Orthodontic Practice US September/October 2019 Vol 10 No 5 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews

Retention and stability — the bane of orthodontics

Dr. Bryan Lockhart

Working together to increase retention through identification and treatment of postural abnormalities

CALIFORNIA

The multifactorial challenges to treating non-growing adult Class III patients

PALM DESERT

FEBRUARY

Dr. Ricky E. Harrell

12-15

PROMOTING EXCELLENCE IN ORTHODONTICS

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September/October 2019 – Vol 10 No 5 • orthopracticeus.com

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We are specialists — aren’t we?

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.

y daughter is currently in dental school and aspires to become an orthodontist. She told me the other day that many of her classmates who also aspire to be orthodontists have been discouraged from doing so by practicing orthodontists in their community. They’ve heard statements such as “We are not making money anymore,” and “Non-orthodontists are taking all our patients.” I agree that the days of easy Class I non-extraction cases are likely over; however, most of my referring dentists offer clear aligners in their own offices and still refer. I get the more challenging cases, but should I be upset? Of course not. Kelly Giannetti, DMD, MPH I have adapted to our new orthodontic reality and am thriving. We are treating traditional surgical cases nonsurgically, classic extraction cases without extractions, and producing amazing results with fewer side effects, resulting in fewer appointments and patient discomfort. I credit this to technological advances and science in our profession. In our offices, we have CBCT technology for unsurpassed diagnosis and information regarding not only teeth and jaws, but also sinuses and airways. We utilize lasers, high-frequency vibration devices, Smartwires™, self-ligation appliances, intraoral scanners, and digital workflow (just to name a few)! With CBCT radiographs, we can view the entire head and neck, screen for airway issues, and create treatment plans that focus on the face. Although we do not diagnose airway or sleep disorders, we can be a knowledgeable member of the team and educate our medical and dental colleagues, many of whom do not know about or have access to the technology. Orthodontists are no longer “wire-benders” and “teeth straighteners”; we are “full-face” dental specialists who have the ability to positively impact our patients’ current and future health. While all of this is exciting, it is also expensive. Many practitioners see their overhead increasing significantly with technology, and rather than adopting new systems into their practices or raising their fees, they struggle with profitability and/or abandon technology altogether. I share the frustration with my colleagues that it can sometimes feel as though we are not being compensated for the knowledge and experience we bring to the table; however, I believe this is a problem of our own making. I recently consulted a second opinion for a patient who was an adult with a skeletal and dental open bite, TMJ issues, and a tongue thrust. I presented a surgical treatment plan combined with myofunctional therapy, and the patient stated, “You explained everything so well, and it all makes sense. When can we get started?” Ironically, during the fee presentation, he told us that our fees for the treatment were $3,000 higher than his first consult in which he had been quoted $5,000 for a surgical treatment plan (my fees were close to this 20 years ago!). His thoughts on the price disparity were, “I really want to come here; I just need to come up with the money.” I will wait patiently, and if the patient decides to go somewhere else due to my fees, I am completely at peace. While some technology makes a practice more profitable, much of it increases expenses. That said, I could never go back in time and give my patients inferior treatment with the assumption that they won’t or can’t pay for my services. Those who embrace technology have an opportunity to provide patients with exceptional experiences and results. Don’t let fear dictate your ability to do what you have been trained for your entire career. We are specialists — aren’t we? Dr. Kelly Giannetti

Kelly Giannetti, DMD, MPH, graduated from Harvard School of Dental Medicine in 1995 and completed her orthodontic residency at UC San Francisco in 1998. She has been in full-time private practice in Sacramento, California, since 1998.

ISSN number 2372-8396

Volume 10 Number 5

Orthodontic practice 1

INTRODUCTION

Sept/Oct 2019 - Volume 10 Number 5

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TABLE OF CONTENTS

Case study Using SureSmile® clear aligners to treat a patient with crowding and narrow arches

Dr. Cory Costanzo describes clear aligner therapy for a patient with an implant

Publisher’s perspective Be a part of the change Lisa Moler, Founder/CEO, MedMark Media................................8

Continuing education Esthetic considerations for the adult orthodontic patient

Case study The multifactorial challenges to treating non-growing adult Class III patients Dr. Bryan Lockhart addresses this patient’s skeletal Class III malocclusion, while correcting the anterior crossbite and obtaining positive overjet

4 Orthodontic practice

Dr. Thomas Sealey says it is essential to identify what cases are suitable for “cosmetic” alignment and which fall into the scope of practice of the specialist orthodontic practitioner .......................................................22

Volume 10 Number 5

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TABLE OF CONTENTS

Continuing education

Retention and stability — the bane of orthodontics

Dr. Ricky E. Harrell examines reasons for relapse following completion of active orthodontic treatment

Going viral “Brace” yourself — don’t be the next victim of a cyberattack Gary Salman outlines what orthodontic practices can do to prevent identity theft.................................................40

Practice management Product spotlight Henry Schein® Orthodontics™ The next-generation of treatment solutions..........................................31

Myofunction junction Working together to increase retention through identification and treatment of postural abnormalities Nicole Cavalea, MS, discusses how strengthening and retraining the muscles and educating patients on breathing techniques can aid in maintaining orthodontists’ results ....................................................... 32

Orthodontic perspective Don’t forget, they’re people Dr. Jeremy D. Smith discusses a human approach to winning with patients........................................... 34

Product profiles Orthocaps® esthetic aligner system

Soft skills can help you deliver tough news to your patients and their parents JoAn Majors, RDA, CSP, discusses four techniques to engage and disarm those who need to hear your message .......................................................42

Small talk

Rocky Mountain® Orthodontics........36

Weathering the storms of leadership

Best practices in instrument care to protect your investment

Drs. Joel C. Small and Edwin McDonald discuss how a seasoned leader can create a balance.............46

Dentronix®...................................... 38

Industry news............... 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

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

6 Orthodontic practice

Volume 10 Number 5

PUBLISHER’S PERSPECTIVE

Be a part of the change

taying relevant in this ever-changing specialty is the unifying goal of all of us. Dentists, hygienists, assistants, and, yes, the team at MedMark, are constantly adjusting strategies to keep a positive and profitable atmosphere surrounding our businesses. It’s exhausting, challenging, awesome, and exhilarating all at the same time. What does the future hold for dentistry? Our future is limitless. Live surgeries for teaching new techniques, stem cell research, and strategies for calming anxious patients all have potential to change how dentists practice and the way they market. These breakthroughs also will change the way patients view their dental professionals and reduce their reluctance to Lisa Moler schedule their dental appointments. Innovations are stimulating, Founder/Publisher, MedMark Media but to reach their full potential, the good news must reach the right audience. So, marketing also has become an integral part of our daily learning curve as well. In this issue of Orthodontic Practice US, Dr. Ricky Harrell examines what he calls, “the 800 lb. gorilla in the orthodontic room” — effective retention protocols. He looks at reasons for relapse, and how it can be minimized and managed within the practice. Dr. Thomas Sealey says it is essential to identify what cases are suitable for “cosmetic” alignment and which fall into the scope of practice of the specialist orthodontic practitioner. A study by Dr. Bryan Lockhart addresses a patient’s skeletal Class II malocclusion, anterior crossbite, and overjet; and Dr. Cory Costanzo’s case study describes clear aligner therapy for a patient with an implant, a scenario that changed his treatment objectives, but will undoubtedly figure into orthodontic plans more frequently as implant therapy becomes more prevalent. Our focus on retention is pursued further in an article by Nicole Cavalea, a speech and myofunctional therapist who works with orthodontists to strengthen and retrain patient’s muscles, correct postural imbalances, restore proper alignment, elevation of the tongue and adequate nasal breathing. Working as a team, the orthodontist and myofunctional therapist can facilitate longer-lasting positive results. Besides our clinical features, this issue brings you information from Gary Salman, a cyberprofessional, in protecting your practice from “phishing” schemes and vulnerabilities in your computer network that can exploit your patient’s and practice’s records. In addition, JoAn Majors points out techniques to deliver tough news to patients and staff that can lead to greater communication and reduce defensive responses. At MedMark, our periodicals are searching for topics and meeting the needs of changing specialties, and it’s getting more fulfilling with each new leap forward. MedMark’s digital innovations bring you orthodontic-related podcasts, webinars, and video chats, as well as offering access to all of our articles online, so you can learn whenever and wherever you are. While you develop strategic options to encourage a healthier America, our team is laser-focused on bringing readers meaningful, life-changing content. Call us, write for us, and help us all move forward and be a part of the change. Together, we will make history and lead innovation. 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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8 Orthodontic practice

Volume 10 Number 5

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CASE STUDY

Using SureSmileÂŽ clear aligners to treat a patient with crowding and narrow arches Dr. Cory Costanzo describes clear aligner therapy for a patient with an implant

ver the past decade, we have witnessed a dramatic increase in the use of clear aligner therapy to provide orthodontic treatment. Fueled by advances in intraoral scanning, computer aided design, and 3D-printing technologies, clear aligner therapy has progressed from an appliance that many practitioners considered only for limited treatment to a comprehensive treatment option applicable to a wide variety of malocclusions. In the past several years, a number of new clear aligner treatment options have been introduced to the market. This influx of new ideas and perspectives continue to push the treatment modality forward. This article presents a case treated using the SureSmileÂŽ aligner system. A 37-year-old female with a chief concern of crowded lower teeth and a narrow smile

was originally evaluated in 2010 (Figure 1). She presented with a slightly convex profile. On posed smile, she displayed 80% of her upper incisors and had prominent buccal corridors. Occlusion was a Class I molar and cuspid relationship on the left and an end-on Class II molar and cuspid relationship on the right. Mandibular midline was deviated 1 mm to the right. The patient had 4 mm of overjet and 3 mm of overbite with mild maxillary crowding and moderate mandibular crowding. The lower right second bicuspid and lower right second molar were missing, and the patient was interested in options for addressing the missing teeth. Three options were discussed: 1. Comprehensive orthodontic treatment with fixed appliances to level and align. Upright LR6 and setup for

Figure 1: Initial consultation photographs

implant LR5. Use Class II elastics on the right side to correct to a Class I and to establish coincident midlines. 2. Comprehensive orthodontic treatment with fixed appliances to level and align. Use TAD anchorage to protract LR6 into LR5 space and attempt to protract the lower right side enough to establish a Class I occlusion and correct the mandibular midline deviation. 3. Comprehensive orthodontic treatment with clear aligners. Attempt to upright LR6 and setup for implant LR5. Use Class II elastics on the right side to correct to a Class I and to establish coincident midlines. Option 2 was not recommended because of the difficult anchorage requirements

Figure 2: Follow-up consultation photographs

Cory Costanzo, DDS, completed his Doctorate of Dental Surgery at the University of the Pacific School of Dentistry and continued there to receive his orthodontic certificate and Master of Science in dentistry. Dr. Costanzo is a Diplomate of the American Board of Orthodontics, a member of the American Association of Orthodontists, and the American Dental Association as well as state and dental societies. Dr. Costanzo maintains a private practice in Fresno, California. Disclosure: Dr. Cory Costanzo is a key opinion leader for Dentsply Sirona Orthodontics.

10 Orthodontic practice

Volume 10 Number 5

CASE STUDY involved with both closing the LR5 space and correcting the end-on Class II. Protracting LR6 would also leave UR7 and UR6 unopposed. Treatment with fixed appliances was presented as preferred over clear aligners due to concerns with how well clear aligners would be able to upright LR6. These concerns were a result of both the state of clear aligner therapy in 2010 as well as a lack of confidence on the part of the practitioner. The patient, however, was unwilling to go through treatment with fixed appliances, so she decided to forgo orthodontic treatment at that time. This patient returned to the office in April 2018 to revisit the options for aligning the lower front teeth and expanding the arches to widen the smile (Figure 2). At this point, however, a LR5 implant had been placed and restored. This limited the treatment objectives, making full correction of the Class II malocclusion on the right difficult if not impossible. Also, significant arch expansion would result in compromised alignment and occlusion of LR5 as the implant would be “left behind” as the rest of the arch expanded. Prior to implant placement, clear aligner therapy was considered the inferior option; however, with the implant in place, clear aligner therapy was now presented as the treatment of choice due to the ability to digitally plan tooth movement using the implant as a fixed anchor. With this in mind, treatment was started using SureSmile® aligners. At the time of case submission, the SureSmile® aligner system provides the practitioner with two options: 1) “Do-It-Yourself” in which he/she does the digital setup, or 2)

This concept of using variable thickness aligners presents an exciting opportunity for advancement and customization of clear aligner therapy. “Full Service” in which a SureSmile® technician does the setup for the practitioner to then modify and approve. This case certainly could have been done as a “Do-It-Yourself,” but due to the practitioner time that would have been involved in setting up the posterior expansion, it was decided to treat this as a “Full Service” case. The “Full Service” setup resulted in an initial sequence of 12 upper and 12 lower aligners. Attachments were planned on upper cuspids and upper right second bicuspid to aid in rotation, and on lower first bicuspids to provide anchorage for intrusion of lower anteriors. Despite significant lower crowding, interproximal reduction was not needed as adequate space was obtained through expansion. With the SureSmile® aligner system, after approval of the setup, there are three different options for production of the aligners: 1. Export the STL files for the staged models, print the models using an in-office 3D printer, and fabricate the aligners in-house. 2. Order 3D printed models from SureSmile® and fabricate the aligners in-house. 3. Order aligners fabricated by SureSmile®.

For this case, due to the in-house time that would have been involved in fabricating 26 aligners, it was decided to have the aligners fabricated by SureSmile®. Attachments were bonded, and aligners were delivered with the instructions to wear 20-22 hours per day for 2 weeks per aligner. The patient was seen every 6-8 weeks to monitor progress. At the end of the initial series of 12 aligners, overall alignment was satisfactory; however, it was decided to rescan and order refinement aligners to idealize the alignment of lower incisors, intrude lower incisors to increase bite opening, and to improve smile esthetics with more posterior expansion. Attachments were left on during the refinement scan as it was decided that they would be beneficial for the additional treatment. The refinement setup resulted in an additional seven aligners upper and lower. An additional attachment was added to aid with the rotation of the lower right cuspid. Because the movements planned in the refinement series were relatively subtle, refinement aligners were worn only 7 days per aligner. Total treatment time was 8 months. Upper and lower .035 Essix® Plus retainers were delivered with instructions to

Figure 4: Comparison of SureSmile® virtual plan and final result

Figure 3: Final photographs 12 Orthodontic practice

Figure 5: Comparison of SureSmile® virtual plan and final result Volume 10 Number 5

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CASE STUDY

Figure 6: Intraoral before and after

wear full time for 3 months and then night time indefinitely. The final records show excellent alignment of upper and lower incisors (Figures 3-7). Significant posterior expansion was achieved with apparent improvement in smile esthetics. Class I occlusion was maintained on the left side. Due to the presence of the lower right second bicuspid implant, the end-on Class II occlusion on the right side was accepted as a compromise. With the upper and lower expansion, the implant was “left behind” and is out of occlusion. The implant crown can be redone in the future to re-establish occlusal contact. One potential advantage of SureSmile® aligners over a leading competitor in this case is the difference in aligner trim line (Figure 8). SureSmile® aligners have a “straight” trim line, while the competitor’s aligners are “scalloped” along the gingiva. The scalloped trim line results in multiple flex-points, one above each interproximal contact. In a case like this requiring posterior expansion, these flex-points, particularly the one at the midline, reduce aligner rigidity, potentially limiting the amount of expansion force that can be applied. The actual clinical significance of the difference in trim lines is still in need of scientific investigation. Although not used in this case, if a case presents in which additional expansion force is required, printed models can be ordered, and aligners can be made in house using a thicker and/or more rigid plastic. SureSmile® aligners are made from .030 Essix® ACE, and this is generally the plastic used to make aligners in-office. However, if additional rigidity and greater expansion force is required, in-house aligners can be made with .035 Essix® Plus or even .040 Essix® Plus. This concept of using variable thickness aligners presents an exciting opportunity for advancement and customization of clear aligner therapy. 14 Orthodontic practice

Figure 7: Smile before and after showing broader arches and reduced buccal corridors

Figure 8: Comparison of straight and scalloped trim lines

In this case, the SureSmile® aligner system was used to successfully treat a patient with crowding and narrow arches. The complicating presence of an implant was well managed and illustrates the advantage of using digital

treatment planning and clear aligner therapy to address this issue. As technology continues to advance, it seems likely that clear aligner therapy will become the treatment of choice for a wide variety of orthodontic problems. OP Volume 10 Number 5

CASE STUDY

The multifactorial challenges to treating non-growing adult Class III patients Dr. Bryan Lockhart addresses this patient’s skeletal Class III malocclusion, while correcting the anterior crossbite and obtaining positive overjet Introduction The adult orthodontic patient often presents a special set of complexities that requires careful analysis and diagnosis. Complications include missing teeth, heavily restored teeth, and periodontal issues (to name a few). Another factor to consider is compliance, especially when modalities such as elastics are required. This is critical because growth cannot be manipulated to aid in the correction of the malocclusion as it can in growing patients. Furthermore, adult patients often require more “coaching” as a lot of them do not like the social distractions that elastics can cause, and treatment time is extremely important. Adult patients want to be in treatment for the shortest time possible without compromising on the results. All of these factors must be taken into consideration before undergoing treatment with adult patients.

Case presentation/diagnosis This case will look at a situation where a 22-year-old adult female (Figures 1A and 1B) expressed her chief concern of not liking how her two front teeth fit behind her lower front teeth. She has a Class III concave profile with a mildly retrognathic maxilla (Figure 2) and normal face height with balanced facial thirds. Dentally, she maintains a Class III molar relationship with an accompanying anterior crossbite involving her maxillary central incisors and maxillary right canine. Originally from Decatur, Georgia, Bryan Lockhart, DDS, attended the University of North Carolina at Chapel Hill for dental school. He attended a 1-year General Practice Residency at Montefiore Medical Center in New York before obtaining his Certificate in Orthodontics from Jacksonville University in Jacksonville, Florida. Dr. Lockhart furthered his learning by attending Jacobi Medical Center for an Orthodontic/Orthognathic Surgical Fellowship. Dr. Lockhart is well versed in fixed appliances as well as clear aligners and has developed his own clear aligner brand, Dualine. Dr. Lockhart is a member of SAO, AAO, and is board-certified with the American Board of Orthodontists (ABO). He has two orthodontic offices in Charlotte, North Carolina, where he practices with his wife, Dr. Lauren Lockhart. Disclosure: Dr. Lockhart has no financial conflicts of interest in this article.

Figures 1A and 1B: A. Initial photos. B. Initial pano 16 Orthodontic practice

Volume 10 Number 5

Your expertise. Our technology. A powerful combination. With your skill and insight, our technology can help create amazing smiles for your teen patients. When you use the Invisalign® system with the iTero® scanner, you can create the seamless digital experience they expect everywhere. In fact, more than 80%1 of prospective teen patients prefer Invisalign clear aligners over traditional metal braces. With 1.6 million teen cases and 6.8 million2 total cases and counting, the mission is clear: Let’s do amazing things together. Learn more at invisalign.com/partner.

Dr. Nicole Clemente Orthodontist Ridgewood, NJ

1. U.S. survey of teens who plan to start orthodontic treatment in the next year and are aware of the Invisalign brand. Data on file at Align Technology as of March 6, 2017. 2. Data on file at Align Technology, Inc. as of April 24, 2019. © 2019 Align Technology, Inc. All rights reserved. MKT-0003106 Rev A

CASE STUDY Her maxillary and mandibular incisors are retroclined with a mandibular curve of Spee of 3 mm. Additionally, she presents with supra-erupted maxillary central incisors, and a maxillary right first premolar that is rotated nearly 90 degrees. Finally, the patient also has uneven gingival zeniths in her maxillary anterior region, mainly in part to the supraerupted central incisors (Figure 3). This case is particularly interesting because the patient presents with a mild skeletal Class III malocclusion that was too minimal to warrant orthognathic surgery. This issue caused us to search for alternative solutions to camouflage a skeletal discrepancy by incorporating dental movements only.

Camouflage treatment can be particularly challenging because we are not able to correct the true cause of the malocclusion, which limits us to simply “mask” the discrepancy. Managing her expectations was critical because she wanted a “perfect” smile which is limited by periodontal support, shape, size, and color of her teeth. Helping her understand that we were treating her skeletal issue nonsurgically was paramount in allowing us to deliver a result that she could be happy with.

Treatment objectives 1. Correct the anterior crossbite 2. Resolve maxillary and mandibular crowding

3. Correct molar classification to Class I 4. Improve torque of the maxillary incisors

Treatment alternatives 1. Surgery: Maxillary premolar extractions and LeFort 1 maxillary advancement

Treatment plan The non-extraction treatment plan involves aligning her maxillary and mandibular teeth, and correcting the anterior crossbite via proclination and intrusion of the maxillary central incisors. This plan will aid in leveling the gingiva in the maxillary anterior region. The excessive lower curve of Spee will be corrected by leveling the lower arch along with Class III elastics for sagittal correction.

Treatment plan sequencing

Figure 2: Class III concave profile with a mildly retrognathic maxilla

Figure 3: Uneven gingival zeniths 18 Orthodontic practice

The patient was given the option of treatment with either metal braces, clear/ ceramic braces, or clear aligners. The patient opted for ceramic braces because she was concerned about her potential noncompliance with clear aligners, but still wanted a more esthetic option than metal braces. The patient was bonded with Symetri™ Clear brackets (Ormco), MBT prescription .022 slot. I chose Symetri for ceramic brackets because it’s not as bulky as other options, and the edges are smooth instead of sharp and rough. Bite turbos for disarticulation were placed on the lower central incisors at the initial appointment. Light wires (0.014 nitinol) were used for a longer period to align her maxillary right first premolar in an effort to minimize exacerbating recession of No. 5. Lingual buttons were placed on the lingual of the first and second maxillary right premolars, and power chains were placed to help derotate her maxillary first premolar.

Figure 4: Initial and progress showing inclination changes Volume 10 Number 5

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CASE STUDY

Having a reliable bracket system designed for refined strength to express the correct amount of torque, and a motivated patient with elastic wear led to great improvement in her smile, a solid bite, and a very happy patient.

Archwires were advanced to 0.018 NiTi and Class III elastics from maxillary first molars to lower cuspids; light 1/4 medium were worn. Archwire sizes were increased to .021" x .025" NiTi to gain more buccal crown torque on her maxillary incisors, and the elastics sizes were increased to 3/16 heavy on the right side only. The proper angulation was obtained while preserving bone facial to the roots of the central incisors shown in Figure 4. Overall, a nice occlusion was obtained, and her arch form was improved as well. Having a reliable bracket system designed for refined strength to express the correct amount of torque, and a motivated patient with elastic wear led to great improvement in her smile, a solid bite, and a very happy patient (Figure 5). We were able to debond her Symetri brackets in one piece without them shattering, which was incredibly convenient for us and our patient (Figure 7). The patient was referred to an oral surgeon for the extraction of her lower third molars (Figure 6).

Conclusion/critiques

Figure 5: Final photos

Figure 6: Final pano 20 Orthodontic practice

I consider this case a success because we were able to achieve our goal of camouflaging the mild skeletal Class III malocclusion by obtaining Class I molars, correcting the anterior crossbite, and obtaining positive overjet. The patient was in treatment for 19 months, which in my opinion, was good enough to reach our goals and not have the patient in treatment any longer than she wanted to be. She was originally quoted a 22-24 month time frame so she was happy to be done in 19 months. Although I’m thrilled with the outcome of this case, there are a couple of things that could have been done better. The occlusion on the right side could have been settled more, and her midlines aren’t optimally coordinated. I think a little more time with elastics could have corrected this, but the patient was delighted with the progress and was ready to complete treatment. In addition, more facial root torque of tooth No. 6 was needed, and gingival contouring from teeth Nos. 6-11 would’ve benefited the esthetics of the case, but she declined. OP

Figure 7 Volume 10 Number 5

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CONTINUING EDUCATION

Esthetic considerations for the adult orthodontic patient Dr. Thomas Sealey says it is essential to identify what cases are suitable for “cosmetic” alignment and which fall into the scope of practice of the specialist orthodontic practitioner

igures released by the British Orthodontic Society (BOS) reveal the rising number of adults seeking orthodontic treatment in the United Kingdom. A survey conducted in June 2016, designed to gather data about adult orthodontics in the UK, was sent to BOS members working in high street practices. Three-quarters of them reported that they had seen an increase in adult treatment, with the main reasons for seeking treatment being a heightened awareness of adult orthodontics in the UK, alongside rising expectations on how treatment can positively impact both appearance and well-being. Of the adult patients in these mixed and private practices, 66% of patients are 26-40 year olds, and 22% are 41-55. More than 10% are 18-25. With more adults seeking treatment and more general dentists learning about simple orthodontic techniques, it is even more important than ever to know which cases are suitable for “cosmetic” alignment and which fall into the scope of practice of the specialist orthodontic practitioner. Most “cosmetic” systems have protocols in place to help general dentists filter out the cases that are above and beyond their level of training, with positive encouragement for patient referral to the specialist centers. If protocols are followed, then both general and specialist practitioners can benefit hugely from the increasing volume of adult patients seeking orthodontic therapy.

Dr. Thomas Sealey, Bchd (2006), MMedEd, MSc Endo, has a special interest in achieving cosmetic smile makeovers using a minimally invasive approach. He lectures on his techniques internationally and has extensive experience in all aspects of cosmetic dentistry — utilizing orthodontics, advanced esthetic composite restorations, and ceramic smile design — to achieve perfectly natural smile transformations. He holds master degrees in both Endodontic Practice and in Medical Education and is the inventor of the ‘”Single visit Orthodontic Lingual and Invisible Dual” (SOLID) retention system. He won in four categories at the recent 2018 UK Aesthetic Dentistry Awards and has won “Best Young Dentist – South East” for 2 consecutive years at the 2015 and 2016 FMC UK Dentistry Awards. Dr. Sealey graduated from Leeds University in 2006 and is currently joint-owner of a private cosmetic dental practice called “Start-Smiling” in Ingatestone, Essex, England.

22 Orthodontic practice

Educational aims and objectives

This clinical article aims to discuss protocols for determining esthetic considerations for the potential adult orthodontic patient.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 25 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Identify what conditions could be considered “cosmetic” alignment and which fall into the scope of an orthodontic specialist.

•

Recognize the effect that root angulations have on prospective treatment.

•

Realize the effect that crown width and length have on prospective treatment.

•

Identify how bone levels are a factor for proper correct incisal edge position, occlusion, and crown-to-root relationships.

•

Discuss the possible ramifications to overjet, overbite, and incisal edges on treatment outcomes.

•

Identify the characteristics of gingival levels and form.

•

Identify some solutions to black triangles.

When any case is deemed suitable for practitioners to begin alignment, whatever their skill level, there are still a number of challenges that any cosmetic dentist or orthodontic specialist must consider before starting treatment. Orthodontic finishing is a continual challenge for most practitioners. In some situations, especially in younger teeth, the alignment relationship seems to correct itself with very little intervention on the part of the clinician. However, in older patients, there are many more challenges to overcome. Examples follow: • How should the teeth be positioned if the patient will require minor or major restoration of the teeth after orthodontic treatment? • How should the clinician finish the occlusion if the patient has had significant periodontal bone loss before orthodontic therapy? • How can the esthetics of a debilitated adult dentition be improved to resemble the non-worn, nonrestored, non-periodontally involved adolescent dentition? The majority of these adult patients are not expecting perfection. They have no concept or indeed no desire to achieve an Angle’s

Class 1; they just want a nice smile and nice front teeth that are even and symmetrical. Their expectations are usually focused on their front teeth only, which makes our lives as practitioners potentially much easier. If we do not need to worry about their posterior teeth and their occlusal scheme, and attention shifts to only their upper or lower anterior segment, then finishing of such cases gets a whole lot more predictable. If the esthetics of the patients' smile is their main driving factor, then final esthetics need to be considered before any orthodontic movement begins. Things to assess are root angulation, bone levels, overbite, overjet, incisal edges, crown length/width, gingival levels/form, and black triangles. These all need assessment and predictions made regarding the end-situation after alignment, so that we can plan into our treatment times and costs for our patients to allow for and consider how any of the above will affect the final outcome. Imagine the consequences of a case like the example in Figures 1 and 2 where considerations and costs were not given pretreatment for the closure of the black triangles that would develop, as well as the leveling of the incisal edges after arch alignment. Careful planning, explanation, and consent are paramount. Volume 10 Number 5

Close root proximity after orthodontic treatment will cause problems in certain restorative patients. If the roots of anterior teeth are in close proximity, and it is planned that the patient will have full crowns or veneers placed afterwards, it may be difficult to obtain an adequate impression of the gingival margins of adjacent tooth preparations or to pack impression cord into the sulcus if the adjacent tooth root is in close contact in the cervical region of the tooth preparation. Another situation where root angulation is important is in the single-tooth implant patient, where space between the roots is needed for the planned implant placement. This type of tooth movement may require several months of adjustment to establish adequate space for the implant.

Bone levels The orthodontist should align the incisal edges of non-worn, non-restored anterior teeth and the marginal ridges of non-worn, non-restored posterior teeth in the adolescent patient; this way the cementoenamel junctions and interproximal bone will be at the appropriate level. In adult patients with prior periodontal disease and interproximal bone loss, the incisal edges or marginal ridges of the teeth are not reasonable guides for vertical positioning of adjacent teeth (Kokich 2002).1 If the patient has horizontal bone loss in the maxillary or mandibular anterior regions, it is best to align the bone levels rather than adjacent teeth. In these situations, equilibration of the incisal edges, as the bone is leveled, is recommended to establish the correct incisal edge position, occlusion, and crown-to-root relationships.

Crown width/length Malformed laterals generally have two different shapes: Some are cone-shaped, and others resemble the shape of a normal lateral incisor, but are significantly narrower, thinner, and shorter. If a lateral incisor is only slightly narrower than normal, and the

Figure 3: Measuring space after alignment to ensure symmetrical veneers placed on both the left and right microdontic laterals Volume 10 Number 5

Figure 1: A case at the beginning of alignment

problem is bilateral, the orthodontist may decide not to provide space to restore the tooth during orthodontic treatment. If the width discrepancy is only slight, the influence on the anterior occlusion, and the impact on esthetics may be indistinguishable (Kokich, et al., 1999).2 However, if the malformation is unilateral, or if the width discrepancy is significant, esthetics and occlusion could be adversely affected if the malformed tooth or teeth are ignored (Lombardi 1973; Ricketts 1982; Chiche and Pinault 1994).3,4,5 Either composite or porcelain veneer restoration, or complete composite or porcelain crowns may be bonded to the enamel with minimal tooth reduction. However, the orthodontist must position the malformed tooth in the proper position to facilitate ideal restoration. Figures 3-5 show how orthodontics was used to develop spacing around bilateral microdontic lateral incisors, a common occurrence in UK teeth, and then how simple no-prep composite bonding was used to restore the esthetics of these teeth.

Overjet, overbite, and incisal edges Anterior overjet is defined as the distance between the labial-incisal edges of the maxillary incisors and canines and the lingual surfaces of the maxillary incisors and canines. The practitioner must be aware that, in many Angle Class II Division 2 patients, there will be an increase in overjet and a decrease in overbite as the upper arch rounds out. These changes must be explained and consented before alignment begins. If the patient does not accept this, then this would be a situation to refer to an orthodontic specialist.

Figure 4: Isolation and composite bonding

Figure 2: After alignment, demonstrating newly formed black triangles and incisal edge asymmetry

Another situation where overjet must be produced during orthodontic finishing is in the patient who has significant tooth abrasion or erosion of the labial surfaces of the mandibular incisors or lingual surfaces of the maxillary anterior teeth. As teeth wear, they usually erupt to maintain contact with the opposing arch. If these teeth are finished in occlusion with the teeth in contact, there will be no space for the dentist to restore the tooth surface loss. In these situations, the method of creating the space often involves intrusion of the eroded or abraded incisors to create the overjet. It is possible to intrude up to four maxillary incisors by using the posterior teeth as anchorage during the intrusion process. This process is accomplished by placing the orthodontic brackets as close to the incisal edges of the maxillary incisors as possible. The brackets are placed in their normal position on the canines and remaining posterior teeth. The patientâ&#x20AC;&#x2122;s posterior occlusion will resist the eruption of the posterior teeth, and the incisors will gradually intrude and move the gingival margins and the crown apically. This creates the restorative space necessary to place bonded composite restorations on the abraded surfaces to re-establish contact with the opposing arch.

Gingival levels and form The relationship of the gingival margins of the six maxillary anterior teeth plays an important role in the esthetic appearance of the crowns (Kokich, et al., 19846; Kokich 1990, 1993, 1996, 19977,8,10,11; Chiche, et al., 19949).

Figure 5: Direct composite veneer and symmetry restored Orthodontic practice 23

CONTINUING EDUCATION

Root angulation

CONTINUING EDUCATION Four characteristics contribute to ideal gingival form. First, the gingival margins of the two central incisors should be at the same level. Second, the gingival margins of the central incisors should be positioned more apically than the lateral incisors and should be at the same level as the canines. Third, the contour of the labial gingival margins should mimic the cementoenamel junctions of the teeth. Last, there should be a papilla between each tooth, and the height of the tip of the papilla is usually halfway between the incisal edge and the labial gingival height of contour over the center of each anterior tooth. Therefore, the gingival papilla occupies half of the interproximal contact, and the adjacent teeth form the other half of the contact. When gingival form is wrong, the teeth have that classic “perio” look, so it is important to maintain the correct relationships of the teeth to ensure symmetry and form. When gingival margin discrepancies are present, the clinician must determine the proper solution for the problem — orthodontic movement to reposition the gingival margins or surgical correction of gingival

Figure 6: Gingival margin correction using a diode laser

margin discrepancies. To make the correct decision, it is necessary to evaluate four criteria. First of all, the relationship between the gingival margin of the maxillary central incisors and the patient’s lip line should be assessed when the patient smiles. If a gingival margin discrepancy is present, but the patient’s lip does not move upward to expose the discrepancy, it does not require correction. If a gingival margin discrepancy is apparent, the next step is to evaluate the labial sulcular depth over the two central incisors. If the shorter tooth has a deeper sulcus, excisional gingivectomy may be appropriate to move the gingival margin of the shorter tooth apically. Figures 6 and 7 show the use of a laser to correct gingival margin discrepancies and to improve the symmetry of the anterior segment. However, if the sulcular depths of the short and long incisors are equivalent, gingival surgery will not help.

restoration with either composite or porcelain restorations. If the periapical radiograph shows that the roots are in their correct relationship, then the open gingival embrasure is due to triangular tooth shape. If the shape of the tooth is the problem, two solutions are possible. One possibility is to restore the open gingival embrasure using composite bonding techniques such as the Clark Anterior Matrix System (BioClear, Optident Ltd.). The other option is to reshape the tooth by flattening the incisal contact and then closing the space. This will result in lengthening of the contact until it meets the papilla. In addition, if the embrasure space is large, closing the space will squeeze the papilla between the central incisors. This will help create a one-to-one relationship between the contact and papilla, and to restore uniformity to the heights between the midline and adjacent papillae.

Black triangles

Conclusion

Occasionally, adults will have open gingival embrasures or black triangles between their central incisors, especially after crowding is relieved using orthodontics. This space is usually due to one of three causes: tooth shape, root angulation, or periodontal bone loss. Most open embrasures between the central incisors are due to problems with tooth contact. The first step in the diagnosis of this problem is to evaluate a periapical radiograph of the central incisors. If the root angulation is divergent, then the brackets should be repositioned, so the root position can be corrected. In these situations, the incisal edges may be uneven and require

The best advice that can be given would be to “start with the end first.” If you first design your final end-esthetic outcome to meet the patient expectations, and then work backwards from there, then you’ll be sure to plan correctly, appropriately cost your time and procedures, and properly explain and consent your patients for the whole treatment — never leaving yourself in the difficult situation where the teeth are straight but the patient still isn’t happy with his/her smile. OP

REFERENCES 1. Kokich VG. The role of orthodontics as an adjunct to periodontal therapy, in Newman MG, Carranza FA, Takei H (eds): Carranza’s Clinical Periodontology, 9th Edition. Philadelphia, PA: Saunders Inc.; 2002. 2. Kokich VO Jr, Kiyak A, Shapiro PA. Comparing the perception of dentists and lay people to altered dental esthetics. J Esthet Dent. 1999;11(6):311-324. 3. Lombardi R. The principles of visual perception and their clinical application to denture esthetics. J Prosthet Dent. 1973;29(4):358-382. 4. Ricketts RM. The biologic significance of the divine proportion and Fibronacci series. Am J Orthod. 1982;81(5):351-370. 5. Chiche G, Pinault A. Replacement of deficient crowns. In: Pinault A, Chiche G, eds. Esthetics of Anterio Fixed Prosthodontics. 1st ed. Chicago, IL: Quintessence; 1994. 6. Kokich VG, Nappen D, Shapiro P. Gingival contour and clinical crown length: their effect on the esthetic appearance of maxillary anterior teeth. Am J Orthod. 1984;86(2):89-94. 7. Kokich V. Enhancing restorative, esthetic and periodontal results with orthodontic therapy. In: Schluger S, Youdelis R, Page R, et al., eds. Periodontal Therapy. Philadelphia, PA: Lea and Febiger; 1990. 8. Kokich VG. Anterior dental esthetics: an orthodontic perspective I. crown length. J Esthet Dent. 1993;5:19-23. 9. Chiche G, Kokich V, Caudill R. Diagnosis and treatment planning of esthetic problems. In: Pinault A, Chiche G, eds. Esthetics in Fixed Prosthodontics. Chicago, IL: Quintessence; 1994. 10. Kokich VG. Esthetics: the orthodontic-periodontic restorative connection. Semin Orthod. 1996;2(1):21-30. 11. Kokich VG. Esthetics and vertical tooth position: orthodontic possibilities. Compendium Contin Educ Dent. 1997;18(12):1225-1231.

Figure 7: Before-and-after showing improved gingival contouring 24 Orthodontic practice

12. Kokich VG. Excellence in finishing: modifications for the perio-restorative patient. Semin Orthod. 2003;9(3):184-203.

Volume 10 Number 5

REF: OP V10.5 SEALEY

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Esthetic considerations for the adult orthodontic patient SEALEY

1. (Regarding esthetics that need to be considered before any orthodontic movement begins) Things to assess are root angulation, ________ incisal edges, crown length/width, gingival levels/form, and black triangles. a. bone levels b. overbite c. overjet d. all of the above 2. If the patient has horizontal bone loss in the maxillary or mandibular anterior regions, it is best to __________. a. align the bone levels rather than adjacent teeth b. align the adjacent teeth rather than the bone levels c. align the incisal edges of worn, restored anterior teeth d. use incisal edges or marginal ridges as reasonable guides for vertical positioning of adjacent teeth 3. Malformed laterals generally have two different shapes: Some are ______, and others resemble the shape of a normal lateral incisor, but are significantly narrower, thinner, and shorter. a. rectangular-shaped b. diamond-shaped c. cone-shaped d. chisel-shaped

Volume 10 Number 5

4. ________ is defined as the distance between the labial-incisal edges of the maxillary incisors and canines and the lingual surfaces of the maxillary incisors and canines. a. Posterior occlusion b. Anterior overjet c. Anterior overbite d. Black triangle 5. The relationship of the gingival margins of the ___ maxillary anterior teeth plays an important role in the esthetic appearance of the crowns. a. two b. four c. six d. eight 6. When gingival margin discrepancies are present, the clinician must determine the proper solution for the problem — ________. a. porcelain veneer restorations b. orthodontic movement to reposition the gingival margins c. surgical correction of gingival margin discrepancies d. both b and c 7. First of all, the relationship between the gingival margin of the maxillary central incisors and the patient’s lip line should be assessed ________.

a. b. c. d.

when the patient smiles when the patient frowns at resting lip posture when the patient sleeps

8. (When evaluating the labial sulcular depth over the two central incisors) If the shorter tooth has a deeper sulcus, ______ may be appropriate to move the gingival margin of the shorter tooth apically. a. composite bonding techniques b. equilibration of the incisal edges c. excisional gingivectomy d. intruding up to four maxillary incisors 9. If the sulcular depths of the short and long incisors are equivalent, gingival surgery _______. a. will still be the best solution b. will not help c. will improve the symmetry of the anterior segment d. will improve the “perio” look 10. Occasionally, adults will have open gingival embrasures or black triangles between their central incisors, especially after crowding is relieved using orthodontics. This space is usually due to ______. a. tooth shape b. root angulation c. periodontal bone loss d. all of the above

Orthodontic practice 25

CE CREDITS

ORTHODONTIC PRACTICE CE

CONTINUING EDUCATION

Retention and stability — the bane of orthodontics Dr. Ricky E. Harrell examines reasons for relapse following completion of active orthodontic treatment Background Retention — the 800 lb. gorilla in the orthodontic room. If you want opinions on retention, ask 10 orthodontists, and you will probably hear several differing views on effective retention protocol. Orthodontic relapse and posttreatment problems have existed since the first active appliance therapy on a patient was discontinued, and the patient’s active treatment was considered competed. The realization of the difficulties of retention dates back to the words of the most universal name in orthodontic retention, Dr. Charles Augustus Hawley. In an essay presented on March 1919 to the Eastern Association of the Graduates of the Angle School of Orthodontics in Baltimore, Maryland, Dr. Hawley was attributed with passing along two statements of his contemporaries with regards to the retention process. The first statement was from his colleague, who stated, “Any fool can move teeth, but it takes a wise man to make them stay.” Another quote attributable to Dr. Hawley’s colleagues was, “If anyone would take my cases after they are finished, retain them, and be responsible for them afterward, I would give him half the fee.”1 For the most part, these words still ring true in contemporary orthodontic practice, regardless of the method used to align the dentition and establish the occlusion. In an article published by Dr. George Hahn in 1944 entitled "Retention — The Stepchild of Orthodontia," he stated, “The newer concept of retention was evolved the hard way, that is by clinical evidence,

Educational aims and objectives

This clinical article aims to discuss reasons for relapse upon completion of orthodontic treatment.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 30 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Realize some history on the philosophy of retention.

•

Identify some common physical/anatomical causes of orthodontic relapse.

•

Identify some soft tissue factors in orthodontic relapse.

•

Realize digit habits as a contributor to relapse.

•

Recognize orthodontic changes as a contributor to relapse.

•

Realize patient cooperation with retention as a contributor to orthodontic relapse.

•

Observe some suggestions to minimize the negative effects of relapse following the active treatment stage.

the result of trial and error, and in all clinical evidence in the history of orthodontia, this one basic fact stands out: That irrespective of the length of time a tooth is held in its new position by any means whatsoever, it will upon release seek a position where it is in balance with the forces that act upon the denture; whether these forces are for good or evil is immaterial, the greatest of these forces is the force of occlusion.”2 Dr. Hahn went on in the article to list some of what he felt were causes of relapse, many of which are pertinent today, especially in the era of non-extraction-at-all-costs treatment. Among those listed were the following that are especially applicable in today’s era: 1. Incorrect diagnosis and failure to plan treatment properly (one treatment fits all approach) 2. Teeth off the ridge laterally — overexpansion.

Ricky E. Harrell, DMD, MA, is a 1979 graduate of the University of the Alabama School of Dentistry. After serving as a Commissioned Officer in the U.S. Public Health Service in the Navajo Area Indian Health Service for 3 years, he returned to the University of Alabama and completed his residency in orthodontics in 1984. He was in the private practice of orthodontics in Westminster, Colorado, from 1984-2006. Upon leaving private practice in 2006, he became a Commissioned Officer in the U.S. Army Reserves, 919th Medical CO (DS) in Aurora, Colorado at the tender young age of 52 as well as joining the faculty at the University of Colorado. He has deployed to Iraq, Afghanistan, and Honduras, and served in the Dominican Republic, Guatemala, and El Salvador. After teaching for 9 years at the University of Colorado, Dr. Harrell became Program Director of the Orthodontic Residency Program at the Medical University of South Carolina from 2015-2017. In 2017, he relocated to Atlanta, Georgia, to serve as Program Director at the Georgia School of Orthodontics. In the past couple of years, he has lectured at Seton Hill, University of Alabama Birmingham, Medical University of South Carolina, Emory University Oral Surgery Residency Program, Meharry College of Dental Medicine, and Augusta University Oral Surgery Residency Program. Disclosure: There were no sources of support in the form of grants, equipment, products, or drugs in the production of this article. There are no conflicts of interest, financial or otherwise, in the production of this article.

26 Orthodontic practice

3. Teeth off the ridge anteriorly — too much forward movement 4. Incorrect arch form (not all facial and head shapes are amenable to a broad arch form) 5. Incorrect apical inclination 6. Winking at rotations (failure to overrotate or to complete rotations) The problem of retention and stability in orthodontics is well over a century-old. In this article we will examine reasons for relapse and emphasize one that is almost universal and yet receives little attention.

Physical/anatomical reasons for relapse Stretching of the periodontal ligament fibers First reported in studies done on dogs by Reitan, it was noted via biopsy, tissue staining, and light microscopy that fibers in the periodontal ligament were stretched during orthodontic rotational movement. Fibers in the apical third of the root were stretched less than fibers in the middle third and even less than fibers in the gingival or the “marginal” third of the root due to the differing circumferences of the root area as one progresses toward the apex from the marginal area. At 232 days of retention, the biopsies demonstrated that the apical- and middle-third fibers had reorganized well, but that the marginal fibers were only partly reorganized at that point in time.3 It was also noted that at the 232-day mark of retention, new bone was well Volume 10 Number 5

Figure 3: Patient at age 11.2 — pretreatment Volume 10 Number 5

Figure 1: Dolichocephalic patient — thin cortical bone

Figure 2: Brachycephalic patient — thick cortical bone

patient with a long, narrow, teardrop-shaped symphysis (Figures 1 and 2). Posttreatment mandibular rotation, especially in a counterclockwise pattern, has been discussed as a potential source of incisor relapse due to deepening of the bite over time or prolonged mandibular growth in Class III patients. Research generally points to a very nominal or no role in incisor relapse following treatment.

In 1975, Proffitt and Mason summed up the phenomena of soft tissue effects, especially with the tongue, when they stated that the resting posture/position of the tongue and its subsequent pressure on the dentition has a much greater influence on tooth position than does pressure by the tongue during swallowing. They also felt that in an effort to reduce orthodontic relapse in patients that actually did exhibit tongue thrust and anterior tongue posture at rest, myofunctional therapy during orthodontic treatment was most effective as opposed to therapy that is done prior to orthodontic treatment.9 It has also been demonstrated that oromyofunctional therapy done in conjunction with orthodontic therapy is more effective in maintaining open bite correction than is orthodontic therapy alone.10 What role might lip pressure play in orthodontic relapse? It is generally agreed that lip pressure exerted on the teeth is less than tongue pressure, and that there is not a balance between pressure exerted on the dentition by the tongue and lips. Again, posture of the lip, especially lower lip, plays a role in relapse. Interposed lower lips and lip pressure can contribute significantly to orthodontic relapse of maxillary incisors.11 However, Doto and Yamato found that pressure exerted by the lips is more contributory to proclined incisor position in Class II patients than is tongue pressure.12 Regardless of whether the tongue or lips is most influential on relapse after orthodontic therapy, the role

Soft tissue factors in orthodontic relapse In the 1950s, Straub generated a wave of excitement among orthodontists with the observations that tongue thrusting was a major component of the creation of an anterior open bite, and that vertical relapse of the incisors could be attributed to tongue thrusting. It seemed logical that patients who swallowed incorrectly should have protruding incisors either before treatment or could relapse to that condition, but after studies were done, it became apparent that tongue and lip pressures during swallowing varied greatly among individuals and did not correlate well with position of the teeth.7 Whalen later demonstrated that vertical pressure on the incisors by the tongue during swallowing has little to do with vertical positioning of anterior teeth. His study demonstrated that vertically directed tongue pressures during swallowing in patients with anterior open bites are less that those with normal vertical relationships.8

Figure 4: Patient at age 15.2 — day of appliance removal

Figure 5: Patient at age 17.5 — 2-year post-debonding with tongue habit still active Orthodontic practice 27

CONTINUING EDUCATION

organized along the stretched periodontal ligament fibers in both the apical and middle third of the roots but only fairly organized along the stretched fibers in the marginal third of the root.3 Redlich, in another relapse study using dogs as the experimental models in 1996, utilized scanning electron microscopy (SEM) as well as transition electron microscopy (TEM) to observe microscopic changes in the periodontal ligament as well as connective tissue fibers in the lamina propria of the gingival tissues around the tooth. Redlich noted that the whole gingival apparatus seemed to move with the rotational movement of the tooth and postulated that the supra-alveolar fibers were not stretched but maintained their continuity with the lamina propria as the whole gingival apparatus was moving with the tooth, and that the elasticity in the gingival tissue, as evidenced by an increase in oxytalan fibers, was partially responsible for relapse.4 The relationship of alveolar bone to orthodontic relapse was investigated by Sharpe, et al., in 1987. Using lateral cephalometric radiographs, bitewings, and full-mouth radiographic series on patients at least 10 years out of retention, it was noted that the greatest amount of relapse occurred in patients who had the greatest amount of tooth movement and the greatest translational movement of teeth, and experienced the greatest amount of root resorption. Crestal alveolar bone was also diminished in the group demonstrating the greatest amount of relapse.5 The thickness of alveolar cortical bone in the incisor region has also demonstrated a positive relationship to orthodontic stability. Rothe, et al., demonstrated that patients with thinner mandibular cortical bone — i.e., long, teardrop-shaped symphysis — exhibit a greater tendency for orthodontic relapse in comparison to patients with a greater thickness of alveolar bone.6 One can extrapolate thickness of cortical bone in the mandibular symphysis to the facial skeletal type — i.e., a brachycephalic patient with a thick, short symphysis would demonstrate thicker cortical bone than would a dolichocephalic

CONTINUING EDUCATION of both must be considered and that teeth should be placed in what is the most harmonious relationship with the soft tissue envelope as determined by the practitioner, and that resting tongue posture be normalized as much as is possible (Figures 3-5).

Digit habits as a contributor to relapse Persistence of digit habits such as thumb- or finger-sucking has been recognized as a factor in orthodontic relapse. Successful dental open bite correction may be negated with orthodontic vertical anterior relapse if digit habits persist following orthodontic therapy.13,14 The incidence, duration, and intensity of the habit will determine if the teeth will compensate unfavorably for the habit following treatment.

Orthodontic changes as a contributor to relapse With the introduction of self-ligating appliances back into the orthodontic marketplace some 20 years ago, the principles of orthodontic stability have taken a back seat to the pursuit of non-extraction orthodontic approaches. Although as a profession we have decreased percentages of extraction treatment to orthodontic treatment as a whole, some have felt that moderation in choosing extraction therapy was not enough, and that non-extraction therapy should be pursued at all cost. How might this contribute to relapse? Inherent to non-extraction treatment in crowding cases where the crowding exceeds 7 mm-8 mm in the mandibular arch is the resultant proclination of mandibular incisors (Figures 6-8) and resultant increase in arch length as well as a deviation from the original mandibular arch form (Figures 9 and 10). Another unintended consequence of nonextraction therapy at all costs is the expansion of mandibular canines greater than 1 mm-1.5 mm in treatment, which in most cases is doomed to eventual relapse.15,16,17,18,19

Figure 8: Resultant bone loss, instability due to excessive proclination 28 Orthodontic practice

Does the literature support the concept that increasing arch length during treatment is doomed to relapse? Yes, it does and has so for many years. In my opinion, one of our outstanding orthodontic practitioners, Dr. James Boley, summed up this concept up in a presentation entitled “Why Try to Fit Teeth into an Ever-Shrinking Arch?” given in the early 1980s to the Colorado Orthodontic Society. An increase in proclination of mandibular incisors, if the mandibular molars do not move mesially, arbitrarily increases mandibular arch length. Study after study demonstrates that this is unstable over the course of a lifetime after retention is discontinued.20,21,22,23,24,25 Relapse tendency is also heightened if there is a significant deviation in arch form from the existing mandibular arch. Again, this is well documented in the literature.26,27,28,29 If mandibular arch form is either willingly or unwillingly violated during treatment, relapse is almost certain after discontinuance of retention. Expansion of the mandibular canines, with rare exception due to canines lingually positioned in the original malocclusion, is also a contributor to orthodontic relapse. Again, this is more than adequately documented and, despite this, some currently willingly and routinely violate this principle with non-extraction modalities. The quality of the result of treatment, as judged by occlusal fit, did not seem to be

influential in relapse with as much relapse tendency noted in “well-treated” cases as in cases with less desirable outcomes.30,31

Figure 6: Incisor position prior to appliance placement

Figure 7: Arch length increase and incisor proclination as a result of non-extraction approach

Figure 9: Pretreatment arch form

Figure 10: Change in mandibular arch form as a result of appliance therapy

Patient cooperation with retention as a contributor to orthodontic relapse Thus far, we have discussed a number of factors in the physical realm of tooth movement that contribute to relapse. Is there something about relapse outside of the realm of tooth movement, anatomic limitations, and physiologic phenomena, which influence relapse, that we have not discussed? Indeed, there is, and that factor is patient cooperation with retention. In our inspection of patient cooperation as a cause of relapse, there is some solace to be found with our brothers and sisters in medicine. Just so that we don’t feel alone in our endeavors with retainer wear, in the medical literature on patient behavior, it was found that less than one-third of asthma patients ever comply with medication instructions, regardless of whether they were educated about the benefits of taking the medication or not, regardless of the severity of the disease or condition to be treated.32 In a study by Kacer, et al., it was found that based on the minimal standard of nighttime retainer wear at the 3-month postdebond mark, fully 31% of patients were not cooperative. At the 7-9 month mark, that percentage had increased to 45% of

Volume 10 Number 5

Clinical guidelines Based on the evidence presented, the following suggestions are made to minimize the negative effects of relapse following the active treatment stage. 1. Plan retention at the treatment-planning stage when the malocclusion is not disguised by tooth movement occurring during treatment. 2. Discuss the importance of retention at the treatment consultation, mention it often during active treatment, and emphasize the importance again at the debonding and postdebonding consult. 3. Treat retention not as an afterthought but as an integral part of the treatment. 4. Because periodontal ligament fibers and the gingival tissues take almost a year to reorganize completely, be aggressive with retention, especially in the first year of this phase of treatment. 5. Follow, whenever possible, the triedand-true principles of orthodontic stability with regards to incisor proclination, mandibular arch form, arch length change, and mandibular canine expansion. 6. Consider surgical procedures (SCF) to assist in minimizing rotational relapse following debonding. Volume 10 Number 5

7. Ensure that oral and digit habits are no longer active at the time of appliance removal. If appropriate, enlist the services of a myofunctional therapist during treatment to help diminish the habits. 8. Remember, it is not the type of retainer that seems to be the critical issue, but rather the cooperation with that retainer and its wearing by the patient.

Conclusion Despite extensive research, the various elements leading to relapse of treated malocclusions are incompletely understood, giving rise to wide variation in retention protocols among clinicians. Informed consent — with emphasis on the features of the original malocclusion and the patient’s growth pattern, the type of treatment performed, the need for adjunctive surgical procedures, the type of retainer, and the duration of retention — should be obtained during the treatmentplanning stage. True perspective on orthodontic retention is lacking, and there is a great need for further research to ensure that evidence-based clinical practice is adopted in retention strategies.35 Orthodontic relapse continues to be a significant issue that we all, as clinicians, must manage. By following the suggested guidelines, relapse can be minimized and manageable within the practice. Stability is one of the most important aspects of treatment to patients. We should strive to provide that for all of our patients and continually work to improve our outcomes. OP

REFERENCES 1. Hawley CA. A removable retainer. Dent. Cosmos. 1919;61 (6):449-554.

myofunctional therapy. Am J Orthod Dentofacial Orthop. 2010;137(5):605-614. 11. Lapatki BG, Mager AS, Schulte-Moenting J, Jonas IE. The importance of the lip line and resting lip posture in Class II Division 2 malocclusion. J Dent Research. 2002;81(5):323-328. 12. Doto N, Yamada K. The relationship between maximum lip closing force and tongue pressure according to lateral craniofacial morphology. Orthodontic Waves. 2015;74(3):69-75. 13. Otuyemi OD, Noar HD. Anterior open bite: A review. Saudi Dent J. 1997;9(3):149-157. 14. Proffit WR. On the aetiology of malocclusion. The Northcroft lecture, 1985 presented to the British Society for the Study of Orthodontics, Oxford, April 18, 1985. Br J Orthod. 1986;13( ):1-11. 15. Braun S, Hnat WP. Fender DE, Legan HL. The form of the human dental arch. Angle Orthod. 1998;68(1):29-36. 16. Braun S, Hnat WP, Leschinksy R, Legan HL. An evaluation of the shape of some popular nickel titanium alloy preformed arch wires. Am J Orthod Dentofacial Orthop. 1999;116(1):1-12. 17. Bishara SE, Jakobsen JR, Treder JE, Stasi MJ. Changes in the maxillary and mandibular tooth size-arch length relationship from early adolescence to early adulthood: A longitudinal study. Am J Orthod Dentofacial Orthop. 1989;95(1):46-59. 18. Sondhi A, Cleall JF, BeGole EA. Dimensional changes in the dental arches of orthodontically treated cases. Am J Orthod. 1980;77(1):60-74. 19. Little RM. Stability and relapse of mandibular anterior alignment: University of Washington studies. Semin Orthod. 1999;5(3):191-204. 20. Nance HN. The limitations of orthodontic treatment: 1. Mixed dentition diagnosis and treatment. Am J Orthod and Oral Surgery 1947;33(4):177-223. 21. Little RM, Riedel RA, Stain A. Mandibular arch length increase during the mixed dentition: postretention evaluation of stability and relapse. Am J Orthod Dentofacial Orthop. 1990;97(5):393-404. 22. Sillman JH. Dimensional changes of the dental arches: longitudinal study from birth to 25 years. Am J Orthod. 1964;50(11):824-842. 23. Sinclair PM, Little RM. Maturation of untreated normal occlusions. Am J Orthod. 1983;83(2):114-123. 24. Barrow GV, White JR. Developmental changes of the maxillary and mandibular dental arches. Angle Orthod. 1952;22:41-46. 25. Shapiro PA. Mandibular dental arch form and dimension: treatment and post-treatment changes. Am J Orthod. 1974;66(1):58-70. 26. Felton J, Sinclair PM, Jones DL, Alexander RG. A computerized analysis of the shape and stability of the mandibular arch form. Am J Orthod Dentofacial Orthop. 1987;92(6):478-483. 27. de la Cruz A, Sampson P, Little RM, Artun J, Shapiro PA. Long-term changes in arch form after orthodontic treatment and retention. Am J Orthod Dentofacial Orthop. 1995;107(5):518-530.

2. Hahn GW. Retention, the stepchild of orthodontia. Angle Orthod. 1944;14(1):3-12.

28. Kahl-Neike B, Fischbach H, Schwarze CW. Treatment and postretention changes in dental arch width dimensions — a long-term evaluation of influencing cofactors. Am J Orthod Dentofacial Orthop. 1996;109(4):368-378.

3. Reitan K. Tissue rearrangement during retention of orthodontically rotated teeth. Angle Orthod. 1959;29(2):105-113.

29. Nojima K, McLaughlin RP, Isshiki Y, Sinclair PM. A comparative study of Caucasian and Japanese mandibular clinical arch forms. Angle Orthod. 2001;71(3):195-200.

4. Redlich M, Shosan, Palmon A. Gingival response to orthodontic force. Am J Orthod Dentofacial Orthop. 1999;116(2):152-158.

30. de Freitas KM, Janson G, de Freitas, MR, et al. Influence of the quality of the finished occlusion on postretention occlusal relapse. Am J Orthod Dentofacial Orthop. 2007;132(4):428.e9-e14.

5. Sharpe W, Reed B, Subtelny JD, Polson A. Orthodontic relapse, apical root resorption, and crestal alveolar bone levels. Am J Orthod Dentofacial Orthop. 1987;91(3):252-258. 6. Rothe LE, Bollen AM, Little RM, et al. Trabecular and cortical bone as risk factors for orthodontic relapse. Am J Orthod Dentofacial Orthop. 2006;130(4):476-484. 7. Straub WJ. Malfunction of the tongue: Part I. The abnormal swallowing habit: Its cause, effects, and results in relation to orthodontic treatment and speech therapy. Am J Orthod. 1960;46(6):404-424. 8. Whalen TR. Vertically directed forces and malocclusion. J Dent Research. 1974;53(5):1014-1022. 9. Proffit WR, Mason RM. Myofunctional therapy for tonguethrusting: background and recommendations. J Am Dent Assoc. 1975;90(2):403-411. 10. Smithpeter J, Covell D Jr. Relapse of anterior open bites treated with orthodontic appliances with and without

31. Ormiston JP, Huang GJ, Little RM, Decker JD, Seuk GD. Retrospective analysis of long-term stable and unstable orthodontic treatment outcomes. Am J Orthod Dentofacial Orthop. 2005;128(5):568-574. 32. Dekker FW, Dieleman FE, Kaptein AA, Mulder JG. Compliance with pulmonary medication in general practice. Eur Respir J. 1993;6(6):886-890. 33. Kacer KA, Valiathan M, Narendran S, Hans MG. Retainer wear and compliance in the first 2 years after active orthodontic treatment. Am J Orthod Dentofacial Orthop. 2010;138(5):592-598. 34. Pratt MC, Kluemper T, Lindstrom AF. Patient compliance with orthodontic retainers in the postretention phase. Am J Orthod Dentofacial Orthop. 2011;140(2):196-201. 35. Melrose C, Millet DT. Toward a perspective on orthodontic retention? Am J Orthod Dentofacial Orthop. 1998;113(5):507-514.

Orthodontic practice 29

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noncooperation, and at the 19-24 month mark, the percentage of patient cooperating with night-only retainer wear had increased to 55%, and cooperation, as judged by regular nighttime wear, had diminished to 45%.33 Another question to be asked about cooperation with retainers is, Does the type of retainer make a difference with retention? Obviously, fixed retention eliminates one set of cooperation variables but introduces its own set of problems outside of cooperation. What about Hawley-type retainer versus vacuum-formed Essix-type retainers? In a study done at the University of Kentucky, it was found that patients were more likely to be cooperative with Essix-type retainers early in retention but more likely to be cooperative with Hawley-type retainers as the retention time from debonding increased. The study determined that among the variables that influenced cooperation were the patient’s understanding of the importance of retainer wear (patient education), the amount of time since debonding (patient fatigue), the patient’s age (older patients less compliant than younger patients), patient’s gender (males less cooperative than females), and type of retainer provided.34

REF: OP V10.5 HARRELL

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.

Retention and stability — the bane of orthodontics HARRELL

1. First reported in studies done on dogs by Reitan, it was noted via __________ that fibers in the periodontal ligament were stretched during orthodontic rotational movement. a. biopsy b. tissue staining c. light microscopy d. all of the above 2. (In the Reitan study) At 232 days of retention, the biopsies demonstrated that the apical- and middlethird fibers had reorganized well, but that the marginal fibers _________ at that point in time. a. were not organized at all b. were only partly reorganized c. were totally reorganized d. were very poorly organized 3. (In the study by Sharpe, et al.) Crestal alveolar bone was ________ in the group demonstrating the greatest amount of relapse. a. also diminished b. increased c. not a factor d. thickened

with a ________ . a. thinner alveolar bone b. thicker maxillary cortical bone c. greater thickness of alveolar bone d. greater thickness of mandibular cortical bone 5. (In the Proffitt and Mason study) They also felt that in an effort to reduce orthodontic relapse in patients that actually did exhibit tongue thrust and anterior tongue posture at rest, _______ was most effective as opposed to therapy that is done prior to orthodontic treatment. a. myofunctional therapy during orthodontic treatment b. myofunctional therapy after orthodontic treatment c. applying pressure on the incisors d. swallowing therapy only 6. ________ can contribute significantly to orthodontic relapse of maxillary incisors. a. Interposed lower lips b. Lip pressure c. Posture of the upper lip only d. both a and b 7.

Rothe, et al., demonstrated that patients with thinner mandibular cortical bone — i.e., long, teardropshaped symphysis — exhibit a greater tendency for orthodontic relapse in comparison to patients

30 Orthodontic practice

(Regarding digit habits) The ________ of the habit will determine if the teeth will compensate unfavorably for the habit following treatment. a. incidence b. duration

c. intensity d. all of the above 8. Inherent to non-extraction treatment in crowding cases where the crowding exceeds ________ in the mandibular arch is the resultant proclination of mandibular incisors and resultant increase in arch length as well as a deviation from the original mandibular arch form. a. 1 mm-3 mm b. 4 mm-5 mm c. 6 mm d. 7 mm- 8 mm 9. In a study by Kacer, et al., it was found that based on the minimal standard of nighttime retainer wear at the 3-month post-debond mark, fully ______ of patients were not cooperative. a. 31% b. 45% c. 55% d. 65% 10. Because periodontal ligament fibers and the gingival tissues take _______ to reorganize completely, be aggressive with retention, especially in the first year of this phase of treatment. a. 1 month b. 2 months c. 6 months d. almost a year

Volume 10 Number 5

CE CREDITS

ORTHODONTIC PRACTICE CE

PRODUCT SPOTLIGHT

Henry Schein® Orthodontics™ The next-generation of treatment solutions

oday’s orthodontic patients are in the driver’s seat: they do their own research, know what they want, make their own decisions, and have high expectations. Living in a social media and selfie culture, patients want instant gratification and expect to improve their smile easily, invisibly, and quickly. Incorporating the SAGITTAL FIRST™ Philosophy, as a new treatment protocol, is the best way to offer your patients what they want, and even exceed their expectations with a positive experience. You can create beautiful smiles for life and correct occlusion, all in a shorter amount of time in brackets or fewer aligners. Another benefit for you? You dramatically decrease patients going over planned treatment time, resulting in improved practice efficiency! The SAGITTAL FIRST™ Philosophy powered by Carriere® MOTION 3D™ Appliance is changing the landscape of the orthodontic industry. Treatment has evolved from lengthy and unpleasant, to expeditious and comfortable — and discreet! Bite correction with Motion 3D Appliance prior to aligner or bracket treatment is becoming common practice among leading industry clinicians. The MOTION 3D Appliance is as easy to place as a bracket or buccal tube. Bonding

Volume 10 Number 5

takes about 15 minutes and can easily fit into a Same-Day Start protocol and increase conversion rates. The vision of SAGITTAL FIRST is to work smarter, not harder, by capitalizing on patients’ heightened compliance at the beginning of their treatment. The SAGITTAL FIRST Philosophy is also considered a nonsurgical approach to bite correction. The Motion 3D Appliance creates space. Simultaneously, it rotates the upper first molars into their correct position; it uprights the maxillary first molars and distalizes the maxillary posterior segment, from canine or first premolar to first molar, as a unit. The combination of these three concurrent actions corrects the anteroposterior (AP) relationship, resolves crowding, generating a movement on average from 3 mm to 6 mm. MOTION 3D CLEAR™ Appliance is the ideal driver to every aligner case. Benefits of beginning treatment with MOTION 3D include achieving a Class I platform in as little as 3 to 6 months prior to starting aligners, reduction in the number of aligners required, and shortened overall treatment time. Important to estheticminded patients, its unique design makes it virtually unnoticeable during treatment. Transitioning to the Attach-Less SLX® Clear Aligners post-occlusion correction with MOTION 3D Appliance reduces both the number of attachments and aligners required. SLX Aligner design features include precision fit and optimized trim heights that capture the hard and soft tissue anatomy for exceptional control without attachments. Conventional clear aligners are manufactured with deep scalloping and loose fit, making multiple attachments a necessity during treatment. Attach-Less SLX Clear Aligners provide an exceptional fit by creating one highly accurate mold of each tooth. The original “perfect” mold is utilized for each aligner. There is no loss of fidelity during this process. Each tooth is moved physically, step by step, as opposed to digitally.

The proprietary thermoforming method lends itself to capturing all available tooth and soft tissue anatomy. This process provides better tracking and a predictable outcome. Optimized trim is an essential focus during the manufacturing process of SLX Aligners. They are precisely contoured to capture the interproximal and gingival margins, further enhancing control independent of attachments and preventing the aligner from slipping. The edges of SLX Aligners are intentionally smooth to provide additional comfort for the patient throughout treatment. In addition to Attach-Less precision fit and contoured trim, SLX Clear Aligners offer improved clarity with ClearWear™ Material. Guaranteed not to stain, this provides another esthetic draw for patients. Precision fit, optimized trim, and the strength of ClearWear Material all work in unison to reinforce force levels. The SAGITTAL FIRST Philosophy brings together the simplicity and effectivity of MOTION 3D Appliance and SLX Clear Aligners to provide impressive results to patients in a shorter amount of time. A new era of orthodontics has arrived, and industry leaders not only have taken notice, but also have taken action to make MOTION 3D Appliance and SLX Clear Aligners the standard in bite correction and fixed-appliance alternatives. The SAGITTAL FIRST Philosophy proves that treatment can be less invasive, more efficient, and provide impressive results in a shorter amount of time. The rising popularity and demand is undeniable. Happy Patients + Happy Practice + Happy Staff + Happy Doctor #TheHappinessRevolution Visit us at HenryScheinOrtho.com. You can also follow us on Instagram and Facebook @HenryscheinOrtho OP This information was provided by Henry Schein® Orthodontics™.

Orthodontic practice 31

MYOFUNCTION JUNCTION

Working together to increase retention through identification and treatment of postural abnormalities Nicole Cavalea, MS, discusses how strengthening and retraining the muscles and educating patients on breathing techniques can aid in maintaining orthodontistsâ&#x20AC;&#x2122; results

rthodontists are often the first professionals to identify a patientâ&#x20AC;&#x2122;s abnormal patterning of the mouth and tongue, as these abnormalities interfere with the structural integrity of orthodontic treatment. A visual assessment of the following characteristics can indicate the need to co-treat with an orofacial, myofunctional therapist: forward tongue protrusion during resting, speech, and/or swallow, open-mouth posture, weak lip seal, postural changes to face, open bite, distorted speech, jaw instability, dark eye circles, long face, and a high narrow palate.

Tongue thrust/atypical swallowing When an individual presents with a tongue thrust, the patient may rest his/her tongue against the teeth, swallow with the tongue pushing against the teeth, and make sounds (meant for placement on the alveolar palate) with tongue pressure against the teeth. Having a tongue thrust applies pounds of pressure on the anterior teeth daily. This postural and functional imbalance may cause serious dental problems and greatly interfere in the efficiency of orthodontic treatment. If incorrect muscle patterning or swallowing have resulted in a malocclusion, learning proper techniques to correct these imbalances may prevent further damage, as special orthodontic appliances or braces will be needed to reposition dental problems that have already occurred. If atypical swallowing is not corrected early, it can cause alterations in the development of the stomatognathic apparatus. Furthermore, the improper function of the tongue, in conjunction

with dental malocclusion, will often lead to jaw instability, thus causing pain and headaches for the patient. For these reasons, myofunctional therapy is a useful adjunct treatment to orthodontics in subjects with myofunctional dysfunction (Saccomanno, et al., 2012). Two important factors in the correction of tongue-thrust swallowing are 1) growth and 2) orthodontic treatment to place the teeth in their proper positions and thus simplify proper tongue placement. However, growth and orthodontic treatment alone will not correct tonguethrust swallowing. In correction therapy, the 22 muscles that are used in normal swallowing should be re-educated to eliminate the tonguethrust swallowing habit in order for the patient to be able to unconsciously swallow in the correct manner (Straub, 1962). Therapy targeting a tongue thrust is aimed to strengthen, coordinate, and retrain the muscles involved in swallowing, resting posture, and speech. First, an assessment is used to determine the nature of the postural imbalances that are present and how they affect craniofacial development. Next, the client is given a set of exercises to activate

Nicole Cavalea is the founder of Strategies for Success, a speech-language pathology practice and myofunctional therapy clinic. She has worked in the field of communication disorders for 19 years. She received her MS degree in Speech and Language Pathology from San Jose State University. Cavalea has extensive expertise working with children of all ages in the assessment, treatment, and management of speech and language disorders, auditory-processing delays, and myofunctional disorders. After incorporating myofunctional techniques into her practice, she began noticing her clients improving with quicker and more precise results, leading her to further her training in myofunctional disorders and treatment, and attending multiple intensive training courses from the Academy of Orofacial Myofunctional Therapy. Recent studies include an advanced course on breathing re-education, focusing on restoring adequate breathing in sleep apnea patients. Recently, Cavalea has expanded her practice nationwide through telepractice, and values and enjoys collaboration and co-treatment with multi-disciplinary teams across the country. Nicole Cavalea can be reached at ncavalea@gmail.com.

32 Orthodontic practice

Figure 1: Treatment before. Here, a tongue thrust is visible by the anterior tongue placement (pushing against teeth)

and strengthen the weakened muscles used incorrectly during swallowing and involved in postural imbalances. Proper placement and precision are taught in regard to the function of swallowing. When swallowing correctly, the client is instructed to voluntarily place the tongue against the roof of the mouth while bringing lips together and creating a suction to swallow. The patient is then taught correct resting posture and speech. Lip exercises to strengthen the lip seal and habituate a closed-mouth posture are elicited. The nature of therapy is to correct habitual use of the tongue, while working on strengthening and patterning of the soft tissue involved. Treatment will last anywhere from 4-6 months, with daily exercises and practice.

Open-mouth breathing Along with a tongue thrust, the identification and treatment of an open-mouth breathing posture and weak lip seal is extremely important for your patients. Oral breathing will often be accompanied by: lack of lip seal, postural changes, dark eye circles, and a long face. Diagnosis and treatment for an anterior

Figure 2: After 11 weeks of treatment. Noticeable postural changes after 11 weeks of a tongue thrusttreatment protocol Volume 10 Number 5

Volume 10 Number 5

expansion have established their roles in the treatment of OSA after demonstrating considerable improvement related to adenoid or tonsillar hypertrophy, maxillary or mandibular deficiency, and orthodontic or craniofacial abnormalities. However, the implementation of other modalities such as myofacial re-education also plays a crucial role in the optimization of sleep-disordered breathing (Guilleminault, et al., 2013). To restore efficiency in breathing, first, the myofunctional therapist will educate the client on proper nasal/diaphragmatic breathing. Once coherence is established, the client will learn a series of exercises that focus on the biomechanical and biochemical aspects of breathing. Biochemically, the client is instructed to breathe in a way that creates a desire for air (such as narrow, light breaths). This technique will decrease the clients sensitivity for CO2, therefore creating a larger threshold to eliminate sleep disturbances. Biomechanically, the client is instructed on ways to practice techniques that maximize breathing skills. For example, the client learns deep, slow breathing through the nose, where the air effectively expands the diaphragm. In conclusion, orthodontic treatment alone, in the presence of bad habits (i.e., oral breathing, atypical swallowing, labial

interposition), and dysfunction of the oro-facial musculature is not enough to solve the orthodontic issues. Therefore, it is necessary to combine it with myofunctional therapy (Saccomanno, et al., 2012). The goal of the myofunctional therapist in co-treatment is to correct postural imbalances, restore proper alignment, elevation of the tongue and adequate nasal breathing. Furthermore, myofunctional therapy helps in eliminating open-mouth posture and correcting jaw instability. Successful treatment will result in creating an efficient swallow and tongue placement during rest and speech. The effect will have a positive impact on the outcome of orthodontic treatment, providing the opportunity for maximum results. OP REFERENCES 1. de Felício CM, da Silva Dias FV, Folha GA, de Almeida LA, de Souza JF, Anselmo-Lima WT, Trawitzki LV, Valera FC. Orofacial motor functions in pediatric obstructive sleep apnea and implications for myofunctional therapy. Int J Pediatr Otorhinolaryngol. 2016;Nov 90:5-11. 2. Guilleminault C, Huang YS, Monteyrol PJ, Sato R, Quo S, Lin CH. Critical role of myofascial reeducation in pediatric sleepdisordered breathing. Sleep Med. 2013;14(6):518-525. 3. Saccomanno S, Antonini G, D’Alatri L, D’Angelantonio M, Fiorita A, Deli R. Patients treated with orthodonticmyofunctional therapeutic protocol. Eur J Paediatr Dent. 2012;13(3):241-243. 4. Straub, WJ. Malfunction of the tongue. Am J Orthod. 1962;48(7):486-503.

Orthodontic practice 33

MYOFUNCTION JUNCTION

open bite and a high narrow palate is usually completed with appliances. Oral breathing may be habitual or due to an obstruction. Symptoms of sleep apnea, allergies, and difficulty concentrating may be reported, and further diagnosis will be needed. The goal of the myofunctional therapist is to restore correct nasal breathing in these patients. Achieving proper nasal breathing will result in improving lung volume, increasing nitric oxide through the body, improvement in sleep, and the reduction of allergies and illnesses. Obstructive sleep apnea (OSA) has become increasingly recognized as a notable health concern in children, given its consequences on behavior, function, and quality of life. Orofacial and pharyngeal muscles are involved in important functions including breathing, with the vital role of maintaining airflow. Any upper airway (UA) obstruction may induce changes in neuromuscular function in order to ensure the passage of air. The most common consequence of UA obstruction is mouth breathing, a functional adaptation that may affect craniofacial growth and development during childhood. Myofunctional treatment is aimed at correcting abnormal breathing patterns and muscular dysfunction that may impair upper airway patency (Felicio, et al., 2016). Adenotonsillectomy and palatal

ORTHODONTIC PERSPECTIVE

Don’t forget, they’re people Dr. Jeremy D. Smith discusses a human approach to winning with patients

eople don’t walk into an orthodontist’s office without a reason. They typically seek out orthodontic treatment, so the patients I see tend to have thought long and hard about what they would like changed. And whether these patients had orthodontic treatment in the past or have seen success through their children’s or a friend’s treatment, they know orthodontics can help get them the result they want. But getting treatment doesn’t mean you have to put your life on hold for a year. When patients walk through my door, it’s up to me to determine how they can get the results they want and need, while ensuring they look and feel good throughout the process. The first step we take for getting them to their ideal result is communicating with patients.

Esthetics has no singular meaning Communication with patients is key. Whenever someone walks into my office, I want to know what he/she is looking for and determine how I can best deliver those results. Part of that conversation is esthetics. Esthetics are important regardless of your age but can mean vastly different things to people. For example, when a 12-year-old tells me what he/she is looking for, more often than not the preteen wants fun, bright colors to show off to friends at school. For those instances, clear brackets with colorful O-ties make the perfect fit. But when it comes to adults, most opt for a subtler look. In those cases, I check to see if they’re a good fit for clear aligners. Many adults who come into my office will specifically ask for clear aligners. If the patient is not an ideal aligner case, I check to see if he/she is comfortable in wearing clear brackets. For the patient who isn’t comfortable with clear braces, we consider the option of lingual braces. Jeremy D. Smith, DDS, graduated from Louisiana State University (LSU) School of Dentistry in 1999 and completed his orthodontic residency shortly thereafter. He returned home to Northwest Arkansas where he has practiced since 2002. He served as President of the Arkansas State Association of Orthodontists from 2010-2013. Since 2015, he has focused on esthetic orthodontic treatment for every patient. Dr. Smith has lectured across the country on topics such as marketing, team development, and overcoming perceived obstacles to esthetic treatment. Disclosure: Dr. Jeremy Smith is a key opinion leader for 3M™.

34 Orthodontic practice

Esthetics are important regardless of your age but can mean vastly different things to people. Talking about compliance No matter what avenue we take for treatment, compliance is key for its success. During our initial conversation, I am careful to take time to set expectations with the patient and stress that it will take work to get to that result that he/she is looking for. Especially in aligner cases, the patient is going to have a little “homework!” When having this conversation, I encourage orthodontists to be honest and clear with their patients and to remember that medical jargon or having a technical tone can be intimidating. When I walk into this conversation, I take a more conversational approach to build trust. After deciding what the treatment needs of a patient are, I will show typodonts of every treatment option. Naturally, a patient is going to be curious about what clear aligners look and feel like. When a patient sees how good the brackets look on the typodont, it goes a long way toward reducing anxiety about the thought of wearing braces. In my experience, the concept of lingual braces is difficult for someone to envision, so having a model on hand is important as well. These typodonts are especially helpful for people who have already been through treatment using older technology.

Technology has come a long way In our office, gone are the days when patients are required to wear clunky headgear — we certainly haven’t used big metal braces in many years. Improvements in technology have opened a new door for esthetics, and I can see how it improves not only the quality of the results, but also my patients’ self-confidence throughout the process. When I decided to add clear aligners to my practice, I wanted to find a company that delivered top-quality products and that I felt had the orthodontists’ best interests in mind. My patients come to me because they trust me to do what’s necessary to get

them to their end goal. And, in turn, I want to trust that the company I’m working with will help me get to that goal easier. I want a company that I can see is making decisions and improvements to its products because that’s what orthodontists need, not just because it helps the company’s bottom line. Ideally, this partner would allow me to easily purchase just what my patient needs through its purchasing system. I value control and flexibility. So, if I’m doing a combo case or need only a set number of aligners, I want to order them and not have to purchase a full case unnecessarily, meaning decreased overhead costs for my practice. I ultimately chose 3M™ and its Clarity™ brand of aligners and brackets because they could do all that I asked. From a product standpoint, these trays are slightly firmer, which is an asset to my treatment and has proven time and time again to have better control of the teeth. With these aligners, some posterior expansion for teeth in crossbite is easier to accomplish. Vertical control of upper laterals and rotational control, in general, are more predictable as a result of the secure fit of the aligners that have a greater surface area in contact with the tooth than any other systems.

Build trust and get your results I’ve been practicing for approximately 18 years. And, like most orthodontists, I’ve tried a lot of systems. While there may be multiple options on the market, I encourage orthodontists to find a product that gives them peace of mind and a company that works with them. A lot of patients come to us after spending quite some time focusing on something they deem imperfect. It is up to us, as the experts, to build trust with patients by listening to what they are saying, utilizing a product we know will get the job done, and helping them maintain self-confidence throughout the treatment by understanding their esthetic desires. OP Volume 10 Number 5

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PRODUCT PROFILE

Orthocaps® esthetic aligner system

he result of years of product development, the Orthocaps® aligner system is designed to address core problems that many aligner systems have — specifically, the inability to transmit force to teeth without mechanical or directional loss and the lack of adequate control while delivering forces that move teeth accurately. Developed by Dr. Wajeeh Khan, an orthodontist in Germany, the Orthocaps® aligner system has many unique features and benefits that arise from the use of high-performance materials and precise high-pressure thermoforming techniques that assure an exact tooth fit to maximize surface area with the aligner. Nearly 30,000 successful, completed cases have been documented using the system. The manufacturing process produces a distinctively clear and esthetic aligner appearance without the striations that commonly appear on the outer surface of most aligner systems due to their printing processes. Orthocaps® aligners are polished to create a smooth surface along the gingival margin, minimizing gum and tongue irritability for improved comfort. The thermoplastic material possesses highly elastic properties essential for tooth movement through light forces. As a consequence, doctors are able to treat complex cases not traditionally chosen for aligner therapy. An innovative Dual Layer Polymer design is a dual-component material that produces a soft inner layer that grips better

Orthocaps® aligners have a distinctively clear and esthetic appearance and are polished to create a smooth surface along the gingival margin, minimizing gum and tongue irritability for improved comfort

than traditional aligners, enabling doctors to express the movement necessary for their prescription. Because of the firm grip of the inner material, fewer attachments are required compared to other aligner systems. The firm outer layer provides strength and force application, protecting against damage and maintaining aligner stability. The combination of these two materials produces improved movement efficiency. Unlike other aligner systems, the Orthocaps® TwinAligner® system uses a thinner daytime aligner for comfort and esthetic appearance, and a slightly thicker nighttime aligner for force-level customization and improved treatment efficiency. The soft inner layer grips the teeth for precise movement. The TwinAligner® solution creates less material stress because day or night aligners are worn no more than 12 hours at a time. This twice daily aligner approach is more hygienic, produces less discoloration, and reduces tray replacement costs if an aligner

is lost. Treatment can continue with a single aligner until the next stage. Another distinctive feature of Orthocaps® is the preformed attachments with Nano Ceramic Resin that come with the aligner tray. “With the precise adaptation of the aligner tray and the ease of having pre-filled attachments, this makes for a much more comfortable experience for the patient, and a more seamless appointment for the doctor and staff by decreasing chair time,” says Dr. Keith Dobrin, Bancroft Orthodontics, Waldwick, New Jersey. With its colormatching system, Orthocaps® trays are virtually invisible. Fraction pad attachments with a .3 mm-.5 mm thickness are available and can be placed or removed at any time. Doctors will experience a rapid and accurate setup process with Orthocaps®. Using the iSetup® digitized treatment planning software, doctors can expect a precise aligner treatment plan the first time. Prescriptions like MBT or Roth can be specified, assuring exact tip, torque, and rotation measurements. With the iSetup® process, doctors can avoid the “back and forth” of refinement common with other aligners during the setup process. After each treatment phase, a detailed 3D evaluation report is made to monitor progress and to adjust and adapt plans for accurate and optimal results. Fewer refinements are typically needed because of the thermoforming process, inner tray material gripping the teeth, and the precision of the iSetup® process. Orthocaps® is designed, engineered, manufactured, and distributed to 35 countries by Ortho Caps GmbH, selected as a “TOP 100” among Germany’s small and medium-sized enterprises. The company was founded by Dr. Kahn in 2006. Orthocaps® is represented by Denver-based Rocky Mountain® Orthodontics (RMO®) in the United States and Canada. OP

After each treatment phase, a detailed 3D evaluation report is made to monitor progress and to adjust and adapt plans for accurate and optimal results

This information was provided Rocky Mountain® Orthodontics (RMO®).

36 Orthodontic practice

Volume 10 Number 5

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PRODUCT PROFILE

Best practices in instrument care to protect your investment

rthodontic pliers represent a significant investment within a typical orthodontic practice. Accordingly, it makes good business sense to understand and apply best practices of care to protect your investment and to help assure a high degree of precision in the clinical tasks they were designed to support.

Within the basic conventional instrument reprocessing protocol of rinsing, ultrasonic cleaning, and sterilization, there are multiple opportunities to accelerate or minimize damage. The choices you make in the supplies you select and the equipment you choose can have a profound effect on the life of your instruments. Here are three areas to pay special attention to:

Cleaning Conventional protocol calls for rinsing of pliers in running water then immediately placing them in an ultrasonic cleaner. Allowing pliers to linger between these steps can allow for corrosion to begin. To further reduce the risk of corrosion, choose your ultrasonic cleaning solution carefully

— not all solutions are equal in the effect they have on pliers. In fact, the wrong solution can accelerate corrosion and degrade your instruments. Orthodontic pliers require a solution that is non-ionic, nonenzymatic, phosphate-free, pH-neutral, and if possible, includes a rust inhibitor. Dentronix® MP-US Plus Concentrate, has all of these features and requires no rinsing and carries no odor.

Maintenance Like any mechanical investment, orthodontic pliers will benefit from routine care and maintenance. Typically, a onceweekly routine is enough to keep your pliers in good working order. Inspect the tips for sharpness, signs of damage or corrosion, and have the inserts repaired or replaced if needed. Dentronix and other providers offer this service. At the same time, lubricate the plier joint to ensure smooth operation and displace trapped moisture. Make sure to use a high-quality food-grade pure silicone lubricant. Apply the lubricant to the joint,

Get the most out of your pliers with proper care

and operate the plier several times to work it in. Don’t reach for a can of WD40® or similar petroleum-based lubricant as it may not be suitable for medical device applications and may form residue that restricts the plier joint if using a dry heat sterilizer.

Sterilization Ideally, orthodontic pliers should be sterilized by the dry heat process. This process is completely inert and will eliminate any moisture present on the plier, minimizing corrosion and extending its life in the process. If dry heat processing is not an option for your practice, select a steam autoclave that offers pre-vacuum/ Class B operation. When using steam sterilization, plier tip materials must be a consideration. Look for pliers that are made with long-wearing, autoclavable tungsten carbide inserts or no inserts at all. Pliers made with traditional vanadium cobalt tool steel inserts will rust in an autoclave — dry heat sterilization is their only option. With a little attention to the details of your plier reprocessing protocol, you can expect your investment to provide a return measured in years of useful service. OP This information is provided by Dentronix® brand.

Dentronix® MP-US Plus Concentrate is formulated to protect orthodontic instruments 38 Orthodontic practice

Dentronix® Multi-Purpose Orthodontic Instrument Lubricant is available in spray and syringe configurations Volume 10 Number 5

At Dentronix®, We Understand The Need For Quality And Precision In The Field Of Orthodontics. To perform your best work, you need to reach for the highest quality precision instruments in the industry. That’s why we’re dedicated to achieving perfection in even the smallest details of our pliers, cutters, and other orthodontic instruments, from the design to the production to the facility they come from. You’re an expert in your field, and we’re the expert craftsmen here to support you in helping your patients improve their lives. For more information visit dentronix.com

Expertly Handcrafted Precision

GOING VIRAL

“Brace” yourself — don’t be the next victim of a cyberattack Gary Salman outlines what orthodontic practices can do to prevent identity theft

t seems that you can’t turn on the TV or visit your favorite news website without reading about cyberattacks crippling businesses and healthcare entities across the United States. Unfortunately, orthodontic practices are now becoming the victims of similar attacks. We often hear orthodontists say, “Why would they want to come after my practice?” Many orthodontists think that because they don’t store “medical records,” they don’t have to worry about protecting patient files. If you store any patient data in your system, it needs to be protected. Practices store critical information that can be used for identity theft and blackmail purposes (i.e., name, address, DOB, social security number, family members, scans of driver’s licenses, insurance cards, health history forms, images, lab reports, etc.). When hackers obtain this information, they will perform identity theft on your patients and/or sell the data on the Dark Web (the black market for hackers). As an orthodontist, you have one of the highest risk databases in healthcare because of the nature of your patients — minors. If your practice has a data breach, the HIPAA Breach Notification Rule requires you to notify every patient of record that a breach occurred, offer identity theft monitoring, and notify the community of the breach by taking out ads in local newspapers and other publications. Imagine the uncomfortable conversations you will have with hundreds of parents related to their child’s data being compromised and possibly being used by

Gary Salman, is Chief Executive Officer, Black Talon Security, Katonah, New York (www.blacktalonsecurity.com). He has more than 26 years of dental technology and IT experience.

40 Orthodontic practice

An undetected vulnerability on your network or even one “wrong click” on an email or attachment could negatively impact your practice. criminals for identity theft purposes. Even worse, what happens if you do not have proper security in place and have a breach that you are not aware of? Then years down the road, you start finding out about the breach, and it is uncovered that numerous patients in your system were the victims of identity theft. Minors may not become aware that identity theft ever occurred until they apply for a credit card or college loan and are turned down because of poor credit. The burden and stress on you and your practice is real. According to a study from Carnegie Mellon, a child is 51 times more likely to be a victim of identity theft.1 Cybercriminals are targeting practices in one of two ways. The first is through phishing or spear phishing campaigns. The attackers will send blanket or targeted emails to you and your staff with the intent of getting them either to click on something or to give up the credentials to your network or email system. We have seen many instances where a practice’s email system gets hacked, and the hackers then send out emails to the practice’s patients with malware attached to them. Imagine opening an email and clicking on what appears to be an invoice and then getting hit with a ransomware or malware attack.

Hackers are also breaking in through vulnerabilities (“unlocked doors and windows”) on your network or, even worse, through your IT vendor. We are now seeing scenarios where practices are targeted because their IT company, or even their accountant’s office, has been hacked and the criminals then use data from these entities to attack or target their practices. You can no longer rely solely on your IT company to protect your network. IT companies are not cybersecurity companies. You need the expertise and knowledge of a specialist in cybersecurity to help ensure the security of your network. Hackers can scan your network for vulnerabilities in a matter of minutes and then identify and exploit these vulnerabilities in order to gain access. This approach is much more common than you may imagine. The FBI and Department of Homeland Security posted a bulletin in the fall of 2018 warning IT vendors that Advanced Persistent Threat Actors (APTs) are targeting IT firms in order to exploit their information to attack their clients. Since your IT vendors typically store your IP address, user name, and password in their database, a breach will give the cybercriminal the “keys to your castle.” You have worked too long and hard to build your reputation in the community, and a data breach can be devastating. An undetected vulnerability on your network or even one “wrong click” on an email or attachment could negatively impact your practice. Don’t be the next victim. OP

REFERENCE 1. Power R. Child Identity Theft. Carnegie Mellon CyLab. 2011. https://www.cylab.cmu.edu/files/pdfs/reports/2011/ child-identity-theft.pdf. Accessed July 16, 2019.

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PRACTICE MANAGEMENT

Soft skills can help you deliver tough news to your patients and their parents JoAn Majors, RDA, CSP, discusses four techniques to engage and disarm those who need to hear your message

“B

ut my daughter wears her rubber bands.” “I was chewing ice/a pen cap.” “It was wrapped in a napkin, so I threw it away by accident.” “The dog ate it!” These statements, as well as a myriad of excuses for broken brackets, misplaced retainers, or any removable appliance, can send orthodontists and their teams over the edge. Most orthodontists have heard all of these, and yet somehow there are times that we just need the “soft skills” that can be disarming and create a new opportunity for listening. Better is the conversation that creates different behavior. Whether it’s patients, parents, or peers, we all have a need to deliver a less-thaneasy message to patients and parents. Some of us can remember with dread a manager delivering news to a team member this way: “Can I see you in my office at the end of today?” This is one of those requests that elicits chills, sweats, even nausea. What is it about a simple request like this that creates dread with everyone involved? Unfortunately, this is the way most people have learned to handle concerns: Take care of business, lay down the law, or just deliver news. I would like to suggest that when it comes to delivering information that might be upsetting, starting with the

JoAn Majors, RDA, CSP®, is a registered dental assistant, published author, and has earned the designation of certified speaking professional from the National Speakers Association. Her vast career in dentistry spans 3 decades. Her biggest block of business is speaking and training specialists and teams along with their referring practices and teams on the skills that matter. JoAn even developed an aftercare program that consists of online short video training that is executed through a monthly meeting with team leads. She is founder and content creation specialist for The Soft Skills Institute, LLC, a nationally recognized AGD PACE provider of seminars and workshops. JoAn’s happy place is at the front of the room inspiring today’s total team to appreciate the significance of soft skills to create greater value for all types of care and in every relationship, they want to keep. The time is now; the choice is yours! To learn more or see her in action visit: www.joanmajors.com

42 Orthodontic practice

right questions and the correct attitude can change everything about the conversation and the outcome. Four suggestions will allow even the most timid at heart, as well as the brutally honest, a way to offer uncomfortable information while maintaining integrity, having empathy, and disarming the recipient. It is important to remember a few parameters and realize that it doesn’t matter if the conversation is between a doctor or clinical team, to a patient, or parent. Starting with a question allows the other parties to listen and participate at their rate of speed, not yours. You must be willing to wait for the answer. This allows the other party to actually choose to engage in the conversation with you. Choosing to engage in a conversation that might not be favorable is something for which we could all use a little more skill. It’s definitely the soft skills that allow us to be able to fall back on a system or navigate a tough conversation rather than to rely on our own natural abilities. The following four techniques for communication with increased soft skills can be used with the orthodontist and or manager to patients, parents, peers, or business vendors.

1. Ask permission to coach When you have an issue with a patient, parent, peers, or practice vendor and need the individual to listen and participate in certain actions following the conversation, you need to engage the person in the process. You can call the person to your office or respectfully have the conversation in a location that is appropriate for your desired outcome. Find something to compliment before delivering the tough news at hand. For example, “Susan (or mom), you are (or Susan is) one of our favorite patients. We enjoy when you share your stories about skating competitions, and we would like to see you (or her) be successful with your (or her) braces as well. Do I have permission to coach you on how other compliant patients do this successfully while in school?” Most people say “yes” because this is less brutal, and it gives you the freedom to discuss her inability to wear her bands successfully or diligently. By having said “yes,” Susan is now involved and engaged in the process. It is a symbiotic relationship; it’s a connection and results in an agreement not a reprimand. Another example; “Ashley, you are one of our best team members when it comes to Volume 10 Number 5

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PRACTICE MANAGEMENT friendliness to our patients. Do I have permission to coach you in another area?” Again, she will most likely say “yes” because this is less confrontational, and it gives you the freedom to discuss her constant tardiness, inability to put her personal phone away and get off Facebook on office time, or whatever the issue is. She is also involved in the next process.

When delivering tough news in or out of the dental office, do not assume you know everything about the individual or the behavior being displayed. It is often more than meets the eye and the main reason we should start by assuming innocence.

2. Ask permission to be honest When a doctor or team member wants to confront an issue with a patient, parent, peers, or practice vendor, the procedure works similarly although the words are different. Timing is important, and you never want to make someone look or feel bad or foolish. This will not serve you well, so be discreet in the practice conversations. For example, one might say to Susan or to her mom, “Susan (or mom), do I have permission to be honest with you?” She will respond with less concern about the outcome because of the level of respect in the request. Besides, who would say, “No, I want you to lie to me?” Another example, for approaching a team member, “Ashley, do I have permission to be honest with you?” Again, this becomes disarming and less than confrontational than blurting out that you don’t understand her inability to be on time and eat breakfast before she arrives rather than in the morning huddle. It shows that you are concerned that it might create a change in policy for all the team if she can’t work out the timing with her daughter’s daycare schedule. In this case, she’s not “in trouble” but instead engaged in an outcome. Often people will seem puzzled that you asked permission. Don’t fill in the silence. Wait for their response. No matter how uncomfortable this might seem, it will create the results you want by allowing both parties to listen differently.

3. Leave out the limiting terms When speaking to someone about their habits, behaviors, or personal life, it is of extreme importance to leave out the limiting terms. For instance, if you are going to discuss a sensitive area, it is normal to want people to like you, so you can use less impactful words such as we, little, just, sort of, and kind of. Let’s take a doctor-to-patient and administrator-to-team-member scenario. Dr. Likeme says, “Susan (or mom), we have a little plaque around these brackets.” Her 44 Orthodontic practice

thought, if “we” have the plaque, and it’s “a little,” then the solution is, you need to brush better! The administrator or doctor says to the team member, “Ashley, we have a little problem with your tardiness.” The thought that follows, if “we” have the problem and it is “little,” don’t call me out! How about this? “Susan (or mom), you (or Susan) has plaque around these brackets; I’m concerned about this, and you should be too.” This allows the patient or mom to own the plaque and concern. For the doctor or administrator and team member, “Susan, there is a problem with your continued tardiness; I am concerned and believe you should be, too.” These scenarios allow the person to hear the concern. These should only be shared after asking permission to be honest. We have already proven that this question allows the party to be engaged at a different level. It also cuts down on a person’s self-justifying or defense mechanism.

4. Assume innocence — don’t use accusatory language When delivering tough news in or out of the dental office, do not assume you know everything about the individual or the behavior being displayed. It is often more than meets the eye and the main reason we should start by assuming innocence. When you ask for permission to coach or be honest, presume that the other party has no idea there is a problem or a concern. In other words, assume innocence. Taking the high road and assume that Susan and/or her mom really don’t fully comprehend the short- and long-term effects of her not wearing her elastics or having plaque around the brackets. Initially, this is only upsetting because you have the age-old belief that you already covered this. You think they should have heard and comprehended this. Research shows the average patient has a dental IQ of a third grader, and that means one mention or initial

review of something in a written policy is often not enough. The hard truth about soft skills is that if you take the time to reframe what you need someone to understand by using a question; it becomes about them and not about you! Just because Ashley is routinely tardy doesn’t necessarily mean she is doing it to disrespect you, her teammates, or the practice. Don’t assume that you know why this is happening. Ashley could be having marital concerns or a new diagnosis that is causing her to have trouble getting kids to daycare. Ashley could have a concern that you should investigate before you use accusatory language that certainly won’t create a culture of trust and understanding. We have to understand the generational shift happening in our practices, and this takes intentional communication. Assuming Ashley is innocent is much more productive for everyone. If your team member is not doing what is expected in the workplace, assume innocence and ask permission to coach, and then ask if he or she can fulfill the request. Just ask. It is not only the question, it is the cure for misguided and bad relationships in the practice and in life. If you wonder what is happening, then just ask. But when you ask, don’t ask with an attitude of insolence. In our signature Soft Skills and Science courses, the Cycle of 6, the second step is to be curious like a small child! They assume innocence until we teach them not to trust or to be suspicious. Finally, remember like all important conversations in the practice with patients, parents, or peers, document the conversation, use exact language, and advise you will be documenting it. It’s even appropriate to have the other party initial that you spoke about this. These four techniques will cut down on the defensive mechanism we all use when we know bad news is coming! Focus on the fix, not the flaw; this can help you encourage others to greatness! OP Volume 10 Number 5

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 5

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 45

SMALL TALK

Weathering the storms of leadership Drs. Joel C. Small and Edwin McDonald discuss how a seasoned leader can create a balance

leader brings the “weather” to the organization that he/she leads, be it large or small. The weather can range from stormy and turbulent to sunny and full of the sun’s energy. A weather that supports healthy, growing lives requires a balance of rain, sun, and the seasonal variations that allow for a complete cycle of life. What kind of weather do we find when the leader is not leading?

A practice in survival mode For all forms of life to be healthy, including human beings, they need the right mix of elements to breathe life into them. Effective, purpose-driven leadership cannot exist without these essential ingredients that create a healthy environment. The first sign that a leader is not leading is that the individuals under their leadership are not thriving; in fact, they are struggling to survive. The most significant leadership competency that correlates with high levels of organizational performance is strong people skills. Those skills pertain more to the leader being personable, approachable, and a good listener rather than possessing a dynamic personality. All people need to be heard and understood and, equally important, need a positive and safe environment that encourages open and direct dialogue. When leadership is deficient, the people’s need to be heard and to have a voice is absent. Their relationship with the leader is superficial and lacks the depth that people need to commit to the organization’s purpose. Their low-level

Drs. Joel Small and Edwin (Mac) McDonald have a total of over 75 years of dental practice experience. Both doctors are trained and certified Executive Leadership Coaches. They have joined forces to create Line of Sight Coaching, a business dedicated to helping their fellow dentists discover a better and more enjoyable way to create and lead a highly productive clinical dental practice. Through their work, clients experience a better work/ life balance, find more joy in their work, and develop a strong practice culture and brand that positively impact their bottom line. To receive their free ebook, 7 Surprising Steps to Grow Your Practice Through Leadership, go to www.lineofsightcoaching.com.

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motivation and commitment reflect an organizational culture that is transactional rather than transformational in nature. Symptoms: high staff turnover, internal conflict, low productivity

defines an enterprise that is stuck and performing below its capability. Symptoms: low productivity, wasted energy, confusion, conflict

Lack of clarity, purpose, and vision

By definition, a team comes together to accomplish something as a group that they could not do by themselves. Each team member has a specific role and responsibility. An effective leader orchestrates the function of the overall team as well as each individual. These leaders communicate the importance of each position and what success looks like. In short, they are great people developers and intentionally empower those that they lead. It is not uncommon, as coaches, to encounter doctors who are seeking a better work/life balance. They are exhausted by the persistent conflict between family and practice — feeling caught between the constant pull of the practice on their purse strings and the opposing pull of their family on their heartstrings. Invariably, these doctors have failed to develop their teams’ capacity to lessen the doctors’ load. These doctors have not provided their staff with the training, resources, and authority to manage and oversee practice systems. Sadly, these doctors have done a great disservice to themselves and their staff. The doctors are

Great leaders bring clarity, establish values, and articulate vision. There exists a commonly shared belief and understanding about where the leader is taking the organization. The team understands the organizational values, and therefore, they know how to make decisions in alignment with the shared purpose. This creates an entire team of decision-makers and energy producers that are working toward the same goal. In this ideal scenario, the doctor is no longer the “bottleneck” through which all decisions emanate. This allows the overall team to develop their capabilities and capacity to be more productive. When clarity, values, and vision are missing, there is greater confusion, more hesitation to act, and more internal conflict. This inevitably results in organizational stagnation. Stagnant teams find themselves spending excessive energy maintaining the status quo, rather than taking necessary measures and calculated risks designed to promote practice growth. This description

Exhaustion

Volume 10 Number 5

Lack of trust The “currency” of relationships is trust. Trusting relationships are the building blocks of a successful contemporary practice. Highly effective leaders understand this and have spent a great deal of time and effort on the inner game of personal development to become more trusting and trustworthy leaders. Most successful practices have leaders and teams that trust one another. They trust in one another’s integrity and capability. Exceptional leaders understand that trust is established through both words and actions. They not only believe in their people, but also speak and act in a manner consistent with this belief. In contrast, underdeveloped leaders cancel out their personal strengths and erode trust with words and behaviors that are grounded in distorted beliefs and assumptions. Let’s use exhausted doctors mentioned earlier as an example. These doctors may be high achievers, but when we look at their team dynamics, it is obvious that they are not utilizing the staff’s capabilities to achieve their goals. These doctors may be harboring the false assumption that they do not need the team’s input or skill to accomplish their goals. The doctors may even believe that their team is incapable of carrying out the more intricate tasks necessary to achieve highpriority goals. Given this false assumption, the doctors may then adopt a self-limiting belief that only they can do the work necessary to accomplish these goals. Thus, these doctors see no value in developing the team — choosing to “go it alone” and isolating themselves — forgoing valuable collaboration and assistance that would lighten the load, allowing for a better work/life balance, and resolving their state of exhaustion. Through the doctor’s words and actions, the team members sense that the doctor lacks confidence in their abilities. They see that the doctor does not value their thoughts or efforts. They feel the obvious lack of trust, and from that point on, dialogue breaks down, creativity and collaboration cease to exist, and stagnation arises. In the absence Volume 10 Number 5

A weather that supports healthy, growing lives requires a balance of rain, sun, and the seasonal variations that allow for a complete cycle of life. of trust, team members will fail to make the commitments that will unlock their potential. Trust will also erode when default leadership results in ill-defined practice values and purpose. Because there is no clarity, there is also no shared understanding of the direction of the practice. Team members, lacking this sense of common values and purpose, are left to define their own values and create their own interpretation of the organization’s purpose. In effect, each team member begins to act out of his/her own self-defined operating system. There is no common driving force within the organization, and dysfunction ensues. Dysfunction is accompanied by distrust as each team member views the other team members’ actions in conflict with his/her own selfdefined organizational values and purpose. Symptoms: conflict, disillusionment, high turnover, lack of team coordination, low production and organizational capacity

Burnout Burnout is different from exhaustion. Exhaustion is the loss of physical stamina due to an excessive workload. Burnout is the loss of passion as well as physical and emotional stamina created by a heavy workload without the benefit of personal development. Recent workforce research has shown personal development to be the secret potion that can prevent burnout. This applies to both the doctor and staff. Along with personal growth come energy, passion, and an interest to continue growing and succeeding. We have found that the most successful healthcare practices expend significant resources in the development of their people. These are the same practices that serve as icons in our industry. With ineffective leadership and an underdeveloped staff, the practice must work harder to compensate for these deficiencies. Often the best people burn out and will eventually leave the practice in search of something more enjoyable and rewarding — a practice that is willing to invest in their personal development. Unfortunately, this

leaves the less qualified team members to carry the load, which soon becomes very heavy and unsustainable. When it becomes obvious that the problems are not solvable through more work, exhaustion, burnout, and poor work/life balance become the unavoidable consequences. If these conditions persist long enough, then disillusionment, anxiety, and depression are the unfortunate outcomes. Symptoms: exhaustion, loss of passion, widespread practice decline, turnover, disillusionment, anxiety, depression

Summary In summary, all the major stress producers that dentists report — managing their team, inadequate income, lack of meaningful work, navigating a complex marketplace — have their basis and their solution around the leader’s competencies. Most dental practice owners are looking for solutions in the latest technology, business management systems, clinical training, and marketing. Without a doubt, these assets are important parts of a comprehensive strategy for success. However, their impact on the practice will have a ceiling that is determined by the level of leadership provided by the doctor. Business performance is directly correlated with the level of leadership operating within the organization. The research and case studies completed over the past 30 years consistently reveal this. There is hope, however. Extensive research into leadership development has resulted in new tools and highly reliable assessments that pinpoint a potential leader’s generative/creative competencies that enhance leadership effectiveness as well as those reactive tendencies that inhibit his/ her leadership capabilities. Armed with this vital information, individualized leadership development programs are now designed for doctors by trained professional coaches. Furthermore, new and creative ways of assessing the efficacy of these individualized leadership development programs are now available and are widely employed in the development process. We now know that great leaders are not born; they are made. Sometimes they are made out of a crisis or adversity. Sometimes leaders are made intentionally by someone who wants to experience a better life. That someone could be you. That journey could begin today. All it takes is an awareness of the importance of leadership and the commitment to develop those skills. There are more resources to guide you now than ever before. It is up to you. OP Orthodontic practice 47

SMALL TALK

exhausted, and their staff has lost an opportunity to experience growth. Even worse, these doctors find that they are spending an inordinate amount of time and energy on lowlevel tasks rather than value-producing tasks that greatly benefit the practice — tasks that only they can accomplish. Symptoms: lack of energy, failure to achieve high-priority goals, undeveloped staff, strained interpersonal relationships, reduced production

INDUSTRY NEWS EverSmile® AlignerFresh™ — when the patient can’t rinse EverSmile® AlignerFresh™ solves the number one problem with wearing aligners: whitening and cleaning on-the-go, which comes in handy for after meals when the patient can’t rinse. AlignerFresh™ uses hydrogen peroxide-based, anionic EverClean™ technology, and in laboratory testing, 99.999% of common oral bacteria were killed within 60 seconds of exposure. AlignerFresh can be applied up to 6 times per day, and it’s easy to use. For more information, visit https://eversmilewhite.com/.

CEREC Ortho SW 2.0: treatment simulation right at the chair for optimal patient communication The introduction of the CEREC Ortho software meant that the Dentsply Sirona CAD/CAM system could be used for orthodontic indications. Before deciding on orthodontic treatment, it is important that patients understand the treatment proposal and its impact. For this, the appropriate simulations are a good way to aid patient communication. This is made possible by new hardware and software — the Primescan AC, which enables a fast, precise impression of the entire jaw. A major element of this new application is the recently introduced CEREC Ortho SW 2.0. It gives users access to special orthodontic functions immediately after the digital impression with Primescan, the new intraoral scanner from Dentsply Sirona. The features include adding a base to the model, a comprehensive model analysis, and a simulation of the treatment outcome that can immediately be used for patient communication. The model analysis, including Bolton and space requirement analysis, is done so quickly that it can be part of the scanning session. It also includes a Moyers mixed dentition analysis, transverse distance, symmetry, occlusion class, overjet, overbite, and much more. The segmentation required for measuring the teeth is done quickly, nearly automatically, and is extremely reliable. In addition, the extensive analysis sheet can be easily exported in PDF format for documentation purposes. For more information, visit www.dentsplysirona.com.

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Carestream Dental announces SureSmile® Certification for CS 8100 3D family Carestream Dental has announced that the CS 8100 3D and CS 8100SC 3D imaging systems have been certified for use with SureSmile® technology platforms (Dentsply Sirona) to give doctors more treatment options. Digital images captured by the CS 8100 3D family in combination with the SureSmile system open new digital workflow options to doctors for case planning, combining 3D diagnostic imaging with computerized treatment planning, robotic archwire customization, and other SureSmile treatment options. The two systems that comprise the CS 8100 3D family offer doctors powerful, compact in-house imaging. The CS 8100 3D provides 2D imaging, cone beam computed tomography, and 3D object scanning, while the CS 8100SC 3D adds scanning cephalometric imaging. Advanced orthodontic software give both systems an advantage such as automatic cephalometric tracing with the CS 8100SC 3D. To learn more, visit carestreamdental.com.

Second-edition dental research handbook validates the use of T-Scan™ Technology for assessing and measuring occlusion The release of the Handbook of Research on Clinical Applications of Computerized Occlusal Analysis in Dental Medicine (3 volumes), edited by Dr. Robert B. Kerstein, DMD, with contributions from 20 industry-leading research and dentistry experts from around the world, is evidence that measuring occlusion with T-Scan™ digital occlusal analysis system is becoming the standard of care for dental practitioners worldwide. The handbook features 19 chapters containing over 800-plus full-color figures and a comprehensive list of references, making it an ideal resource for dental healthcare providers, educators, researchers, students, and dental healthcare professionals. Innovative findings and research on applications for occlusal analysis technologies — such as, dental arch digitalization, temporomandibular disorders, hypersensitive dentition, temporomandibular joint vibration analysis, orthodontic monitoring, orthodontics, periodontal treatment, and implant and conventional prosthodontics — are contained within. For more information, visit www.tekscan.com or publisher IGI Global at www.igi-global.com.

Volume 10 Number 5

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