls incisor change (upper incisor X and Y changes minus lower incisor X and Y changes, in mm) versus the ratio of ∆GnX/∆Gn. 5B. Graph of relationship between MARA boys and girls incisor change (upper incisor X and Y changes minus lower incisor X and Y changes, in mm.) versus the ratio of ∆GnY/∆Gn Orthodontic practice 29

RESEARCH

There was a 81% increase in horizontal chin growth comparing MARA boys to control boys and a 82% increase in horizontal chin growth comparing MARA girls to control girls (probably at least partly due to managing incisor movements). There was a 1.9 mm increase in horizontal chin change comparing MARA boys to control boys and a 1.3 mm increase in horizontal chin change comparing MARA girls to control girls. The MARA did not move the boys’ or girls’ lower dentition much forward compared to controls (less than 1.0 mm forward). The MARA barely changed the vertical component of chin growth compared to controls (21% increase for boys; 44% increase for girls). For non-deep-bite cases, braces are compatible with the MARA but not necessary. Some of these MARA boys were treated with Invisalign after the MARA. OP

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Treating mixed dentition cases with clear aligner therapy and low pulsatile forces Drs. Jasmine Gorton and Sona Bekmezian discuss a viable treatment option for mixed dentition cases

ixed dentition treatment can be important and effective at ensuring that patients have healthy, beautiful smiles as they grow and develop. It also lays the foundation for any ensuing orthodontic treatment experience they may have in their lifetime. Also known as Phase I treatment or interceptive therapy, mixed dentition treatment seeks to correct focused clinical conditions while the child is still actively growing. The American Association of Orthodontists urges orthodontic screening of children at age 7. Perceived benefits of Phase 1 include1: • Growth modification • Prevention of dental trauma/wear • Improved patient self-esteem and parental satisfaction • Prevention of permanent tooth impaction • Stability • Less extensive subsequent treatment The goal of this article is to present a novel approach to mixed dentition treatment through the combination of technologies usually thought to be reserved for older patients.

Protocol for mixed dentition cases This practice was one of 54 orthodontic offices worldwide that was asked by Invisalign® (Align Technology, Inc., San Jose, California) to develop a protocol for using clear aligners for expansion in young children. Typically, patients in this category are between the ages of 7 and 10.

Educational aims and objectives

This clinical article aims to present a novel approach to mixed dentition treatment through a combination of technologies.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 35 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Identify perceived benefits of screening patients for Phase I treatment beginning at 7 years old.

•

Recognize some benefits of using clear aligner therapy with younger children (typically between the ages of 7 and 10).

•

Recognize some reasons that younger patients would not tolerate traditional treatment as well as clear aligner therapy.

•

Realize the protocol for use of the clear aligners.

•

Realize the protocol for other technologies used in this type of treatment.

•

Realize other necessary recommendations for patients in this category such as aligner seaters and toothpaste.

•

Identify CBCT as an important part of the authors’ practice’s diagnosis and treatment planning for mixed dentition cases for the purpose of evaluating craniofacial morphology and dental development.

The traditional treatment process for these cases involves separators and metal expanders. In most situations, the patient would also receive braces on the upper and/ or lower front teeth to address alignment. From sour-tasting glue, to tissue impingement, and speech and swallowing interference, these methods involve inconvenience and discomfort.2 Clear aligner therapy is hygienic, comfortable, and convenient. It is also a single simultaneous appliance, providing expansion, alignment, and upper and lower arch coordination, and thus obviating the need for fixed appliances in conjunction with expanders

Jasmine Gorton, DMD, graduated from the University of California, Berkeley with Bachelors degrees in Integrative Biology and Social Sciences, and then received her Doctor of Dental Medicine degree with honors from the Harvard School of Dental Medicine. She completed a postdoctoral fellowship in Growth and Development from the University of California, San Francisco, followed by an orthodontic residency with a Master of Science degree in Oral Biology. Dr. Gorton received the American Association of Orthodontics Award for Craniofacial Research and the Harvard Odontological Society Award for Excellence in Research. A boardcertified orthodontist, she is the owner of Gorton & Schmohl Orthodontics in Larkspur, California. Sona Bekmezian, DDS, is an associate orthodontist at Gorton & Schmohl Orthodontics in Larkspur, California. She graduated from the University of California, Los Angeles with a Bachelor of Science degree in Biology and then earned her Doctor of Dental Surgery degree from the University of California, San Francisco (UCSF). She also completed her orthodontic residency with a Master of Science degree in Oral and Craniofacial Sciences at the UCSF. Dr. Bekmezian is a board-certified orthodontist. Disclosure: The authors disclose they have not been compensated for this article nor do they have financial interests in any of the products mentioned.

32 Orthodontic practice

and/or functional appliances. As a result, in many cases, we have been able to complete Phase 1 treatments within 6 months. In contrast to expanders and brackets, there are no dietary restrictions in clear aligner therapy and no barriers to oral hygiene. Since the aligners are removable, patients have unrestricted access to brush their teeth, floss, and receive professional prophylaxis. However, as such, clear aligners are a 100% compliance-dependent appliance. The practice uses Invisalign® First clear aligner therapy in conjunction with the AcceleDent® Optima (OrthoAccel® Technologies, Inc., Bellaire, Texas) vibratory device. AcceleDent Optima is an FDA-cleared Class II medical device that applies precisely calibrated micropulses, which transmit through the roots of teeth to stimulate the surrounding bone and, as a result, increase cellular activity.3 Our practice has found that regular use of the AcceleDent Optima improves the predictability of mixed dentition cases, provides relief from the discomfort of tooth movement, and provides greater assurance that the aligners are tracking according to the programmed movements. Volume 10 Number 3

Diagnosis and treatment planning An important part of our practice’s diagnosis and treatment planning for mixed dentition cases is evaluating craniofacial morphology and dental development with cone beam computed tomography (CBCT).4 We also confirm that the airway morphology is within normal limits for the patient’s age.5 Patients and parents have a choice of treatment modality as long as they present with normal airway findings on the pretreatment CBCT and do not report symptoms of sleep-disordered breathing, for which fixed rapid maxillary expansion is prescribed. During the treatment planning phase in Clincheck®, we strategically program attachments to optimize intrusion/extrusion, root control, and rotations. Our current protocol is to place attachments on all available permanent teeth (because these teeth tend to have larger bonding surfaces), and also on the lower deciduous first molars to address hyper-eruption of the lower anterior teeth.6 Attachments are placed during the initial aligner delivery appointment, but in our experience are best to avoid altogether in patients with special needs or hypersensitivity. Since Invisalign® First does not currently offer a specialized retainer option for Phase 1 cases, the practice’s retention protocol is an upper removable Hawley. The practice does not prescribe mandibular retention for Phase 1 patients who have acceptable pretreatment Volume 10 Number 3

CONTINUING EDUCATION

Mixed dentition patients are instructed to wear their aligners 20 to 22 hours per day, use the AcceleDent Optima for 20 minutes daily (or more, as needed for pain relief), and change aligners twice weekly (every 3 to 4 days). The practice also recommends the frequent use of Chewies™ for proper aligner seating and provides Clinpro™ 5000 (3M) sodium fluoride anti-cavity toothpaste for this age group. Our patients are able to comply with all of these instructions without the help of an adult. However, as many of our patients are unable/unwilling to brush/floss their teeth regularly following meals and snacks at school, we suggest a thorough swishing with water before replacing the aligners. Clinpro 5000 toothpaste is provided to help alleviate the risk of enamel decalcification given the likely increased plaque load. Brushing and flossing after meals and snacks is encouraged prior to aligner replacement at home. Aligner delivery is scheduled 3 weeks after the initial record gathering and scanning appointment to minimize eruptive changes that could compromise aligner fit. Following delivery, monitoring appointments are scheduled at 6-week intervals.

Figure 1: Initial photographs

alignment and arch length; however, cases with moderate pre-treatment misalignment are prescribed a bonded retainer on the lingual of the lower anterior teeth, and cases with severe pre-treatment lower crowding are prescribed a lower lingual holding arch.7

Patient example An 8-year-old female presented with anterior crossbite of the lateral incisors and bilateral posterior crossbite (Figure 1). Other clinical findings included a central diastema, generalized lower spacing, a V-shaped maxillary arch, anterior open bite tendency, and excess proclination of the upper and lower anterior teeth; overjet and overbite were minimal. Further clinical examination revealed a developmentally delayed/congenitally missing lower left second premolar and ankylosis of the lower right first deciduous molar. Profile was flat, and an anterior tongue thrust was present. There were prominent mamelons on the upper central incisors and lower lateral incisors. The treatment goals were correction of the anterior and posterior crossbites, space closure, and improvement in overjet and overbite. Invisalign® First clear aligner therapy was recommended to achieve treatment goals comfortably and efficiently. For her initial set, the patient was prescribed 22 aligners

for the maxillary and mandibular arches. Expansion was programmed into the upper arch to resolve the posterior crossbite, with simultaneous alignment of the anterior teeth for anterior crossbite resolution as well as space closure. There was no interproximal reduction prescribed, and there were no auxiliaries used. Extrusion of upper central and lateral incisors was programmed with optimized extrusion attachments to improve smile arc. Attachments were placed at initial aligner delivery. The patient was instructed to wear her aligners 20 to 22 hours per day, use the AcceleDent Optima for 20 minutes daily, and change aligners twice weekly (every 3 to 4 days). She was also instructed to use Chewies™ for proper aligner seating and brush with Clinpro 5000 toothpaste. Appointment intervals were every 6 weeks. There was a refinement phase of 20 aligners for the maxillary and mandibular arches (Figure 2). The refinement aligners were prescribed for increased lateral expansion to achieve complete resolution of the posterior crossbite, continued space closure for the upper and lower incisors, and extrusion of the upper anterior teeth for increased overbite. The patient completed active treatment in 6 months (Figure 3). All treatment goals were achieved, including improved axial inclination of the anterior teeth and improved interincisal Orthodontic practice 33

CONTINUING EDUCATION angle. The author was also pleased with the esthetic smile line and arch coordination. The patient was prescribed an upper Hawley retainer (with the acrylic cut away from the posterior teeth to allow for unimpeded permanent tooth eruption) for daily nighttime wear. A fixed lingual retainer was bonded to the lower central and lateral incisors to maintain space closure.

Discussion

Figure 2: Treatment progress photographs

Phase I treatment with aligners is still relatively uncommon. This case report, as well as others that are pending publication, should provide validation that this treatment approach is not only a viable treatment modality for mixed dentition cases, but also an advantageous option. Aligners allow orthodontists to simultaneously achieve anterior alignment, posterior expansion, and arch coordination. Aligners also provide the flexibility to regain space in the canine area if the patient has early loss of deciduous canines or a midline shift. While the fact that these patients are constantly growing throughout treatment can present challenges, the benefit lies in their rapid biological response. Additionally, these patients tend to have a more regimented sleep routine of 10 or more hours of sleep per night.8 This longer sleep cycle allows uninterrupted aligner wear for longer stretches of time, improving total compliance. All of these factors contribute to the successful and predictable treatment of many mixed dentition patients within 6 months. OP

REFERENCES 1. Suresh M, Ratnaditya A, Kattimani VS, Karpe S. One Phase versus Two Phase Treatment in Mixed Dentition: A Critical Review. J Int Oral Health. 2015;7(8):144â&#x20AC;&#x201C;147. 2. Gecgelen M, Aksoy A, Kirdemir P, et al. Evaluation of stress and pain during rapid maxillary expansion treatments. J Oral Rehabil. 2012;39(10):767-775. 3. Pavlin D, Ravikumar A, Vishnu, Gakungaa PT. Cyclic loading (vibration) accelerates tooth movement in orthodontic patients: A double-blind, randomized controlled trial. Semin Orthod. 2015;21(3):187-194. 4. Scarfe WC, Azevedo B, Toghyani S, Farman AG. Cone Beam Computed Tomographic imaging in orthodontics. Aust Dent J. 2017;62(suppl 1):33-50. 5. Alwadei AH, Galang-Boquiren MTS, Kusnoto B, et al. Computerized measurement of the location and value of the minimum sagittal linear dimension of the upper airway on reconstructed lateral cephalograms compared with 3-dimensional values. Am J Orthod Dentofacial Orthop. 2018;154(6):780-787. 6.

Liu Y, Hu W. Force changes associated with different intrusion strategies for deep-bite correction by clear aligners. Angle Orthod. 2018;88(6):771-778.

7. Woods MG. Mandibular arch dimensional and positional changes in late mixed-dentition Class I and II treatment. Am J Orthod Dentofacial Orthop. 2002;122(2):180-188.

Figure 3: Final photographs 34 Orthodontic practice

8. Galland BC, Taylor BJ, Elder DE, Herbison P. Normal sleep patterns in infants and children: a systematic review of observational studies. Sleep Med Rev. 2012;16(3):213-222.

Volume 10 Number 3

REF: OP V10.3 GORTON/BEKMEZIAN

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Treating mixed dentition cases with clear aligner therapy and low pulsatile forces GORTON/BEKMEZIAN

Perceived benefits of Phase 1 include: growth modification, _________, stability, and less extensive subsequent treatment. a. prevention of dental trauma/wear b. improved patient self-esteem and parental satisfaction c. prevention of permanent tooth impaction d. all of the above

2. Mixed dentition patients are instructed to wear their aligners ______ hours per day, use the AcceleDent Optima for 20 minutes daily (or more, as needed for pain relief), and change aligners twice weekly (every 3 to 4 days). a. 5 to 9 b. 10 to 14 c. 15 to 18 d. 20 to 22 3. Aligner delivery is scheduled _______ after the initial record gathering and scanning appointment to minimize eruptive changes that could compromise aligner fit. a. 1 week b. 2 weeks c. 3 weeks d. 4 weeks 4. Following delivery, monitoring appointments are

Volume 10 Number 3

scheduled at _______ intervals. a. 6-week b. 8-week c. 12-week d. 15-week 5. An important part of our (the authors’) practice’s diagnosis and treatment planning for mixed dentition cases is evaluating craniofacial morphology and dental development with _________. a. cone beam computed tomography (CBCT) b. traditional 2D film X-rays c. digital photographs d. transillumination technology 6. Patients and parents have a choice of treatment modality as long as they present with normal airway findings on the ________ and do not report symptoms of sleep-disordered breathing, for which fixed rapid maxillary expansion is prescribed. a. patient’s history b. pretreatment CBCT c. visual exam d. 2D digital X-ray 7. During the treatment planning phase in ClinChek®, we strategically program attachments to optimize intrusion/extrusion, root control, and rotations. The attachments are placed on all available permanent

teeth because these teeth tend to have ________. a. a smaller bonding surface b. a larger bonding surface c. less hypersensitivity d. less hyper-eruption 8.

Attachments are placed during ______ appointment, but in our experience are best to avoid altogether in patients with special needs or hypersensitivity. a. the initial aligner delivery b. the second appointment after aligner delivery c. halfway through treatment d. during the retention phase

9. Since Invisalign® First does not currently offer a specialized retainer option for Phase 1 cases, the practice’s retention protocol is a/an ________. a. bonded permanent retainer b. upper removable Hawley c. Essix retainer d. none of the above 10. While the fact that these patients are constantly growing throughout treatment can present challenges, the benefit lies in their ________. a. total compliance b. rapid biological response c. slow biological response d. short sleep routine

Orthodontic practice 35

CE CREDITS

ORTHODONTIC PRACTICE CE

CONTINUING EDUCATION

A concept and approach for correcting posterior crossbites Dr. Suhail A. Khouri discusses a technique that facilitates the correction of crossbites and Class III malocclusions Abstract Palatal expanders have long been the principal treatment for the correction of crossbites over the last century, despite their lengthy fabrication procedures, possible complications, and difficulty in achieving satisfying results. Although advances have affected every aspect of the orthodontic specialty over the past few decades, researchers have not found a simpler alternative approach other than palatal expanders for crossbite correction. This study attributes the extreme difficulty of current crossbite correction approaches to the cuspal blockage of posterior teeth perpetuated by the persistent chewing habit and suggests that even the vigorous forces of traditional expander hardware are incapable of eliciting the corrective lateral teeth movement. Eliminating this cuspal blockage and disengaging posterior teeth constitutes the rationale for a new treatment approach that allows transverse forces to have effectiveness in transverse teeth movements. Placing composite buildups on the occlusal surfaces of posterior mandibular teeth disengages the occlusion and temporarily breaks the shifted chewing habit during the corrective procedure and enables the light and consistent transverse forces of regular super elastic archwires to the transverse teeth movements. Also, inserting V-bends in both super elastic archwires by Bendistal pliers, can intrude anterior and posterior teeth and extends the time of anterior and posterior teeth disengagement. This facilitates the posterior crossbite correction, mandibular incisor retraction, and simultaneously treats any coexisting Class III malocclusion. With this simplified approach, clinicians can easily activate regular NiTi archwires to deliver vertical intrusive forces, and transverse

Suhail A. Khouri, DDS, is an orthodontist in private practice in Chesterfield, Missouri. He is a member the American Association of Orthodontists and the College of Diplomates of the American Board of Orthodontics. You can email Dr. Khouri at suhailkhouri@ sbcglobal.net. Disclosure: Dr. Khouri is the inventor of Bendistal pliers and V-Bend treatment technique.

36 Orthodontic practice

Educational aims and objectives

This clinical article aims to discuss a technique that facilitates the correction of crossbites and Class III malocclusions.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 42 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Identify some traditional treatments for correction of crossbites.

•

Identify the technique that includes using V-bends to intrude anterior and posterior teeth.

•

Recognize the rationale behind the V-bend approach.

•

Outline the technique using V-bends.

•

Identify the torquing activations of both maxillary and mandibular archwires for bilateral crossbite final correction.

crossbite corrective forces at buccal, rather than palatal sides of teeth for correcting those challenging malocclusions. This paper displays several patient therapies using this innovative technique.

Introduction Removable acrylic expanders and Frankel appliances have been widely used for correcting posterior crossbites1-3 with complete patient cooperation.4-5 To ensure their efficiency without patient cooperation, fixed cemented to posterior teeth6-10 — such as a quad helix, Hyrax appliance, and others11-15 — were developed and dominated the trend of this correction. They were mainly

used for opening the midpalatal sutures in prepubertal patients; opening closed sutures typically requires surgery to open the palatal suture to facilitate palatal expansion in adult patients.16-18 To simplify the crossbite correction and reduce the hardware involved, some researchers have developed the palatal arches approach19,20 that could move molars in more than one plane. But the high skill and precision required in this customization, activating and placing them in the patient’s palate, have limited their clinical applicability. More recently, thick super elastic wires were introduced to replace stainless steel in making fixed palatal expanders,21-24

Figures 1A and 1B: A. Buccal cusps of the maxillary molar are blocked out by the mandibular molar buccal cusp. The underbite height D blocks corrective lateral movement, due to the shifted chewing function. Note the abnormal axial inclination in red lines. B. Shows the composite buildup in the central groove of the mandibular molar (in brown), which unlocks the maxillary molar cusp and prepares it to move by the light corrective force (in blue). Note corrected axial inclination lines in blue Volume 10 Number 3

Figure 2: Shows the effects of V-bends. The equal and opposite moments created by V-bends favorably disengage anterior and posterior teeth distant to the bends. These created moments disengage the occlusion and speed up the correction of both crossbites and Class III corrections.

Rationale of this approach Although the height of D as shown in Figure 1A does not seem deep enough to block the buccal cusps of maxillary molars from achieving corrective jumps over the mandibular molar cusps, actually they can and do. This small occlusal depth incapacitates even the expander’s vigorous forces from overcoming the abnormal chewing and locking habit, which makes crossbite correction difficult. This new crossbite corrective approach starts by eliminating occlusal blockage by placing composite buildups on mandibular molars (Figure 1B), which frees the interlocked teeth to expand.

Figures 3A-3C: The Bendistal pliers set (DynaFlex) used. 3B. Shows expanding midline V-bend in maxillary 0.016” x 0.022” NiTi archwire fully engaged. 3C. Shows transverse expanding step out bend placed before tying archwires for correction

The technique Clinicians have previously used composite buildups on anterior teeth to open the bite and correct crossbites.25-27 But this new technique places the composite buildups on the central grooves of mandibular posterior teeth (Figure 1B), which disengages posterior and anterior teeth, and temporarily breaks the persistence of the altered chewing pattern. This approach recruits the following elements already available to orthodontists: 1. Bendistal pliers to insert lasting V-bends that launch vertical NiTi forces. 2. Recruits the vertical light, consistent forces of NiTi wires in simplifying teeth intrusion. 3. Harnesses this intrusion to simplify the correction of crossbites and Class III malocclusions. Disengaging posterior teeth makes it possible for light transverse forces launched by step out/in V-bends of regular NiTi archwires to move teeth out of crossbites without blockage. The therapy starts by using 0.016" NiTi archwires for the initial alignment in both dental arches. After aligning all teeth, insert intrusive V-bends with Bendistal pliers’ intraorally distal to the canines. The tips of these bends should always point occlusally in both Volume 10 Number 3

Figure 4:Torquing activations of both maxillary and mandibular archwires for bilateral crossbite final correction. Note the clockwise torquing activation on the right side of both the maxillary and mandibular archwires and the anti-clockwise torquing activation on the left sides of the same both archwires. Combining all these activations on both sides of both archwires will expand the maxillary dental arch by moving both molars out and correct the abnormal axial inclinations of their roots, and constrict the mandibular dental arch by moving both molars inward and correct their root axial inclinations as well

maxillary and mandibular archwires to intrude posterior and anterior teeth located on both sides of these bends. This intrusion permits occlusal disengagement and allows buccal forces from regular archwires to expand the maxillary molars and correct posterior crossbites. This also and facilitates retraction of the mandibular incisors to correct Class III malocclusions. The use of NiTi archwires in this technique not only simplifies initial teeth alignment without loops, springs, or helixes, while their light and consistent forces of V-bend mechanics applied on both sides also simplifies intrusion and occlusal disengagement. Additionally, the extrusion of adjacent canines and first premolars on both sides of the maxillary V-bends have the advantage of augmenting the disengagement of the more distant teeth (Figure 2). Similar but inverted, V-bends in mandibular archwires will double the extent and time of teeth disengagement and will assist the simultaneous correction of

crossbite and Class III malocclusion. Rectangular 0.016" x 0.022" NiTi archwires, or larger, with V-bends, will deliver relatively stronger forces when more disengagement is required. A V-bend inserted in the midline of a maxillary NiTi archwire will activate it to bilaterally and gently expand the maxillary posterior teeth (Figure 3B). Double opposite transverse V-bends can activate archwires to expand and/or constrict posterior teeth on the affected sides. Flexibility of NiTi archwires allows easy engagement of step bends for more efficient and faster movement of teeth. These mechanics continue for about 2 to 4 months until restoration of anterior and posterior teeth overjets. Afterward, remove the composite buildups and pursue further stages of treatment, including closing the resulting open bites, using finishing archwires and intermaxillary elastics to bring treatment to the normal occlusal standards. When dealing with more severe skeletal cases, torquing of stainless steel 0.016" x 0.022" Orthodontic practice 37

CONTINUING EDUCATION

in order to deliver lighter and more consistent expanding forces than traditional expanders. Despite the success using all these laboratory-dependent expanders, their costly clinical and lab fabrication procedures have added to patients’ inconvenience and made finding a simpler treatment strategy a professional requisite. Most expanders deliver their vigorous expansion forces from the lingual surfaces of the posterior teeth. Thus, the question is, Why have there not been attempts in the past 100 years to apply forces from the buccal surfaces of teeth by activating archwires? This article offers an alternative concept and rationale that satisfies this objective.

CONTINUING EDUCATION archwires or larger (Figure 4) can restore the normal crown’s overjet, and correct the abnormal bucco-lingual roots axial inclinations often found in crossbites, and help establish stability (Figure 5).

Torquing effects Torquing activations of maxillary and mandibular stainless steel rectangular archwires acting on posterior teeth, as illustrated in Figure 4, will correct the bucco-lingual axial inclination of posterior teeth and finish the correction of bilateral crossbites. Upon inserting the torqued distal parts of archwires in the molar tubes and premolar brackets, moments at the molar tube sites start to expand maxillary posterior teeth crowns and push their roots lingually, while the same direction torque on mandibular archwires constricts mandibular posterior teeth crowns and pushes their roots buccally, as illustrated in Figures 5A and 5B. Monitoring these mechanics is required at regular visits to avoid undesirable side effects. Overtreatment of 1 mm-2 mm per side helps minimize relapse. Finishing treatment will require the use of bite closing and/ or intermaxillary elastics to achieve normal occlusal standards and intercuspation.

Figure 5A: Shows the effects of inserting the maxillary stainless steel torqued archwire in both maxillary molar tubes. The equal and opposite moments acting inside molar tubes will increase maxillary intermolars width and correct their correct (in purple), the abnormal (in torques), bucco-lingual axial inclination. V-bends do not create forces. They result in equal and opposite moments only with no forces.

Figure 5B: Effects of similar torquing directions on mandibular archwire when inserted into the molar tubes. Note the equal and opposite moments constricting mandibular intermolar width, and correct their abnormal bucco-lingual axial inclination, which provide better stability

Patient 1 Patient 1: Top row shows intraoral photographs of a 16-yearold female patient with a left posterior crossbite involving a segment from left lateral incisor to second premolar. Second row shows an initial NiTi wire with a 6 mm step-up bend fully engaged to brackets of those blocked-out left maxillary teeth to intrude and disengage them as an initial step. Mandibular 0.016” x 0.022” NiTi archwire with intrusive V-bends and composite buildup placed on the left molar enhanced disengagement. Third row shows treatment images showing the halfway movement of the affected canine and premolars before removing the composite. Fourth row shows posttreatment intraoral photographs after 7 months of treatment

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Patient 2: Top row shows pretreatment models of a 14-yearold female patient with a severe skeletal Class III (7 mm underjet), and bilateral posterior crossbite. Treatment plan called for mandibular first premolars extraction, consolidating existing spaces, and using V-bend 0.016" x 0.022" NiTi archwires, which intruded mandibular incisor teeth to create a torque that prevents incisors tipping during the space closing forces. Later, stainless steel archwires helped stabilized retraction of the mandibular incisor teeth. Second row shows final stage of treatment with both bilateral crossbite and Class III malocclusion corrected. Third row shows posttreatment intraoral photographs 3 years after retention. Fourth row illustrates that the posttreatment panoramic and cephalometric radiographs show no root resorption

Patient 3 Patient 3: Top row shows intraoral pretreatment photographs of a 14-year-old female patient with a right unilateral posterior crossbite, anterior crowding, and Class III canine relation. Treatment called for four premolar extractions and crossbite correction. Second row shows that after alignment, the interlock, the composite buildups on mandibular molars enhanced by the bend. Bends on maxillary and mandibular 0.016" x 0.022" NiTi archwires disengaged posterior teeth. Third row shows the correction of crossbite and Class III relations have been achieved at the finishing stage. Bottom row shows the posttreatment photos using this technique

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Orthodontic practice 39

CONTINUING EDUCATION

Patient 2

CONTINUING EDUCATION Patient 4 Patient 4: First row shows the pretreatment photographs of a 14-year female patient with severe left side posterior crossbite and deep Class III malocclusion. Second row shows the use of composite buildups and the V-bend NiTi archwires disengaged posterior and anterior teeth on both side, and facilitated correction of the massive crossbite and Class III occlusion. Third Row shows posttreatment photos. Fourth row shows pre- and-posttreatment cephalometric radiographs exhibiting improved incisal relation without root resorption

Patient 5 Patient 5: Top row shows retreatment intraoral photos of a 15-year-old female patient with total right unilateral posterior crossbite and Class III malocclusion. Second row shows the intrusive effects of the V-bend 0.016â&#x20AC;? x 0.022â&#x20AC;? NiTi archwires disengaged anterior and posterior teeth in the right side without composite buildups, allowing effective transverse forces of activated archwires to correct this massive crossbite and the Class III relation as well. Bottom row shows the posttreatment intraoral photos

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Patient 6: Top row shows pretreatment intraoral photographs of a 13-year old female patient with a bilateral crossbite and class III tendency. Nonextraction treatment was performed using the V-Bend technique as usual. Second row shows post treatment photographs.

Discussion This article presents a diagnostic rationale for the difficulty of current strategies of crossbite correction and provides a solution for them. Molar cusp blockage accentuated by the persistent shift of chewing acts as an anchorage to elicit unwanted undesirable expansion of the normal side of maxillary teeth only. This article illustrates how Bendistal pliers can place V-bends on NiTi archwires, which launches light and consistent forces that create moments that facilitate the correction of crossbites and Class III malocclusions simultaneously. Furthermore, it shows how torquing stainless steel rectangular archwires can help restore normal bucco-lingual axial inclinations of the teeth involved in the crossbites and enables the corrections. This approach conserves chair time, laboratory time, and cost involved in expander’s custom-making and provides convenience to patients and orthodontists who can correct these challenging orthodontic problems by activating adjustment of regular archwires during patient’s routine visits. OP

REFERENCES 1. McDougal PD, McNamara JA Jr, Dierkes JM. Arch width development in ClassII patients treated with the Fränkel appliance. Am J Orthod. 1982;82(1):10-22. 2. Brin I, Ben-Bassat Y, Blustein Y, et al. Skeletal and functional effects of treatment for unilateral posterior crossbite. Am J Orthod Dentofacial Orthop. 1996;109(2):173-179.

Monitoring these mechanics is required at regular visits to avoid undesirable side effects. Overtreatment of 1 mm-2 mm per side helps minimize relapse. Finishing treatment will require the use of bite closing and/or intermaxillary elastics to achieve normal occlusal standards and intercuspation.

6. Erdinç AE, Ugur T, Erbay E. A comparison of different treatment techniques for posterior crossbite in the mixed dentition. Am J Orthod. Dentofacial Orthop. 1999;116(3):287-300. 7.

Boyson B, La Cour KA, Thanasiou AE, Gjessing PE. Threedimensional evaluation of dentoskeletal changes after posterior cross-bite correction by quad-helix or removable appliances. Br J Orthod. 1992;19(2)97-107.

8. Wedrychowska-Szule B. [Treatment of lateral cross-bite with active plates in condition of raised dental occlusion and by the quad helix method]. [Article in Polish] Ann Acad Med Stetin. 1995;41:233-243. 9. Bench RW. The quad helix appliance. Semin Orthod. 1998;4(4):231-237. 10. Erverdi N, Okkar I, Kücükkeles N, Arbak S. A comparison of two different rapid palatal expansion techniques from the point of root resorption. Am J Orthod Dentofacial Orthop. 1994;106(1):47-51. 11. Braun S, Bottrell JA, Lee KG, Lunazzi JJ, Legan H. The biomechanics of rapid palatal expansion. Am J Orthod Dentofacial Orthop. 2000;118(3):257-261. 12. Memikoglu TU, Iseri H. Effects of a bonded rapid palatal expansion appliance during orthodontic treatment. Angle Orthod. 1999;69(3):251-256. 13. Toroglu MS, Usel E, Kayalioglu M, Uzel I. Asymetric maxillary expansion (AMEX) appliance for treatment of true unilateral posterior crossbite. Am J Ortho Dentofacial Orthop. 2002;122(2):164-173.

3. Firatli S, Ulgen M. The effects of the FR-3 appliance on the transversal dimension. Am J Orthod Dentofacial Orthop. 1996;110(1): 55-60.

14. Chang JY, McNamara JA, Herberger TA. A longitudinal study of skeletal side effects induced by rapid maxillary expansion. Am J Orthod Dentofacial Orthop. 1997;112(3):330-337.

4. Kirjavainen M, Kerjavainen T, Haavikko K. Changes in dental arch dimensions by use of an orthopedic cervical headgear in ClassII correction. Am J Orthod Dentofacial Orthop. 1997;111(1):59-66.

15. Bell RA, LeCompte EJ. The effects of maxillary expansion using a quad helix appliance during the deciduous and mixed dentitions. Am J Orthod. 1981;79(2):152-161.

5. Kirjavainen M, Kerjavainen T. Maxillary expansion in ClassII correction with orthopedic cervical headgear. A posteroanterior cephalometric study. Angle Orthod. 2003;73(3):281-285.

Volume 10 Number 3

16. Bell WH, Jacobs J. Surgical-orthodontic correction of horizontal maxillary deficiency. J Oral Surg. 1979;37(12):897-902. 17. Lehman JA Jr, Haas AJ, Haas DG. Surgical-orthodontic

correction of transverse maxillary deficiency: a simplified approach. Plast Reconstr Surg. 1984;73(1):62-68. 18. Chung CH, Goldman AM. Dental tipping and rotation immediately after surgically assisted rapid palatal expansion. Eur J Orthod. 2003;25(4):353-358. 19. Wichelhaus A, Sander C, Sander FG. Development and biomechanical investigation of a new compound palatal arch. J Orofac Orthop. 2004;65(2):104-122. 20. Baldini G, Luder HU. Influence of arch shape on the transverse effect of transplalatal arches of Goshgarian type during application of buccal root resorption. Am J Orthod. 1982;81(3):202-208. 21. Ciambotti C, Ngan P, Durkee M, Kohli K, Kim H. A comparison of dental and dentoalveolar changes between rapid palatal expansion and nickel-titanium palatal expansion appliance. Am J Orthod Dentofacial Orthop. 2001;119(1):11-20. 22. Karaman AI. The effects of titanium maxillary expander appliances on dentofacial structures. Angle Orthod. 2002;72(4):344-354. 23. Ferrario VF, Garattini G, Colombo A, et al. Quantitative effects of nickel-titanium palatal expander on skeletal and dental structures in primary and mixed dentition: a preliminary study. Eur J Orthod. 2003;25(4):401-410. 24. Kenworthy CR, Sheats RD. A bonded functional ramp to aid in asymmetric expansion of unilateral posterior crossbites. Am J Orthod Dentofacial Orthop. 2001;119(3):320-322. 25. Tzatzakis V, Gidarakou I. Correction of anterior crossbite using occlusal buildups. J Clin Orthod. 2007;4(7):393-397. 26. Tzatzakis V, Gidarakou I. A new clonical approach for the treatment of anterior crossbites. World J Orthod. 2008;9(4):355-365. 27. Janakiraman K, Abadi S, Nanda R, Uribe F. An alternative method for correcting unilateral posterior crossbite with functional shift in an adult patient. J Clin Orthod. 2015;49(8):525-532. 28. Khouri SA. Using V-bends on NiTi Wires for nonsurgical correction of Class III malocclusions. Orthodontic Practice US. 2016;7(1):24-29.

Orthodontic practice 41

CONTINUING EDUCATION

Patient 6

REF: OP V10.3 KHOURI

FULL NAME

AGD REGISTRATION NUMBER

LICENSE NUMBER

ADDRESS

CITY, STATE, AND ZIP CODE

TELEPHONE/FAX

Please allow 28 days for the issue of the certificates to be posted.

A concept and approach for correcting posterior crossbites KHOURI

1. Clinicians have previously used composite buildups on anterior teeth _______. a. to open the bite b. to correct crossbites c. to prevent resorption d. both a and b 2. The therapy (the technique discussed in this article) starts by using ________ NiTi archwires for the initial alignment in both dental arches. a. 0.014" b. 0.016" c. 0.018" d. 0.020" 3. The use of ________ in this technique not only simplifies initial teeth alignment without loops, springs, or helixes, while their light and consistent forces of V-bend mechanics applied on both sides also simplifies intrusion and occlusal disengagement. a. stainless steel archwires b. Frankel appliances c. NiTi archwires d. acrylic expanders 4. A V-bend inserted _______ of a maxillary NiTi archwire will activate it to bilaterally and gently expand the maxillary posterior teeth. a. in the midline

42 Orthodontic practice

b. to the right c. to the left d. both b and c 5. These mechanics (using specific V-bends to active archwires to expand and/or constrict posterior teeth on the affected sides) continue for about ______ until restoration of anterior and posterior teeth overjets. a. 1 to 2 weeks b. 1 month c. 2 to 4 months d. 6 months 6. When dealing with more severe skeletal cases, torquing of stainless steel 0.016" x 0.022" archwires or larger can ________. a. restore the normal crownâ&#x20AC;&#x2122;s overjet b. correct the abnormal bucco-lingual roots axial inclinations often found in crossbites c. help establish stability d. all of the above 7. Torquing activations of maxillary and mandibular ________ archwires acting on posterior teeth, as illustrated in Figure 4, will correct the buccolingual axial inclination of posterior teeth and finish the correction of bilateral crossbites. a. stainless steel rectangular

b. multi-strand NiTi braided c. cobalt-chromium d. beta-titanium 8. (In the Torquing effects section) Overtreatment of _______ per side helps minimize relapse. a. 1 mm-2 mm b. 3 mm-4 mm c. 5 mm-6 mm d. none of the above 9. Finishing treatment will require the use of ________ to achieve normal occlusal standards and intercuspation. a. double elastics b. bite-closing elastics c. intermaxillary elastics d. both b and c 10. (According to the author) This approach conserves ________ and provides convenience to patients and orthodontists who can correct these challenging orthodontic problems by activating adjustment of regular archwires during patientâ&#x20AC;&#x2122;s routine visits. a. chair time b. laboratory time c. cost involved in custom-making expanders d. all of the above

Volume 10 Number 3

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TECHNOLOGY

Taking control of aligner planning Dr. Tim Dumore outlines the steps for an easy and efficient aligner workflow

he book, Who Moved My Cheese, by Dr. Spencer Johnson is a motivational business fable that encourages readers to acknowledge a change in their environment and learn to adapt if they wish to survive. While it was written 20 years ago, its message is more relevant than ever, and it certainly applies to our world of orthodontics. Orthodontics is currently in a time of massive change. The reality is that the orthodontic industry is experiencing one of the most significant paradigm shifts in its history, and I am excited to have the opportunity to participate. When I finished my residency 20 years ago, these were the trends: • Alginate impressions were used to make plaster casts. Intraoral scanning was still years away. • Photos consisted of slides taken with an analog camera. • Cephalometric and panoramic X-rays used film. Digital X-rays were just emerging, and CBCT didn’t exist in the orthodontic practice. • Conventional brackets and bands were the orthodontic appliance of choice. Self-ligating brackets were a minor consideration, and aligners had not yet been invented. • Websites and social media? Corporate dentistry? Direct-to-consumer aligners? They were not even on the radar. It’s safe to say that things have changed a little since then, but the degree to which orthodontic practices have adopted these currently available technologies varies widely. While all of these things have affected my practice, the most significant change in my clinical workflow is the incorporation of in-office fabricated aligners. I want to share

with you my experience and perhaps offer some insight. First, a little background to show you how my practice evolved into one with a strong focus on in-house aligners. Like many orthodontists, I’ve always been a bit of a sucker for technology and toys, and I’ve tried to use it to benefit the patients in my practice. • I was an early adopter of the following: ❍ OrthoCAD iQ for indirect bonding ❍ Laser treatment • I was the first to adopt all of the following in Canada: ❍ Planmeca digital ceph-Pan

❍ iTero® ❍ Objet30 Printer And now I can add to my list of firsts to adopt in Canada — uLab Systems aligner planning software. What started with printing models for IDB and minor tooth movement cases has evolved to the point that all my retainers are made from printed models. Every patient is scanned pre-and post-treatment. (We have been alginate-free for almost 5 years.) Most finished cases receive a few finishing aligners, and the vast majority of our aligner treatment is done in-house. We treat the entire

Figure 1: Pre-treatment intraoral photographs

Tim Dumore, DMD, BSc, MSc, practices at Dr. Dumore & Team Orthodontics, located in Winnipeg, Canada. His motivation is to help orthodontists take back control of their aligner world, while increasing the number and complexity of aligner cases in their practice. Disclosure: Dr. Dumore currently works with uLab as a clinical advisor and is also on the board.

Figure 2: Pre-treatment intraoral scan views 44 Orthodontic practice

Volume 10 Number 3

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TECHNOLOGY

Figure 3: Pre-treatment intraoral scan occlusal views

spectrum of aligner cases from straightforward cases with a few aligners to very challenging case treatment.

How has this benefited my practice? Some clinicians feel that a scanner and 3D printer are too expensive or still too cutting-edge and are not comfortable being early adopters. The reality is that this technology is well past the cutting-edge and primed to advance to more of the market. At orthodontic meetings and in orthodontic publications, there are many examples of doctors who have adopted this workflow and are making it work. Many practices that have switched to intraoral scanning are just using the data for diagnostic models and aligner-manufacturing submissions and are missing out on the ability to manufacture aligners in-house. Rather than submitting my scans to a company with facilities in another country, I’m more comfortable knowing that the work is kept on home soil, in my office. Other workflow concepts often require multiple time inputs between the dentist and the aligner manufacturing company, and that workflow consumes many hours of doctor time each week. However, when creating aligners, I’ve found that a software program called uLab Systems has simplified my in-house aligner process. In fact, I would say

Figure 5A: Model trimming with uLab 46 Orthodontic practice

Figure 4: uLab initial occlusal views

this software program saves me a significant amount of time versus my previous more manual method of piecing together multiple software programs. Once I have finished planning using this technology, I can immediately begin the aligner fabrication process. In my practice, I use uLab for full cases and also for finishing hybrid or combination treatment where I switch between braces and aligners (or vice versa), Phase I treatment, and relapse cases. The essential workflow is to scan the patient, use that data to plan the aligner treatment plan, print the models, and then use the models to thermoform and produce the aligners. I’ll go through each of these steps.

Scan According to an informal survey conducted the by the Journal of Clinical Orthodontics, 62% of respondents indicated they now use an intraoral scanner. The speed of scanning has increased such that it can be faster than taking alginate impressions once the time of prep and cleanup is factored in, and the majority of patients prefer being scanned to having a tray of alginate stuffed in their mouth for 2 minutes. In the world of Who Moved My Cheese, alginate is that hunk of moldy cheddar that has been forgotten at the back of the fridge! Some doctors worry about the cost and learning curve of transitioning to intraoral

scanning, but those are minimal obstacles. At the very least, an intraoral scanner is the entry point for in-house aligners. The question of which scanner to buy is indeed relevant, but most aligner programming software will accept any STL (the output file type of most scanners). Once the patient is scanned, I get that data from the scanning software and transfer it to the program that I will use for designing my virtual treatment. The raw scans on the scanning monitor look pretty, but in fact, typically require a significant amount of “cleanup” before they can be used in another program. Just like plaster needs to be trimmed after pouring, the data needs to be trimmed as well. This process can be cumbersome. I find uLab’s software simplifies the process as it is done automatically and takes just seconds. Once the data is in the programming software, additional work is needed to help the program identify the teeth, along with tooth anatomy landmarks that will be referenced for tooth movement. A great strength of this software program is the speed and ease with which it takes the raw data and gets it to the point where the doctor can begin planning tooth movement. Keep in mind, all of the work done up to this point has been completed by one of my team members, so it hasn’t cost any of my valuable time. Do note, however, that operating a scanner does have some

Figure 5B: Model segmenting with uLab Volume 10 Number 3

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TECHNOLOGY

Figure 6A: Choosing the setup with uLab

cost beyond the purchase price of the unit. Typically, there are monthly fees as well as consumables such as scanner sleeves. However, the switch to intraoral scanning has been cost-effective and efficient in my practice.

Plan With the virtual models prepared, I am ready to program tooth movements. For years this has been the missing puzzle piece. How can I create an end-to-end aligner movement plan on my own? A clean version of the software that did it all didn’t exist. uLab makes this process easy for the doctor. A “pre-setup” function generates an initial aligner plan that I can assess and adjust using uLab’s intuitive adjustment tools until the movement sequencing and final occlusion are visualized. With the program’s built-in artificial intelligence, the quality of the preset up will continue to improve with time. The program does allow for IPR and attachment placement at the orthodontist’s discretion as well as staging and rates of tooth movement. In my practice, simple cases where I’m programming two to four aligners at debonding might take a minute or two of my time while the most complex cases might take 10 minutes or so. Either way, once I’m done, I’m done, and I won’t need to think about that case again until I see the patients in the chair to check their aligners. There may be some fear about the difficulty of creating one’s own aligner treatment plans, but clinicians who have experience with aligners in general have the background to plan treatment cases on their own. Dentists can also increase their knowledge base in the following ways: • Attending in-office courses (Drs. Ed Lin, Jason Cope, Bill Laymen, and David Kemp) • Signing up for the excellent online course such as Aligner Fellowship 48 Orthodontic practice

Figure 6B: Adding Attachments with uLab

by Drs. Jonathan Nicozisis and Maz Moshiri • Purchasing great books such as Clear Aligner Technique by Dr. Sandra Tai and Insider’s Guide to Invisalign Treatment by Dr. Barry Glaser • Joining many great Facebook groups such as the Ortho 3D Aligner Study Group where dentists can learn and ask questions from others with experience and new users as well who likely have the same questions

Print models Once I have programmed my virtual aligner stages, I turn it into reality. The individual model files need to be prepared for printing, including labeling the stage number on the model and patient information on the model base. Additionally, the models need to be organized so that the printer can print to its capacity. This can be a very timeconsuming process with some programs. Thankfully, uLab does this all automatically in seconds. It is possible to send these print files to an outside lab, and that may be a good option for some practices. However, the benefit of having my own 3D printer as part of my in-house lab is enormous. The cost of 3D printers used in orthodontics has come down significantly while the capability has steadily increased so that owning a 3D printer is a very reasonable option. For this process, I dedicated some space in my existing lab for the printer and post-processing.

Create aligners Once I have printed the models, it is simply a matter of thermoforming plastic over the models, then trimming and polishing them. This necessitates a good quality thermoforming machine such as the Biostar® or Drufomat, along with an electric lab handpiece. uLab has a trimming tool called the

uContour that uses a trim line generated within the software to automatically trim the aligners as fast or faster than a human without the physical wear and tear on the lab technicians’ body. The next version of the uContour that is in development will allow the clinician to load at least 12 models at once so that the technician can perform other duties while the machine works. Another consideration is what material to use for the aligners. There are a number of excellent quality materials available on the market that effectively move teeth for a dollar or two per sheet.

Packaging and branding For years, we packaged our finished aligners in Ziploc® bags and used DYMO labels to identify the individual packages but realized that the quality of the packaging should reflect the quality of our product. Professionally produced packaging is inexpensive and allows me to deliver the aligners with my own practice branding.

Turnkey This hopefully reinforces what those who are already producing aligners in-house have done in practice. To help those who are new to this concept, uLab is breaking down the entire process from start to finish and developing a turnkey model that will guide the clinician through the process of integrating in-house aligner treatment. The key to it all, in my opinion, is keeping your aligner manufacturing in-house to reduce turnaround time and cost. For patients who are eager to begin treatment, same-day starts can become a reality. By taking control of the entire process, my colleagues can gain the ability to do what’s best for their patients and practice, just as I have. To go back to my earlier reference of Who Moved My Cheese, you have a choice between having stale cheese (or losing all your cheese?) or brandnew cheese for years to come! OP Volume 10 Number 3

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PRACTICE DEVELOPMENT

Five ways to differentiate your orthodontic practice Rich Carnahan discusses ideas to set a practice apart from the competition

hat makes your orthodontic practice different? If “We really care about our patients” flashed through your mind, you have officially joined the ranks of thousands of other orthodontists, including some in your market, who think the same thing about their practice. Unfortunately, with so many doctors making this claim, caring is no longer a differentiator. The good news is there are many types of differentiators you can use to set yourself apart from your competitors.

Why you need differentiators as an orthodontist As the desire for healthier, more attractive smiles grows in the United States, so does the number of orthodontists. In 2014, the Bureau of Labor Statistics estimated that practicing orthodontists would increase by 18% by 2024.1 Dentists, some of whom also offer orthodontic services, were also expected to grow at the same rate. With approximately 8,600 orthodontists actively practicing as of October 2018, it’s no surprise that the competition for patients, especially in more populated areas, is fierce.2 Having differentiators will help you stand out from the competition and attract more patients who will then become ambassadors of your practice and refer more patients.

Types of differentiators There are five different differentiation strategies: 1. Price differentiation 2. Product differentiation 3. Service differentiation 4. Relationship differentiation 5. Reputation differentiation While price is probably the most wellknown differentiator, the other four can also be applied to your practice. We’ll talk about

Rich Carnahan (rcarnahan@orthosalesengine.com) is the co-founder and senior consultant for Ortho Sales Engine, a Charleston, South Carolina-based growth agency focused exclusively on orthodontics. Since its inception in 2016, the company has been exponentially increasing new starts for its clients, and its blog, “The Ortho Marketer,” has been gaining momentum as a premier orthodontic marketing resource.

50 Orthodontic practice

each one separately, share ways to incorporate them into your practice, and give examples of how you may already be using some of them. 1. Price differentiation Differentiating yourself by offering extremely low prices is fairly easy to do, but it can be hard on your bottom line, especially if your competitors decide to match your offers, which means you have to lower your prices even more. Fortunately, there are other ways to use price to set your practice apart. If your competitors don’t accept many insurance plans, offering this option to patients can make treatment less expensive for them without reducing your profit. Offering permanent discounts to select groups of people (teachers, healthcare workers, firefighters, etc.) is a nice way to give back and encourages members of these groups to come to you for treatment, while offering monthly promotions with deeper discounts can temporarily differentiate your practice and encourage new patients to try your services. 2. Product differentiation Product differentiation is exactly what it sounds like: You can set yourself apart

by offering a different product than your competitors. It’s reasonable to assume they are offering braces and some form of clear aligner, just like you and every other orthodontist in the U.S. But there are different products you can offer to potential patients. If tweens and teens make up the majority of your patients, or if you want to increase the number of patients in this age group, WildSmiles® are braces with different bracket shapes that appeal to younger patients and are as effective as braces with square brackets.3 If you have a popular college sports team in your area, you can look into becoming the exclusive provider of Mascot Braces® for that team.4 Other product differentiator options include gold braces, lingual braces, and selfligating braces. None of these products are particularly new to the market or hard to find. In fact, you may already be offering some or all of them. But if your main competitors don’t have one of these products and you do, that may be reason enough for a patient to come to your office instead. 3. Service differentiation You can differentiate your practice both with the services you offer and how you service your patients. Volume 10 Number 3

4. Relationship differentiation While this may sound similar to the “We care about our patients” mentioned in the first paragraph, it is possible to differentiate your practice based on the relationships you have with your patients. Believe it or not, having a smaller practice and only one location can be seen as a positive by some patients. If you are competing with an orthodontist with multiple offices and dozens of staff, emphasize the personal relationships your patients will have with your team because they see the same people at every appointment instead of whoever is available or working in a certain office that day. Or make a point to see every patient at every appointment, even if it’s just for a quick greeting or to answer any questions about his/her treatment. It may seem like a small gesture to you, but it matters to your patients and their families. 5. Reputation or image differentiation This differentiator is similar to relationship differentiation because it is based on your patients’ perception of you rather than something concrete like a product or hours of operation. Before you try to differentiate your practice this way, you should decide what reputation or image you want to have. If you want to appeal to kids, having a reputation of being fun or silly (while still providing quality treatment) can make you different from your competitors and appealing to parents who Volume 10 Number 3

Having differentiators will help you stand out from the competition and attract more patients who will then become ambassadors of your practice and refer more patients.

don’t have to drag their kids to their orthodontic appointments. If adults looking for Invisalign® make up your target market, having a more serious, grown-up image can attract the patients you are looking for. One of the best ways to project a reputation or image differentiator is through your website and on social media. Posting pictures of you and your staff wearing flannel PJs on National Pajama Day or having a silly string fight in your office on your Facebook and Instagram pages shows you are a fun place kids will want to visit. Having informative, well-written blogs and page content on your website helps solidify your reputation as an expert in your field, and someone patients can trust with their care. Sharing stories about your team’s involvement in local service projects portrays you as a valuable member of your community who likes to give back.

promotions, he has the base price for his silver braces prominently displayed in all of his marketing. If patients want to upgrade their treatment by adding bells and whistles (gold or ceramic braces instead of silver, different-shaped brackets instead of rectangular ones), there is an extra fee. This transparency of price lets new patients know what they’re going to pay before they even walk through the door, eliminating the sticker shock that can turn some people away. Two orthodontists combine image and service differentiation. One offers a lifetime guarantee on a patient’s smile. If a patient’s teeth shift at any point after his/her treatment is complete, the practice will fix the issue for only 10% of the cost of the initial treatment. The other offers noninvasive cosmetic treatment and spa services in her office, making it a one-stop shop for patients wanting to improve their image and well-being.

Truly unique differentiators

Finding the right differentiators for your office

We aren’t saying you should apply these particular differentiators to your practice. We are just pointing out that you shouldn’t be afraid to get creative. A common instruction orthodontists give patients with new braces is to eat soft foods and apply an ice pack or drink something cold to relieve any discomfort. One doctor takes it a step further by providing ice cream to his patients. And it’s not just a little cup of pre-packaged ice cream; he has an actual ice cream shop in his office with two different flavors that his patients vote on every month. That’s quite an image differentiator. Another orthodontist is using price differentiation with a twist. Instead of offering discounts to select groups or monthly

It’s important to choose differentiators that make sense for your practice. Review your patient personas to determine what type of people you want to attract. Do some competitive analysis on practices in your area to see what differentiators they are using and make sure you do something else that makes you stand out. And finally, select differentiators that you can live with. If lowering prices keeps you up all night worrying about your bottom line, or you can’t tell your patients to watch their sugar intake and offer them ice cream in the same visit with a clear conscience, don’t put these practices in place. There are many other ways to make you and your practice memorable. OP

REFERENCES 1. Burger D. Orthodontists, dentists atop list of best jobs in U.S. ADA News. Jan 26, 2019. https://www.ada.org/en/publications/ ada-news/2016-archive/january/orthodontists-dentists-atop-list-of-best-jobs-in-us. Accessed April 22, 2019. 2. Henry J. Kaiser Family Foundation. Professionally active dentists by specialty field. March 2019. https://www.kff.org/other/stateindicator/dentists-by-specialty-field/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%2 2asc%22%7D. Accessed April 22, 2019. 3. WildSmiles website. https://www.wildsmilesbraces.com. Accessed April 22, 2019. 4. Mascot Braces website. https://www.mascotbraces.com. Accessed April 22, 2019.

Orthodontic practice 51

PRACTICE DEVELOPMENT

Orthodontic surgery, TMD treatment, early orthodontics, sleep apnea correction, and orthognathic surgery are services not all orthodontists offer. Having these services available at the same place where they will get their braces or clear aligners can be enticing to potential patients, so it’s important to promote them. How you serve your patients can also be a differentiator. For busy families with a single parent or two working parents, an orthodontist who has evening or weekend hours can be more attractive than one who is only open 8:00 a.m to 4:00 p.m. Monday through Friday, making extended hours a strong differentiator. If your competitors use an answering service or rely on voicemail for calls received after hours, having an on-call phone that is answered by you or a member of your team can set you apart, especially in the eyes of a parent whose child has an orthodontic emergency outside of business hours.

PRODUCT PROFILE

Gaidge® What it means to be a modern orthodontic practice In today’s business environment, practice owners must take on the CEO role to drive operations, efficiencies, profitability, and strategy. With the changing orthodontic market, practices have more external pressures than ever before. To thrive, growth must be pursued, while also navigating a competitive climate where general dentists are offering more orthodontics, corporate dentistry is driving costs down, and directto-consumer solutions are having an impact on patients’ willingness to pay as well as their understanding of quality clinical outcomes. Successful business leaders, interested in even basic sustainability have been relying on data for fact-based decision-making for over a decade. When one is looking for growth and expecting profitability, the need is compounded. Data analysis, business intelligence, and insights have become requirements for successful decision-making in all industries. While “big data” has been around for some time, we continue to face the problem of what to do with it all. How do we make use and make wise decisions from all the information that we have gathered? Large companies have teams of analysts as standard practice, pulling everything from quarterly financial data to individual customer trends by product, time of purchase, method of purchase, and so on. And yet, the data must be synthesized in such a way that leaders can understand,

Suzanne Wilson joined Gaidge as the Chief Marketing Officer in September 2018. She has held leadership positions in operations, marketing, and business development in the oral care industry over the past 20 years. She earned her Bachelor of Arts in English and Executive MBA from the University of Utah. To learn more, visit https://www.linkedin.com/in/suzanne-wilson-8a158b1a/.

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digest, and determine a path forward. This is where we are seeing the greatest opportunity.1 Data science is a relatively new field that has emerged due to the need to gather, understand, and communicate large sets of information in simple actionable ways. It takes on the latest stumbling block: making all the information we have at our fingertips meaningful.2 Gaidge® answers the complicated question of what to do, and how to do it. We bring the analysis and the data science to the orthodontic practice.

Powering your practice with data analytics The Gaidge platform’s powerful features work seamlessly to give you unprecedented visibility into your practice’s performance, essential business metrics, and your most important goals. Gaidge is a business intelligence software, custom-designed for orthodontists. It fully integrates with your practice management software for seamless operations. More importantly, Gaidge provides significant timesavings and automation for up-todate information about your practice. The Gaidge software takes large data sets stored in practice management software databases and synthesizes it into easy-to-understand dashboards that provide actionable business insights about performance. It also features goal setting tools, comparisons, and benchmarks so that you can construct your unique path to progress. Fifty years of combined experience in practice operations and software technology laid the foundation for the knowledge required to bring data analytics and data science to the business of orthodontics. Gaidge was founded by a need to support the highly detailed work of practice management consultants, increasing efficiency and value during the consulting process with the end goal of helping clients’ businesses improve and thrive in a way that was sustainable daily. Gaidge users describe the software as an essential tool3 that is easily accessed via

desktop or mobile. It features customized permissions so each member of the office can participate and contribute. Gaidge practices are also part of a community with access to national and regional comparison metrics, so they can see how they perform compared to others like them. The company offers robust onboarding support, data entry protocols, user meetings, CE webinars, and online communities for tips, sharing, and updates. For the modern orthodontic practice, there is an abundance of choices to explore when considering how to best run the business and how resources should be allocated. The first step is to know and understand the key performance indicators (KPIs) that communicate the health, efficiency, and profitability of your practice. It is our goal to enhance knowledge and improve the quality of decisions while reducing the time it takes to get there, so clinicians and teams can better focus on patient care and a positive treatment experience.

About Gaidge Gaidge is an essential business management tool that provides business intelligence dashboards, benchmarking, and performance comparisons for orthodontic practices. Our cloud-based analytics software provides 80-plus metrics daily on the health and progress of the practice, increasing business acumen and enhancing productivity and satisfaction for doctors and their staff. Gaidge fully integrates with the leading practice management systems to ensure accuracy and to streamline office functions and operations. To learn more, visit www.gaidge.com. OP REFERENCES 1.

Bean R, Davenport TH. Companies are failing in their efforts to become data-driven. Harvard Business Review. February 5, 2019. https://hbr.org/2019/02/companies-arefailing-in-their-efforts-to-become-data-driven. Accessed April 8, 2019.

2. Bowne-Anderson H. What data scientists really do, according to 35 data scientists. Harvard Business Review. August 15, 2018. https://hbr.org/2018/08/what-data-scientists-really-do-according-to-35-data-scientists. Accessed April 8, 2018. 3. Gaidge. https://www.gaidge.com/. Accessed April 8, 2019.

Volume 10 Number 3

The Metrics of Winning Data analytics that drive your practiceâ&#x20AC;&#x2122;s performance.

Ready. Set.

Learn more at Gaidge.com or 800.287.3396.

PRODUCT PROFILE

Bond Aligner™ Solution: Bonding attachments to clear aligners

ears in development, Bond Aligner™ was specifically designed to address the inability to bond to clear aligners. Recognizing that weak link in the adhesive world, we felt we could offer a definitive answer. The lack of the ability to bond to clear aligners has been a huge detriment and frustration for clinicians reducing the number and types of cases that can be treated with clear aligners and the ability to facilitate optimal treatment outcomes. Treatment planning and setup as well as clinical troubleshooting are critical to getting optimal results with CAT. To this end, products like Bond Aligner™, developed by Reliance Orthodontic Products, in conjunction with Dr. Laurel Martin, are being designed to address the inability to bond to clear aligners. Sandblasting or roughening up the surface of the aligner was attempted as an early solution to address bonding to clear aligners. With Bond Aligner™, clinicians have the convenience of simply applying this adhesive to the base of any desired auxiliary, placing it on the aligner, and light curing. No matrix preparation or primers are necessary. The newest technology provides an even more

Aligner attachments with elastics to TADs 54 Orthodontic practice

Stainless steel buttons bonded to aligner

esthetic solution for intraoral buttons. By removing metal buttons from the equation, the patient’s smile will disclose only clear material. This is achieved by simply filling a silicone mold that will produce a retentive button once polymerized. This adhesive has several unique characteristics. The most important, however, is a low modulus of elasticity within the resin matrix allows the retainer to be twisted and flexed without the bond failing. After the auxiliary is light cured, the bond strength of Bond Aligner™ is such that the auxiliary is often difficult to remove. A button, cured to the surface of an aligner with Bond Aligner™, generally needs to be removed with a dental handpiece and bur. Bond Aligner™ will adhere to most clear thermoplastic aligner materials. Before Bond Aligner™, it was often necessary to make cuts or remove small

sections of an aligner to allow for the bonding of an auxiliary directly to a tooth surface. As a detrimental consequence of those reliefs, the mechanical integrity of the aligner is compromised at the cutaway site resulting in a weak spot in the aligner. In addition, the reduction in adaptation of the aligner to a tooth adversely impacts the biomechanical forces at the site relieved, reducing the aligner’s ability to facilitate tooth movement and function properly. Finally, unwanted movement can occur at the tooth being used as an anchorage site. All of the above are reasons for the need to bond to an aligner rather than directly to a tooth to achieve the tooth-moving forces that are wanted and to eliminate those that are not. When minor tooth movement is desired to fine-tune an aligner case, small dimples are often placed in an aligner using dimpling pliers. Filling retention dimples with Bond Aligner™ will reinforce the detail dimple, thus preventing collapse and optimizing the movement achievable with those dimples. By placing those dimples in the aligner at tooth undercuts interproximally, the dimples can also be used to increase retention of an aligner. Again, Bond Aligner™ can be used to back up this function. The ability to bond auxiliaries to aligner materials results in more optimal reliable CAT, not to mention fewer emergency visits as a consequence of debonding of auxiliaries. Difficult movements with aligners are now possible with more reliable results including, but not limited to, single tooth intrusion, segmental intrusion, anterior/posterior arch coordination, root uprighting, anterior extraction, posterior extraction, posterior intrusion, and even full arch intrusion. The end result is improved practice efficiency and increased satisfaction for both the clinician and the patient. OP This information was provided by Reliance Orthodontic Products.

Volume 10 Number 3

Missing Teeth? Want Aesthetics and Simplicity?

Perfect A Smile®

Before Perfect A Smile®

Perfect Smile!

Perfect A Smile® and a clear thermoplastic tray is ideal for: • Missing or lost teeth during clear aligner therapy. • Temporary teeth during bone graft healing. • Implant restorations after placing posts. • Congenitally missing teeth.

EIGHT NEW SHADE S! C oming Soon

Simple and fast application of Perfect A Smile®

Beautiful aesthetics for missing teeth is now Easy, Fast, Perfect! • Developed by Orthodontist Dr. Laurel Martin, Perfect A Smile® is the easy, fast solution for pontic replacement of missing teeth.

• Perfect A Smile® flexes with the plastic and will not fail due to stress or flex.

• Perfect A Smile® bonds directly to clear thermoplastic aligners – no conditioner or plastic preparation is needed. Simply paint the inside of the aligner tooth socket and light cure.

• Eight new shades coming soon • You can mix paint for custom shades if required.

Invisalign® is a registered trademark of Align Technologies, Inc.

For more information, contact… (800) 323-4348 • (630) 773-4009 • Fax (630) 250-7704 www.RelianceOrthodontics.com

PRODUCT PROFILE

3Shape Clear Aligner Studio The innovative all-in-one clear aligner software solution

Shape, a leading global innovator of digital 3D solutions for dental labs and practices, is changing dentistry by developing innovations that provide superior dental care for patients. In 2018, 3Shape launched an open clear aligner workflow that enables laboratories and practices, no matter what size, to enter the market and thrive in the attractive and profitable clear aligner market. With 3Shape Clear Aligner Studio, clinicians have the power to make aligners in their own offices, reducing patient waiting time, and increasing business by offering cost-effective and time-efficient same-day start of treatments. Clear Aligner Studio offers full control over orthodontic diagnostics, setup, and staging, and clear aligner production workflow. The Clear Aligner Studio digital workflow is made possible by the 3Shape TRIOS® intraoral scanner and offers seamless integration with a wide range of 3D printers. The intraoral scanner is supported by an ever-growing number of patient-excitement apps like TRIOS Treatment Simulator, TRIOS Patient Monitoring, and 3Shape Smile Design. The digital impression solution is recognized for its documented accuracy, scanning speeds, and ease of use. In addition this provides the opportunity for digital indirect bonding, which allows for digital treatment planning through guided and preference-based workflows, while reducing excessive materials and time spent on treatment planning. Digital indirect bonding improves patients’ experience and comfort, and saves chair time by bonding all brackets in one go, instead of applying brackets one by one with direct bonding.

The open and innovative 3Shape clear aligner workflow is made up of a growing network of integrated design and production service-providers supported by 3Shape technology. Depending on the expertise of the lab or practice wanting to provide clear aligner treatments, they can either outsource design and production to 3Shape partners, and/or design and produce in-house using 3Shape orthodontic software. 3Shape offers one of the largest number of integrations and partnerships and can connect users with an unrivaled range of collaborative workflows, design services, integrated bracket libraries, customers, and interfaces to virtually all manufacturing equipment and materials. TRIOS provides orthodontists connections to new clear aligner providers such as 3M™ Clarity™ Aligners, Orthocaps®, and ClearCorrect.

3Shape TRIOS is the proud winner of the Cellerant “Best of Class” award for a recordbreaking 6 years in a row. Orthodontists recognize the value of integrating this system in their practice workflow. Dr. Christian Groth, a Diplomate of the American Board of Orthodontics since 2012, noted, “Clear aligners are changing what we do. Because it’s bringing a whole new segment of patients to our office. There’s a lot of people who want to have orthodontics, but they don’t want to have metal braces and so; we have options now to offer treatment in a much more esthetic and streamlined fashion. Clear aligners are the primary way we do that. In my practice, moving aligner design and production in-house has been one of the greatest things we’ve done. It affects a lot of things we do; turnaround time is a major benefit.” Getting started with in-house aligners can be as simple or as advanced as the orthodontist wants to make it. You can bring the design and production of aligners in-house with software like Clear Aligner Studio, or bring a 3D printer online, and fabricate in-house. Or if you want to go more slowly, simply outsource the design and/or manufacturing portion just to deliver the treatment portion to your office. Feel free to mix and match, depending on you and your staff’s skill set and space requirements. Shape your practice’s future with 3Shape’s clear aligner treatment planning, design, and production prep. To learn more about how 3Shape can help you go digital today, visit www.3shape.com. OP This information was provided by 3Shape.

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Volume 10 Number 3

Ken Berley, D.D.S., J.D.

Steve Carstensen, D.D.S. Glennine Varga, R.D.A.

Learn from experts at the new ADA Dental Sleep Medicine Conference! ADA presents the new Dental Sleep Medicine Conference, held September 4-5 in San Francisco at the ADA FDI World Dental Congress. This two-day course has been designed from the ground up to give you the information and the process you need to support how you make Dental Sleep Medicine/Airway Therapy happen for you, your team, your professional colleagues, and your patients. Hear three of the leading experts in Dental Sleep Medicine explain each point in the ADA Policy Statement, supporting practical, you-can-do-this clinical wisdom with the latest in medical science and professional guidelines and protocols. Course code: 4113, CE Hours: 14 ADA FDI 2019 takes place September 4-8.