Orthodontic Practice US July/August 2019 Vol 10 No 4 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews

PROMOTING EXCELLENCE IN ORTHODONTICS

Dr. Robert Kaspers

The age of airway goes mainstream Drs. Barry Raphael and Mark Cruz

Time for a paradigm change Drs. Larry W. White, Reginald W. Taylor, and Matt Brown

Increased orthodontic retention and tongue posture Sarah Hornsby, RDH

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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 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.

ntroducing a new service to your orthodontic practice can be a daunting task. I often liken it to changing a tire while your car is speeding down the highway at 60 mph. Still, if you’re willing to make the effort, it can help grow your practice. This month’s issue of Orthodontic Practice US focuses on the emergence of sleep dentistry in orthodontics. Since the founding of the American Academy of Dental Sleep Medicine in 1991, sleep specialists and dentists have increasingly worked together to find solutions to help the approximately 50 to 70 million Americans with ongoing sleep disorders (CDC. MMWR Weekly. https://www.cdc. gov/mmwr/preview/mmwrhtml/mm5842a2.htm). Addressing key orthodontic treatment such as airway development, sleep dentistry is just beginning to gain a level of popularity with a small number of orthodontic practices. It’s a service that offers new hope to patients with sleep disorders and new opportunities for orthodontists seeking practice growth. If sleep dentistry is new to you, you’re probably wondering if it’s even worth exploring within your practice. I get it. Growing your practice is always your No. 1 goal (and has been Levin Group’s core mission for over 35 years), but it’s more comfortable to work with what you already have. When I counsel orthodontists on the best ways to grow their practices, I explain the four core pathways to build their businesses: 1. Sell more of your existing services to your existing customers. 2. Sell new services to your existing customers. 3. Sell your existing services to new customers. 4. Sell new services to new customers. The most obvious (and comfortable) paths for orthodontists to take are to sell more existing services (orthodontics) to new or existing customers (patients). However, playing it safe can mean missing out on bigger rewards or, even worse, missing out on the next big thing that will change the direction of orthodontics. Remember when aligners first came on the scene? Most orthodontists balked at the idea of aligner ortho, and many still do. And while we could have a pretty robust debate on the merits of traditional orthodontics versus aligner orthodontics, it’s clear that aligners are here to stay. General dentists are increasing aligner treatment by approximately 40% each year; aligner companies continue to expand within in the marketplace, and there are a growing number of companies offering direct-to-consumer aligners with or without a doctor appointment. While sleep dentistry may not be as game-changing as aligners have been, I’ve talked with several industry leaders and share their belief that it offers progressive orthodontic practices an excellent opportunity to add an entirely new service and revenue stream. Keep in mind that like any new service, there will be a learning curve. Remember the whole changing-the-tire scenario? Well, while you’re continuing to run your office, you must master new clinical techniques and understand important business management factors such as where referrals will come from, medical coding rules, insurance coverage, and all of the policies and procedures associated with sleep dentistry. It sounds like a lot, but remember, orthodontics is changing, and adding a new area of dentistry to your service mix is a great way to help set your practice apart in a highly competitive orthodontic field. There is help available to shorten the learning curve. Plus, it can be exciting and invigorating to tackle a new challenge. If sleep dentistry sounds as though it may be a good addition to your practice, I urge you to start planning sooner than later. Like any new trend, early players will have the advantage of building a brand and reputation that will generate buzz and increase referrals. It’s critically important for today’s orthodontic practices to remain focused on increasing the number of patients seeking traditional orthodontics, but it’s also an excellent strategy to add an entirely new service. Change can be risky, and mastering a new service may feel overwhelming, but new service options must be considered in order to keep orthodontic practices successful and growing. Sleep dentistry is one of those options. On whatever pathway you decide to take, I wish you continued practice success! Roger P. Levin, DDS Roger P. Levin, DDS, is the CEO of Levin Group, a leading dental management consulting firm. Founded in 1985, Levin Group has worked with over 30,000 dental practices. Through extensive research and cutting-edge innovation, Dr. Levin is a recognized expert on propelling practices into the top 10%. He has authored 65 books and over 4,000 articles on dental practice management and marketing. Dr. Levin sits on the editorial board of five prominent dental publications. He has been featured in The Wall Street Journal, The New York Times, and Time magazine and is the creator of the Levin Group Tip of the Day, which has over 30,000 subscribers. To contact Dr. Levin, visit www.levingroup.com, or email rlevin@levingroup.com.

ISSN number 2372-8396

Volume 10 Number 4

Orthodontic practice 1

INTRODUCTION

July/Aug 2019 - Volume 10 Number 4

Let sleep dentistry awaken new growth in your practice

TABLE OF CONTENTS

Case report SureSmile case report: DIY aligner generalized spacing case for superior control and cost-effective treatment

Publisher’s perspective Turn your dreams into reality .........................................................6

Dr. Edward Y. Lin discusses the steps to an affordable clear aligner treatment option

Continuing education How to diagnose and treat the fulcrum effect

Orthodontic concepts The age of airway goes mainstream

Dr. Robert Kaspers discusses the effect that the musculature and the occlusion have on the condylar position............................................20

Drs. Barry Raphael and Mark Cruz explain how “Airway” goes well beyond Obstructive Sleep Apnea

2 Orthodontic practice

Volume 10 Number 4

® COMPREHENSIVE SOLUTION. CONFIDENT OUTCOMES.

SureSmile has been empowering orthodontic professionals for over 20 years. 400,000 treatment plans later, it has become the go-to for the most powerful Treatment Management system in digital orthodontics. With one integrated platform, you have the power to choose options that best fit your practice. Plan lingual and labial bracket cases, including custom archwire, IDB design or hybrid therapy. Aligner options include SureSmile Aligners fabricated in our Tech Center or DIY aligners. SureSmile 360 delivers all the software, support, and appliance fabrication services you need to give each patient customized orthodontic treatment for the smile they want in the best possible way.

Start treatment planning today with greater confidence and predictability. Explore the transformative power of SureSmile treatment planning at suresmile.com

TABLE OF CONTENTS Technology Achieving excellence in orthodontics with digital technology Dr. Thomas R. Pitts discusses how digital technology can benefit the doctor, practice, and patients.......... 32

Marketing momentum 11 steps to branding your sleep practice for success Marc Fowler outlines how success depends on people knowing who you are............................................36

Practice management Offering care for OSA and temporomandibular joint disorders â&#x20AC;&#x201D; tips for billing

Continuing education Time for a paradigm change

Drs. Larry W. White, Reginald W. Taylor, and Matt Brown discuss diagnosis, treatment planning, and therapy for Class II malocclusions that rely on a blend of techniques

Christine Taxin discusses how to help patients get the necessary care and coverage ....................................... 38

Orthodontic concepts Practice development Materials & equipment Increased orthodontic retention and tongue posture Sarah Hornsby, RDH, discusses the benefits of myofunctional therapy as a multidisciplinary part of the orthodontic practice.......................................... 41

How to improve your orthodontic practice by texting with patients

Kenneth Burke discusses how texting can improve communication efficiency with patients....................................42

....................................................... 45

Industry news............... 46 Industry awards.......... 48

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

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Volume 10 Number 4

PUBLISHER’S PERSPECTIVE

Turn your dreams into reality

ecently, I had the exciting experience of interviewing Shaquille O’Neal for our publications. Shaq’s sleep (and health) have been impacted over the years by his sleep apnea, and our discussion primarily focused on his journey to finding a solution. Fortunately, we also had time to delve into his philosophy of life, his path to fulfillment, and future goals. Two of his basic tenets of life resonated with me, so much so that I wanted to share them with you in this issue’s message. First, he noted that one of his favorite quotes is from General Dwight D. Eisenhower, who said, “The greatest leaders are the ones smart enough to hire people smarter than them.” How true. While you bring the clinical knowledge to the practice, Lisa Moler surrounding yourself with the best and the brightest opens up Founder/Publisher, MedMark Media your world to ideas, insights, and talents beyond your own in other important areas. Thankfully, we have done that with the team at MedMark Media, and recommend that our readers should also take advantage of all of the experienced people who can expand your practice’s management, clerical, social media, and even clinical options in this very competitive specialty. Second, Shaq developed his life’s mission from another concept that he learned from his mother. He had given her some material gifts, to which she responded, “‘I don’t want these, Baby; I love you very much. What have you done to brighten up someone else’s day?” This reinforced what we try to practice every day. We know that taking care of business is our daily focus, but we also need to focus on taking care of others — and what better way than changing lives through our life’s calling! For me, it is improving dentists’ and patients’ health through bringing to light the important concepts and breakthroughs of our profession through our authors and advisors. You can expand patient care possibilities through CEs, our articles, webinars, DocTalk Dental videos, or any of the many educational options available in this quickly changing dental industry. While you’re at it, let your patients know how your practice is capable of changing or improving their lives! Use your social media, smartphones, and websites to spread the word. We’d like to spread the word about our July/August issue, where we feature Dr. Larry White and colleagues’ article on a paradigm change for diagnosis, treatment planning, and therapy for Class II malocclusions. Dr. Robert Kaspers discusses the effect the musculature and the occlusion have on the condylar position — a concept he calls “the fulcrum effect.” Dr. Edward Y. Lin outlines the steps to an affordable clear aligner treatment option using the Sure-Smile software platform, and Dr. Thomas R. Pitts discusses how digital technologies like 3D imaging, intraoral scanners, practice management software, and even a 3D printer saved him time and money and increased his speed and accuracy. Drs. Barry Raphael and Mark Cruz explore obstructive sleep apnea (OSA) and inspiratory flow limitation and their potential impact on your patients and practice. While my interview with Shaq mainly focused on his nighttime sleep, we ended up discussing how to make every day count — a topic which always is our goal for all of you and your teams. To your best success! Lisa Moler Founder/Publisher MedMark Media

Published by

PUBLISHER Lisa Moler lmoler@medmarkmedia.com MANAGING EDITOR Mali Schantz-Feld, MA mali@medmarkmedia.com | Tel: (727) 515-5118 ASSISTANT EDITOR Elizabeth Romanek betty@medmarkmedia.com VP, SALES & BUSINESS DEVELOPMENT Mark Finkelstein mark@medmarkmedia.com NATIONAL ACCOUNT MANAGER Celeste Scarfi-Tellez celeste@medmarkmedia.com CLIENT SERVICES/SALES SUPPORT Adrienne Good agood@medmarkmedia.com CREATIVE DIRECTOR/PRODUCTION MANAGER Amanda Culver amanda@medmarkmedia.com MARKETING STRATEGIST Matt Simpson emedia@medmarkmedia.com SOCIAL MEDIA & PR MANAGER April Gutierrez medmarkmedia@medmarkmedia.com CONTENT MARKETING Lauren Nash emedia@medmarkmedia.com FRONT OFFICE ADMINISTRATOR Melissa Minnick melissa@medmarkmedia.com

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6 Orthodontic practice

Volume 10 Number 4

The future of teen and preteen orthodontics is here. Introducing InvisalignÂŽ treatment with mandibular advancement and Invisalign First clear aligners. Clinically proven outcomes and a treatment experience you and your growing patients will appreciate. Learn more at Invisalign.com/treatingteens

CASE REPORT

SureSmile case report: DIY aligner generalized spacing case for superior control and cost-effective treatment Dr. Edward Y. Lin discusses the steps to an affordable clear aligner treatment option

s the old saying goes, “With age comes wisdom.” This is most certainly true with what I have seen transpire over the past 20 years with the inception and development of clear aligner therapy in orthodontics. As a technology embracer and young orthodontist, I readily embraced Invisalign® when it first came to market in 1999 and started my first Invisalign patient nearly 20 years ago in November of that year. Invisalign was without a doubt a disruptive dental technology, and it has forever changed the way we all practice orthodontics because it is a highly desirable treatment option for patients seeking esthetic orthodontic treatment. In addition, Invisalign will forever be known as the first digital orthodontic treatment modality invented by the founders of Align Technology, Zia Chisti and Kelsey Wirth. However, in October of 2017, approximately 40 of Align’s patents expired, which has paved the way for many new clear aligner competitors to come to market.1 With this recent development, orthodontists now have multiple options for clear aligner treatment and at different price points to offer to our patients, which I personally feel is a great thing for orthdodontists and, most importantly, for our patients to have different options for treatment. In this case report, I am going to review a generalized spacing case that I treated utilizing SureSmile’s software applications.

Patient information This patient presented to me for her new patient examination as a healthy 27-year, 5-month-old adult female. She stated that her chief complaint was that she wanted a nicer looking smile as she did not like her

Figure 1: AP – Initial records

generalized spacing in both maxillary and mandibular arches. Her maxillary (MX) and mandibular (MD) arch forms were slightly asymmetrical and ovoid.

Diagnosis and etiology Intraoral examination revealed a Class I malocclusion (Figure 1). She presented with an overbite (OB) of 20% and overjet (OJ) of 1 mm. There was 4 mm of spacing present in her maxillary arch and 6 mm of spacing present in her mandibular arch. There was excess maxillary and mandibular incisal wear present. Frontal facial evaluation revealed a symmetrical and balanced facial pattern

Edward Y. Lin, DDS, MS, has 15-plus years of experience and over 5,000 patients treated with SureSmile Dr. Lin grew up in Green Bay, Wisconsin, and after graduating from Abbot Pennings High School and the University of Chicago, continued his dental education and orthodontic residency at Northwestern University Dental School. He is a member of the American Association of Orthodontists, the American Dental Association, and the World Federation of Orthodontists as well as state and local dental societies. Dr. Lin has been in private practice since 1999. Disclosure: Dr. Lin is a speaker on advanced orthodontic technologies, including SureSmile, i-CAT™ 3D imaging, and Invisalign®. He also sits on the clinical and faculty advisory board for SureSmile and the advisory board for American Orthodontics.

8 Orthodontic practice

for her upper, middle, and lower facial third heights. Profile evaluation revealed a straight profile with normal chin with nasio-labial angle equal to 120 degrees. Her upper and lower lips were both in normal positions and competent at repose. A frontal smile evaluation revealed acceptable upper and lower smile lines with no buccal corridors present. Her maxillary midline was centered with her facial midline, and her mandibular midline was deviated to her right by 1 mm. The patient was pregnant at this time, so no cephalometric or panoramic X-rays were taken. Instead, we evaluated the periapical and bitewing radiographs from her dentist, which displayed very good dental health.

Treatment summary This patient expressed a strong desire for an esthetic orthodontic treatment option. As a result, DIY aligners using SureSmile software were proposed to her as the treatment option of choice. An intraoral scan was taken and was then uploaded to SureSmile for both Volume 10 Number 4

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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.

CASE REPORT maxillary and mandibular DIY aligner design to create her Diagnostic Model 1 for staging of her aligners. At this time, we were still in the process of setting up our digital lab and 3D printers. As a result, we were scheduling 6 weeks in between the intraoral scan and the aligner delivery to give our digital lab enough time to create the aligner stages, to have the doctor review the individual aligner stages, to 3D-print the models, and then to fabricate, package, and label the aligners. Currently, we can do all of this in 1 week if necessary, but we typically schedule 3 weeks in between the intraoral scan and the aligner delivery to not stress our digital lab. The aligner stages were created by our digital lab and then approved by me for both maxillary and mandibular arches. There were a total of 11 maxillary aligners and 10 mandibular aligners with tooth movements for U3-3 and L4-4 only (Figures 2 and 3). Six weeks later, the patient returned to our practice for her DIY aligner delivery. A total of five maxillary and five mandibular aligners were given to the patient with instructions to change her aligners every 2 weeks and to wear them 20 hours per day. There were no attachments prescribed for her as my aligner philosophy tries to minimize attachments necessary during treatment. As clinicians, we should remember that with aligner therapy, patients do not like attachments, especially in the maxillary anterior region. My aligner philosophy for attachments is based off of a research study performed at the University of Nevada, Las Vegas, which has demonstrated that trimming the aligners 2 mm past the gingival margin increases retention of the aligners by 4 times in comparison to a scalloped trim (Figure 4).2 As a result, our lab trims our aligners with a straight cut 2 mm past the gingival margin, which minimizes the need for attachments. Another important factor for retention is the size or surface area of the clinical crowns. Larger clinical crowns will have greater retention, and smaller clinical crowns will have less retention. Undercuts are also another important factor for retention. For spacing cases, our lab does wax out slightly between the spaces. However, there is a great deal of retention still in the areas of spacing. A few months later, the patient returned to our practice for delivery of her remaining aligners (Maxilla – Aligners 6 – 11 and Mandible – Aligners 6 – 10). The patient returned to our practice for aligner refinement, and a second intraoral scan was taken on the patient with updated photos to create her Diagnostic Model 2 for staging 10 Orthodontic practice

Figure 2: AP – DIY maxillary aligners’ staging

Figure 3: AP – DIY mandibular aligners’ staging

of her refinement aligners (Figure 5). Her refinement aligner stages were created by our digital lab and then approved by me for both maxillary and mandibular arches. Again, no attachments were prescribed. Her refinement aligners were then delivered. There was a slight delay in her treatment of approximately 1 month due to the delivery of her baby. Almost a year after the initial intraoral scan was taken, the patient’s DIY aligner

design treatment was completed. Because of her generalized maxillary and mandibular spacing, we direct-bonded U2-2 and L3-3 lingual splints. An intraoral scan was taken for her final retainer, which was given to her about 1 week after treatment completion. Her total treatment time in DIY aligners from delivery of her initial aligners, including the time for staging and fabrication of her refinement aligners, was 10 months and 2 days. Volume 10 Number 4

CASE REPORT

Figure 4: The Journal of Clinical Orthodontics study illustrating aligner trim. Ginigival-margin designs of aligners tested in this study. A. Scalloped margin. B. Straight cut at gingival zenith. C. Straight cut 2 mm above gingival zenith

Summary and conclusions It is my belief that we are now entering the next stage of development for aligner treatment in our esteemed profession of orthodontics, where the orthodontist is now taking back control of treatment in the digital biosphere because we now understand how to treat in the digital world. The digital era of orthodontics for treatment began with Invisalign in 1999. However, from 1999 to the present time, many other digital orthodontic technologies have emerged (SureSmile®, Insignia™, Incognito™, eBrace, Harmony, ClearCorrect, etc.). We as orthodontists now have many different options for digital orthodontic treatment for labial- and lingual-fixed appliances and even more so with aligner therapy. As a result, over the past 20 years, many clinicians are now very comfortable treating with digital technology, and the younger generation of orthodontists is even more comfortable since they have grown up with technology in their hands from childhood. In our three practices, we have chosen OraMetrix as our preferred aligner partner for four reasons: 1. SureSmile’s software applications give us superior control for staging, which I personally feel gives us better treatment outcomes for our patients. 2. SureSmile’s Cloud is phenomenal, fast, and reliable. I have worked on cases on SureSmile’s Cloud all over the world in my travels over the past 15-plus years with no issues. 3. OraMetrix understands the importance of digital workflow and has created an incredibly efficient digital workflow system. We use it every single day in our clinics, and it helps the clinics to flow seamlessly. SureSmile’s digital workflow platform has been in existence and continuous development for over 20 years, and 12 Orthodontic practice

Figure 5: AP – DIY aligner refinement

Figure 6: AP – Maxillary DIY alignment stages

Figure 7: AP – Mandibular DIY alignment stages

Figure 8: AP – DIY aligner digital workflow sequence (14 maxillary and 11 mandibular aligners) Volume 10 Number 4

Volume 10 Number 4

Table 1: DIY Aligner Cost Analysis (MX — 14 Aligners and MD — 15 Aligners) Diagnostic Model at $45 Each x 2 = $90 29 Total MX and MD Aligners x $4/Model = $116 29 Aligners x $2/Sheet of Essix Ace .030" = $58 5 Minutes of Labor to Fabricate and Package Each Aligner x 29 = 2 Hours and 25 Minutes x $20/Hr = $50 We Only Print 20 Aligners at a Time and Have an Internal Tracking System to Control Waste of 3D-Printed and Unused DIY Aligner Stages $90 + $116 + $58 + $50 = $314

or healthcare, when a technology goes mainstream. In this case, it pertains to clear aligner treatment in orthodontics. Technologies will always continue to evolve, develop, and improve, and this is true for clear aligner technologies as well. In addition, with increased utilization, this results in decreased expenses. Because of this cost savings, we can offer aligners to our patients at a lower cost but still make the same profit margin. In my opinion, this is a win-win for us as clinicians as well as for all our patients. I do know that my patients love hearing that I can offer them a more affordable clear aligner treatment option than my competitors. Plus,

with the SureSmile software platform, I have added flexibility to seamlessly use the higher experienced TechCenter in Dallas, Texas, to fabricate my aligners, such as when I have greater demand than planned or am gearing up a new office. In my opinion, this is just smart business practice, and that is a beautiful thing! OP

REFERENCES 1. Tindera, M. Bracing for Competition. Cheaper Challenger’s Enter Invisalign’s 1.5 Billion Market. Forbes: May 2, 2018. 2. Cowley, D; Mah, J; O’Toole, B. The Effect of GingivalMargin Design on the Retention of Thermoformed Aligners. J Clin Orthodontics. 2012, 46(11):697.

Orthodontic practice 13

CASE REPORT

there are no other companies other than Invisalign that have that much history in the digital orthodontic world or understands it as well. 4. Finally, with DIY aligner design, we can now control our aligner overhead expenses much better by staging and fabricating the aligners ourselves. We have two digital orthodontic labs with five 3D printers (three Structo Dentaforms, one EnvisionTEC Vida 3D, and one Envision One). We print all our models and then fabricate all our aligners within our two labs. This obviously has resulted in significant savings with the cost of our DIY aligners for our three practices. I have provided a cost breakdown for this patient’s case report for review (Table 1). The total cost for labor and supplies for this aligner case was $314. The only cost that was not factored into this cost analysis is for my time in evaluating her case. This SureSmile DIY aligner design case that I have reviewed in this case report is the perfect example of what happens to any sector of business, whether in industry

ORTHODONTIC CONCEPTS

The age of airway goes mainstream Drs. Barry Raphael and Mark Cruz explain how “Airway” goes well beyond Obstructive Sleep Apnea Introduction Whether you have a deep understanding of the relevance of the airway and breathing to dentistry and facial development, or whether you are still wondering what “this airway fad” is all about, one thing is for certain — with the American Dental Association’s 2017 Policy Statement on the Role of the Dentist in Sleep Disordered Breathing, the issue is now a bona fide part of the profession. Whether you treat airway, breathing, or sleep problems or not, now every dental, pediatric, and orthodontic practice must at least screen for these problems, even if you have to refer patients for treatment elsewhere. In this article we will describe to you some of the significant aspects of the ADA policy and how it will (or can) impact your practice. We will also discuss how some are trying to limit the conversation to an overly narrow focus. It is important to consider two factors in the airway issue. The first is that there is a distinction between obstructive sleep apnea (OSA) and inspiratory flow limitation (IFL). The two are different conditions along a continuum and require different approaches. The second is that there is a difference between adult and pediatric conditions.

OSA versus IFL Obstructive sleep apnea (OSA) implies a stoppage of breathing accompanied by a lowering of blood oxygen and usually (thankfully), an arousal from deep sleep when the situation becomes too dire for survival. The

combination of desaturation, an unrequited effort to breathe, and the constant rebooting of sleep levels takes a tremendous toll on the heart, the brain, and many other bodily systems. Hypoxia can result in specific symptoms that are often treated independently by medical specialists without realizing that sleep may be a central etiology. People who suffer from OSA have trouble keeping awake during the day.

Barry D. Raphael, DMD, received dental degree from the University of Pennsylvania School of Dental Medicine and his Certificate in Orthodontics from the Fairleigh-Dickinson University School of Dentistry, Department of Orthodontics. He is a lecturer and staff member at Mt. Sinai School of Medicine, Pediatric Dental Residency; Clinical Instructor at Institute for Family Health. He is a life member of the American Dental Association, a member of the American Association of Orthodontists, and Fellow of the American College of Dentists. Dr. Raphael is in private practice of orthodontics at The Raphael Center for Integrative Orthodontics Clifton, New Jersey and is owner/director of The Raphael Center for Integrative Education. Mark A Cruz, DDS, graduated from the UCLA School of Dentistry in 1986 and started a dental practice in Monarch Beach, California upon graduation. He has lectured nationally and internationally and is a member of various dental organizations including the American Academy of Gnathologic Orthopedics (AAGO), North American Association of Facial Orthotropics (NAAFO), Pacific Coast Society for Prosthodontics, and the American Academy of Restorative Dentistry. He was a part-time lecturer at UCLA and member of the faculty group practice and was past assistant director of the UCLA Center for Esthetic Dentistry. He has served on the National institute of Health/National Institute of Dental & Craniofacial Research (NIH/NIDCR) Grant Review Committee in Washington D.C., and on the Data Safety Management Board (DSMB) for the National Practice-Based Research Network (NPBRN) overseen by the NIDCR, as well as on the editorial board for the Journal of Evidence Based Dental Practice (Elsevier).

14 Orthodontic practice

Inspiratory flow limitation (IFL) on the other hand, happens when there is enough of a narrowing of the airway to make breathing more difficult but not enough to stop it. In IFL, there may be only minimal drops in blood oxygen. Typically, the body will react to flow limitation with an arousal as well, but it happens quickly enough that there is no or very little desaturation. A shot of adrenaline, a quick spike in heart rate, a shift in the body’s position, and an opening of the oral airway keep the air flowing. While this can help a person avoid some of the sequelae of desaturation, it also fragments sleep by lessening the amount of deep and REM sleep a person has. Fragmented sleep often results in more global symptoms such as chronic pain, central sensitization, metabolic dysregulation, autonomic imbalance, anxiety or depression, and neurocognitive deficits. People who suffer from IFL are more fatigued than sleepy during the day. It is important to note that IFL is not just a problem of sleep, although sleep tends to aggravate the problem as flow can Volume 10 Number 4

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ORTHODONTIC CONCEPTS become more restricted as we lie flat in bed and muscles relax. Instead, IFL should be considered a breathing problem independent from sleep. In IFL, there can be restriction in the structure of the airway (physical narrowing, poor posture, fat deposits, active lymphatic tissues), the physiologic function of the airway (anything that creates swelling, inflammation, mucus, or trauma), and the behaviors we use to breathe often adopted as compensations for the first two limitations (like mouth breathing, chest breathing, and chronic hyperventilation). One can almost assume that if you are having trouble breathing during the day that there is little chance you’ll be able to breathe well at night. It is also critical to note that while the incidence of OSA is a shocking 20% among our adult population and may include millions of American adults, the incidence of flow limitation is far greater, including perhaps 50% of the population. The reasons for this are many, but for one, anthropologists affirm that the modern human face is not developing as fully as it did only a few hundred years ago, evidenced not only by increasing incidence of small jaws, malocclusion, and impacted third molars, but most significantly, smaller nasal and pharyngeal airways. This is not so much a genetic deficit as it is an epigenetic reaction to our modern environment — one that challenges our physiology to cope with the rapid changes of environment and culture that is so different than the one our bodies were developed in. As a result, we are now more susceptible to flow limitation from birth onward. We must understand OSA as merely the end stage of a long process that starts in childhood.

Pediatric versus adult airway In children, frank OSA is rather limited since children can adopt a number of compensations to prevent apnea. However, with allergies, neurocognitive deficits, and deficient jaw growth on the rise, there are many reasons why a child can have trouble breathing and yet not have apnea. It is the case that swollen lymph tissue can clog up the airway and cause apnea in children. The American Academy of Pediatrics recognizes that if a child has OSA and the tonsils and adenoids are the proximate cause, then removal is indicated. However, if the tonsils and adenoids are swollen, but the child does not have more than one apnea per hour, then the tissues are left in place no matter how difficult they make continuous breathing. Medical guidelines allow a child to suffer through 5 to 7 episodes of upper 16 Orthodontic practice

It is also critical to note that while the incidence of OSA is a shocking 20% among our adult population and may include millions of American adults, the incidence of flow limitation is far greater, including perhaps 50% of the population. respiratory infections each year before a physician can choose to do something definitive. Meanwhile, flow limitation constantly demands breathing compensations like open mouth posture, forward head posture, restless sleep, and soft tissue dysfunctions that negatively influence the way the facial bones grow and the teeth erupt. Unfortuntately, children whose facial development is deformed from an early age are often being put on long-term steroids and being told to wait for braces to straighten their teeth. The negative growth trajectory of the face that increases the risk factors for airflow limitations is left to progress unabated and often left untreated. Standard orthodontic practices call for adapting the teeth to the poorly grown face since it is often too late to change the facial structures at “braces age.” Worse yet, the literature is clear that the fragmented sleep caused by flow limitation, even when no apnea is present, is damaging to a child’s brain development. It is critical to understand that facial and airway growth is a process that can be allowed to deteriorate or can be enhanced by reducing the obstacles to good growth. So when the ADA’s policy statement says that it is our job is to help children develop “an optimal physiologic airway and breathing pattern,” it means that we must do more than watch a child suffer. We must remove obstacles to growth and foster conditions that will enhance facial and airway growth as soon a poor growth is discovered or as soon as the habits that will lead to poor growth are seen. Our children need more than just relief of symptoms, like apneas. We need a fundamental rethinking of how we manage health in children. It calls for a whole-body focus on proper growth and development that eliminates the need compensatory behaviors that would otherwise lead to trouble down the line.

The dangers of an OSA-based policy In reaction to the attention that airway and sleep has gotten from both the dental

profession and mothers that are demanding more responsiveness, the American Association of Orthodontists held a “consensus conference” with a follow-up White Paper: Obstructive Sleep Apnea and Orthodontics in 2019. The title alone belies the contents and recommendations. Essentially, the policy concludes that every orthodontist “should” screen for OSA in children and refer to a sleep physician if OSA is suspected. But while the AAO recognizes that the orthodontist is well placed to address craniofacial growth and development, the policy defers diagnosis and treatment to the sleep physician and relegates the orthodontist to a supportive role when the physician recommends orthodontic treatment. There are two significant dangers in this policy. First, this policy assumes that the sleep physician knows about the relevance of flow limitation to facial growth and sleep fragmentation in the absence of apnea. And while many physicians are learning more about UARS, the sleep labs and their technicians have to be specifically instructed to score the PSG for more than just apnea lest the condition is missed. Currently it is not a routine protocol. Second, a child who has flow limitation but does not register apneas in a polysomnogram will be returned to the orthodontist being told that the test was negative for OSA. Parents will be misled to think that “no OSA” means “no problem,” and treatments that could have helped alleviate the flow limitation will be overlooked. When the AAO came out with its white paper, it recognized “upper airway resistance” as part of the sleep and breathing disorders but chose to limit its focus to OSA alone. And while the guidance that only a physician can diagnose and proscribe treatment to OSA is sound, no mention was made of how to handle children or adults who do not qualify under current guidelines that define OSA. This is a crucial point to understand. OSA is an illness. IFL is suboptimal wellness. Flow Volume 10 Number 4

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ORTHODONTIC CONCEPTS limitation is a precursor to OSA. If all we do is pay attention to apnea we are just managing a medical symptom. But if we want to live the best lives we can, we work toward optimal health and wellness. When we see children who are not well, and we want to help them to be the best they can be, we must use best practices to help them achieve optimal structure, function, and behavior to do so.

Treatment strategies The current “gold standard” treatment strategy for OSA is to somehow pry open the naso- and oral-pharyngeal airway enough to keep it from collapsing. Treatments use forced air (CPAP), pull the jaws forward (mandibular advancement device or jaw advancement surgery), pull the tongue forward (hypoglossal stimulator, advancement genioplasty),or remove tissue from the nose and throat (plasty, T&A, nasal surgery). While these techniques have their place for the very ill, they only address the symptoms and not the cause of the limited airflow. As such, they are themselves compensations designed solely to help a person get through the night. On the other hand, the treatments for flow limitation directly address the daytime etiologies in order to make the breathing space easier to breathe through and with less effort. To create an optimal airway one must: 1. Improve the anatomy to minimize turbulence by helping bones grow and remodel to reduce constrictions in the nose and pharynx, and provide maximal tongue space in the front of the mouth 2. Address physiology by reducing swelling, inflammation, mucus, and trauma while also toning muscles to keep the airway flexed open 3. Teach efficient breathing behaviors that don’t create so much turbulence in the airway.

Making the transition While all this may be easy to say, adding wellness services into an orthodontic practice can be challenging. It requires moving from a “mechanical” mindset to a “wholebody” mindset. Fortunately, there are protocols that can be installed in an orthodontic practice without interrupting the flow of the day. 18 Orthodontic practice

The first thing to do is create a staff position called “Health Coach.” The Health Coach should be someone who is good with kids, likes to teach, and will take on a project and run with it. He/she will run the wellness program by teaching patients good health habits just like the dental hygienist teaches oral hygiene. Lessons will include the basic tenets of good growth and development including the following: 1. Nasal breathing 2. Lip competence 3. Tongue-resting posture on the palate 4. Swallowing with the tongue on the palate without having to recruit the facial musculature to help 5. Good body posture to keep the head upright over the shoulders 6. Good nutrition with food that nourishes and doesn’t inflame the body 7. Good sleep habits to allow for peaceful, unfragmented sleep 8. Good breathing behaviors during rest and stress that efficiently deliver oxygen to the brain, organs and muscles The second thing is for the orthodontist to learn about why these habits are so important and how the orthodontist can

help develop an anatomical structure for the child that will aid in learning these good habits. It is important to note that while “palatal expansion” is a helpful adjunct, the maxilla may need development in three dimensions of space. Learning to augment sagittal development is probably more important than lateral development since the tongue needs room to come forward to be out of the breathing space. There are several techniques — many of which have been practiced for decades — that can help sagittal development. And of course, techniques that may hamper sagittal development are rarely, if ever, indicated. If a child has such crowding or overbite that extraction and retraction are even contemplated, the odds are great that flow limitation is already at play. Retraction mechanics may not “cause” flow limitation, but it certainly ignores it and may lock the risk factors in perpetually, and therefore should be avoided at all costs. Finally, once you realize the health costs of flow limitation, you will never want to let it fester until a child is ready for braces — or until it becomes apnea. Addressing these issues as soon as they are discovered must become the standard of care. OP

REFERENCES 1. American Association of Orthodontists. (2019). Obstructive sleep apnea and orthodontics [White Paper]. https://www1.aaoinfo. org/wp-content/uploads/2019/03/sleep-apnea-white-paper-amended-March-2019.pdf. Accessed June 21, 2019. 2. Catalano PJ, Walker J. Understanding Nasal Breathing: The key to evaluating and treating sleep disordered breathing in adults and children. Curr Trends Otolaryngol Rhinol. 2018; CTOR-121. https://www.gavinpublishers.com/articles/Review-Article/ Current-Trends-in-Otolaryngology-and-Rhinology/Understanding-Nasal-Breathing-The-Key-to-Evaluating-and-Treating-SleepDisordered-Breathing-in-Adults-and-Children#solid-justified-tab6. Accessed June 21, 2019. 3. Fitzpatrick MF, McLean H, Urton AM, Tan A, O’Donnell D, Driver HS. Effect of nasal or oral breathing route on upper airway resistance during sleep. Eur Respir J. 2003; 22(5):827-832. 4. Georgalas C. The role of the nose in snoring and obstructive sleep apnoea. Eur Arch Otorhinolaryngol. 2011;268(9):1365-1373. 5. Gold A. Functional somatic syndromes, anxiety disorders and the upper airway: a matter of paradigms. Sleep Med Rev. 2011;15(6):389-401. 6. Gold A, Dipalo F, Gold MS, O’Hearn D. The symptoms and signs of upper airway resistance syndrome: a link to the functional somatic syndromes. Chest. 2003;123(1):87-93. 7. Gozal D, Kheirandish-Gozal, L. Neurocognitive and behavioral morbidity in children with sleep disorders. Curr Opin Pulm Med. 2007;13:505–509. 8. Guilleminault C, Sullivan S. Towards restoration of continuous nasal breathing as the ultimate treatment goal in pediatric obstructive sleep apnea. Enliven: Pediatrics and Neonatal Biology. 2014;1(1). 9. Kim P, Sarauw MT, Sonnesen L. Cervical vertebral column morphology and head posture in preorthodontic patients with anterior open bite. Am J Orthod Dentofacial Orthop. 2014;145(3):359-366. 10. Litchfield PM. CapnoLearning: Respiratory Fitness and Acid-Base Regulation. Psychophysiology Today. 2010;7(1):6-12. 11. Luc GTM, Burschtin O, Setlur J, et al. REM-Associated Nasal Obstruction: A study with Acoustic Rhinometry during Sleep. Otolaryngol Head Neck Surg. 2018;139(5):619-623. 12. Luginbuehl M, Bradley-Klug K, Ferron J, Anderson WM, Benbadis SR. Sleep Disorders: Validation of the Sleep Disorders Inventory for Students. School Psychology Review. 2008;37(3):409-431. 13. Morais-Almeida M, Wandalsen GF, Solé D. Growth and mouth breathers. J Pediatr (Rio J). 2019;95(suppl 1):66-71. 14. O’Brien LM, Mervis CB, Holbrook CR, et.al. Neurobehavioral correlates of sleep-disordered breathing in children. J Sleep Res. 2004;13(2):165-172. 15. Pavone M, Cutrera R, Verrillo E, Salerno T, Soldini S, Brouillette RT. Night-to-night consistency of at-home nocturnal pulse oximetry testing for obstructive sleep apnea in children. Pediatr Pulmonol. 2013;48(8):754-760. 16. Simmons MS, Clark GT. The potentially harmful medical consequences of untreated sleep-disordered breathing. J Am Dent Assoc. 2009;140(5):536-542.

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CONTINUING EDUCATION

How to diagnose and treat the fulcrum effect Dr. Robert Kaspers discusses the effect that the musculature and the occlusion have on the condylar position

or years, orthodontists have utilized twodimensional radiographs to treatment plan their orthodontic treatment. Fortunately, the advent of cone-beam computed tomography (CBCT) allows an orthodontist to take a “functional” radiograph, so the condylar position can be evaluated, and an accurate orthodontic diagnosis can be achieved. Okeson and Dawson defined both centric relation and a seated condylar position to help clinicians in their attempts to treat patients with TMD.1 Ikeda and Kawamura used MRI and LCBT to establish the optimal spatial relationships between the condyle and fossa in healthy joints. Their studies concluded that in healthy joints, the joint spaces (anterior space [AS], superior space [SS], and posterior space [PS]) showed consistent mean values of 1.3 mm (AS), 2.5 mm (SS), and 2.1 mm (PS), thereby verifying a concentric position of the condyle2 (Figures 1 and 2). Splint therapy has been utilized over the years to help seat the condyles. Without 3D technology, dentists and orthodontists treated TMD patients based on symptoms and not structural information. Splint therapy would many times cause the patient’s occlusion to change dramatically to that of an anterior open bite. Roth noted that in some patients when the mandible closed to intercuspation, the posterior teeth distracted the condyle downward and backward.3 In June 2012, I developed the Five Condylar Positions© to help orthodontists

Dr. Kaspers received his DDS with honors from the University of Michigan. He then completed specialty training in orthodontics at the Northwestern University Dental School and earned a Master of Science degree in Radiology. While in Ann Arbor, Dr. Kaspers worked with Dr. Major Ash on research projects pertaining to temporomandibular dysfunction. Dr. Kaspers has lectured to hundreds of dentists and orthodontists on diagnosis and treatment for both orthodontic and TMD cases. Dr. Kaspers is the founder of the Five Condylar Positions©, which has helped make diagnosing and treatment planning easier for the practitioner. Dr. Kaspers is the founder of ProActive Orthodontics, and it is his desire to help the profession understand the advantages of the CBCT scan machine so that diagnosis of orthodontic cases can be made more easily and more accurately. Currently, Dr. Kaspers maintains a private orthodontic and TMD practice in Northbrook, Illinois. Disclosure: Dr. Kaspers is the developer of the Five Condylar Positions©. He has no financial interest in BiteFX.

20 Orthodontic practice

Educational aims and objectives

This clinical article aims to discuss the effect that the musculature and the occlusion have on the condylar position.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 24 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Identify some of the traditional concepts for treatment of condylar position.

•

Realize how CBCT imaging has improved orthodontists' awareness of the patient's structural asymmetry.

•

Identify the retruded-and-down condyle and the centered-and-down condyle positions.

•

Define the fulcrum effect and its effect on musculature and occlusion.

•

View a patient who benefited from knowledge of the fulcrum effect.

•

Recognize potential treatment for a patient with the fulcrum effect.

diagnose their orthodontic cases more accurately. The seated condylar position and the protruded and retruded condylar positions have been thoroughly documented over the years in the literature. However, two new condylar positions have been established to help diagnose the “fulcrum effect.” The retruded condyle, which is down in the fossa, is a condylar position created when the patient fulcrums around a posterior contact (usually a molar) to achieve maximum intercuspation. Both the anterior joint space (AS) and the superior joint space (SS) have

increased in size, while the posterior joint space (PS) has decreased in size (Figure 3). This condylar position is achieved when the patient activates the lateral pterygoid muscles to move the mandible forward and then activates the masseter and medial pterygoid muscles to close the bite into maximum intercuspation.

Figure 1: Mean distances and ratios for optimal condylar position as defined by Ikeda

Figure 2: Joint spaces — anterior joint space (AS), superior joint space (SS), and posterior joint space (PS) Volume 10 Number 4

Volume 10 Number 4

Figure 3: Retruded-and-down condylar position

Figure 4: Centered-and-down condylar position

Figure 5: Betty’s photos

Figure 6: Betty’s initial CBCT scan Orthodontic practice 21

CONTINUING EDUCATION

The centered condyle, which is down in the fossa, is the fifth condylar position. This condylar position is similar to the retrudedand-down condylar position in that the patient fulcrums around a premature posterior contact. The difference between this position and the retruded-and-down condylar position is that this position possesses a significantly larger skeletal Class II component and a larger vertical component (a larger anterior open bite) (Figure 4). Both condylar positions are similar in design but differ in the degree of the anterior-posterior and vertical discrepancy. Both condylar positions are created by the “fulcrum effect,” which is a combination of the patient’s orofacial musculature forcing maximum intercuspation around posterior interferences. Roth defined the fulcrum as a condition in which the condyle distracts away from the eminence when the mandible closes into maximum intercuspation.3 Many clinicians have questioned the concept of a condyle distracting away from the eminence. They believe that an anteriorly displaced disc is the reason a condyle appears distracted from the eminence. Over the past 2 years, I have taken both CBCT scans and MRI scans on patients to see if appliance therapy could recapture an anteriorly displaced disc. Even though discs were never recaptured (as verified by MRI scans), it was quite helpful to compare CBCT scans with MRI scans. The direction and extent of disc displacement are well correlated with changes of the condylar position within the fossa.4 Ikeda shows us that an anteriorly displaced disc can force a condyle posteriorly and superiorly from the normal condylar position.5 But none of these studies have looked at the change in the superior joint space and the effect the musculature and the occlusion have on the condylar position. A patient, Betty Z, wanted her bite improved, and yet her masseter muscles were sore from excessive grinding of her teeth. An initial CBCT scan was taken (in maximum intercuspation) to evaluate the condylar position and diagnose her case. Her right condyle was in a centered-anddown position while her left condyle was forward 4 mm-5 mm on the eminence. An MRI was also taken to verify the position of the disc. Splint therapy was utilized to relieve the musculature and establish a seated condylar position. The MRI showed an anteriorly displaced disc in both temporomandibular (TM) joints (at 12:00), but the anterior joint space was twice as large in the centered-anddown position.

CONTINUING EDUCATION When the muscle soreness had dissipated, a progress CBCT scan was taken to verify a seated condylar position. Splint therapy had allowed the musculature to heal and had properly loaded the TM joints. The progress CBCT scan showed the condyles 3 mm-4 mm forward on the eminence. The anterior joint space on the right condyle had reduced to a normal dimension with splint therapy. Both discs were still slightly anteriorly displaced, and yet the condyles were forward on the eminence. The key to diagnosing this case properly was the increase in the superior joint space. Betty’s mandible was more retruded even though her condyles were now forward on the eminence. Betty had been fulcrumming around second molars on her right side, which was the reason her right condyle was centered-and-down in the fossa. Betty actually possessed an anterior-posterior discrepancy of 6 mm-7 mm and an anterior open bite. Her first premature contact was her 12-year molars on her right side. Without the prior knowledge of the centered-and down condylar position, Betty’s TMD therapy and orthodontic diagnosis would have been completely wrong, and Betty’s TMD symptoms would have persisted.

Figure 7: Betty’s MRI

Figure 8: Betty’s progress CBCT scan with a bite plate in place

Treatment of the fulcrum effect Explaining the “fulcrum effect” to orthodontists can be complex, but explaining the pivoting action to a patient is even more challenging. I have utilized the animated movies that BiteFX provides to help the patients understand their structural problem. It is amazing how patients have a better appreciation for their condition and the proposed treatment, and how it will help them, if they have an understanding of their structural asymmetry. BiteFX is the only program that shows how the patient’s occlusion effects his/her condylar position. Since the patient is pivoting around his/ her molars, intrusion of the maxillary molars will eliminate the premature contacts in the patient’s occlusion. A CBCT scan is extremely helpful for intruding maxillary molars because the clinician can determine if the roots are in medullary bone (softer bone) or are getting caught up in the dense cortical bone. If a particular root is getting caught up in cortical bone, the CBCT scan gives the clinician the necessary information to torque the root back into medullary bone. A transpalatal bar is useful for torquing the roots of the molars as well as maintaining their root position in the medullary bone while intrusion forces are applied to these teeth. 22 Orthodontic practice

Figure 9: Comparing Betty’s initial and progress lateral cephalograms

Figure 10: Centered-and-down condylar position Volume 10 Number 4

Figure 12: CBCT scan shows the roots of the maxillary molars centered in the medullary bone

Figures 13 and 14: 13. TADs and vertical elastics can intrude the maxillary molar. 14. Custom NTI is used to properly load the temporomandibular joint while orthodontic treatment is intruding the maxillary molars

Several types of intrusion mechanics can be utilized to intrude the maxillary molars. High-pull headgear and vertical-pull headgear can intrude maxillary molars very effectively. A transpalatal bar should be used in conjunction to keep the roots of these teeth in medullary bone. If the patient cannot get the necessary hours (11 hours/day) of headgear wear, temporary anchorage device (TADs) can be used in combination with vertical elastics. Nitinol coils and elastic chain can also be used instead of vertical elastics if the patient has a difficult time remembering to change his/her elastics. The fulcrum effect has fooled orthodontists for quite some time. In the past (before CBCT), I would treat a TMD patient with splint therapy and see his/her bite open in a matter of weeks. I had no idea that the bite would open or that the patient was fulcrumming around his/her molars. After splint therapy had alleviated the patient’s symptoms, I would treat the patient orthodontically to what I believed was a seated condylar Volume 10 Number 4

position. I did not realize that the patient would continue to fulcrum around the molars even though I was intruding their molars during treatment. Finally, one of my TMD patients (which I had treated orthodontically) informed me that she was grinding her teeth again. I took a CBCT scan of the patient and found out that both of her condyles were in a “retruded-and-down” position. I thought I had treated her to a seated condylar position, but obviously I did not. I began to realize that I needed to load the temporomandibular joint while I treated the fulcrum effect. Utilizing a CBCT scan, I could construct a custom NTI so that I could continue loading the TM joints properly while I treated the patient to a seated condylar position. The vertical dimension of the custom NTI can be reduced as the maxillary molars are intruded. The autorotation of the mandible helps correct part of the anterior-posterior discrepancy, but it is important to remember that the patient was activating his/her lateral pterygoid muscles to

achieve maximum intercuspation. Therefore, the clinician must analyze the case in all three dimensions (anterior-posterior, transverse, and vertical) to determine the necessary mechanics to achieve anterior coupling and cuspid guidance while maintaining a seated condylar position. Knowledge of the Five Condylar Positions© will help the clinician attain the necessary information to acquire a proper diagnosis and treatment plan. OP

REFERENCES 1. Okeson, Jeffrey P. Management of Temporomandibular Disorders and Occlusion. St. Louis, MO: Mosby Elsevier; 2008. 2. Ikeda K, Kawamura A. Assessment of optimal condylar position with limited cone-beam computed tomography. Am J Orthod Dentofacial Orthop. 2009;135(4):495-501. 3. Roth RH, Rolfs DA. Functional occlusion for the orthodontist. Part II. J Clin Orthod. 1981;15(2):100-123. 4. Brand JW, Whinery JG Jr, Anderson QN, Keenan KM. Condylar position as a predictor of temporomandibular joint internal derangement. Oral Surg Oral Med Oral Pathol. 1989;67(4):469-476. 5. Ikeda K, Kawamura A. Disc displacement and changes in condylar position. DentoMaxillofac Radiol. 2013;42(3): 84227642.

Orthodontic practice 23

CONTINUING EDUCATION

Figure 11: BiteFX animated movie of the retruded-and-down condylar position

REF: OP V10.4 KASPERS

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How to diagnose and treat the fulcrum effect KASPERS

1. The ________, which is down in the fossa, is a condylar position created when the patient fulcrums around a posterior contact (usually a molar) to achieve maximum intercuspation. a. retruded condyle b. centered condyle c. seated condylar position d. protruded condyle 2. The _________, which is down in the fossa, is the fifth condylar position. a. retruded condyle b. centered condyle c. seated condylar position d. protruded condyle 3. The difference between this position (the centered condyle) and the retruded-anddown condylar position is that this position possesses a significantly larger skeletal ________ component and a larger vertical component. a. Class I b. Class II c. Class III d. none of the above 4. ______ defined the fulcrum as a condition in

24 Orthodontic practice

which the condyle distracts away from the eminence when the mandible closes into maximum intercuspation. a. Ikeda b. Brand c. Roth d. Okeson 5. ______ shows us that an anteriorly displaced disc can force a condyle posteriorly and superiorly from the normal condylar position. a. Ikeda b. Brand c. Roth d. Okeson 6. (On patient Betty Z) An initial _______ was taken (in maximum intercuspation) to evaluate the condylar position and diagnose her case. a. MRI b. CBCT scan c. 2D digital X-ray d. a film panoramic X-ray 7. (For patient Betty Z) A/An ______ was also taken to verify the position of the disc. a. MRI

b. 2D digital X-ray c. transilluminated image d. cephalogram 8. The key to diagnosing this case properly was ______ in the superior joint space. a. the protrusion b. the stability c. the decrease d. the increase 9. Since the patient is pivoting around his/her molars, intrusion of the maxillary molars will _______ the premature contacts in the patientâ&#x20AC;&#x2122;s occlusion. a. eliminate b. equalize c. increase d. progress 10. If the patient cannot get the necessary hours (____) hours/day of headgear wear, temporary anchorage device (TADs) can be used in combination with vertical elastics. a. 4 b. 6 c. 8 d. 11

Volume 10 Number 4

CE CREDITS

ORTHODONTIC PRACTICE CE

Drs. Larry W. White, Reginald W. Taylor, and Matt Brown discuss diagnosis, treatment planning, and therapy for Class II malocclusions that rely on a blend of techniques Introduction First impressions often endure far beyond their usefulness, and that seems particularly true with professional preferences. Orthodontics’ first and only instrument for treating protruded maxillary incisors and mandibular incisors was a headgear of some design, and even into the 1980s, this therapy remained a mainstay for the correction of Class II and Class III malocclusions. For many years, the principal therapy applied to both Class II and Class III malocclusions was some type of cranialsupported force to the maxilla or mandible (Figures 1 and 2). It was not until Calvin S. Case1 and Henry A. Baker developed the use of intermaxillary elastics late in the 19th century that clinicians had effective and easily applied forces for addressing sagittal discrepancies. The belief orthodontists developed from this early headgear therapy considered the maxilla and its dentition as the principal Larry W. White, DDS, MSD, FACD, is a graduate of Baylor Dental College and Baylor Orthodontic Program, and he now has an orthodontic practice in Dallas, Texas.

Reginald W. Taylor, DMD, DMSc, is currently Associate Professor and Director of Undergraduate Orthodontics at the Texas A&M College of Dentistry (TAMCOD). Dr. Taylor received his DMD, his Orthodontic Certificate, and Doctor of Medical Sciences in Oral Biology from the Harvard School of Dental Medicine and the Forsyth Dental Center. After receiving his degree and certificate, he accepted a full-time faculty position at the University of Alabama School of Dentistry. There, Dr. Taylor taught pre- and post-doctoral orthodontics until accepting his current position at TAMCOD in the year 2000. In addition to his teaching, research, and administrative responsibilities, Dr. Taylor has enjoyed the opportunities to engage in extramural and intramural clinical orthodontic practice. Dr. Taylor has published original articles as well as given oral presentations in both clinical and basic science research areas, and is a Diplomate of the American Board of Orthodontics. Matt Brown, DDS, MS, graduated summa cum laude in 2006 from Oklahoma State University with a degree in Biochemistry. He then went on to attend dental school at Baylor College of Dentistry and ultimately completed his 3-year orthodontic residency program in Orthodontics and graduated in 2013. Dr. Brown currently has practices in Highland Village, Mabank, and Canton, Texas.

Volume 10 Number 4

Educational aims and objectives

This clinical article aims to discuss a paradigm for diagnosis, treatment planning, and therapy for Class II malocclusions that rely on a blend of techniques.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 31 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Realize some historical background behind treatment for Class II malocclusions.

•

Recognize some challenges to the commonly accepted paradigm for treatment for Class II malocclusions.

•

Recognize some drawbacks to the reliance on the mandibular incisor position and inclination as the determinant of orthodontic therapy.

•

Observe two patients treated with this new paradigm in mind.

•

Recognize the essential task of deciding on the principal etiology and then planning and applying correct therapies.

•

Realize that using the maxillary incisor as a guide, along with properly done VTOs, can develop reasonable targets for incisor positions, and once established, said objectives can help orthodontists design their treatment mechanics to achieve those goals.

etiology of Class II malocclusions, and this paradigm has persisted even to this day evidenced by the pervasive development and employment of Class II “distalizers.” This article will offer a different paradigm for the diagnosis, treatment planning, and therapy for Class II malocclusions that rely on a blend of labors previously presented by several astute researchers and clinicians.

Solidifying the paradigm By the time Tweed2 popularized the extraction of premolars, the paradigm of maxillary etiology for Class II malocclusions was well established, and his reliance on positioning the mandibular incisors at 90° ± 3° to the mandibular plane further necessitated retraction of the maxillary dentition because once the mandibular dentition retracted to this new upright position, the maxillary dentition had to retract to allow proper overjet and overbite. This maxillary retraction necessitated the use of varying types of occipital anchorage along with robust Class II and Class III elastics. Soon after Tweed had developed his diagnostic Tweed Triangle, Cecil Steiner3,4,5 created a diagnostic regimen using cephalometric standards that ostensibly placed the mandibular incisors into ideal positions.

Figure 1: Cranial strap to limit mandibular growth

Figure 2: Occipital pull facebow to control maxilla and maxillary incisors Orthodontic practice 25

CONTINUING EDUCATION

Time for a paradigm change

CONTINUING EDUCATION Although Tweed and Steiner used different methods, the final decision of whether to extract premolars more often than not coincided.6 These two diagnostic and treatmentplanning systems dominated orthodontic diagnosis and treatment planning for about 4 decades. Interestingly, neither in their treatmentplanning boxes considered the maxillary incisors. One of the first to challenge the maxillary etiology for Class II malocclusions was McNamara.7 While studying components of Class II malocclusions in 9-year-olds, he found mandibular deficiencies and/or neutral maxillae in approximately 87% of the examined Class II patients. Thus he considered mandibular deficiencies as a principal feature of Class II malocclusions and shifted the blame from maxillary protrusions as the etiology. Others8,9 have made similar discoveries, and this has reinforced the emphasis on protrusion of mandibular dentitions as desired therapy for those patients. However, Mastorakas10 in a 1983 thesis discovered in a group of 12 to 14-year-olds with Class II malocclusions that protrusive maxillae persisted more often than those in the 9-year-olds of McNamara’s study and, rather than clarifying the subject, led to some confusion about the etiology of Class II malocclusions. Even with the development of A pointPogonion line as a diagnostic and treatment-planning guide first suggested by Williams11 and later endorsed by Ricketts,12 the emphasis continued on using the position of the mandibular incisors as the focus of diagnostic and treatment planning. Williams suggested placing the mandibular incisors on or within 1 mm of the APo line. Ricketts eventually expanded the acceptable position to 2 mm, but 1 mm or 2 mm provides a narrow limit for acceptable positions of the mandibular incisors and, though more generous than either the Tweed or Steiner, still required the maxillary dentition to conform to restricted mandibular incisor positions. Casko and Shepherd13 completed perhaps the most important and yet most neglected study ever done on adults with orthodontically untreated Class I occlusions and attractive faces. They discovered “normal” Class I occlusions with attractive faces occurred within wide ranges, for instance: • ANB angle ranged from -3° to 8°; (an example herewith extends this to 10°) • Maxillary incisor to SN ranged from 93° to 120° • Mandibular incisor to APo ranged from -3 mm to 6 mm • IMPA ranged from 83° to 106° 26 Orthodontic practice

Figure 3: Cephalometric tracings of a patient with ideal facial measurements — (left) prior to therapy with four premolar extractions suggested by the Tweed Triangle; (right) an unappealing streamlined profile. Illustrations used with permission of the American Journal of Orthodontics & Dentofacial Orthopedics

Figure 4: Holdaway’s subnasale sulcus is on the left, while the H line is on the right along with their measurements of 3 mm and 5 mm

(an example herewith extends this to 114°) They found a strong correlation between the A-B discrepancy and the position of the mandibular incisors. As the distance of A to B enlarges, the mandibular incisors must lean more forward to make contact with the maxillary incisors. As the distance between A and B diminishes, the mandibular incisors adapt more lingually. A few years later, McNamara14 made a similar study of Class I adults with ideal occlusions and attractive faces and corroborated what Casko and Shepherd had previously found. Even Tweed15 had previously discovered a wide range of measurements within his partisan collection of Class I occlusions accompanied by straight profiles or slightly concave, which he preferred. Why he decided on placing mandibular incisors at 90° ± 3° to the mandibular plane remains a mystery. But the profession endorsed it and continues to use it despite its serious limitations.

Challenges to the commonly accepted paradigm Holdaway16,17 first suggested using the maxillary incisor rather than the mandibular incisor as a guide for diagnosis and

treatment planning. Ostensibly, the maxillary incisor bears the primary responsibility for lip support, and the frequent loss of lip support he and others received from using the mandibular incisor for treatment planning precipitated the necessity of using soft tissue as a guide (Figure 3). Others,18-21 alluding to Casko’s and McNamara’s studies, soon added to Holdaway’s seminal suggestion about deferring to the face, the upper lip, and the maxillary central incisors as determinates of where to position the maxillary and ultimately the mandibular incisors. Unfortunately, few clinicians seem to know about Holdaway’s discoveries, much less subscribe and use them. Holdaway’s cephalometric analysis, which incidentally applied only to Caucasian faces, has two important measurements for maxillary lip position (Figure 4): 1. The subnasale sulcus measurement that extends a perpendicular line from Frankfort Horizontal to the outer contour of the upper lip and ideally measures 3 mm ± 1 mm; 2. The harmony or H line uses a line from the soft tissue pogonion to the outer contour of the upper lip and ideally measures 5 mm ± 1 mm. Volume 10 Number 4

The A Line diagnosis and treatmentplanning system In 2001, Alvarez18 published an article that presented his findings vis-a-vis Casko’s study of Class I occlusions. He discovered that the facial surface of the maxillary central incisors in those patients occupied a position that was one-third ±1 mm of the distance between soft tissue A point and osseous A point, which he called the A Line (Figure 5).

Figure 5: The A Line — a perpendicular line extended from a line parallel to true horizontal to a point one-third of the distance between osseous A point and soft tissue A point

A case in point The following orthodontically untreated individual (Figures 6 and 7) illustrates exactly what Casko, Shepherd, McNamara, Holdaway, Alvarez, Bass, Creekmore and others were convinced of: i.e., the mandibular incisor varies in its position to the maxilla and its dentition, and that the maxilla and its dentition carries the responsibility for the contour of the lips and the facial profile. Therefore, the diagnostic dynamic should rest upon the maxillary incisors rather than the mandibular. These discoveries, however difficult for some to accept, invalidates the reliance on the mandibular incisor position and inclination as the determinant of orthodontic therapy. This young lady has an ideal profile with Holdaway measurements of 3 mm and 5 mm for the subnasale and H line, respectively. She also displays an ideal Class I occlusion untouched by orthodontic treatment. But interestingly, she has an A-B discrepancy of 12 mm (an ANB discrepancy of 10°), which is 3 times what is conventionally regarded as ideal. Consequently, the mandibular incisor has an IMPA of 114°, which is 24° from the upright position suggested by Tweed. Additionally, the mandibular incisor lies 5 mm ahead of the APo line and exceeds Williams’ suggested position by 4 mm and even what Ricketts suggested by 3 mm. However, note that the interincisal angle for such an individual with an A-B discrepancy of 12 mm is ideal at 115°. The lower lip lies -1 mm from the H line, which is within the range of

Figure 6: An ideal orthodontically untreated face and dental occlusion Volume 10 Number 4

ideal suggested by Holdaway. The maxillary incisor lies 1 mm anterior to the A Line, which is within the range of ideal position as suggested by Alvarez.

Clinical examples of soft tissue diagnosis, treatment planning, and therapy Patient 1 The following 11-year-old adolescent female (Figure 8) had a maxillary arch length discrepancy of 7 mm, whereas the mandibular arch length discrepancy measured 13 mm with a blocked-out mandibular left second premolar. She also displayed features of a maxillary protrusion and a mandibular retrusion, but the principal trait was the mandibular retrusion caused primarily by a short mandible. The maxillary central incisors showed a slight protrusion (2 mm anterior to the A Line) reinforced by a lower lip bite habit, whereas the maxilla itself had an optimal length. The protruded maxillary incisors, which lay 2 mm anterior of the A Line, caused some lip strain in the upper lip, but the subnasale sulcus measurement registered only 1 mm, which is sub-minimal for an esthetic face. The harmony line of Holdaway measured an unusually large 10 mm due to the retrusive mandible. These soft tissue measurement of the lips resulted in a seemingly protrusive profile that was more true in appearance than reality. The short mandible contributed appreciably to the large A-B discrepancy of 12 mm as opposed to the average of 4 mm

�Figure 7: Cephalometric tracing of the ideal untreated face and dental occlusion Orthodontic practice 27

CONTINUING EDUCATION

Obviously, different racial types along with doctor discretion and patient preferences require accommodations, but the contention that the maxillary incisor essentially controls lip posture is obvious. By making it the cornerstone of diagnosis and treatment planning, clinicians can avoid streamlining the profile.

CONTINUING EDUCATION

Figure 8: Adolescent female Class II Division 1 malocclusion complicated by maxillary and mandibular arch length discrepancies and a short mandible with a retruded mandibular dentition

Figure 9: Initial cephalometric tracing of malocclusion

Modified Steiner Box

Cephalometric Values

Max

Man

-7

-13

Relocation Incisor

-5.5

Mesial Molar Movement

-2.5

Norm

Patient

Upper Lip Sulcus

Upper Lip Sulcus to H Line

Maxillary Incisor to A Line

Lower Lip to H line

Distal Molar Movement

Md to Mx difference

Curve of Spee

Lower Anterior Face Height

A-B Discrepancy

Arch Length Discrepancy Arch Development

Interproximal Reduction 15

Total Net

Figure 10: Visualized Treatment Objective (striation) superimposed on the initial tracing

Figure 11: Cephalometric measurements and modified Steiner Box for treatment planning

and signaled a requirement for the mandibular incisors to need a more forward position. The patient had a deep bite and large overjet with Class II canines and a malocclusion classified as a Class II Division 1, which some might wish to correct by intruding and retracting the maxillary incisors while they simultaneously apply a distal force to the maxillary dentition. But applying heavy distal forces to the maxilla carries the risk of extruding the maxillary molars, which would drive the mandible down and back and make the achievement of Class I canines more difficult. The cephalometric tracing, (Figure 9) and constructed VTO (Figure 10) that changes the occlusal plane to 5 mm-6 mm below the lip embrasure (suggested for adolescents) allows one to see that the deep overbite and overjet need correction by intrusion

and advancement of the mandibular incisors, along with the lingual retraction of the maxillary incisors. These cephalometric measurements, along with the arch length discrepancies, prompted the decision to remove the maxillary first premolars for space to retract the maxillary incisors and place the maxillary canines in a Class I occlusion, while bringing the maxillary posterior teeth forward and occluding in a Class II arrangement. The mandibular arch would undergo nonextraction therapy. Please refer to the modified Steiner Box (Figure 11). Advancement of the mandibular incisors remains an anathema to clinicians weaned on Tweed, Steiner, and APo diagnoses and treatment plannings; but as Casko and McNamara have shown in previously cited studies of the variation in Class I occlusions, as the distance between point A and

28 Orthodontic practice

Extractions

point B enlarges, the mandibular incisors must lean forward to have contact with the maxillary incisors. Although this adolescent patient will continue to grow, rather than using an unpredictable chaos-ladened growth Visualized Treatment Objective (VTO), I designed this VTO as a nongrowing patient. That is, clinicians need to know what it would take right now to give this patient an acceptable overbite, overjet, and posterior occlusion while solving the arch length discrepancies. The therapy proceeded as planned, and as seen in the final photographs, cephalometric tracings, and the cephalometric superimpositions (Figures 9-15), the treatment outcome validates that plan. The profile has improved markedly by relieving the upper lip strain and the mandibular forward growth, which also reduced the A-B discrepancy by 2 mm. Volume 10 Number 4

Patient 2 The following patient (Figure 16) displays a Class II malocclusion complicated by a deep bite and maxillary and mandibular arch length discrepancies. Her A-B discrepancy is 10 mm, which is 3½ times the average of 4 mm. The mandible-maxilla discrepancy is 18 mm, which indicates a short mandible. Both maxillary and mandibular incisors are retroclined and need forward positioning, while the maxillary incisors need much more axial inclination. The initial tracing and VTO (Figures 17 and 18) encourages the correction to come from forward movement of the maxillary incisors and the entire mandibular

dentition. The patient’s cervical vertebrae show little evidence of further pubertal growth, so any correction will come from dentoalveolar adaptation. At first glance at the VTO, it would seem impossible for that

much forward movement of the mandibular dentition to occur. Nevertheless, as the final photographs and cephalometric superimpositions show (Figures 19 and 20), that occurred exactly with a “distalizing

Figure 12: Photos of treatment outcome

Figure 13: Posttreatment cephalometric values and tracing

Figures 14 and 15: 14. Superimpositions of initial and final cephalometric tracings at SN (left) and on the palatal plane and the mandibular plane (right). 15. Superimposition on the maxilla to show coincidence of the VTO teeth to those of the final positions. (VTO — solid line and final — dotted line)

Figure 16: Patient with a Class II malocclusion with a deep overbite and maxillary and mandibular arch length discrepancies Volume 10 Number 4

Figure 17: Initial cephalometric tracing Orthodontic practice 29

CONTINUING EDUCATION

Many would dispute the wisdom of advancing mandibular incisors so far, but intruding them simultaneously will diminish the risk of stripping the gingiva, and the outcome photos illustrate that no such stripping has occurred. Additionally, those who question the advancement of mandibular incisors must realize that many times correct therapy requires such movement. Also, by superimposing on the maxilla, one can see how the maxillary and mandibular incisors have responded as planned in the VTO (Figures 14 and 15). Some clinicians additionally complain that the advancement of mandibular incisors will encourage a rapid relapse. To test this theory, the wires were left off this appliance for a range of time before removal of the brackets and bands with no apparent relapse. Once teeth have an optimal occlusion, the retention becomes self-sustaining, and this patient experienced that.

CONTINUING EDUCATION appliance,” aka, the Forsus. Note not only how the mandibular dentition has moved forward, but also how the symphysis has bent forward from this mesial force. Simultaneously, the VTO illustrates how the maxillary incisors initially are lingual vis-a-vis the A Line and needed forward movement and more apical inclination.

Conclusion Carl Sagan popularized the aphorism that “Extraordinary claims require extraordinary evidence.” This article fulfills that requirement by relying on research by reliable investigators and the experience of both skillful clinicians and the authors. Personally, in designing treatment plans for patients with Class II malocclusions, far more retrusive mandibular dentitions are found than protrusive maxillary; and often with patients who do show protrusive maxillary dentitions, as in the first patient shown, they will concomitantly display a retrusive mandibular dentition. Dr. Calvin S. Case (1847-1923), when he invented Class II elastics, knew he was creating both distal and mesial forces, and so it is with every intermaxillary Class II mechanism. Without many exceptions, most of the correction from so-called “distalizers” results in protraction of the mandibular dentition. When clinicians show “distalizing” effects with superimpositions, it is usually immediately after the Class II correction has occurred. Readers seldom see superimpositions made at the termination of treatment, which, more often than not, show previously retracted maxillary molars with more mesial positions and the mandibular incisors positioned more facially. Obviously, one should not expect the treatment of two patients to engender a change in the paradigm of diagnosis, treatment planning, and therapy of Class II patients, but the previously mentioned untreated patient and the two treatments do illustrate the truths provided by multiple researchers and clinicians that question the long-held belief regarding the mandibular incisor as the key to diagnosis, treatment planning, and therapy. Additionally, this article should alert clinicians to the essential task of deciding on the principal etiology and then planning and applying correct therapies. By using the diagnostic and therapeutic discoveries of Holdaway, Casko, McNamara, Bass, Alvarez, and others, clinicians can establish the primacy of the maxillary incisors rather than mandibular and realize that the mandibular incisor simply and naturally adapts to the position of the maxillary incisor 30 Orthodontic practice

Figure 18: VTO constructed on the initial cephalometric tracing

vis-a-vis the A-B discrepancy as documented by Casko and McNamara. Establishing the mandibular incisor as the principal treatment objective, based upon a dubious supposition not always found in nature, should give pause to those who continue to insist upon its validity. No one questions the excellent therapies provided by using the mandibular incisor as a diagnostic and treatment-planning guide. But one must realize that satisfactory clinical outcomes often occur in spite of planning rather than because of it. By using the maxillary incisor as a guide along with properly done VTOs, clinicians can develop reasonable targets for incisor positions, and once established, said objectives can help doctors design their treatment mechanics to achieve those goals. OP

Figure 19: Final cephalometric tracing superimposed on the initial tracing at SN, which shows the forward displacement of the mandibular dentition but also the bending of the symphysis that accommodates the proper interincisal contact. Additionally, note the minimum distal movement of the maxillary molars and the lack of mandibular growth this patient experienced as the mandible dropped down and back with no forward movement

Figure 20: Photographs of treatment outcome

11. Williams R. The diagnostic line. Am J Orthod. 1969;55(5): 458-476. REFERENCES 1. Case C. Disto-mesial intermaxillary force. Chicago Dental Society. 1893;Chicago, IL. 2. Tweed CH. The Frankfort-mandibular incisor angle (FMIA) in orthodontic diagnosis, treatment planning and prognosis. Angle Orthod. 1954;24(3):121-169. 3. Steiner CC. Cephalometrics for you and me. Am J Orthod. 1953;39(10):729-755. 4. Steiner CC Cephalometrics in Clinical Practice. Angle Orthod. 1959;29(1):8-29 5. Steiner CC. The use of cephalometrics as an aid to planning and assessing orthodontic treatment. Am J Orthod. 1960;46(10):721-735. 6. Priewe DE. An evaluation of cephalometric analysis and extraction formulas for orthodontic treatment planning. Am J Orthod. 1962;48(6):414-428. 7. McNamara JA Jr. Components of class ii malocclusion in children 8-10 years of age. Angle Orthod. 1981;51(3):177-202. 8. Jacob HB, Buschang PH. Mandibular growth comparisons of Class I and Class II Division 1 skeletofacial patterns. Angle Orthod. 2008;84(5):755-761. 9. Stahl F, Baccetti T, Franchi L, McNamara JA Jr. Longitudinal growth changes in untreated subject with Class II Division 1 malocclusion. Am J Orthod Dentofacial Orthop. 2008;134(1):125-137. 10. Mastorakos WL. Components of Cl II Malocclusions in 12-14 year-olds, in Orthodontics. St. Louis University: St. Louis, MO; 1983.

12. Ricketts R., Bioprogressive Therapy. 2nd ed. 1979, Denver: Rocky Mountain/Orthodontics., Denver. 13. Casko JS, Shepherd WB. Dental and skeletal variation within the range of normal. Angle Orthod. 1984;54(1):5-17. 14. McNamara JA, Ellis E 3rd. Cephalometric analysis of untreated adults with ideal facial and occlusal relationships. Int J Adult Orthodon Orthognath Surg. 1988;3(4):221-231. 15. Tweed CH. The Frankfort mandibular incisor angle (FMIA) in orthodontic diagnosis, treatment planning and prognosis,. Angle Orthod. 1954;24(3):121-169. 16. Holdaway RH. A soft tissue cephalometric analysis and its use in orthodontic treatment planning, Part I. Am J Orthod. 1983;84(1):1-28. 17. Holdaway RH. A soft tissue cephalometric analysis and its use in orthodontic treatment planning, Part II. Am J Orthod. 1984;85(4):279-293. 18. Bass NM. The aesthetic analysis of the face. Eur J Orthod. 1991;13(5):343-350. 19. Creekmore, TD. Where teeth should be positioned in the face and jaws and how to get them there. J Clin Orthod. 1997;31(9):586-608. 20. Alvarez A. The A Line: A New Guide for Diagnosis and Treatment Planning. J Clin Orthod. 2001;35(9): 556-569. Erratum in J Clin Orthod 2002 Jan;36(1):24. 21. Bass NM. Measurement of the profile angle and the aesthetic analysis of the facial profile. J Orthod. 2003;30(1):3-9. 22. Kieferorthopädie. 2004;18():45-54. 23. Jasper J. The Physics of Cl II Correction. Orthodontic Practice US. 2018;9(5):12-16.

Volume 10 Number 4

REF: OP V10.4 WHITE, ET AL.

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.

Time for a paradigm change WHITE, ET AL.

1. By the time _______ popularized the extraction of premolars, the paradigm of maxillary etiology for Class II malocclusions was well established, and his reliance on positioning the mandibular incisors at 90°± 3° to the mandibular plane further necessitated retraction of the maxillary dentition because once the mandibular dentition retracted to this new upright position, the maxillary dentition had to retract to allow proper overjet and overbite. a. Tweed b. Steiner c. McNamara d. Holdaway 2. One of the first to challenge the maxillary etiology for Class II malocclusions was _______. a. Tweed b. Steiner c. McNamara d. Holdaway 3.

Even with the development of ______ as a diagnostic and treatment-planning guide first suggested by Williams and later endorsed by Ricketts, the emphasis continued on using the position of the mandibular incisors as the focus of diagnostic and treatment planning. a. A point-Pogonion line b. B point-Nasion c. B point supramentale d. frontotemporale While studying components of Class II malocclusions

Volume 10 Number 4

in 9-year-olds, he (who was one of the first to challenge the maxillary etiology for Class II malocclusions) found mandibular deficiencies and/or neutral maxillae in approximately _____ of the examined Class II patients. a. 26% b. 38% c. 60% d. 87% 5.

Williams suggested placing the mandibular incisors on or within _____ of the APo line. a. 1 mm b. 2 mm c. 3 mm d. 4 mm

6. Casko and Shepherd discovered “normal” Class I occlusions with attractive faces occurred within wide ranges, for instance: … Maxillary incisor to SN ranged from ________ a. 58° to 64° b. 75° to 83° c. 85° to 89° d. 93° to 120° 7. Casko and Shepherd discovered “normal” Class I occlusions with attractive faces occurred within wide ranges, for instance: … Mandibular incisor to APo ranged from _______ a. -3 mm to -6 mm b. -3 mm to 6 mm c. -1 mm to -2 mm

d. none of the above 8.

Alvarez discovered that the facial surface of the maxillary central incisors in those patients occupied a position that was one-third ±1 mm of the distance between soft tissue A point and osseous A point, which he called the ________. a. Alvarez dynamic b. H line c. A Line d. Frankfort Horizontal

9. The untreated individual in Figures 6 and 7 illustrates exactly what Casko, Shepherd, McNamara, Holdaway, Alvarez, Bass, Creekmore and others were convinced of: i.e., the mandibular incisor varies in its position to the maxilla and its dentition, and that the maxilla and its dentition ________ the contour of the lips and the facial profile. a. has no effect on b. carries the responsibility for c. invalidates d. has no correlation to 10. Dr. Calvin S. Case (1847-1923), when he invented ________, knew he was creating both distal and mesial forces, and so it is with every intermaxillary Class II mechanism. a. Class II elastics b. the Forsus appliance c. the Herbst appliance d. the transpalatal bar

Orthodontic practice 31

CE CREDITS

ORTHODONTIC PRACTICE CE

TECHNOLOGY

Achieving excellence in orthodontics with digital technology Dr. Thomas R. Pitts discusses how digital technology can benefit the doctor, practice, and patients

any orthodontic practices seeking excellence are moving into the direction of a “fully digital workflow.” What does a fully digital workflow include? • Going from impression material to scanning, eliminating alginate • Digital models instead of mounted plaster casts • Working with a digital lab that will use only 3D-printed models for all appliances made in lab • Digital smile design for bracket placement • Digital 3D imaging for radiology and hard tissue measurements • Three-dimensional volumetric measurements for airway analysis (Figure 3) • Digital statistics for practice management • And, of course, digital charting and image collection It’s a lot to take in. Even when focusing on just one aspect of a digital workflow — imaging in this case — the decision to invest in digital technology is not to be taken lightly. However, ultimately, it’s one that will benefit doctor, practice, and patient alike.

No going back Most orthodontic practices that are committed to excellence have either already made the switch to digital or are seriously considering transitioning to 3D imaging for their patients. Cone beam computed

tomography (CBCT) is a great diagnostic and communication tool; it’s become an absolute “must” in my practice for every patient. I use the CS 9300C (Carestream Dental), along with CS 3D Imaging and CS Orthodontic imaging software. In addition to 3D imaging, this system also allows for 2D and necessary cephalometric imaging; or a lateral ceph and a panoramic image can be quickly rendered from the 3D scan (Figure 1). Having used this system for 5 years, there is no way that

I would go back to 2D. Not only does CBCT imaging give a more accurate view of the exact positioning of all teeth (Figure 2), roots and erupting teeth, it’s essential for studying the airway; evaluating bone density for mini implants; and understanding the exact relationships of impacted teeth to adjacent teeth. Often, CBCT imaging reveals a supernumerary that is hard to see in a traditional 2D panoramic image. In addition to enhancing a doctor’s diagnoses and expanding treatment

Figure 1: The CS 9300C allows for both 2D and 3D imaging

Tom Pitts, DDS, MSD, graduated from the University of Washington’s orthodontic program in 1970. After graduating, he simultaneously practiced and consulted orthodontists on practice management and clinical protocols. Pitts previously served as a consultant for Ormco Corp, in Anaheim, California, and OC Orthodontics in Oregon. He was an associate clinical professor in orthodontics at the University of the Pacific School of Dentistry for 20 years and now teaches at the University of Las Vegas orthodontic program. Pitts currently resides in Reno, Nevada, and practices orthodontics with his son. He travels the world presenting lectures and training in clinical esthetic orthodontics. Disclosure: Dr. Pitts is a key opinion leader for Carestream Dental.

Figure 2: CBCT imaging gives views from every angle 32 Orthodontic practice

Volume 10 Number 4

THE ORTHODONTIC SOLUTION FROM START TO FINISH

Accurate digital X-ray

Fast intraoral scanning

Low dose CBCT

Cephalometric and airway analysis

Model analysis and set-up

Complete practice management software

WORKFLOW INTEGRATION I HUMANIZED TECHNOLOGY I DIAGNOSTIC EXCELLENCE

Carestream Dental systems give you a fast, safe and efficient orthodontic workflow When every piece in the chain is designed to work together, your workflow, practice and patients all benefit. Carestream Dental’s digital systems combined with CS OrthoTrac software offer numerous options for diagnosis, treatment planning and consultations—giving you the tools necessary to transform patient care and the way you present treatment options and goals.

For more information, call 800.944.6365 or visit carestreamdental.com

TECHNOLOGY

Figure 3: Airway analysis is a growing field in orthodontics

Figure 4: 3D imaging shows the relationship of impacted teeth

capabilities, CBCT images and slices are excellent communication tools for patients and parents to follow an eruption path, locate impacted positions, show forces needed to correct inclinations and identify mesiodens and other supernumeraries (Figures 4 and 5). Naturally, these easy-to-view-and-share 3D images also go a long when communicating with a primary care dentist as well.

Next steps in the digital workflow

Figure 5: A supernumerary is revealed thanks to 3D imaging

In addition to my CBCT system, my fully digital workflow includes an intraoral scanner (CS 3600, Carestream Dental), modeling software (CS Model +, Carestream Dental), and CS OrthoTrac practice management software. Now, to move my practice even more toward excellence, the next step to enhancing my fully digital workflow is the addition of a 3D printer in order to print TMD, sleep and intraoral appliances in-house from scanned models. This will save time and money in the future by using past scanned images captured with the intraoral scanner for the fabrication of lost or broken appliances. The patient will need to come in for only the delivery appointment, not an additional impression appointment. This methodology will also speed up the time for delivery of appliances in practices with an in-house lab. The open architecture of my existing digital technology allows me to invest in the printer of my choice. Introducing digital technology to my practice has made achieving excellence in orthodontics easier than ever. Once you have practiced with the speed and accuracy of digital 3D imaging, thereâ&#x20AC;&#x2122;s no going back to traditional methods. OP

Figure 6: CS 9300C 34 Orthodontic practice

Volume 10 Number 4

ESSENTIALS

IN ORTHODONTICS

Sandra Tai This best-selling book approaches clear aligner treatment from a diagnosis and treatment-planning perspective, discussing time-tested orthodontic principles like biomechanics and anchorage and demonstrating how to apply them to orthodontic cases using these appliances. Learn how to program a suitable treatment plan using available software, how to design the digital tooth movements to match the treatment goals, and finally how to execute the treatment clinically and finish the case well. 320 pp; 1,344 illus; ÂŠ2018; ISBN 978-0-86715-777-2 (B7772); US $218

Editor-in-Chief: Werner Schupp The Journal of Aligner Orthodontics is a peerreviewed journal that publishes clinically relevant articles on the entire range of digital aligner orthodontics. Articles present basic procedures, case reports, multidisciplinary treatment including aligner procedures, original studies, expert discussions, and tips and tricks. Subscribe today! Published quarterly. Annual subscription: $116

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MARKETING MOMENTUM

11 steps to branding your sleep practice for success Marc Fowler outlines how success depends on people knowing who you are

aving worked with dozens of dental practices, from those that have just started treating sleep patients to some of the most productive sleep practices in the country, it has become evident that in order to maximize the growth of a dental sleep practice, you must have a brand identity for your sleep practice that is independent of your orthodontic practice brand. Your goal is to position yourself as the expert in airway and sleep-breathing issues in the minds of prospective patients. Webster’s dictionary defines an expert as “one with special skill or knowledge representing mastery of a particular subject.” The subjects of dentistry and sleep apnea treatment don’t naturally go together. When prospective patients see sleep apnea listed in your services section next to Phase 1 orthodontic treatment and clear aligners for teens, they will have trouble making the connection. In other words, simply adding a page or two about sleep to your orthodontic practice website does little to position you as the expert to prospective sleep patients. Bullseye Media has developed the following checklist of steps necessary to establish an effective brand identity and differentiate your sleep practice.

Sleep practice branding checklist 1. Select a name for your sleep practice. The practice name should not contain the word “dental.” When patients see “dental sleep,” they’re most likely thinking sedation. 2. Purchase a website domain name. Ensure the domain is easy to spell and remember. The shorter the better. Ideally, choose the .com version of your new sleep practice name. 3. Design a new logo. The logo needs to be professionally designed and visually pleasing. The graphics should communicate the message Marc Fowler is the founder of Bullseye Media. Since 2006, the team at Bullseye Media has provided branding, website design, video, and online marketing services for dental practices across the United States and Canada. He can be reached at (214) 592-9393, Marc@ BullseyeDental.com, or DentalSleepMarketing.com.

36 Orthodontic practice

An example of a dedicated sleep website

that you help patients breathe and sleep better. 4. Establish a separate phone number. You’ll need a separate phone number to claim online directory listings for your sleep practice. It will also enable your staff to answer incoming calls using the name of your sleep practice. 5. Build a dedicated sleep website. When prospective patients land on your website, they’re forming an impression of your practice within seconds. A well-executed sleep website will educate, establish authority, and ultimately convert website visitors into scheduled sleep consultations. 6. Create and optimize a Google My Business™ listing for the new

entity. Critical elements include your sleep practice name, website address, and dedicated phone number. Optimize your listing by uploading your logo along with some professional photos of you, your team, and the office. 7. List your practice on the leading online directories. If you aren’t sure which ones to focus on first, do a few Google searches incorporating your city name into the search term and see which directories show up consistently. The key directories will differ by city and keyword search terms. 8. Start a Facebook page for the new practice. Utilize your new logo and colors for brand consistency. Have someone in your office post

An example of a sleep practice Facebook page Volume 10 Number 4

important. Reviews from sleep patients will resonate with potential sleep patients as well as provide valuable keywords to help Google associate your practice with sleeprelated searches. 10. Create a YouTube channel. YouTube is the third most visited

Sleep apnea brochure

website in the United States and the second largest search engine after Google. Cisco estimates that by 2021, 82% of all internet traffic will be video. The practices that leverage video now will have a significant competitive advantage during the coming years. 11. Print sleep apnea brochures to place throughout your practice. Include your new logo, phone number, and sleep website address on the brochure. A well-executed brochure will act as a conversation starter, educate patients, and make it easy for them to refer others to you. Implementing these 11 steps will not only increase your visibility and build your brand as a sleep provider, but also go a long way toward positioning you as the go-to authority for sleep apnea treatment in your target market. To learn the three steps to successfully building a sleep practice and to hear from other doctors who have, please visit DentalSleepMarketing.com. OP

Stay Connected Between Issues Like us on Facebook at facebook.com/OrthodonticPracticeUS Share with us on Instagram at instagram.com/orthodonticpracticeus Follow us on Twitter at twitter.com/orthopracticeus 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 4

Orthodontic practice 37

MARKETING MOMENTUM

to it weekly. Important details to include in the About section: a link to your new sleep website, your office address, your phone number, and an overview of your sleep practice. 9. Collect patient reviews for your sleep practice. Google, Yelp, and Facebook reviews are the most

PRACTICE MANAGEMENT

Offering care for OSA and temporomandibular joint disorders — tips for billing Christine Taxin discusses how to help patients get the necessary care and coverage

ince the recommended amount of sleep for a child ages 6- to 12-years-old is between 9 and 12 hours each night,1 when that sleep is continually interrupted or not the best quality, many problems can arise in the young bodies of developing children. With this in mind, how can orthodontists help gently guide their parents to answers? Management and care of obstructive sleep apnea (OSA) can help improve the overall health and wellness of the children and allow them to flourish during childhood

Christine Taxin is founder and president of Links2Success & Dental Medical Billing, an online school for all billing issues. She serves as an adjunct professor at the New York University (NYU) Dental School and Resident Programs for New York City Programs. Taxin is on the board of the Stem Cell Collection and the Board of Certification for 3D Scans, and has a Fellowship with the AIDA. The AGD has approved her company Links2Success as a national provider of PACE® continuing education credits. Taxin’s workbooks “Introduction to Medical Billing,” “Introduction to CT Scan Billing,” and “Oral Surgery and Implant Surgery” have been received by many as the go-to workbook for training. The Second Insurance Extravaganza will be held in Las Vegas, Nevada, October 17-18, 2019. Use code 2NDINS at https:// insuranceextravaganza.com for your article discount. To contact Christine Taxin, email ctaxin@links2success.biz.

38 Orthodontic practice

rather than struggle with an untreated airway issues.2 In 2013, a position paper, developed by a Task Force of the American Academy of Craniofacial Pain on Mandibular Advancement Oral Appliance Therapy for Snoring and Obstructive Sleep Apnea, contained recommendations for dentists engaged in the management of patients with snoring and obstructive sleep apnea utilizing mandibular advancement oral appliances.3 Therefore, a large percentage of children being treated with expanders and appliances that can grow with the child should be billed as medical. Some dental ofﬁces avoid billing medical insurance for covered dental procedures because they fear that they will be accused of fraud. However, most states have laws recognizing both DDS and DMD providers as capable of billing medical insurance for conditions that fall under their specialties. The American Dental Association has put together an overview of some of these state laws. In most states, if an insurer covers a procedure when a physician or nurse practitioner performs said procedure, it must also cover the same procedure when a dentist performs it.4

How does the law pertain to the orthodontic practice? What does the law define, and how can it apply to dental practitioners? As of 2014, the definition of physician/practitioner has been revised as follows: “For purposes of this provision, the term ‘physician’ is limited to doctors of medicine; doctors of osteopathic medicine; doctors of dental surgery or of dental medicine; doctors of podiatric medicine; and doctors of optometry who are legally authorized to practice dentistry, podiatry, optometry, medicine, or surgery by the State in which such function or action is performed; no other physicians may opt out.”4 Now that we have established how the orthodontist and practice are covered and able to bill from dental to medical, let’s take a look at how to use this specific type of billing to help patients obtain the care and coverage they need. For example, both removable and ﬁxed appliances are routinely covered under most medical plans and programs, including temporomandibular joint dysfunction (TMD) issues, the correction of mandibular position or narrow airway leading to obstructive sleep apnea, and the modiﬁcation or Volume 10 Number 4

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PRACTICE MANAGEMENT correction of development anomalies such as a narrow palatal vault. Additionally, it is imperative to remember that the American Academy of Pediatrics reports that OSA is a common condition among children and can cause signiﬁcant complications when left untreated.5 There are certain steps to begin the journey of adding the ability to refer a child for diagnosis for either treatment of sleep apnea or TMD. Of course, you must determine the treatment after the test results are available and collaborate with your patients’ medical provider. Know the questions to ask. Does the child: • Take any medications? • Have medical professionals taking care of him/her? Get their name and number. • Walk around during the night? • Urinate in his/her sleep? • Sleep in class? • Act out in class or at home? • Mouth-breathe? (Children with enlarged adenoids tend to breath with their mouths open.) • Experience breathing pauses during sleep? • Exhibit daytime sleepiness? • Have difficulty concentrating? • Have poor performance at school? Because enlarged tonsils and/or adenoids are the most common causes of sleep apnea for children, having surgery to remove the tissues often corrects the symptoms of sleep apnea in 90% of cases.6 For children whose sleep apnea is attributed to obesity, weight management and lifestyle programs are usually employed to help children manage their weight. Additionally, continuous positive airway pressure (CPAP) therapy may be recommended; however, many cannot tolerate the CPAP. The medical provider can send a form to the dental professional for treatment using an oral appliance with a copy note that the patient cannot tolerate the CPAP. Dental appliances then may be recommended, or if the primary physician does not recommend surgery at this time. Most children need to have severe issues for a surgical procedure at least 3 times within a certain period. Bottom line: Every insurance policy is different. Always know the guidelines. For OSA, when walking through the documentation needed for each specific patient case, establishment of medical necessity is imperative. For example, pediatric orthodontics requires documentation 40 Orthodontic practice

All insurance carriers have slightly different requirements, so be sure to call ahead to find out what is covered. to support the severe handicapping malocclusion and the presence of a qualifying medical condition, and a score of 42 points or greater on the Modified Salzmann Index. Documentation must include a completed Salzmann assessment and a written report from the attending medical specialist who is treating the patient for deformity/anomaly.7 Progress notes, photographs, and other relevant supporting documentation may be included as proper. To be considered medically necessary (needed to treat, correct, or improve a medical defect or condition), orthodontic services must be an essential part of an overall treatment plan developed by both the physician and the dentist in consultation with each other. Note: Orthodontic treatment for dental conditions that are primarily cosmetic in nature or when self-esteem is the primary reason for treatment does not meet the definition of medical necessity. When addressing TMD, the Salzmann assessment record is intended to show whether a handicapping malocclusion is present and to assess its severity according to the criteria and weights (point values) assigned to them. The weights are based on tested clinical orthodontic values from the standpoint of the effect of the malocclusion on dental health, function, and esthetics. Etiology, diagnosis, planning, complexity of treatment, and prognosis are not factoring in this assessment. Here is a brief broad-brush overview of nonsurgical management of TMJ/TMD: Reversible intraoral appliances may be considered medically necessary in selected cases only when there is evidence of clinically significant masticatory impairment with documented pain and/or loss of function. Prolonged (greater than 6 months) application of TMD/TMJ intraoral appliances is not considered medically necessary unless, upon individual case review, documentation supports prolonged intraoral appliance use. Only one oral splint or appliance is considered medically necessary for TMD/ TMJ therapy. For plans that cover intraoral

appliances, adjustments of intraoral appliances performed within 6 months of initial appliance therapy are considered medically necessary; while adjustments performed after 6 months are subject to review to determine necessity and appropriateness.8 Note: All insurance carriers have slightly different requirements, so be sure to call ahead to ﬁnd out what is covered.

Conclusion Treatment of OSA in children and adults is an important endeavor. The beneﬁts of treatment include better sleep, better health, and a better quality of life for patients. For the dental professional, the beneﬁts are numerous. You can set your practice apart from the competition by offering sleep apnea services. By building a network of referring physicians, you will see more patients that may come to you for all their dental needs. With medical coverage of oral appliance therapy, you can add a valuable stream of income to your practice as well. OP REFERENCES 1. Marcus, MB. New Sleep Guidelines for babies, kids and teens. CBS News, CBS Interactive June 13,2016. www. cbsnews.com/news/new-sleep-guidelines-for-babies-kidsand-teens. Accessed June 19, 2019. 2. American College of Physicians/Internal Medicine. (ACP). https://www.acponline.org/online-learning-center/obstructive-sleep-apnea. Accessed June 19, 2019. 3. Spencer, Patel M, Mehta N, et al Special consideration regarding the assessment and management of patients being treated with mandibular advancement oral appliance therapy for snoring and obstructive sleep apnea. Cranio. 2013;31(1):10-13. 4. MMA-Private Contract Manual Change to Include Dentists, Podiatrists, and Optometrists in the Definition/List of Physicians Who Can Opt Out of Medicare. https://www. cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/downloads/MM3016. pdf. Accessed June 19, 2019. 5. Section on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome. American Academy of Pediatrics. Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2002;109(4):704-712. 6. Mehra P, Wolford LM. Surgical management of obstructive sleep apnea. Proc (Bayl Univ Med Cent). 2000;13(4): 338– 342. 7. Salzmann Evaluation Form. Aetna Dental [Claim Submission Tips & Guidelines]. https://www.aetnadental.com/professionals/pdf/salzmann-evaluation-index.pdf. Accessed June 19, 2019. 8. Temporomandibular Disorders. Aetna [Clinical Policy Bulletins/Medical Clinical Policy Bulletins]. www.aetna.com/cpb/ medical/data/1_99/0028.html. Accessed June 19, 2019.

Volume 10 Number 4

Sarah Hornsby, RDH, discusses the benefits of myofunctional therapy as a multidisciplinary part of the orthodontic practice

ost patients assume that the results of their orthodontic treatment will be permanent. But as dental professionals, we recognize that orthodontic relapse is a common occurrence. In many cases, the patient has not been compliant with retainer use, but there are other variables that we can identify as well — thirdmolar eruption, latent mandibular growth, genetics, and mesial drift, for example. We also see those “perfect patients,” who seem to have none of the possible factors that contribute to relapse, and who are incredibly diligent with wearing their retainers, yet they still experience occlusal changes. So, what else could be going on?

Tongue posture From the anatomical and anthropological perspectives, we know that the tongue should rest in the palate. The posture of the tongue can have a significant impact on orthodontic treatment and retention. For example, if the tongue has an interdental resting posture, we can see the impact of tongue position on occlusion in anterior and posterior open bites. For optimum orthodontic stability, the body of the tongue should fill the entire space of the oral cavity. The tip of the tongue should rest on the incisive papilla or the alveolar ridge area, and the dorsum of the tongue should make contact with the hard and soft palate.

Causes of incorrect tongue posture When the tongue drops from the palate, we may begin to see changes in occlusion. In the above example of the anterior or posterior open bite, what we often fail Sarah Hornsby, RDH, BS, graduated with a bachelor’s degree in dental hygiene from Eastern Washington University. She has pursued advanced training with the Academy of Orofacial Myofunctional Therapy (AOMT) and the International Association of Orofacial Myology (IAOM). She opened her practice, Faceology, in 2010 in Seattle. In 2014, Hornsby transformed Faceology into the world’s first telehealth myofunctional therapy practice. She has been working with patients and doctors from across the country and around the world since then. In 2015, Hornsby created MyoMentor to support hygienists and dentists who want to learn more about myofunctional therapy. Over 150 dental professionals have graduated from her mentoring program.

Volume 10 Number 4

to understand is that the tongue has lost contact with the palate. It has dropped to the floor of the mouth and, as a functional compensation, has begun to rest between the teeth and push forward or laterally during swallowing. We can identify this clinically as a tongue-thrust swallowing pattern. So, what would cause this postural change to the tongue? Possible reasons for this type of compensation are a retained infantile swallowing reflex or oral breathing. When our patients breathe through the mouth, it’s not physiologically possible to keep the tongue in the correct position. Another reason that the tongue may lose contact with the palate (or never achieve it in the first place) is ankyloglossia. Ankyloglossia is a congenital anatomical condition that restricts the lingual frenum and function of the tongue. This condition can interfere with breast feeding, speech, oral health, and of course, orthodontic treatment and stability. Identifying these specific postural and functional problems with the tongue can be the first step to an increased likelihood of orthodontic retention.

How to identify a low tongue Ankyloglossia (or tongue-tie) occurs on a spectrum. We typically think of ankyloglossia as the tip of the tongue being fully attached to the floor of the mouth. However, even a small amount of lingual restriction or tension

can prevent the tongue from making contact with the palate. There are a number of protocols for identifying and classifying ankyloglossia. A skilled myofunctional therapist will be familiar with these protocols, so a referral may be necessary. Patients who mouth-breathe may be easier to identify. Anyone with a history of allergies, asthma, large tonsils and adenoids, deviated septum, large turbinates, or sinus infections will be very likely to breathe through the mouth. Even if the mouth breathing occurs only during the night, the hours spent with a low tongue posture have a cumulative effect on orthodontic stability, especially if patients do not wear their retainers.

A possible solution Myofunctional therapists teach patients exercises to increase the tone and coordination of the tongue so that it can rest in the palate and function optimally for chewing, swallowing, speaking, and breathing. The goal of the myofunctional therapist is to teach correct tongue posture during the day and at night, which can be a perfect complement to orthodontic treatment. In my practice, I work closely with orthodontists during all phases of treatment. In fact, they’re my most active referral partners, and working together as a multidisciplinary team, our patients achieve optimal results and long-term orthodontic stability. OP Orthodontic practice 41

ORTHODONTIC CONCEPTS

Increased orthodontic retention and tongue posture

PRACTICE DEVELOPMENT

How to improve your orthodontic practice by texting with patients Kenneth Burke discusses how texting can improve communication efficiency with patients

ore revenue and an easier workday don’t have to just be dreams. Orthodontists across the nation are seeing better results (and saving time) by texting with patients throughout the customer journey.

Why bother with texting? According to Software Advice, less than 28% of Americans are willing to answer phone calls from local phone numbers if they’re available to field the call.1 Unfortunately, your business hours are the same as your patients, and so the chances of their answering a call drop significantly. Your office staff spends hours calling people who don’t answer, and they leave a voicemail for almost everyone. That’s good, right? Not quite. eVoice and CBS reported that only 18% of people listen to voicemail messages.² Coca-Cola and JP Morgan made headlines a few years back for cutting voicemail from their corporate offices. I spoke to a manager at Coca-Cola about it. He laughed and said, “No one ever listened to them.” Then he turned somber and said, “It caused a lot of problems.” Orthodontists are experiencing problems, too, such as missed appointments, lost revenue, and low patient engagement. Texting will help each of these, but what about email? According to Constant Contact, only 16.5% of emails from health professionals are opened, and only 1% get a click-through or response.³ These poor engagement rates place a lot of undue stress on your staff and your bottom line. But 95% of texts are read within 3 minutes of being sent,4 and the average response time for a text is only 90 seconds.5 Kenneth Burke is the director of marketing for Text Request, a business text-messaging software company that works with clients from a wide variety of industries across North America. He has been awarded for his work in sales and psychological research, and has helped dozens of businesses, from pre-launch startups to billion-dollar companies, achieve their goals. Mr. Burke and his insights have been featured in numerous publications, including Forbes, Entrepreneur, and Startup Nation.

42 Orthodontic practice

If implemented properly, text messaging can revolutionize your practice. Emily Beglin, DDS, and founder of SelectBraces, summarizes the benefits well: “Our clients have been two-way texting with patients and prospects for more than 2 years. This has been by far one of the most beneficial pieces of software that practices have implemented in the past 10 years. You do not want to be late to the market with new technology that better serves today’s convenience-obsessed consumers. Once a practice begins two-way texting with their patients and prospects, they wonder how they ever conducted business without it.” Here are some tips to show you how to get the most out of texting.

Earn more online reviews Did you know that 78% of consumers place as much value in online reviews as they do personal recommendations?6 The first thing most people do when looking for an orthodontist is to jump on Google and see what others have to say about your practice. In fact, reviews are so valuable that they’re even a major ranking factor in search engine results. All this means one thing: More reviews equal more patients. So how does texting help you get more reviews? Patients are more likely to open and click a link inside of a text message than they are to click a link in an email, and that — as healthcare clients have told us from internal customer responses and feedback at Text Request — leads to 100% to 600% more online reviews. The process is simple, too. Send your patients a text after their visit; just be mindful of your timeline and process. If you have a patient coming by once a month, for instance, you don’t want to send him/her the same message every time. You might wait until his/her treatments are completed, or only ask once every 6 months. Depending on the software your practice uses, you can schedule these messages in advance or have them triggered based on patient behaviors. I’ll touch on platforms more at the end.

Bring in new clients About two-thirds of mobile traffic comes through Google searches from people who are looking for your services.7 Text messaging is also the most requested and highest rated channel for business communications.8 Here’s why that matters. New patients almost always have questions before you see them. They either want to know what services you offer, your appointment availability, what the cost might be, or something similar. And many prospects are asking different orthodontists the same questions at the same time. Patients are finding you through their phones, and they want to text you. So let them text your office from your website. “Click-to-Text” is a button on your website that viewers can click to send your business a text. “SMS Chat” is similar, except it looks like a normal live chat option. Messages come into your business as texts, and your replies go to that person’s cell phone. These options can work on both your desktop and mobile websites, but they’re primarily important for mobile users. They’d rather text you and move on with their day than call or wait online for a representative. Volume 10 Number 4

Orthodontic Practice US

Address the Orthodontic Complexities You Face Everyday with...

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PRACTICE DEVELOPMENT Schedule (and keep) more appointments Scheduling takes a little back-and-forth to find a time that works, and even once you have patients on the books, there’s no guarantee they’ll show up for their appointment. That’s why you send confirmation emails, and why your office staff calls and leave voicemails. But what if you could save time while keeping more appointments? Confirmation texts are the way to do it. Text messages are read almost instantly, so you’ll be able to get responses almost immediately and reduce no-shows. If your text system allows for two-way conversations, you can also find a new time for patients who can’t make it to their original appointments. You’ll turn no-shows into rescheduled appointments. Another option that’s been effective is to fill last-minute openings by texting overdue patients. Let’s say your 3 p.m. appointment cancels or reschedules that morning. You can text 10 or 50 patients who are due for a checkup that there’s a last minute opening, and you thought they might want to take advantage of it. The slots go to the first to respond. This is helpful for your busy patients, and helps you turn a lost appointment into more business.

Improve customer service while saving time Patients are constantly reaching out with questions, and according to Twilio, 89% of them would rather text you than call.9 That would be good for you, too. A staff member can only handle one phone conversation at a time, but he/she can handle multiple text conversations at once. Phone calls also put staff under the gun to look up details and explain them on the spot, while a text gives them more flexibility. A patient can text in a question (maybe through SMS Chat), and a staff member can say “Let me look that up for you real quick.” If you can respond within 10 minutes or so, people are going to be happy. This process also improves the customer experience, which means patients will be more likely to leave you a glowing review and tell their friends.

Get your promotion in front of the right people Few things are better for business than happy customers. When you’re trying to 44 Orthodontic practice

drum up appointments and referrals, these are a great source to tap into. So send past patients a promotional text whenever you’re running specials. Virtually every text is read, and the average click-through rate is anywhere from 30-50% (Text Request, Salesforce).10 Your engagement through SMS promotions is likely going to be more effective (and cost less) than any ads or commercials, and your message is more likely to spread. Even if your promotion doesn’t appeal directly to the patient you sent it to, there’s a high chance they have a friend or family member to whom it does apply, and who they’ll share it with. The worst case scenario is that it’s another touch point to strengthen your brand.

A note on compliance I’m not a lawyer, and this is not legal advice, but there are two things you should know. Number one, unless the patient has to download a secure app to text with you (which is clunky and hard to get people to do), there is no such thing as a “HIPAAcompliant texting” tool.¹¹ The signals used to send SMS text messages are not encrypted as they travel between cell towers. However, you can text compliantly for each use case mentioned in this article. The golden rule is, Do not share any personal health information (PHI), such as date of birth or confidential patient notes. Avoid that, and you’ll be in the clear. Number two, you need to have permission to text a patient. A rule of thumb is that you can text patients who give you their cell phone number unless they ask you not to. You also need to make sure they know how to stop receiving texts from you should they ever want to. Most texting services include a STOP (opt out) function to make this easier on everyone. The spirit of the law when texting as a business is to communicate like you would with friends — i.e., don’t harass your patients. Use texting as the everyday communication tool it is, and everyone will be happy.

How can your orthodontic practice manage texting? You’re going to want a professional system with a few bells and whistles so you can experience all the benefits covered in this article without adding to your to-do list.

To start, you need an online dashboard, so your staff can text from their computers. You’ll want multi-user functions, so you can see if another employee is already handling a conversation, and so you can always know who said what to whom and when (for oversight and compliance). You’ll also need the system to be secure and hold a permanent record of texts. One thing orthodontists love is being able to text from their same office phone number. That way, you just have one number patients can text or call, which is more convenient for everyone. Other things to consider are individual and group (broadcast) texting, features such as message templates and auto responses, importing contacts, and being able to text from inside your CRM. There are so many benefits to texting in your orthodontic practice, and consumers are moving more and more to texting for business communications like these. My recommendations are to talk through this with your team, and to then research text messaging solutions to make sure you’ve got everything you need to succeed. OP

REFERENCES 1. Borowski C. Survey: Local Presence Dialing — Foot in the Door or Door Slammer? Software Advice. https://www.softwareadvice.com/resources/local-presence-dialing-survey/. Accessed June 6, 2019. 2. Vanderkam L. Are you still checking voice mail?. CBS News. April 11, 2013. https://www.cbsnews.com/news/are-youstill-checking-voice-mail/. Accessed June 6, 2019. 3. Average Industry Rates for Email as of March 2019. Constant Contact. May 7, 2019. https://knowledgebase.constantcontact.com/articles/KnowledgeBase/5409-average-industryrates?lang=en_US. Accessed June , 2019. 4. Olenski S. Pulling Back the Curtain on Text Message Mobile Marketing. Forbes. March 4, 2013. https://www.forbes.com/ sites/marketshare/2013/03/04/pulling-back-the-curtainon-text-message-mobile-marketing/#3390288110d9. Accessed June 5, 2019. 5. Hopkins J. 9 Amazing Mobile Marketing Statistics Every Marketer Should Know. HubSpot. September 26, 2011. https://blog.hubspot.com/blog/tabid/6307/bid/24082/9Amazing-Mobile-Marketing-Statistics-Every-MarketerShould-Know.aspx. Accessed June 6, 2019. 6. Murphy R. Local Consumer Review Survey 2018. BrightLocal. December 7, 2018. https://www.brightlocal. com/research/local-consumer-review-survey/. Accessed June 6, 2019. 7. Large Companies are Becoming More Dependent on Smartphone Traffic. Here’s Where Those Visitors Come From. MarketingCharts. September 18, 2017. https://www.marketingcharts.com/digital-80280. Accessed June 6, 2019. 8. Burke K. 107 Texting Statistics That Answer All Your Questions. Text Request. January 24, 2019. https://www. textrequest.com/blog/texting-statistics-answer-questions/. Accessed June 6, 2019. 9. How Consumers Use Messaging Today. Twilio. 2016. https:// www.twilio.com/learn/commerce-communications/howconsumers-use-messaging. Accessed June 6, 2019. 10. Young H. Is SMS Marketing Right for Your Brand? 6 Things to Consider. Salesforce. November 6, 2019. https://www. salesforce.com/blog/2016/11/sms-marketing.html. Accessed June 6, 2019. 11. HIPAA Regulations for SMS. HIPAA Journal. https://www. hipaajournal.com/hipaa-regulations-for-sms/. Accessed June 6, 2019.

Volume 10 Number 4

M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT 3Shape and Ivoclar Vivadent take orthodontic treatment simulation and smile design to the next level with AR technology

3M previewed new digital bonding system at AAO Orthodontists will soon be able to create a prescription via the 3M™ Oral Care Portal using select 3M brackets that 3M will use to manufacture a bonding tray designed to deliver improved bonding speed and bracket placement accuracy, avoiding the need for in-office tray production. For combination cases, orthodontists will be able to create a digital setup with aligners on one arch and brackets on the opposing arch. For these treatment plans, the trays will be delivered in a single package, making preparation for appointments easier for the practice. To learn more, visit 3M.com/dental.

Ormco™ previewed Spark™ Clear Aligner System and showcased SmartArch™, Symetri™ Clear, and Damon™ Q2 at the AAO Ormco Corporation, a leading provider of advanced orthodontic technology, previewed Spark™ Clear Aligner System, a new entry to the clear aligner category at the American Academy of Orthodontics (AAO) annual meeting in advance of its upcoming U.S. launch. Ormco featured its most innovative product lineup in years, introducing SmartArch™, an archwire designed to enable clinicians to move into a finishing wire after just two wires; Symetri™ Clear, an advanced esthetic ceramic bracket designed for refined strength, patient comfort, and easy debonding without fracturing (now available in the .018 slot option); and Damon™ Q2, the leading passive self-ligating (PSL) bracket, with 2x rotation control for optimal precision, predictability, and efficiency. For more information, visit www.ormco.com.

Volume 10 Number 4

3Shape and Ivoclar Vivadent announce the integration of Ivoclar Vivadent’s IvoSmile augmented reality (AR) technology with 3Shape orthodontic and restorative applications. The collaboration enables orthodontists, dentists, and lab professionals to take advantage of Ivoclar Vivadent’s IvoSmile when using 3Shape TRIOS® Treatment Simulator for orthodontics and 3Shape restorative design software. IvoSmile, powered by Kapanu®, the AR-technology company within the Ivoclar Vivadent group, uses augmented reality for real-time visualization during consultation for esthetic dental makeovers directly on the patient in 3D. IvoSmile uses live patient images taken on an iPad® or iPhone®. Coupled with 3Shape orthodontic and restorative applications, the integration now creates a very powerful and emotional consultation tool for patient engagement and to promote treatment acceptance. Orthodontists can first simulate an orthodontic treatment using the TRIOS Treatment Simulator app, which is included with the TRIOS 3 and TRIOS 4 intraoral scanners. They then use IvoSmile as a “virtual mirror” to visualize the orthodontic treatment proposal created by the TRIOS Treatment Simulator app directly in the patient’s face. The patient can freely move his/her head with IvoSmile to view the treatment proposal from all angles. IvoSmile augments the patient’s teeth images to show the proposed orthodontic treatments and restorative esthetic options, while the 3Shape TRIOS Treatment Simulator app proposes orthodontic treatments using animated teeth based on an intraoral scan. For more information about Ivoclar Vivadent or 3Shape, visit www.ivoclarvivadent.com or https://www.3shape.com/en.

The George Gauge™ is now autoclavable Great Lakes Dental Technologies has announced that the George Gauge™ bite registration and mandibular repositioning device is now autoclavable. The George Gauge is recommended for all mandibular repositioning appliances and allows clinicians to capture the protrusive bite registration and vertical opening without relying on the patient to achieve proper positioning. The George Gauge eliminates guesswork, is extremely accurate and easy to use, and is available in 2 mm, 3 mm, and 5 mm sizes. For more information, contact Great Lakes product customer service at 800-828-7626, or visit greatlakesdentaltech.com.

Orthodontic practice 45

INDUSTRY NEWS RMO presents revolutionary aligner system at AAO Annual Session

Glidewell Dental kicks off exciting leadership program geared toward women in dentistry

Rocky Mountain Orthodontics (RMO) demonstrated Orthocaps® aligners at this year’s AAO Annual Session. An innovative duallayer polymer delivers a soft inner tray for better grip and a firm outer tray for better force application. Unlike other aligner systems, Orthocaps® uses a daytime aligner for comfort and esthetics and a nighttime aligner for force-level customization and improved treatment efficiency. This creates less material stress, is more hygienic, and reduces tray replacement costs. The digitized iSetup® is a virtual model that meets treatment preferences, ensuring accuracy and correct treatment plans, eliminating the time-consuming back-and-forth doctors experience with other aligner setups. Unlike other aligners, the thermoforming process creates a precise patientspecific tray that is more comfortable and transparent. Orthocaps® aligners, manufactured by Ortho Caps GmbH, in Hamm, Germany, are exclusively distributed in the United States and Canada through RMO. The U.S. Food and Drug Administration (FDA) cleared Orthocaps® to be marketed in the U.S. late last year. To learn more about Orthocaps® aligners, visit www.ortho caps.com, or contact Shane Burden, North American Orthocaps Manager, at 800-525-6044 ext. 8466.

Glidewell Dental, an industry-leading provider of dental laboratory services, products, technologies, and clinical education, has officially launched Guiding Leaders, a dynamic leadership development program for women in dentistry. Glidewell kicked off Guiding Leaders with a 2-day training course in Irvine, California, with a group of 13 female dentists and one Fellow participating in the program’s premiere year. Guiding Leaders empowers practicing women clinicians to become influential voices in dentistry by providing them with elite training from top industry professionals. The 12-month program, which covers a range of topics, including practice management, effective communication, and principles of finance, began with a session from facilitator Jo Schaeffer-Crabb of the Arbinger Institute discussing the importance of developing an outward mindset. Glidewell plans to continue Guiding Leaders next year with a new group of participants with the goal of building an ongoing community of women who provide support and guidance to each other while mentoring newer professionals in coming years. For more information, please visit glidewelldental.com.

Registration now open for Carestream Dental’s 2019 Global Oral Health Summit

Ultradent launches the VALO™ Grand Corded curing light Ultradent has announced the newest addition to its award-winning, innovative VALO™ curing light family, the VALO Grand Corded curing light. The new VALO Grand Corded curing light features all of the benefits of its counterpart, the VALO Grand cordless curing light, with the addition of a cord for a lighter weight, a more affordable option that features consistent and constant power output without the use of batteries. The VALO Grand and VALO Grand Corded curing lights feature all the benefits of the award-winning VALO light, but with a 50% bigger lens — measuring 12 mm. Both VALO Grand curing lights also come with a handy back activation button for ease of use. Their highly efficient broadband LEDs (395 nm–480 nm) keep the wand body cool to the touch while the unique unibody construction (each light is precision milled from a single bar of high-quality aircraft-grade aluminum) and ergonomic shape allow for extreme durability and unprecedented access to all restoration sites. Moreover, the VALO Grand curing light’s optimally collimated beam delivers consistent, uniform power to the curing site. To learn more, visit ultradent.com, or call 800-552-5512.

46 Orthodontic practice

This November, Carestream Dental opens registration for its 2019 Global Oral Health Summit. At the Summit, every attendee can learn to “Power the Performance of Your Practice” from trainers, industry leaders, and Carestream Dental designers and developers. From November 7-9, 2019, in Nashville, Tennessee, at the Gaylord Opryland Resort & Convention Center, hundreds of doctors, office managers, assistants, and hygienists from across all specialties will learn more about combining their practice management software and equipment as a perfect duet to change patients’ lives. The summit includes hands-on training for CS OrthoTrac, CS PracticeWorks, CS SoftDent, and CS WinOMS users, and topics such as working in a cloud environment and using software for revenue cycle management. However, sessions also cover industry trends that would appeal to all oral healthcare professionals — whether or not they’re Carestream Dental customers — such as optimizing social media and mastering patient engagement. Specialty education tracks will also address trends specific to each field, such as implant guided surgery, restorative optimization with a mill, airway management, and mastering 3D printing. To learn more call 1-800-944-6365, or visit carestreamdental. com/GlobalSummit.

Volume 10 Number 4

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

Submitting articles Orthodontic Practice US requires original, unpublished article submissions on orthodontic topics, multidisciplinary dentistry, clinical cases, practice management, technology, clinical updates, literature reviews, and continuing education. Typically, clinical articles and case studies range between 1,500 and 3,000 words. Authors can include up to 15 illustrations. Manuscripts should be double-spaced, and all pages should be numbered. Orthodontic Practice US reserves the right to edit articles for clarity and style as well as for the limitations of space available. Articles are classified as either clinical, continuing education, technology, or research reports. Clinical articles and continuing education articles typically include case presentations, technique reports, or literature reviews on a clinical topic. Research reports state the problem and the objective, describe the materials and methods (so they can be duplicated and their validity judged), report the results accurately and concisely, provide discussion of the findings, and offer conclusions that can be drawn from the research. Under a separate heading, research reports provide a statement of the research’s clinical implications and relevance to implant dentistry. Clinical and continuing education articles include an abstract of up to 250 words. Continuing education articles also include three to four educational aims and objectives, a short “expected outcomes” paragraph, and a 10-question, multiple-choice quiz with the correct answers indicated. Questions and answers should be in the order of appearance in the text, and verbatim. Product trade names cited in the text must be accompanied by a generic term and include the manufacturer, city, and country in parentheses. Additional items to include: • Include full name, academic degrees, and institutional affiliations and locations • If presented as part of a meeting, please state the name, date, and location of the meeting • Sources of support in the form of grants, equipment, products, or drugs must be disclosed • Full contact details for the corresponding author must be included • Short author bio • Author headshot Volume 10 Number 4

Pictures/images

Disclosure of financial interest

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

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

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

References References must appear in the text as numbered superscripts (not footnotes) and should be listed at the end of the article in their order of appearance in the text. The majority of references should be less than 10 years old. Provide inclusive page numbers, volume and issue numbers, date of publication, and all authors’ names. References should be submitted in American Medical Association style. For example: Journals: (Print) Greenwall L. Combining bleaching techniques. Aesthetic & Implant Dentistry. 2000;1(1):92-96. (Online) Author(s). Article title. Journal Name. Year; vol(issue#):inclusive pages. URL. Accessed [date].

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

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

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

Or in the case of a book: Greenwall L. Bleaching techniques in Restorative Dentistry: An Illustrated Guide. London: Martin Dunitz; 2001. Website: Author or name of organization if no author is listed. Title or name of the organization if no title is provided. Name of website. URL. Accessed Month Day, Year. Example of Date: Accessed June 12, 2011. Author’s name: (Single) Doe JF

(Multiple) Doe JF, Roe JP

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

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

Orthodontic practice 47

INDUSTRY AWARDS

Cellerant announces the 2019 Best of Class Technology Award winners

ellerant Consulting Group has announced the 2019 Cellerant Best of Class Technology Award winners. “We are entering a new era in dentistry — one that will change how we diagnose, treat, and manage our patients and practices,” said Dr. Lou Shuman, CEO of Cellerant and founder of the Best of Class Technology Awards. “This was a breakthrough year in product and services technologies. The panel spent hundreds of hours in close discussion reviewing and analyzing the corporate landscape. Pay close attention to our winners as they are truly leading the way to provide you what is best in today’s contemporary practice.” The 2019 Cellerant Best of Class Technology Award Winners are: • 3Shape TRIOS® • Apteryx XVWeb® + 3D Module • Bausch OccluSense® • Bien-Air iOptima INT • Bien-Air Tornado • BlueLight Analytics • Carestream CS 9600 • DDS Rescue • Dentsply Sirona Primescan • DEXIS™ Titanium by KaVo • Exocad ChairsideCAD • Garrison Dental Solutions ComposiTight® 3D Fusion™ Sectional Matrix System • Ivoclar Vivadent® Bluephase® G4 • MMG™ Fusion ChairFill • Orascoptic™ EyeZoom™ • Patient Prism® • Schein ONE OmniCore™ • Shofu EyeSpecial C-III • SICAT • SleepArchiTx™ • Tokuyama OMNICHROMA • Ultradent Gemini® 810 + 980 • Ultradent VALO™ Grand • Vista Dental Products Phasor™ • WEO Media Out of all 25 winners, 14 are winning the award for the first time. “The Cellerant Best of Class Award creates an even playing field for dental manufacturers,” said Chris Salierno, DDS, Cellerant Best of Class panel member. “Major players stand next to start-ups, and their technologies compete on innovation and disruption rather than marketing budgets and branding.” 48 Orthodontic practice

The Cellerant Best of Class Technology Award is the only award of its kind, as it is covered by every major dental journal in North America and is presented at the American Dental Association’s Annual Meeting. This year winning products will be showcased at the 2019 ADA FDI World Dental Congress, which will be held in San Francisco from September 5–7. Attendees will have the unique opportunity to experience the Best of Class technologies firsthand at the ADA meeting, as well as hear the panel members lecture on these products at the Digital Future of Dentistry Technology Expo. The expo also features free continuing education taught by the leading experts in technology integration and social media. More information can be found online at ada.org/meeting.

About the Cellerant Best of Class Technology Award Since the inaugural presentation in 2009, the Best of Class Technology Awards have grown to occupy a unique space in dentistry by creating awareness in the community of manufacturers that are driving the discussion as to how practices will operate now and in the future. The 2019 Cellerant Best of Class Technology Award is selected by a panel of the most prominent technology leaders in dentistry: Paul Feuerstein, DMD, technology editor for Dentistry Today; John Flucke, DDS, technology editor for Dental Products Report; Marty Jablow, DMD, known as America’s technology coach; Pamela Maragliano-Muniz, DMD, editor-in-chief of Inside Dental Hygiene; Chris Salierno, DDS, editor-in-chief of Dental Economics; and Lou Shuman, DMD, CAGS, founder and creator of the Best of Class Technology Award. Over the course of each year, the panel members seek out and conduct research on potentially practice-changing technologies, with deliberations on nominees and final voting taking place in February. Panelists are precluded from voting in any category where they have consulting relationships. The entire selection process is conducted and managed on a not-for-profit basis.

About Cellerant Consulting Group Founded and led by CEO Lou Shuman,

DMD, CAGS, Cellerant provides strategic dental market insights, clinical expertise, implementation resources, and support to accelerate growth for client dental companies. Cellerant services include new concept incubation, clinical product evaluation, product development, continuing education program development and CE sponsorship, strategic branding and marketing, online marketing, content marketing, and dental media relations management. As an orthodontist and former owner of a 10-doctor multi-specialty private group practice, Dr. Shuman guides clients to offer products that engage dental customers and provide sustained differentiation. Cellerant operates under a unique model that merges leading voices in clinical product evaluation and strategic partner companies to provide a menu of services from one easily accessible network. For more information on the Cellerant Best of Class Awards and the 2019 Award Winners, go to cellerantconsulting.com/ bestofclass. OP Volume 10 Number 4

Dental Sleep Practice is honored... to have been chosen again to sponsor the Sleep Apnea Symposium at the Greater New York Dental Meeting, Nov. 29-Dec. 4, 2019

Dental Sleep Practice will sponsor lectures each day from Sunday, December 1 through Wednesday, December 4. These seminars, taught by industry leaders who represent the top educators in sleep dentistry, will support dentists through practical sleep apnea education. The program will be led by DSPâ&#x20AC;&#x2122;s Editor in Chief Dr. Steve Carstensen. DSP in partnership with the GNYDM will give you the facts and information you need to expand your practice in this growing and important field of dentistry. Watch for more details this Summer: Connect. Be Seen. Grow. Succeed.

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