Orthodontic Practice US September/October 2020 Vol 11 No 5

Drs. Fabio Oliveira Coelho, Francesca Scilla Smith, and Larry W. White

A comparison of efficacy and efficiency of clear aligners versus braces postCOVID-19 Dr. David Alpan

Using Spark™ Clear Aligners in open bite closure with TADs Dr. Bill Dischinger

Class II Division I, 9 mm overjet Dr. Aron Dellinger

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Application of the 20/20 Molar Bracket

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Dr. Aron Dellinger & The PhysioDynamic System

clinical articles • management advice • practice profiles • technology reviews September/October 2020 – Vol 11 No 5 • orthopracticeus.com

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Sept/Oct 2020 - Volume 11 Number 5

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

R

emember when your children were learning to ski? If you mentioned the word “ski school,” your kids would freak out. However, if you said, “You have a coach for the day,” they saw a fun day ahead!

Continuing education in orthodontics is no different! Throughout our orthodontic programs, we had dedicated faculty members, both full-time and part-time, to help shape our knowledge base. And we rode this out for years. However, for a number of different reasons, there’s a time in one’s career when the need for retooling or coaching becomes apparent. This realization may come from looking at your practice outcomes with a critical eye. As examples, it may be a professional friend who diplomatically points out a consistent shortcoming in your cases. It may be realizing your expected results are inconsistent or not what you anticipated.

You may notice extended treatment times. Through a more experienced or detailed lens, you may see outcomes like open-bite relapses during follow-up care or short lower jaws that did not respond favorably to your mechanics. These outcomes may not happen often, but when they do, it eats at all of us! It does not make for a clean practice or, in some cases, creates an unhappy patient.

The growth of an orthodontic practice has three stages: 1. The growing stage: Your practice begins slowly, and as your reputation develops, your practice begins to develop exponentially.

2. The thriving stage occurs next as your practice is busier than you can handle, and you now have “growing pains.”

3. The maintenance stage is defined in many ways, but essentially, you have a little debt, children are out of college, and your practice continues to thrive. At this stage, you have many options. One may be to master your craft. These three growth stages require different levels of information or education.

Advanced orthodontic learning can be divided into four areas: 1. Fine-tuning your diagnosis and developing clearer and measurable treatment goals for the occlusion, facial symmetry and smile esthetics, airway patency, periodontal, and TMJ health.

2. Mastering mechanics for both mixed and permanent dentition and managing time efficiently, including your time, patient treatment time, and staff time.

3. Treating rewarding and complex interdisciplinary cases with specialists who share the same treatment goals.

4. Understanding the 4 P’s of practice development — People, Place, Promotion, and Product.

When is a good time to consider “upping” your game and making it more fulfilling? Further analyzing outcomes? No better time than now!

Advanced learning is more available and more easily accessible than ever. Technology has made this possible. Let’s use it. During this terrible COVID-19 pandemic, we can go from “onsite” learning to “interactive virtual learning” and continue to educate, inspire, and thrive. It’s better than ever. Consider programs that are able to specialize in your individual orthodontic practice needs.

Let’s make use of this “no travel time” for virtual learning platforms to share information throughout the world! Cyberlearning will be our sole source of education until the vaccine for the COVID-19 is developed. We then can return to some form of normalcy and traditional “onsite” and hands-on learning. I firmly believe that both can be done to benefit the doctors and, more importantly, our patients.

So just as your kids said, “No ski school!” let’s think of this next learning phase as “coaching” and have fun interacting during this new normal.

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 2020. 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.

Straty Righellis, DDS, is a Diplomate of the American Board of Orthodontics and an Associate Clinical Professor at the University of California at San Francisco, School of Dentistry. He is a reviewer for the American Journal of Orthodontics and Dentofacial Orthopedics, has written over 40 articles and papers on treatment efficiency and treatment excellence, and has lectured to more than 450 groups nationally and internationally. Dr. Righellis has authored a chapter on treatment efficiency and excellence in the textbook Goal-Directed Orthodontics. He is a faculty member at the FACE teaching program and is past President of the Edward H. Angle Society, Northern California. A graduate from UCLA Dental School and UCSF orthodontic residency, he is an active private practice in Oakland, California.

Dr. Righellis currently offers interactive virtual learning as well as onsite learning. If you are interested in any aspect of his orthodontic coaching, go to StraightFromStraty.com, and/or email straty.er@gmail.com for additional information.

ISSN number 2372-8396

Volume 11 Number 5

Orthodontic practice 1

INTRODUCTION

Coaching — why, when, and how

TABLE OF CONTENTS

Publisher’s perspective Staying empowered Lisa Moler, Founder/CEO, MedMark Media................................6

Clinical Into the unknown: emerging evidence regarding risks of aerosols in the dental office

8

Case study Using Spark™ Clear Aligners in open bite closure with TADs Dr. Bill Dischinger illustrates treating a patient’s narrow arches and anterior open bite with clear aligner therapy .......................................................14

Dr. Maria L. Geisinger discusses likely modes of transmission for the virus that causes COVID-19

Continuing education A comparison of efficacy and efficiency of clear aligners versus braces post-COVID-19

Case study

12

Dr. David Alpan discusses evolving treatment plans in the wake of COVID-19........................................18

Class II Division I, 9 mm overjet Dr. Aron Dellinger discusses treatment with the Roncone PhysioDynamic System (PDS) application of the 20/20 molar bracket ON THE COVER Cover images courtesy of Dr. Bill Dischinger. Article begins on page 14.

2 Orthodontic practice

Volume 11 Number 5

SureSmile® Aligner

by Dentsply Sirona

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Visit dentsplysirona.com/SureSmileStories to view Dr. Shah’s complete experience. *Data on file.

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TABLE OF CONTENTS

Step-by-step Historical evolution of Gold Mesh Pad with swivel and chain for impacted cuspids Dr. Lloyd Taylor illustrates a technique for impacted cuspids........................31

Continuing education The MPA 5

25

Drs. Fabio Oliveira Coelho, Francesca Scilla Smith, and Larry W. White discuss the evolution and efficacy of the mandibular protraction appliance (MPA)

Service profile

Product profiles

Book review

Empower 2 Clear Self-Ligating brackets.......................................34

New Straight Wire: Strategies and Mechanics for a Programmed Approach to Orthodontic Treatment

COVID-19 impact on practice values — short and long term

The universal language of business

Chip Fichtner discusses how orthodontists can add liquidity and a strong growth partner to their practices..........................................32

Suzanne Wilson, Chief Marketing Officer of Gaidge, discusses how to keep a pulse on essential performance metrics in your business..................36

Francesco Pedetta, MD, DDS 2020, Quintessence Publishing Co. ....................................................... 37

Industry news................. 38

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

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

4 Orthodontic practice

Volume 11 Number 5

PUBLISHER’S PERSPECTIVE

Staying empowered

Published by

W

elcome back! By the time you read this, patients will have returned to your chairs, and you and your teams will be hard at work providing your essential quality dental care. Although dental offices have always been recognized for their high standards in sterilization and sanitization protocols, now they have advanced these practices to even higher levels for the continued health and safety of patients and staff.

Policies concerning PPE and aerosol containment are firmly in place and will probably become a part of daily life. In the news and in discussions with dental professionals, I repeatedly hear the term “new normal” — much has changed, and once “uncharted territory” has borne solutions that have become Lisa Moler mainstream. With all of the precautions to curb the spread Founder/Publisher, MedMark Media of COVID-19 in and out of the dental office, I would like to propose a new term for use in our healing world. I hope that we can stop saying the “new normal” and achieve an “optimistic normal” that is comfortable and inviting — where you, your patients, and staff all feel safe enough to be thinking once again of your craft, your options, and expansion of your skills and techniques.

To help you continue to “think outside the box,” the articles in this issue focus on your craft. Dr. David Alpan’s CE compares clear aligners and braces in post-COVID-19 treatment plans. His article can help you achieve more effective scheduling and more efficient treatment options. Drs. Fabio Oliveira Coelho, Francesca Scilla Smith, and Larry W. White’s CE delves into the history and evolution of the mandibular protraction device and its simplified placement and improved function. Dr. Maria L. Geisinger discusses aerosols in dental settings and potential mitigation strategies for highly protective infection control practices. The case study by Dr. Bill Dischinger and the product profiles showcase inventiveness and potential for both your clinical practice and your business.

At MedMark Media, we are realistic and optimistic. COVID-19 is not over yet, but we are getting closer each day and have used this time for introspection, invention, implementation, and all of the other “-ions” that it takes for us to return to our fulfilling, balanced, profitable, busy lives. The world knows now that dentists are essential, and your positive outlook, tenacity, and dedication to your patients and the specialty are inspiring. Stay positive, stay focused, and stay with us as you have over the years. We appreciate and value you all.

All the best, Lisa Moler Founder/Publisher MedMark Media

PUBLISHER Lisa Moler lmoler@medmarkmedia.com DIRECTOR OF OPERATIONS Don Gardner don@medmarkmedia.com MANAGING EDITOR Mali Schantz-Feld, MA, CDE mali@medmarkmedia.com | Tel: (727) 515-5118 ASSISTANT EDITOR Elizabeth Romanek betty@medmarkmedia.com MANAGER CLIENT SERVICES/SALES Adrienne Good agood@medmarkmedia.com CREATIVE DIRECTOR/PRODUCTION MANAGER Amanda Culver amanda@medmarkmedia.com MARKETING & DIGITAL STRATEGY Amzi Koury amzi@medmarkmedia.com EMEDIA COORDINATOR Michelle Britzius emedia@medmarkmedia.com SOCIAL MEDIA & PR MANAGER April Gutierrez medmarkmedia@medmarkmedia.com FRONT OFFICE ADMINISTRATOR Melissa Minnick melissa@medmarkmedia.com

MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Toll-free: (866) 579-9496 www.orthopracticeus.com www.medmarkmedia.com

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6 Orthodontic practice

Volume 11 Number 5

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CLINICAL

Into the unknown: emerging evidence regarding risks of aerosols in the dental office Dr. Maria L. Geisinger discusses likely modes of transmission for the virus that causes COVID-19

A

erosols created during dental procedures have been suggested as a risk for disease transmission for patients and practitioners in the dental office. The current worldwide pandemic of COVID-19 caused by the transmission of SARS-CoV-2 represents a novel disease and presents unique challenges for our profession moving forward. As we continue to assess transmission rates and modalities, we continue to learn about the risks posed by the airborne transmission of this virus and the risks for dental healthcare professionals and patients. Risk mitigation efforts have been suggested, but such measures should be reasonable and informed by scientific evidence and the known understanding of likely modes of transmission and subsequent infectivity.

The CDC has stated that the modes of SARS-CoV-2 transmission are most likely to be via airborne droplets and close, prolonged contact with infectious persons. Furthermore, while the infectivity of asymptomatic carriers is questionable, presymptomatic individuals have been demonstrated to be capable of viral spread. The risk of spread of infection by aerosolized particles may be affected by the type of aerosol generated, aerosol kinetics, pathogen bioload in the aerosol source, and

Maria L. Geisinger, DDS, MS, is a Professor and Director of Advanced Education in Periodontology in the Department of Periodontology at the University of Alabama at Birmingham (UAB) School of Dentistry. Dr. Geisinger received her BS in Biology from Duke University, her DDS from Columbia University School of Dental Medicine, and her MS and Certificate in Periodontology and Implantology from The University of Texas Health Science Center at San Antonio. Dr. Geisinger is a Diplomate of the American Board of Periodontology. She has served as the President of the American Academy of Periodontology Foundation and on multiple nationally and regionally organized dentistry committees. She currently serves as Chair of the ADA’s Council on Scientific Affairs and is a member of the AAP’s Board of Trustees. She has authored over 45 peer-reviewed publications. Her research interests include periodontal and systemic disease interaction, implant dentistry in the periodontally compromised dentition, and novel treatment strategies for oral soft and hard tissue growth.

Dr. Geisinger lectures nationally and internationally on topics in periodontology and oral healthcare.

8 Orthodontic practice

Visible threshold 30-40μm Aerosol threshold 50μm Fine aerosol (may remain suspended in air) 5μm Particles may penetrate the lower respiratory tract 1μm Average bacterial size 0.2μm

Human hair 70-100μm

Figure 1: Droplet particulate size comparisons

the type of pathogen. Practically, within the dental office, it is important for dental practitioners to be familiar with the following: • Risks associated with differing modes of transmission, including droplets, aerosols, and fomite surfaces • Types of aerosols generated by common dental procedures • The nature, quantity, and sources of microbial load in such aerosols • The efficacy of current and emerging practices in mitigating aerosol-generated microbial load

Splatter and aerosols: physical and microbial properties It is well established that airborne infections may be transmitted via droplets, including splatter and aerosols.1 Splatter droplets are defined as those with particle sizes ≥50μm, generally act as a projectile, and are only airborne briefly prior to hitting a surface or falling to earth with gravitational forces. They are spread by close contact (typically within 1 meter) with the host. The particle size of aerosols is <50μm. They may remain airborne for prolonged periods of time, carry viable pathogens, and are capable of being deposited on distant surfaces. It

has been demonstrated that droplets >5μm generally remain in the upper respiratory tract while droplets ≤5μm can be inhaled into the lower respiratory tract and those ≤1μm can enter alveoli2,3 (Figure 1).

The interaction and kinetics of droplets in aerosols and splatter are complex.

In general, aerosols are always produced in conjunction with splatter, and aerosol droplets may collide with each other, causing them to coalesce and altering their size and physical properties.4 Additionally, larger droplet particles may break down into smaller particles, which may influence the microbial load and particle size.

Droplets, including splatter and aerosols, are routinely generated during physiologic activities such as breathing, talking, coughing, and sneezing. The microbial load created from these activities also differ based upon the type of microorganisms, the infectious course of each disease, and mitigation strategies such as patients wearing surgical masks.5-11 Given these findings, it can be assumed that there is signficant heterogeneity in the amount, types, and infectivity of droplets produced by individuals in vivo.

The oral cavity contains an extremely diverse microbiome and generally contains Volume 11 Number 5

Aerosols in the dental office It is well established that many dental procedures produce splatter and aerosols.

The highest amounts of aerosols produced during dental procedures are derived from the use of powered scalers, high-speed handpieces, and/or laser use.

Powered scaler use Sonic, ultrasonic, or piezoelectric devices all produce high levels of aerosol, and the amounts and distance traveled of these droplets is comparable among these devices.16-19 Aerosols produced by ultrasonic instrumentation have been detected as far away as 2 to 11 meters from the treatment site, which could extend throughout dental operatories or offices.20,21 In clinical settings, the levels of aerosols return to preoperative levels within 30 minutes to 2 hours.22,23 High-speed handpiece use High-speed handpieces can generate droplets, including splatter and aerosols containing blood and other components.20,24-27 The microbial bioload generally correlates with the microbiota present in the tooth being treated26 and the extent of caries in individual patients.28 It has been reported

that microbial fallout from restorative procedures can extend up to 1.5 to 2 meters; however, this may be mitigated by the type of evacuation used, and this has not been fully reported.29 Laser instrumentation Class IV lasers used in dentistry to excise tissue do so through vaporization.

This process generates gaseous material often referred to as a smoke plume, which is composed of 95% water.30 The remaining 5% has been reported to contain blood, particulate, and microbial matter. The particle size generated by lasers ranges from 0.1-2Îźm.30 Although there is no evidence available on disease transmission associated with lasers used in dental operatories, Escherichia coli, Staphylococcus aureus, human papillomavirus, human immunodeficiency virus, and hepatitis B virus have been detected in medical laser plumes.30 Clinical implications While much focus has been placed on the theoretical risk of disease transmission from dental aerosols, there is limited data identifying the source and infective potential of pathogens in such aerosols. Microbes such as Staphylococcus aureus, beta hemolytic Streptococci, Escherichia coli, spore-forming bacteria, fungi belonging to the genera Cladosporium and Penicillium, and Micrococccus have been identified in dental aerosols.21,31-33 As such, these findings may indicate that microbial sources potentially include saliva, dental water reservoirs, including dental unit water lines (DUWL), or respiratory droplets, with the majority of cultivatable organisms

derived from non-patient sources. Water coolant used in conjunction with rotary handpieces and powered scalers has a typical flow rate of 10 to 40 mL per minute34 generally five- to 10-fold greater than unstimulated and stimulated saliva; it can be theorized that significant dilution of salivary or respiratory pathogens occurs in these settings. Because it is expected that SARS-CoV-2 and other airborne pathogens are likely transmitted via human secretions, this dilution may prove to reduce the overall pathogenic bioload and, therefore, infectivity of such aerosols (Table 1).

Bioaerosol mitigation in the dental office Although there is no evidence implicating dental procedures in the spread of viral particles, the recent COVID-19 epidemic has created an increased awareness of airborne disease transmission and has increased interest in the potential to mitigate aerosol exposure for dental healthcare providers and patients. Strategies to achieve this may include the following: 1. Better identifying potentially infectious individuals 2. Reducing aerosol bioload 3. Barriers that reduce droplet deposition and aspiration for dental healthcare providers 4. Reduction of aerosol droplets in room air.19 Strategies to achieve this may include screening prospective patients for common disease symptoms and/or testing prior to invasive procedures, implementing pre-procedural mouth rinses, use of advanced respiratory protections during

Table 1: Aerosol-generating procedures in dentistry and perioperative mitigation strategies Aerosol-generating risk associated with procedures

Dental devices/procedures

Airborne contamination potential

Potential mitigation for droplet/aerosols

High

Powered scalers

Considered to be the greatest source of aerosol contamination in dental practice

High-volume during powered scaler use reduces airborne contamination by > 95%

High-speed handpiece use without rubber dam barrier

High-aerosol production

Rubber dam use and high-volume evacuation during high-speed use can significantly reduce aerosol production

Air polishing

Airborne bacterial counts indicate aerosol production nearly as high as with ultrasonic scalers

High-volume evacuation during powered scaler use reduces airborne contamination by > 95%

Air-water syringe

Airborne bacterial counts indicate aerosol production nearly as high as with ultrasonic scalers

High-volume evacuation during powered scaler use reduces airborne contamination by > 99%

Tooth preparation with high-speed handpiece and rubber dam placement

Reduced airborne contamination if proper placement of a rubber dam is in place

High-volume evacuation is indicated

Tooth preparation with air abrasion

Microbial contamination is unknown. Extensive contamination with abrasive particles has been shown

Use of a rubber dam and high-volume evacuation is indicated

Moderate

Low

Volume 11 Number 5

Orthodontic practice 9

CLINICAL

a high number of microorganisms. Exogenous infections within or originating from the oral cavity may be influenced by the exposure to and pathogenicity of the infectious organism as well as host susceptibility.

Host factors that may influence infectivity include age, immune-inflammatory status, smoking status, and/or concomitant microbial infections.12-15

CLINICAL aerosol-generating procedures, utilization of high-volume evacuation during procedures known to generate dental aerosols, and implementation of advanced technologies to “scrub” the air, including air filtration and/ or ultraviolet light decontamination.19,27,35-40

Gaps in our current understanding The dental profession continues to have unanswered questions about aerosol production in the dental office and its ability to infect dental practitioners, staff, and subsequent patients. Information regarding the bioload of aerosols produced in clinical dental settings and the necessary infective doses of various airborne pathogens are critical to our understanding of risks.

Additional research focusing on factors that influence aerosol spread in dental offices, such as airflow and mitigation strategies, is critical. Lastly, epidemiologic evidence of the prevalence of infections in dental healthcare providers and a comparison to populations as a whole may shine a light on highly protective infection control practices that can be implemented to keep practitioners and patients as safe as possible.

Conclusion In summary, available evidence suggests the following: 1. Aerosols are generated by all individuals during many routine activities, including speaking, eating, and breathing.

2. The bioload in aerosols correlates with disease severity for respiratory diseases.

3. Aerosols are also created during most dental procedures. The dental procedures associated with the highest levels of aerosols are powered scalers, high-speed handpieces, air-water syringes, and air polishers.

4. Most current evidence suggests that dental water reservoirs are the primary source of pathogens in these aerosols, rather than saliva or respiratory secretions.

5. Several methods are effective in mitigating the production of dental aerosols and in reducing bioload. Chief among these are the use of highvolume evacuators and pre-procedural mouth rinsing, but effectiveness may vary based upon implementation within dental practices.

6. Similarly, several barrier techniques are effective in protecting the 10 Orthodontic practice

occupants of the dental operatory from direct and indirect aerosol exposure. These include commonly used PPE such as surgical masks/respirators, face shields, fluid impermeable gowns, and gloves.

7. No evidence exists to suggest that dental healthcare professionals are at a higher risk of airborne viral disease transmission than the general population, and emerging evidence suggests that the risk may be lower during the delivery of dental care than in other healthcare settings.

8. Nonclinical areas within the dental office and/or community exposure of dental personnel may pose a significant risk within the dental office, and adherence to public health guidelines is critical to limit spread of airborne illness. OP

REFERENCES 1. Keene CH. Airborne Contagion and Air Hygiene. William Firth Wells. J Sch Health. 1955;25:249-249.

2. Annex C—Respiratory Droplets. In: Atkinson J, Chartier Y, Pessoa-Silva CL, et al., eds. Infection Control in HealthCare Settings. WHO Press, World Health Organization.

Geneva, Switzerland; 2009. https://www.who.int/water_ sanitation_health/publications/natural_ventilation.pdf.

Accessed July 6, 2020.

3. Micik RE, Miller RL, Mazzarella MA, Ryge G. Studies on dental aerobiology, I: bacterial aerosols generated during dental procedures. J Dent Res. 1969;48(1):49-56.

4. Hinds WC. Aerosol Technology: Properties, Behavior, and Measurement of Airborne Particles. 2nd ed. Hoboken, NJ: John Wiley & Sons (Wiley-Interscience); 1999.

5. Zheng Y, Chen H, Yao M, Li X. Bacterial pathogens were detected from human exhaled breath using a novel protocol. J Aerosol Sci. 2018;117:224-234.

6. Knibbs LD, Johnson GR, Kidd TJ, et al. Viability of Pseudomonas aeruginosa in cough aerosols generated by persons with cystic fibrosis. Thorax. 2014;69(8):740-745.

7. Hatagishi E, Okamoto M, Ohmiya S, et al. Establishment and clinical applications of a portable system for capturing influenza viruses released through coughing. PLoS One. 2014;9(8):e103560.

8. Yan J, Grantham M, Pantelic J, et al. Infectious virus in exhaled breath of symptomatic seasonal influenza cases from a college community. Proc Natl Acad Sci USA. 2018;115(5):1081-1086.

9. Tang JW, et al. Absence of detectable influenza RNA transmitted via aerosol during various human respiratory activities — experiments from Singapore and Hong Kong. PLoS One. 2014;9;e107338. doi:10.1371/journal.pone.0107338 10. Milton DK, Fabian MP, Cowling BJ, Grantham ML, McDevitt JJ. Influenza virus aerosols in human exhaled breath: particle size, culturability, and effect of surgical masks.

PLoS Pathog. 2013;9(3).

11. Wood ME, Stockwell RE, Johnson GR, et al. Face Masks and Cough Etiquette Reduce the Cough Aerosol Concentration of Pseudomonas aeruginosa in People with Cystic Fibrosis. Am J Respir Crit Care Med. 2018;197(3):348-355.

12. To KKW, Yip CCY, Lai CYW, et al. Saliva as a diagnostic specimen for testing respiratory virus by a point-of-care molecular assay: a diagnostic validity study. Clin Microbiol Infect. 2019;25(3):372-378.

13. Kim YG, Yun SG, Kim MY, et al. Comparison Between Saliva and Nasopharyngeal Swab Specimens for Detection of Respiratory Viruses by Multiplex Reverse TranscriptionPCR. J Clin Microbiol. 2017;55:226-233.

14. Tada A, Shiiba M, Yokoe H, Hanada, Tanzawa H. Relationship between oral motor dysfunction and oral bacteria in bedridden elderly. Oral Surg Oral Med Oral Pathol Oral

Radiol Endod. 2004;98(2):184-188.

15. Tada A, Hanada N, Tanzawa, H. The relation between tube feeding and Pseudomonas aeruginosa detection in the oral cavity. J Gerontol A Biol Sci Med Sci. 2002;57(10):M71-M72.

16. Gross KB, Overman, PR, Cobb C, Brockmann S. Aerosol generation by two ultrasonic scalers and one sonic scaler.

A comparative study. J Dent Hyg. 1992;66(7):314-318.

17. Rivera-Hidalgo F, Barnes JB, Harrel SK. Aerosol and splatter production by focused spray and standard ultrasonic inserts. J Periodontol. 1999;70(5):473-477.

18. Graetz C, Plaumann A, Jule Bielfeldt J, et al. Efficacy versus health risks: An in vitro evaluation of power-driven scalers.

J Indian Soc Periodontol. 2015;19(1):18-24.

19. Harrel SK, Barnes JB, Rivera-Hidalgo F. Aerosol and splatter contamination from the operative site during ultrasonic scaling. J Am Dent Assoc. 1998;129(9):1241-1249.

20. Grenier D. Quantitative analysis of bacterial aerosols in two different dental clinic environments. Appl Environ Microbiol.

1995;61(8):3165-3168.

21. Singh A, Shiva Manjunath RG, Singla D, et al. Aerosol, a health hazard during ultrasonic scaling: A clinico-microbiological study. Indian J Dent Res. 2016;27(2):160-162.

22. Dutil S, Meriaux A, de Latremoille M-C, et al. Measurement of airborne bacteria and endotoxin generated during dental cleaning. J Occup Environ Hyg. 2009;6(2):121-130.

23. Veena HR, Mahantesha S, Joseph PA, Patil SR, Patil SH. Dissemination of aerosol and splatter during ultrasonic scaling: a pilot study. J Infect Public Health. 2015;8(3): 260-265.

24. Bennett AM, Fulford MR, Walker JT, et al. Microbial aerosols in general dental practice. Br Dent J. 2000;189(12):664-667.

25. Osorio R, Toledano M, Liébana J, Rosales JI, Lozano JA. Environmental microbial contamination. Pilot study in a dental surgery. Int Dent J. 1995;45(6):352-357.

26. Bentley CD, Burkhart NW, Crawford JJ. Evaluating spatter and aerosol contamination during dental procedures. J Am Dent Assoc. 1994;125(5):579-584.

27. Yamada H, Ishihama K, Yasuda K, et al. Aerial dispersal of blood-contaminated aerosols during dental procedures.

Quintessence Int. 2011;42(5);399-405.

28. Serban D, Banu A, Serban C. Tuta-Sas I, Vlaicu B. Predictors of quantitative microbiological analysis of spatter and aerosolization during scaling. Rev Med Chir Soc Med Nat Iasi. 2013;117:503-508.

29. Rautemaa R, Nordberg A, Wuolijoki-Saaristo K, Meurman JH. Bacterial aerosols in dental practice — a potential hospital infection problem? J Hosp Infect. 2006;64(1):76-81.

30. Bargman H. Laser-generated Airborne Contaminants. J Clin Aesthet Dermatol. 2011;4(2):56-57.

31. Hallier C, Williams DW, Potts AJC, Lewis MAO. A pilot study of bioaerosol reduction using an air cleaning system during dental procedures. Br Dent J. 2010;209(8):E14, 32. Teanpaisan R, Taeporamaysamai M, Rattanachone P, Poldoung N, Srisintorn S. The usefulness of the modified extra-oral vacuum aspirator (EOVA) from household vacuum cleaner in reducing bacteria in dental aerosols.

Int Dent J. 2001;51(6):413-416.

33. Kobza J, Pastuszka JS, Bragoszewska E. Do exposures to aerosols pose a risk to dental professionals? Occup Med (Lond). 2018;68(7):454-458.

34. Lea SC, Landini G, Walmsley AD. Thermal imaging of ultrasonic scaler tips during tooth instrumentation. J Clin Periodontol. 2004;31(5):370-375.

35. Jacks ME. A laboratory comparison of evacuation devices on aerosol reduction. J Dent Hyg. 2002;76(3):202-206.

36. Yadav N, Agrawal B, Maheshwari C. Role of high-efficiency particulate arrestor filters in control of air borne infections in dental clinics. SRM J Res Dent Sci. 2015;6:240-242.

37. American Society for Healthcare Engineering. ASHE™ website. Air filtration. https://www.ashe.org/compliance/ ec_02_05_01/01/airfiltration. Accessed July 5, 2020.

38. Chen C, Zhao B, Cui W, et al. The effectiveness of an air cleaner in controlling droplet/aerosol particle dispersion emitted from a patient’s mouth in the indoor environment of dental clinics. J R Soc Interface. 2010;7(48):1105-1118.

39. Alexander DD, Bailey WH, Perez V, Mitchell ME, Su S. Air ions and respiratory function outcomes: a comprehensive review. J Negat Results Biomed. 2013;12:14.

40. Lindblad M, Tano E, Lindahl C, Huss F. Ultraviolet-C decontamination of a hospital room: Amount of UV light needed.

Burns. 2020;46(4)842-849.

Volume 11 Number 5

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CASE STUDY

Class II Division I, 9 mm overjet Dr. Aron Dellinger discusses treatment with the Roncone PhysioDynamic System (PDS) application of the 20/20 molar bracket Initial impressions utilizing the PDS QuicKlear with 20/20 molar bracket The active clip maintains excellent engagement of the double .014 archwire and provides significant control from the start of treatment. Due to excellent wire retention in the slot, fewer visits are needed to keep the wires engaged. The 20/20 molar prescription creates excellent control of molar position in maximum anchorage cases and increases the effectiveness of early short Class II elastics.

Figure 2: Pre- and posttreatment buccal segments

History and etiology This 10 year 11-month-old young lady presented to my practice with concerns about overjet. There was a family history of Class II. She reported her brother teasing about her protruding upper incisors. She was eager to pursue orthodontic treatment. She had no history of thumb or finger habit. She did present with a lip trap and reported that the condition was getting worse.

Skeletal diagnosis • Mild Class II skeletal with A point slightly forward • Mild vertical maxillary excess (VME) • Normal gonial angle • Horizontal occlusal plane Aron Dellinger, DDS, MSD, graduated from Indiana University School of Dentistry and Saint Louis University orthodontics. He returned to Northern Indiana to practice with his dad, Gene, brother, Eric, and uncle, Jack Hamilton. Dr. Dellinger has now practiced there for 20 years.

He was approached early in his career to serve as Indiana director to the Great Lakes Association of Orthodontists (GLAO) in which he has served as president. He has also served on the AAO House of Delegates and as the president of the Indiana Association of Orthodontists (IAO). During his time as IAO president, the AAO started the Donated Orthodontic Services (DOS) program. Dr. Dellinger has been on the DOS board from its inception and helped start the DOS program in Indiana as one of the first five pilot states. Dr. Dellinger is ABO-certified and volunteers for the ABO. He is also an Angle Midwest Affiliate. Drs. Gene and Aron Dellinger worked together to invent and develop a new orthodontic tooth retention appliance; together, they hold several patents and a trademark for the MagneTainer appliance.

Disclosure: Dr. Dellinger is the founder of MagneTainer which Forestadent has the exclusive rights to sell and manufacture.

12 Orthodontic practice

Figure 1: Pre- and posttreatment frontal photos

Figure 3: Pre- and posttreatment profile photos

• V-shaped maxilla • Normal mandibular form

• Full upper lip nicely positioned in E plane, lower lip forward of E plane

Dental diagnosis

Treatment sequence

• Late mixed dentition/maxillary E’s still present, arch space available for distalizing the upper 3’s • Class II end on molar bilaterally/maxillary 6’s rotated mesial in • Class II canine, beyond end on bilaterally • Overjet 9 mm • Overbite 70%, deep curve of Spee • Maxillary and mandibular premolars lingually tipped • Maxillary incisors severely proclined • Mandibular incisors proclined • Upper 1-1 diastema, UL 1 slight incisal edge chip (mesial mamilon)

• Remove upper E’s to allow 5’s to erupt • Bond x/ 6-6 with PDS QuicKlear brackets utilizing 20/20 maxillary molar bracket to facilitate control of anchorage and prevent mesial molar slip • Composite turbos on upper 1’s, bond /x 6-6 with PDS QuicKlear® brackets, start short Class II elastics on day one, x/x double .014 NiTi wires • Allow to work for 6 months with double .014 and continue short Class II elastics • x/x 19x25 NandAlloy wires, start long Class II elastics, bond x/x 7’s • Segment posterior to allow settling • Direct composite to restore chipped UL1 • x/x retainers • 20 months

Facial diagnosis • Convex profile • Chin projection soft, minimal pogonion projection • Mentalis strain with lips together • Good symmetry, vertical proportions WNL • Mild maxillary gingival excess (at lateral incisors), evident altered passive eruption • Nasal tip turned upward, nasiolabial angle obtuse, nares symmetrical, no deviation

Posttreatment • Full correction of Class II molar • Overjet ideal • Decreased gingival display of upper laterals • Mentalis strain eliminated • Lower lip to E plane improved • Total of 3 upper wires and 2 lower wires • 20 months total treatment time OP Volume 11 Number 5

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CASE STUDY

Using Spark™ Clear Aligners in open bite closure with TADs Dr. Bill Dischinger illustrates treating a patient’s narrow arches and anterior open bite with clear aligner therapy

M

y orthodontic training taught me how to close skeletal anterior open bites utilizing maxillary impaction surgery. I was fortunate enough to treat two patients in conjunction with the oral surgery department at my university using this technique. The patients, the surgeon, and I were thrilled with the results. We achieved bite closure as well as a very pleasing facial esthetic result.

Upon entering private practice, I discovered quite quickly that many patients would not accept surgery as an option. There were various reasons for this including a lack of finances, fear, or just plain unwillingness.

We still had patients that did accept this route, but more would not. I was struggling to achieve the results I desired as an orthodontist, but meet the demands patients were placing on me. This began to change in 2008 when I treated my first skeletal anterior open bite utilizing TADs as anchorage to intrude the maxillary molars. This case turned out beautiful with little to no complications. I used a transpalatal arch to maintain torque in my molars while intruding.

Over the years, I tried various techniques I would see presented in lectures, written in articles, or observed by colleagues. All of the techniques had merit, but all of them also had drawbacks. Maintaining arch form and torque during active intrusion was always the challenge. I found I needed either to place transpalatal bars or pull on both the buccal

Bill Dischinger, DDS, received his dental degree from Oregon Health and Science University School of Dentistry and his certificate in orthodontics from Tufts University. In private practice in Lake Oswego and Canby, Oregon, he also serves as adjunct professor in orthodontics at the University of The Pacific in San Francisco.

Dr. Dischinger has been married to his wife, Kari Lynn, since 1994, and they have four sons.

Disclosure: As an Ormco™ key expert, Dr. Dischinger was invited to trial the Spark™ Clear Aligner System in 2018 and is lecturing on his experience with Spark worldwide. Having employed the Damon™ System for 21 years, he is also a Damon System certified educator, and lectures around the world on a variety of subjects.

14 Orthodontic practice

Microscopic image of aligner surface (10x magnification)

I am very excited by the success of these treatments and how much easier and quicker they are than what I was previously doing with fixed appliances. and lingual, and even with all of this, I just wasn’t seeing the easy results I was trying to achieve.

In 2018, our practice began working with Spark™ Clear Aligners from Ormco™ Corporation. As we began treating cases with this new product, we started to see results that were better and more predictable than I had achieved with previous aligners.

The more predictable results that I have found with Spark are likely due to a combination of Spark’s TruGEN™ material, which has proven to have higher sustained force retention compared to the leading aligner brand, and Spark’s use of the latest in aligner manufacturing technology, which results in better contact surface area between the tooth and the aligner than the leading aligner brand.* Once I started to feel more comfortable with aligners as my primary treatment of choice for many types of malocclusions, we began to expand our number of clear aligner cases across all demographics in our practice. As I began to feel more comfortable and confident in this form of treatment, I, of course, began to treat more difficult cases with Spark.

I have taught for many years at the University of the Pacific in San Francisco, where Dr. Robert Boyd was the chairman for over 20 years. Dr. Boyd was a pioneer in clear aligner treatment and wrote an article stating that he felt open bites were treated more easily with clear aligners than with fixed appliances. At the time, I was intrigued, but doubtful. I wasn’t quite ready for that jump in my practice. After using Spark for about a year, I decided to start treating skeletal anterior open bites utilizing TADs and Spark aligners as I would in my cases treated with braces. My hope was that even though I didn’t place a transpalatal bar, I could maintain molar torque.

What I found amazed me. Having full coverage of the molars with the aligner provides a number of advantages. The first, and in my opinion the most important, is that molar torque is maintained. Fully encapsulating the molars, so to speak, completely controls them as they are intruded. They don’t rotate, and they don’t lose torque control — they just purely translate in an intrusive movement. The second advantage I found was the speed in which intrusion Volume 11 Number 5

the mandible to auto rotate into a proper overbite relationship (Figure 1).

I have heard some clear aligner presenters preach to not do vertical mechanics at the same time as arch-broadening mechanics.

I decided to disregard their advice (just because I am not always the smartest decision-maker). Actually, using this new aligner

technology, I wanted to see if we could be more efficient and accomplish both.

Treatment progression The primary round of aligners consisted of 19 active stages and 4 stabilizing aligners.

I set up for 3 mm of posterior molar intrusion with 5 mm of autorotation in the anterior,

Diagnosis The case presented in this article is a 45-year-old female. She has narrow arches with an anterior open bite. In looking at her smile, I did not want to extrude the anterior teeth as I felt it would give her a gummy smile if I extruded the maxillary anteriors, and if I extruded the mandibular incisors, we would have too much display of the lower incisors. My plan was to intrude the maxillary molars to level the occlusal plane, allowing

Figures 1A-1D: Initial records

Figures 2A-2C: 10-week progress photos

Figures 3A-3C: 19-week progress photos. End of first round of active aligners Volume 11 Number 5

Orthodontic practice 15

CASE STUDY

occurred. I placed TADs between the 6’s and 7’s in the maxillary arch both buccally and palatally. We have the patient wear an elastic (1/8" 6oz.) from buccal TAD, over the occlusal of the aligner to palatal TAD full time. In addition, we are now placing rectangular attachments on the occlusals of the upper molars. We do not place composite on the teeth, but just use the occlusal attachment “bubble” in the aligner to give more occlusal contact and force on the molars to help give a mastication intrusion force. My feeling is that the molars intrude faster for two reasons. First, the elastics are changed out 3 to 4 times per day and thus stay fresh without any fatigue. With fixed appliances, I would activate the power chain every 4 to 5 weeks and probably lost some force in the last couple weeks. Second, keeping the molars in constant occlusal contact with the aligners aids in the intrusion effect.

CASE STUDY closing down the bite. I placed four 10 mm Vector TAS TADs between the maxillary 6’s and 7’s, with two being buccal and two being palatal. At delivery, we showed her how to place the elastics, again using 1/8" and 6 oz. in force.

We checked in at 10 weeks to see the progress and make sure the aligners were fitting properly. (This has now turned into a

virtual visit for these appointments post COVID-19 shut down.) I was shocked at the progress after just 10 weeks (Figure 2).

We were gaining width in the maxillary arch, uprighting the canines and premolars, and her open bite had just about fully closed in the central incisor area. I was very excited. At 19 weeks, she was through her first round of active aligners. In all honesty, we could have

completed her treatment at this point. Her open bite was fully closed, and alignment looked great (Figure 3). I wanted to upright her maxillary canines and premolars further though to give her a broader smile. I ordered another 13 active aligners to complete her treatment.

At this time unfortunately, we ran into the beginning phases of the COVID-19 pandemic. We ended up doing a “drivethrough” aligner pickup 7 weeks after sending in her refinement scans. She wore the aligners for 13 weeks, at which point we had been allowed to open back up and see patients. She was thrilled with her bite and smile, and we both agreed she was done with treatment (Figure 4).

Conclusion The patient actively wore aligners fulltime for 32 weeks. She did wear them at nighttime only while in the transition into refinement for 7 weeks due to the COVID-19 shutdown. I saw her in our office for a new patient consultation, an initial aligner delivery, a checkup for aligner fit (which would now be done virtually), a refinement scan appointment, another aligner delivery (which we actually just handed to her in her car in the parking lot), and a final placement of lingual bonded retainers and final records. Kathy had a total of six appointments in our office, which included the consultation and the final records. With our virtual appointments now being utilized, this would have been a 5-appointment treatment over 7.5 months of active treatment.

The patient was our first treatment performed in this fashion, but her success gave me the confidence to utilize this in more open-bite cases. We have since started many such cases and completed a number of them. We are also utilizing this for gummy smile intrusion cases as well.

I am very excited by the success of these treatments and how much easier and quicker they are than what I was previously doing with fixed appliances. My only regret is that I did not listen to Dr. Boyd years ago.

I no longer treat cases in which I will be intruding maxillary teeth with TADs in fixed appliances. I only treat these with Spark Clear Aligners. OP

*80% better printing resolution than leading aligner brand; more uniform surface area than leading aligner brand; 19% better contact surface area between the tooth and aligner than leading aligner brand. Data on file with Ormco™

Figures 4A-4G: Final records. 39 weeks of treatment with 32 weeks of full-time active aligner wear 16 Orthodontic practice

Volume 11 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 11 Number 5

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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, managing editor 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.

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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, managing editor, with any questions via email: Mali@medmarkmedia.com

Orthodontic practice 17

CONTINUING EDUCATION

A comparison of efficacy and efficiency of clear aligners versus braces post-COVID-19 Dr. David Alpan discusses evolving treatment plans in the wake of COVID-19 Abstract Is clear aligner treatment more effective than braces? What about during a pandemic? Evidence-based research statistically finds that clear aligner treatment facilitates improved oral hygiene compared to braces and creates fewer negative side effects.7,12 Research shows that the gingival health with clear aligner treatment is better in comparison to conventional fixed braces.6,7 With clear aligner therapy, it has been proven to be less painful than braces and overall more comfortable with no food restrictions.3,6,7 Clear aligner treatment is marketed and promoted to the consumer more than braces,4,5 yet braces are still utilized more frequently than clear aligners worldwide.

The American Association of Orthodontics (AAO) posted that there are 4.5 million Americans with braces in 2020, and Invisalign® is currently celebrating 8 million cases treated since 1999 worldwide. There are over 30 companies currently manufacturing clear aligners and braces. Why is it that there are so many more braces' patients than clear aligner patients? There are lots of reasons that we may not be able to explore in this paper. I have found in clinical practice after 23 years that any case types with patients who are compliant, clear aligners are more efficient and effective to use than braces, especially in a COVID-19 world.9 Patients with poor compliance will never achieve an excellent result, no matter the appliance utilized.12 When combining

Educational aims and objectives

This article aims to discuss the efficacy of clear aligner treatment and/or braces in post-COVID-19 treatment plans.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 24 or take the quiz online at orthopracticeus.com to earn 2 hours of CE from reading this article.

Correctly answering the questions will demonstrate the reader can: •

Realize some history of clear aligner and traditional braces therapies in orthodontics.

•

Recognize possible clinical and treatment issues that may arise resulting from the COVID-19 period that may have a lasting effect on orthodontics.

•

Realize some characteristics of the biology of tooth movement that will affect patients during COVID-19 treatment.

•

Recognize the role that compliance plays in orthodontic treatment.

•

Observe some techniques with traditional braces, clear aligner therapy, or a combination of both.

excellent compliance with acceleration and clear aligners, orthodontic treatment is more efficient and effective than braces in many case types, and that is what I will explain in this report. When treating extractions or impacted teeth, a combination of braces and clear aligners is required, as the aligners alone are not efficient with extrusion or changing position of the root apex or torque control5,8,9 — for example, the need for root parallelism post-extraction to help keep the space closed long-term is challenging for clear aligners.9,11,12 Mildto-moderate crowding, spacing, rotations, surgical orthodontics, and open bite cases treat more efficiently and effectively with clear aligners than braces.18,19 Any severe rotations or tipping will be more effectively treated with braces than clear aligner treatment.8,9,10,11

David Alpan, DDS, MSD, earned his Doctor of Dental Surgery in 1996 and completed his orthodontic specialty certificate from the University of the Pacific (UOP) in 1998 with a Master of Science in Dentistry, as he wrote a thesis on the results of a TMJ research project. Dr. Alpan and Associates has four private practice locations: Los Angeles, Century City, Woodland Hills, and Hawthorne. Dr. Alpan can be contacted at dalpan@aeortho.com or (310) 344-5260.

Dr. Alpan is an active member of ADA, CDA, LADS, PCSO, AAO, CAO, AO, OKU, and TKO. His hobbies are racing cars as a member of Pirelli cup NASA, POC, PCA, CSM, and BMW CCA. He spends his free time with his wife, Mary; son, Zephyr; and daughter, Ambryn.

Disclosures: From 1992 to 1998, Dr. Alpan lectured for Invisalign® at over 250 locations to over 10,000 people. He played an integral part of implementing the Invisalign system into the universities. Dr. Alpan was an Ormco™ insider and helped 3M™ as a research panelist. He is a key opinion leader for AcceleDent® and Propel® and has published several articles on accelerated orthodontics. As a Center of Excellence member for 3M™ Incognito™ and a high-volume Insignia™ provider, Dr. Alpan has incorporated several digital-based systems with custom brackets and wires into his digital workflow.

18 Orthodontic practice

Braces can deliver a more controlled force application over a longer range of time and, therefore, are more efficient with impacted or severely tipped teeth needing lots of torque.9,10,11,12 Minor rotation control of incisors and molars is equally as effective with clear aligners compared to braces.9,12

Introduction As an orthodontist, I have a variety of treatment plans utilizing multiple appliances in my armamentarium, but I choose to focus on my list of goals related to the desired treatment outcomes. The list begins based on my initial diagnosis defining all the areas of concern and a treatment plan addressing those concerns.1 The options orthodontists offer to patients can be influenced by many factors: Examples include training, experience level with a certain system, local orthodontic community and dental schools, associations, marketing to the public or the profession, the esthetics of the appliance, the effectiveness, the default or error rate, the negative sequela, etc. The list of influences is as long as the list of orthodontic tools available worldwide to provide orthodontic care.

I choose my appliances based on how well they can achieve my desired goals, and combining modalities or techniques can lead to my ultimate result. A blog on the AAO website states: "One appliance is not inherently better than another. What is used for an Volume 11 Number 5

History The introduction of clear aligner therapy or a series of tooth positioners dates back to 1944.14 At that time, it was not efficient and did not compare to braces as a reliable tool for many reasons. Comparing the effectiveness of appliances across the world is impossible, as the variables are too numerous and not controllable. Comparing clear aligners to braces in my own practice after 23 years is significant, yet admittedly also anecdotal. I have been in private practice since 1999 and have treated 5,000 patients with braces and 2,500 patients with clear aligners, so my experience is weighted toward braces. It is agreed by peer-reviewed research articles in many journals that clear aligner therapy is shorter in duration than braces.9,11 This may be due to the population of patients treated with clear aligners in those studies, which are typically not as severe, or the goals are not as comprehensive. It could also be that the tooth movements for the cases chosen for the studies eliminated the outliers (difficult tooth movements). Many scientific research articles have found that braces are more effective with rotation of round-shaped teeth and extrusion of anterior teeth.9,12,26 The statistics show that very difficult extreme movements of teeth are better suited with braces.8,9,10 Traditional metal braces started with no prescriptions — zero torque, tip, and angulation programmed into the bracket.

Dr. Edward Angle, considered the father of modern orthodontics, used a vertical gold wire with a loop on a band cemented to the tooth to deliver force to create orthodontic tooth movement according to Weinberger.27 Volume 11 Number 5

Figure 1: Tooth movement predictability chart for clear aligners by Weir14 Tooth movement

Predictability with aligners alone Predictable

Moderate

Difficult

Crowding or spacing per arch

Up to 6 mm

6-8 mm

> 8 mm

Midline discrepancy

Up to 2 mm

2-3 mm

> 3mm

Central incisor rotation

Up to 0°

40°-50°

> 50°

Lateral incisor rotation

Up to 30°

30°-40°

> 40°

Canine and premolar rotation

Up to 45°

45°-55°

> 55°

Molar rotation

Up to 20°

20°-30°

> 30°

Anterior extrusion per arch

Up to 2.5 mm

2.5-3 mm

> 3 mm

Anterior intrusion per arch

Up to 0.5 mm

0.5-1 mm

> 1 mm

Posterior intrusion per arch

Up to 0.5 mm

0.5-1 mm

> 1 mm

Posterior extrusion per arch

0 mm

0.5 mm

> 0.5 mm

Expansion per quadrant

Up to 2 mm

2-3 mm

> 3 mm

Anteroposterior correction

Up to 2 mm

2-4 mm

> 4 mm

Incisor lingual root torque

0°-10°

10°-15°

> 15°

Posterior tooth lingual root torque

0°-5°

5°-10°

> 10°

Posterior tooth distal movement (maxilla)

0-2 mm

2-4 mm

> 4 mm

Posterior tooth mesial movement

0-1 mm

1-2 mm

> 2 mm

Currently, there are hundreds of bracket prescriptions based on preferences, tooth morphology, and various functional or esthetic features. It is common for wellknown orthodontists to put their name on the prescription. There is over 100 years of published data on various tools used to control and improve the efficiency of orthodontic tooth movement. As I am an orthodontist focused on excellent outcomes, which set of tools will I be most successful with in the future is a constantly evolving process in private practice orthodontics.

Are braces or clear aligners clinically different when the patient is not able to visit the office as frequently as they had prior to the COVID-19 world? Do I evaluate my outcomes based on the number of visits or how well the teeth finished? Do I compare the effectiveness of my appliance choice based on my most difficult malocclusions and how they finished? Or do I compare the moderate or the easy malocclusions and how they finished? I don’t think there is a right or wrong answer to these questions. The choices begin to be clearer as the list of treatment goals becomes achievable, and the need for efficiency is forced upon us, as is with directto-consumer competition or limited access to patients in the COVID-19 world. I started treating my clear aligner patients in 1998

with a mindset that my goals were limited to Class I molar and cuspid cases with 0 mm-3 mm of spacing or crowding. Today I have no limitations with the combination of braces, clear aligners, acceleration, and a compliant patient. As a general reference to understand the difficulty of predictability of tooth movement, see the chart in Figure 1, copied from Weir.14 Currently, there are only a few advantages that require me to use braces, as they are more efficient for root torque and extruding impacted or severely tipped teeth. Modern orthodontics allows me to offer any patient clear aligner therapy in combination with braces, if absolutely necessary, to achieve the desired results.

My clinical goals are based on my desired results defined by my treatment plan, not my appliances. The appliance of choice needs to be able to achieve those results predictably and reliably in a wide range of case types.18,19

Biology The effectiveness of orthodontics is related to the biology of tooth movement and can be influenced in a negative way with patients taking nonsteroidal anti-inflammatory drugs NSAIDs. During 1988 to 2010, multiple researchers found that the application of NSAIDs decreased the rate of tooth movement significantly.15,16,17 Based on this Orthodontic practice 19

CONTINUING EDUCATION

individual’s correction will be based on the goals of treatment and the patient’s lifestyle needs. … The type of appliance used in orthodontic treatment is far less important than the skill in the hands of the person who is providing the treatment.

Rely on the skills of the AAO orthodontist, who has the education, experience, and expertise to evaluate diagnostic findings, and translate those into a treatment plan that will help you or your child achieve a healthy and beautiful smile.1" Djeu G, et al., conclude, “The outcome can only be as good as the orthodontist’s skill in each method. It takes time for a practitioner to develop expertise with any appliance.”2 Therefore, it is safe to say that a skilled orthodontic provider can create just as good of a result with appliance A as another can do with Appliance B.

CONTINUING EDUCATION research, all my patients are advised not to take NSAIDs during orthodontic treatment; we only recommend Tylenol® (acetaminophen). Unless the research studies on tooth movement effectiveness tracked if the patients were using NSAIDs to control pain, the results are questionable. I offer vibratory acceleration with pulsatile forces because they offer an analgesic effect,20 which micro-osteo perforations (MOPs) do not. Most patients prefer vibration as a form of acceleration versus MOPs, even though vibration cannot be localized. Accelerated orthodontics with vibration or MOPs has shown a significant result in affecting the treatment outcome and duration.18,19 Incorporating accelerated orthodontics with the use of bone modulation technologies, such as vibration or MOPs, has shown reduction in treatment time and increased treatment predictability.18,19 When comparing clear aligner treatment combined with acceleration, clinical findings show increased predictability with a decrease in treatment time.18,19,20

Results Braces have a role in very complex situations, and clear aligners can equally be used more than previously understood and accepted. During a pandemic, when our goal is to reduce contact with people, clear aligner treatment is truly more efficient and effective at reducing the number of appointments and reducing overall treatment visits to the office.

Clear aligner treatment can be facilitated with virtual initial and progress consults better than braces for the patients and doctors.

There is no need for a highly trained assistant, and there are a large number of reduced visits to the office compared to braces.

Compliance “Compliance is part of any and all orthodontic treatment and contributes a significant part to the success of the treatment outcome. All patients must brush and floss their teeth daily and will need to wear retainers posttreatment.”1 Compliance is a factor that can contribute highly to the outcome independent of the appliance chosen or the complexity of the treatment plan. Many studies have shown increased compliance with clear aligners and a reduction of negative sequela — no effect on speech, no food restrictions, no white spots, less root resorption due to decreased force levels, less pain/discomfort, and reduced treatment time. For example, Figures 2-13 demonstrate treatment with clear aligners combined with vibration. The patient (HA) 20 Orthodontic practice

Figure 3: HA initial ceph, nothing abnormal

Figure 2: HA initial images mild crowding, Class I molar and cuspid, narrow arches

Figure 4: HA initial pano, nothing abnormal

Figure 5: HA initial TMJ series, nothing abnormal

Figure 6: HA progress images at 4 months, resolving crowding with clear aligners with vibration

Figure 7: HA case refinement at 7 months, more expansion requested

Figure 9: HA arches before treatment

Figure 8: HA final image with fixed retainers 1 year from initial exam, only 10 months of active treatment

Figure 10: HA arches after treatment of 10 months Volume 11 Number 5

was in the office for a total of 12 months with 10 office visits, which included exam, diagnosis, treatment plan, records, iTero and i-CATâ&#x201E;˘ scans, delivery of aligners, one case refinement, occlusal adjustments, incisal edge recontouring, bonded-fixed retainers, and clear vacuum-formed retainers for retention. There was a delay from exam to delivery of 4 weeks and another 4 weeks for the case refinement processing, so she was in active treatment for 10 months. With no emergencies, no negative side effects, the patient was able to resolve all crowding and rotations, and expansion of arches with settled and adjusted occlusion. In our COVID-19 protocol, this treatment would require three virtual visits and five office visits: Three virtual visits 1. Virtual exam 2. Virtually evaluate progress and send more aligners 3. Virtually progress evaluation CR and send more aligners Five office visits 1. Photos, iTero, i-CAT scan, Dx/Tx Inv submission 2. Bonding attachments, IPR, deliver aligners 3. Incisal edge recontouring, CR scan, photos 4. Occlusal adjustment, impression for retainers 5. Deliver retainers Extraction cases Extraction cases with braces can take on average 24 to 30 months. Clear aligners alone are not recommended for extraction cases unless the root apex is where we want the finished position to be. Unless fixed appliances are used in conjunction with clear aligners, there is a high probability statistically that the roots will not end up parallel at the end of treatment. If the roots are not parallel, a space will typically open in the retention phase. A combination of sectional braces (cuspid to second molar) with acceleration Volume 11 Number 5

Figure 12: HA final pano, nothing is abnormal

Figure 13: HA final TMJ series nothing is abnormal

Figure 14: SK initial images of Class III skeletal with asymmetry and minimal crowding

Figure 15: SK initial pano nothing is abnormal

Figure 16: SK initial ceph demonstrates Class III skeletal discrepancy

Figure 17: SK presurgical models set up created by oral surgeons (LACOMS)

Figures 18 and 19: 18. SK post-surgery pre-case refinement. 19. SK final post-ortho and surgery 19 months overall treatment time with only 10 months of active treatment with clear aligners and vibration with a maxillary and mandibular surgery Orthodontic practice 21

CONTINUING EDUCATION

Figure 11: HA final ceph, nothing is abnormal

CONTINUING EDUCATION can accomplish root parallelism and space closure in 6 months. I will then continue with an average aligner treatment of 12 to 18 months to complete all the other goals.

My appliance of choice for extraction cases is the combination of braces for leveling and aligning roots and clear aligners to complete the torque, tip angulations, and space closure for compliant patients. Compliance is a huge factor when utilizing clear aligners and patients who are not compliant will be treated with braces only to increase the efficiency and effectiveness.

Surgical orthodontics Surgical orthodontics is offered for the most severe patients with maxillary and mandibular excess or deficiencies. Orthognathic surgery treatment is considered in orthodontics as one of the most complicated forms of orthodontic treatment. Published results from across the world show orthognathic surgery treatment times on average range between 24 to 30 months and with extractions can be 6 months longer.21,22,23,24 When combining accelerated orthodontics with clear aligner therapy, I can successfully and reliably achieve a total treatment time of 18 to 24 months, including extraction cases.19 Based on my experience with treating orthognathic surgical patients, braces take longer and are not more effective or efficient.18,19 I achieve the same or better results in less time and create a better experience for the patient; therefore, my appliance of choice for all orthognathic cases is clear aligners.

I do not put brackets on the teeth at all, and the surgeon will place one to two TADs per quad and fixate the segments at the time of surgery. Elastics are used from the TADs to initiate function immediately. If I need to extract teeth I will use sectional braces initially to control my root angulations, then followed with clear aligners. Custom digital brackets or aligner systems have shown to be more effective in reducing treatment time for surgical cases due to the coordination of arches digitally.19,21,22 For example, Figures 14-23 show a patient (SK) treated with clear aligner treatment with vibration and orthognathic surgery for a total treatment time of 19 months. A 5-month delay occurred from the date of the exam to delivery of the initial aligners. The patient also waited 2 months for surgery, and each case refinement took about 4 weeks, so he was in active treatment for 10 months and had 11 visits to the office.

In our COVID-19 protocol, we can reduce this to three to four virtual appointments and six in-office visits.

22 Orthodontic practice

Figure 20: SK final ceph shows stabilization screws and plates for maxilla and mandible

Figure 21: SK final pano shows screws and plates for maxilla and mandible

Figure 22: SK final before-and-after facial smiling images to compare results

Figure 23: SK closer look of bite and smile post-ortho and surgery with clear aligners, vibration, and compliance

Anterior open bite cases Anterior open bite cases can range from mild, moderate to severe, depending on the amount of vertical growth of the maxilla or protrusion of the dentition. The more severe the open bite, the less it is solely related to the dentition and would require the need for surgical intervention. Mild open bite is defined as a negative 1 mm-3 mm from incisal edge of the maxillary incisors to incisal edge of the mandibular incisors. A moderate open bite can be defined as negative 3 mm-5 mm, and severe is anything greater than negative 5 mm with skeletal discrepancies. The mild-to-moderate open bite cases actually

treat out faster and better with clear aligners than with braces according to multiple articles published by Dr. Robert Boyd. Aligners provide a posterior intrusive effect that does not occur with braces, which assists in the bite closure. Aligners prevent extrusion of teeth as braces cause an extrusive effect in general, which is not helpful to close anterior open bites. My appliance of choice for mild and moderate open bite cases is clear aligners with acceleration and no NSAIDs. My appliance of choice for severe skeletal open bite cases is clear aligners, acceleration, and no NSAIDs combined with orthognathic surgery.

Volume 11 Number 5

REFERENCES

In conclusion, based on the literature review and my own clinical experience in practice after 23 years, utilizing clear aligners for compliant patients has led to more efficient9,19,12 and effective treatment outcomes than braces alone. When combining acceleration with compliant clear aligner patients, treatment outcomes are shorter and more effective in achieving the goals than braces in a wide range of case types. In my noncompliant patients, I found that braces are more efficient and effective in achieving the goals independent of the case type. Combining braces and clear aligners with acceleration has facilitated difficult orthodontic tooth movements and allowed me to achieve excellent clinical outcomes in shorter times.

Combining acceleration has led to increased predictability and shorter treatment times overall.18,19 Clear aligners offer a more esthetic-oriented treatment process that is more friendly, tolerable, comfortable, and acceptable to the patient. The use of clear aligners is more favorable to the patients’ gingival health before, during, and after orthodontic treatment. The use of clear aligner treatment during a pandemic is far more efficient and effective than braces, as it reduces the number of office visits and emergencies.

The reduced health risk by sending more aligners versus doing a braces adjustment in the office is far better for everyone in a COVID-19 world. OP

1. Braces vs. Clear Aligners [blog]. Association of American Orthodontists (AAO) Member Site. www.aaoinfo.org/blog/ braces-vs-clear-aligners. Published January 30, 2019.

Accessed August 10, 2020.

2. Djeu G, Shelton C, Anthony Maganzini A. Outcome assessment of Invisalign and traditional orthodontic treatment compared with the American Board of Orthodontics objective grading system. Amer J Orthod Dentofacial Orthop.

2005;128(3):292-298.

3. Gao M, Yan X, Zhao R, et al. Comparison of pain perception, anxiety, and impacts on oral health-related quality of life between patients receiving clear aligners and fixed appliances during the initial stage of orthodontic treatment. Eur J Orthod. 2020;1-7.

4. Metal Braces vs. Invisalign: Which is Best? Bright Now! Dental website. https://www.brightnow.com/about-us/ post/metal-braces-vs-invisalign-which-is-best. Published October 10, 2017. Accessed August 10, 2020.

5. Gu J, Tang JS, Skulski B, et al. Evaluation of Invisalign treatment effectiveness and efficiency compared with conventional fixed appliances using the Peer Assessment Rating index. Amer J Orthod Dentofacial Orthop.

2017;151(2):259-266.

6. Buschang PH, Shaw SG, Ross M, Crosby D, Campbell PM. Comparative time efficiency of aligner therapy and conventional edgewise braces. Angle Orthod. 2014;84(3):391396.

7. Azaripour A, Weusmann J, Mahmoodi B, et al. Braces versus Invisalign®: gingival parameters and patients’ satisfaction during treatment: a cross-sectional study. BMC Oral Health.

2015;15:69.

8. Zachrisson S, Zachrisson BU. Gingival condition associated with orthodontic treatment. Angle Orthod. 1972;42(1):26-34.

9. Papadimitriou A, Mousoulea S, Gkantidis N, Dimitrios K. Clinical effectiveness of Invisalign® orthodontic treatment: a systematic review. Prog Orthod. 2018;19(1):37.

treatment: a case-control study. Am J Orthod Dentofacial Orthop. 2020;157(3):357-364.

13. Kravitz N, Kusnoto B, BeGole E, Obrez A, Agran B. How well does Invisalign work? A prospective clinical study evaluating the efficacy of tooth movement with Invisalign. Am J Orthod Dentofacial Orthop. 2009;135(1):27-35.

14. Weir T. Clear aligners in orthodontic treatment. Australian Dental J. 2017;62:(Suppl 1):58-62.

15. Kesling HD. The philosophy of tooth positioning appliance.

Am J Orthod. 1945;31(6):297-304.

16. Teixeira CC, Khoo E, Tran J, et al. Cytokine expression and accelerated tooth movement. J Dent Res. 2010;89(10):1135-1141.

17. Arias OR, Marquez-Orozco MC. Aspirin, acetaminophen, and ibuprofen: their effects on orthodontic tooth movement.

Am J Orthod Dentofacial Orthop. 2006;130(3):364-370.

18. Davidovitch Z, Nicolay OF, Ngan PW, Shanfeld JL. Neurotransmitters induces high numbers of cells expressing IFN-gamma at mRNA and protein levels. J Interferon Cytokine Res. 1988;20:7-12.

19. Alpan D. Combining accelerated orthodontics with orthognathic surgery to reduce overall treatment time. Orthodontic Practice US. 2018;9(5):39-43.

20. Alpan D. A review of accelerated orthodontics. Orthodontic Practice US. 2017;7(5)28-32.

21. Lobre WD, Callegari BJ, Gardner G, et al. Pain control in orthodontics using a micropulse vibration device: a randomized clinical trial. Angle Orthod. 2016;86(4)625-630.

22. Paunonen J, Helminem M, Peltomaki T. Duration of Orthognathic-Surgical Treatment. Acta Odontol Scand. 2017;75(5):372-375.

23. Luther F, Morris DO, Karnezi K. Orthodontic treatment following orthognathic surgery: how long does it take and why? A retrospective study. J Oral Maxillofac Surg. 2007;65(10):1969-1976.

24. Dowling PA, Espeland L, Krogstad O, Stenvik A, Kelly A. Duration of orthodontic treatment involving orthognathic surgery.

Int J Adult Orthodon Orthognath Surg. 1999;14(2):146-52.

10. Gu J, Tang JS, Skulski B, et al. Evaluation of invisalign treatment effectiveness and efficiency compared with conventional fixed appliances using the peer assessment rating index. Am J Orthod Dentofacial Orthop.

2017;151(2)259-266.

25. Slavnic S, Marcusson A. Duration of orthodontic treatment in conjunction with orthognathic surgery. Swed Dent J. 2010;34(3):159-66.

11. Charalampakis O, Iliadi A, Ueno H, Oliver DR, Kim KB. Accuracy of clear aligners: A retrospective study of patients who needed refinement. Am J Orthod Dentofacial Orthop. 2018;154(1):47-54.

26. Rossini G, Parrini S, Castroflorio T, Andrea Deregibus A, Debernardi CL. Efficacy of clear aligners in controlling orthodontic tooth movement: A systematic review. Angle Orthod. 2015:85(5):881-889.

12. Christou T, Abarca R, Christou V, Kau CH. Smile outcome comparison of Invisalign and traditional fixed-appliance

27. Wienberger W. Dr. Edward Hartley Angle, his influence on orthodontics. Am J Orthod. 1950;36(8):596-607.

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Volume 11 Number 5

Orthodontic practice 23

CONTINUING EDUCATION

Conclusion

REF: OP V11.5 ALPAN

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Each article is equivalent to two CE credits. Available only to paid subscribers.

Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 24 CE credits for only $149; call 866-579-9496 or visit www.orthopracticeus.com to subscribe today. To receive credit, complete the 10-question test by circling the correct answer, then either: n Go online to orthopracticeus.com/ce-articles, click on the article, then click on the take quiz button, and enter your test answers n Mail this completed quiz to: Orthodontic Practice US CE 15720 N. Greenway-Hayden Loop. #9, Scottsdale, AZ 85260 To provide feedback on this article and CE, please email us at education@medmarkmedia.com Legal disclaimer: Course expires 3 years from date of publication. The CE provider uses reasonable care in selecting and providing accurate content. The CE provider, however, does not independently verify the content or materials. Any opinions expressed in the materials are those of the author and not the CE provider. The instructional materials are intended to supplement, but are not a substitute for, the knowledge, skills, expertise and judgement of a trained healthcare professional.

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A comparison of efficacy and efficiency of clear aligners versus braces post-COVID-19 ALPAN

1. The American Association of Orthodontics (AAO) posted that there are 4.5 million Americans with braces in 2020, and InvisalignÂŽ is currently celebrating ________ cases treated since 1999 worldwide. a. 500,000 b. 1.5 million c. 8 million d. 10 million 2. When treating extractions or impacted teeth, a combination of braces and clear aligners is required, as the aligners alone are not efficient with _______ â&#x20AC;&#x201D; for example, the need for root parallelism post-extraction to help keep the space closed long-term is challenging for clear aligners. a. extrusion b. changing position of the root apex c. torque control d. all of the above 3. Mild-to-moderate crowding, spacing, rotations, surgical orthodontics, and open bite cases treat more efficiently and effectively with _________. a. clear aligners than braces b. braces than with clear aligners c. headgear d. robotic archwires

24 Orthodontic practice

4. The introduction of clear aligner therapy or a series of tooth positioners dates back to ________. a. 1944 b. 1957 c. 1962 d. 1979 5. During 1988 to 2010, multiple researchers found that the ________ decreased the rate of tooth movement significantly. a. application of acetaminophen b. application of NSAIDs c. application of vibratory acceleration d. application of MOPs 6. Incorporating accelerated orthodontics with the use of bone modulation technologies, such as _______, has shown reduction in treatment time and increased treatment predictability. a. vibration b. MOPs c. TADs d. both a and b 7. ________ are not recommended for extraction cases unless the root apex is where we want the finished position to be. a. Retainers

b. Braces alone c. Clear aligners alone d. Implants 8. A combination of sectional braces (cuspid to second molar) with acceleration can accomplish root parallelism and space closure in _______. a. 3 months b. 6 months c. 9 months d. 12 months 9. Published results from across the world show orthognathic surgery treatment times on average range between ________ and with extractions can be 6 months longer. a. 3 to 6 months b. 9 to 12 months c. 18 to 20 months d. 24 to 30 months 10. The ___________ actually treat out faster and better with clear aligners than with braces according to multiple articles published by Dr. Robert Boyd. a. mild-to-moderate open bite cases b. severe open bite cases c. cases requiring orthognathic surgery d. cases of severe rotation

Volume 11 Number 5

CE CREDITS

ORTHODONTIC PRACTICE CE

Drs. Fabio Oliveira Coelho, Francesca Scilla Smith, and Larry W. White discuss the evolution and efficacy of the mandibular protraction appliance (MPA) Introduction As far back as 1880, dentists have had an obsession with correcting overbites and overjets by protracting the mandible.

Kingsley1 was one of the first to describe his vulcanite plate for “jumping the bite,” and it became the ancestor of the myriad functional appliances that now exist. In the United States, Angle’s2 influence and development of the edgewise bracket combined with Case’s3 discovery and use of elastics gave orthodontic clinicians a fixed alternative for protracting the mandibular dentition to correct malocclusions with excessive overbites and overjets. In Europe, orthodontists continued using removable functional appliances such as the Andresen4 activator, the Bionator,5 the Bimler5 appliance, and most important after WW II, the Fränkel6 appliances.

Permissive appliances have never found a large acceptance in the United States, and as a result of that prejudice, fixed functional appliances have found an enthusiastic audience. Even in the European cradle of removable functional appliances, fixed functional

Educational aims and objectives

This article aims to discuss the evolution and efficacy of the mandibular protraction appliance (MPA) plus its effectiveness, safety, and value.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 30 or take the quiz online at orthopracticeus.com to earn 2 hours of CE from reading this article.

Correctly answering the questions will demonstrate the reader can: •

Realize some history of the MPA.

•

Identify some differences between the iterations of the MPA.

•

Realize the simplified placement of the MPA 5 and its improved function.

•

Observe a protocol for placement of the MPA 5.

•

Observe some cases in which the MPA 5 provided positive results.

•

Realize both advantages and disadvantages of the MPA.

appliances were being developed more than 100 years ago and were first described in a publication by Emil Herbst.7 World War II interrupted orthodontic information coming from Germany for several decades until the Herbst* rediscovery by Pancherz8 in 1979.

This created renewed interest in fixed functional appliances and gained new traction in the United States.

The MPA Nos. 1-4

Figure 1: The MPA No. 1

Dr. Carlos Martins Coelho Filho first described the mandibular protraction appliance, aka MPA, in 1995, and this first iteration was about as simple a Class II corrective mechanism as could be imagined. The MPA consisted of a single .036 stainless steel wire that connected the maxillary molar and mandibular archwire and protruded the mandible, held it there, and formed a template for the eruption of the posterior teeth into a Class I occlusion while simultaneously correcting the overbite, overjet, and midline (Figure 1). The MPA provided patients with an effective corrective for excessive overbite, overjet, and Class II malocclusion but limited their opening to about 30 mm.

More versions quickly followed.10-12 Each of these MPAs connected to the maxillary molar through the distal opening of the headgear tube with a .036 pin that was turned up or down on the mesial to lock it in. The second iteration (Figure 2) began to use a 9

Fabio Oliveira Coelho, DDS, MSD, graduated from Ceuma University in 2002. He then decided to pursue his master’s degree in Orthodontics at Uniararas University where he graduated in 2006. Dr. Coelho started his private practice journey in São Luís-Maranhao, Brazil, by joining his father Carlos Martins Coelho Filho after his DDS graduation in 2002. Dr. Coelho worked as Associate Professor and Coordinator of the Orthodontics department at Brazilian Dental Society/Maranhao, Brazil, from 2006 until 2017.

Francesca Scilla Smith, DDS, MS, was born and raised in Arezzo, Italy. She graduated summa cum laude from the University of Florence Dental School and obtained her orthodontic degree from Nova Southeastern University College of Dental Medicine in Fort Lauderdale, Florida, with a master thesis on conventional and digitally driven indirect bonding. Dr. Scilla Smith practices orthodontics in Dallas, Texas.

Larry W. White, DDS, MSD, FACD, is a graduate of Baylor Dental College and Baylor Orthodontic Program and now has an orthodontic practice in Dallas, Texas.

Volume 11 Number 5

Figure 2: The MPA No. 2

Figure 3: The MPA No. 3 Orthodontic practice 25

CONTINUING EDUCATION

The MPA 5

CONTINUING EDUCATION Guerin lock as a stop on the mandibular wire.

The third version (Figure 3) started the use of a stainless steel tube with a rod that slid through it and contained a compressible coil spring on its mesial end that allowed greater opening and a softer closure.

Dr. Coelho Filho details the construction and use of the fourth version13 in the ascribed Journal of Clinical Orthodontics article (Figures 4 and 5). The MPA No. 4 has endured much longer than the others and differs from the third iteration by using a small occlusal circle on the mandibular archwire between the canine and the first premolar into which the rod enters from the lingual before inserting into the tube, which then attaches to the maxillary molar via a .036 pin through the distal opening of the headgear tube.

Figure 4: The MPA activated with the mandible protracted

Figure 5: A typodont MPA displaying the range of opening

MPA No. 5 Before Dr. Coelho Filho died in 2015, he developed a final iteration that greatly simplified the placement of the appliance and improved its function. The following illustrations show the instrumentation and a protocol for the MPA 5 implementation (Figures 6-10).

Protocol for placement of the MPA Step 1 Construct a .017 x .025 or a .019 x .025 SS mandibular archwire (according to the bracket size the clinician uses) with extremely small occlusal circles for the MPA rod between the mandibular canines and first premolars. Ligate the wire in the brackets with 3M™ AlastiKs™ and turn down the ends distal to the mandibular molar tubes (Figure 11).

Step 2 Dry and mark the maxillary and mandibular incisors with a Sharpie pen, and with a patient-held mirror, guide the bite into a proper corrective occlusion (Figure 12).

Figure 6: The complete left and right MPA mechanisms

Figure 7: The stainless tubes and the 3M™ AlastiK™ chains that will attach the MPAs

Figure 8: The stainless tubes, each with an AlastiK chain

Figures 9-11: 9. The tube slides over the rod and inserts into the mesial end of the headgear tube with one AlastiK stretching to engage the headgear pin extending distally by 3 mm-4 mm from the headgear tube. 10. Both AlastiK chains engaging the headgear pin. 11. The mandibular arch with the small occlusal circles for the rod 26 Orthodontic practice

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Figures 13 and 14: 13. With the maxillary and mandibular incisor midlines centered with the desired overbite and overjet and the locking pin in the mesial opening of the headgear tube, mark the tube in the center of the small circle. 14. Cutting the MPA tube with a small, thin disc

Figure 15: The MPA rod extending distally from the tube by 2 mm-3 mm only

Figure 16: Threading the MPA rod into the small circle from the lingual direction

Figure 17: Stretching the AlastiK chain over the locking pin

Step 3 Place the headgear locking pin of the MPA tube into the mesial opening of the right maxillary molar band. With the patient holding the bite with desired overbite, overjet, and midline position, measure the length of the tube needed by marking it in the center of the small circle between the mandibular canine and premolar (Figure 13).

MPA mandibular rod will move through the MPA tube without any resistance (Figure 14).

lingual, and turn them upwards, making sure that the ends of the rods do not escape from the small circles. If the circles are too large, use Weingart or Howe pliers to squeeze the circle until the rod does not escape (Figure 16).

Step 4 Cut off the measured tube with a small disc in the air turbine, and smooth off any frayed ends of the tube. Make certain that the

Step 5 With the mandibular rod in the newly adjusted MPA tube, cut the rod so that no more than 2 mm-3 mm of rod protrudes from the distal end of the maxillary MPA tube (Figure 15).

Repeat steps 3, 4, and 5 for the left side.

Step 6 Insert the mandibular MPA rods into the mandibular archwire small circles from the

Figure 18: Patient No. 1 before nonextraction treatment with MPAs Volume 11 Number 5

Step 7 On the right side, slide the maxillary tube over the mandibular rod, and insert the maxillary headgear locking pin that should extend no more than 3 mm-4 mm distally from the maxillary headgear tube, and stretch the two AlastiK O-rings over the protruding locking pin to secure the MPA (Figure 17).

Figure 19: Patient No. 1 midtreatment with the MPAs. Note the eruption of the premolars into Class I occlusion Orthodontic practice 27

CONTINUING EDUCATION

Figure 12: The maxillary and mandibular incisor midlines marked and centered with the desired overbite and overjet

CONTINUING EDUCATION

Figure 20: Patient No. 1 treatment outcome with ideal overbite, overjet, Class I occlusion, and improved profile

Figure 21: Patient No. 2 Class II malocclusion with a severe overjet, maxillary incisor protrusion, and mandibular incisor retrusion

MPA No. 5 patient therapies Patient No. 1 (Figures 18-20) Patient No. 1 displays an adolescent female with a Class II, Division 1 malocclusion with a large overjet, deep overbite, a lip bite habit, a lower lip curl, short mandible, a large A-B discrepancy, protrusive maxillary incisors, retruded mandibular incisors, and excessive space in the maxillary arch.

Figure 22: Patient No. 2 displaying occlusion before and after MPA insertion

Patient No. 2 (Figures 21-25) Patient No. 2 displays a female adolescent with a Class II, Division 1 malocclusion with a large overjet and deep overbite, lip incompetence, a lip bite habit, maxillary spacing, a large A-B discrepancy, protrusive maxillary incisors, retruded mandibular incisors, and only marginal growth potential.

Figures 23-25: 23. Patient No. 2 treatment outcome. 24. Patient No. 2 (9 years after treatment) displays a perfect Class I occlusion and no sign of relapse. 25. Superimposition of images for Patient No. 2 at the pterygoid fissure. Note the retraction and extrusion of the maxillary incisors and the maxillary A point. Also, note the protraction of the entire mandibular arch, which has effected the occlusal correction, even as the mandible has moved down and back and had minimum growth as initially expected 28 Orthodontic practice

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Patient No. 3 (Figures 26-28) Patient No. 3 is a male adolescent presenting with a Class II malocclusion characterized by a maxillary arch length discrepancy, mandibular arch spacing, an overbite, overjet, posterior crossbite, root canal therapy on No. 30 and limited growth potential. Correction with the MPAs will be almost entirely with dentoalveolar effects.

Summary The MPA has proven its effectiveness, safety, and value in the treatment of Class II malocclusions for more than 25 years and has proven that this new iteration — the MPA 5 — is a significant improvement: It places pressure on the maxillary dentition through the mesial opening of the molar headgear tube and attaches via a double AlastiK chain. This has several distinct advantages: • Makes it much easier to attach.

• Makes adjustments much easier.

• Increases the attachment angle of the tube and rod, thereby avoiding interference with the mandibular molar.

• Allows easier repairs when breakage of any part of the appliance occurs.

As with all other variations of the MPA, the MPA 5 does not require a laboratory technique and can be delivered with one appointment chairside.

Even so, as with any beneficial mechanism, it has distinct advantages and some disadvantages. Since orthodontic clinicians have to construct this appliance, it loses its appeal for many. This disadvantage, however, is offset by its inexpensive and simple fabrication. Dr. Coelho resisted Volume 11 Number 5

several requests from companies to make the appliance because he knew that would require a patent and ultimately a more expensive appliance, while he wanted everyone to have the opportunity to use the appliance without restriction. Although the MPA is small compared to other functional appliances, it has proven equal in effectiveness to the Herbst*14,15 and other fixed, functional appliances,16,17 while it offers stability,18 more clinician control, and patient comfort than removable functional appliances and many of the larger fixed Class II correctors. OP

Figure 28: Patient No. 3 illustrating the treatment outcome with excellent overbite, overjet, and posterior occlusion. Note the improved facial profile

REFERENCES 1. Kingsley NW. A treatise on oral deformity with appropriate preventive and remedial treatment. New York, NY: D. Appleton and Company; 1880.

2. Angle EH. The latest and best in orthodontic mechanism. Dental Cosmos. 1929;71(2):164-174.

3. Case C. Disto-mesial intermaxillary force. Chicago Dental Society: Chicago, IL; 1893.

4.

Andresen V. The Norwegian system of functional gnatho-orthopedics. Acta Gnathol. 1936;1:5-36.

5. Balters W. Krafteinwirkung oder formgestaltende Reiszsetzung? Zahnärztl Welt. 1952;7:437-441.

6. Fränkel R. The theoretical concept underlying treatment with function correctors. Trans Eur Orthod Soc. 1966;42:233-250.

7. Herbst E. 30 years’ experience with the retention joint Herbst appliance. Zahnartzl Rundschau.1934;443:515-1524.

8. Pancherz H. Treatment of Class II malocclusions by jumping the bite with the Herbst appliance. Am J Orthod. 1979;76(4):423-442.

9. Coelho Filho CM. Mandibular protraction appliances for Class II treatment. J Clin Orthod. 1995;29(5):319-336.

10. Coelho Filho CM. Clinical application of the mandibular protraction appliance. J Clin Orthod. 1997;31(2):92-102.

11. Coelho Filho CM. The Mandibular Protraction Appliance No. 3. J Clin Orthod. 1998;32(6):379-384.

12. Coelho Filho CM., Mandibular Protraction Appliances IV. J Clin Orthod. 2001;35(1):18-24.

13. Coelho Filho CM. Mandibular Protraction Appliance IV. J. Clin Orthod. 2001;35(1):18-24.

14. Alves PFA. Estudo comparativo dos efeitos esqueleticos dentarios e tegumentares, promovidos pelo tratamento da ma oclusao Classe II mandibular com o aparelho de Herbst e com o aparelho de protracao mandibular. Rev Dent Press Ortodon Ortop Facial. 2006;5(1):85-105.

15. Pereira AF, et al., Eficiencia do tratamento da Classe II propiciada por aparelhos funcionais fixos, in Resumos, Baru:FOB-USP, Editor. 2007: Bauru, Brazil.

16. Kamache NG, Iani TMS, Oliviera AG, et al. Estudo cefalométrico comparativo dos efeitos esqueléticos e dentários promovidos pelos aparelhos APM3 (Aparelho de Protração Mandibular) e Jasper Jumper nas fases inicial e imediatamente após avanço mandibular. Rev Dent Press Ortodon Ortop Facial. 2006;11(4):53-65.

17. Humberto HJC, Henriques RP, Henriques JFC, Moratelli R. Estudo compartivo do tratamento da classe II com jasper jumper 3 APM. Anais Eletronicos; 2011.

18. Guimaraes CH Jr, Franco E, Henriques JFC,et al. Estabilidade em longo prazo do tratamento da Ma Oclusao de Classe II, divisao 1, com a utilizacao de um aparelho funcional propusorr mandibular fixo: Relato de caso. [Long-term stability of Class II, division II, malocclusion treatment with the use of a mandibular protrusive fixed functional appliance: case report] Rev Clin Ortod Dental Press. 2012;11(6):116-123. * Trademark of Dentarum Co.

Orthodontic practice 29

CONTINUING EDUCATION

Figures 26 and 27: 26. Patient No. 3 displays a Class II malocclusion with maxillary arch length discrepancy, mandibular spacing, overbite and overjet, posterior crossbite with limited growth potential. 27. Patient No. 3 displays the mouth prepared for MPAs and immediately after their placement. Note the initial change in profile

REF: OP V11.5 WHITE

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The MPA 5 WHITE

1. ________ was one of the first to describe his vulcanite plate for “jumping the bite,” and it became the ancestor of the myriad functional appliances that now exist. a. Kingsley b. Angle c. Case d. Bimler 2. ________ first described the mandibular protraction appliance, aka MPA, in 1995, and this first iteration was about as simple a Class II corrective mechanism as could be imagined. a. Dr. Emil Herbst b. Dr. Carlos Martins Coelho Filho c. Etienne Bourdet d. Dr. Pierre Fauchard 3.

The (first iteration) MPA consisted of a single _______ that connected the maxillary molar and mandibular archwire and protruded the mandible, held it there, and formed a template for the eruption of the posterior teeth into a Class I occlusion while simultaneously correcting the overbite, overjet, and midline. a. .016 NiTi wire b. .017 stainless steel wire c. .018 stainless steel wire d. .036 stainless steel wire

4. The MPA provided patients with an effective corrective for _________ but limited their opening to about 30 mm.

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a. excessive overbite b. overjet c. Class II malocclusion d. all of the above 5. The second iteration began to use a ______ as a stop on the mandibular wire. a. Guerin lock b. crimpable lock c. foldable lock d. lingual cleat

8. The MPA has proven its _______ in the treatment of Class II malocclusions for more than 25 years and has proven that this new iteration — the MPA 5 — is a significant improvement: It places pressure on the maxillary dentition through the mesial opening of the molar headgear tube and attaches via a double AlastiK chain. a. effectiveness b. safety c. value d. none of the above

6. (Step 5) With the mandibular rod in the newly adjusted MPA tube, cut the rod so that no more than _______ of rod protrudes from the distal end of the maxillary MPA tube. a. 2 mm-3 mm b. 3 mm-4 mm c. 5 mm-6 mm d. none of the above

9.

One of the distinct advantages of the MPA 5 is that it _________ the attachment angle of the tube and rod, thereby avoiding interference with the mandibular molar. a. decreases b. increases c. equalizes d. simplifies

7. On the right side, slide the maxillary tube over the mandibular rod, and insert the maxillary headgear locking pin that should extend no more than _______ distally from the maxillary headgear tube, and stretch the two AlastiK O-rings over the protruding locking pin to secure the MPA. a. 1 mm-2 mm b. 3 mm-4 mm c. 5 mm-6 mm d. 7 mm-8 mm

10. Although the MPA is small compared to other functional appliances, it has proven equal in effectiveness to the Herbst and other fixed, functional appliances, while it offers ________ than removable functional appliances and many of the larger fixed Class II correctors. a. stability b. more clinician control c. more patient comfort d. all of the above

Volume 11 Number 5

CE CREDITS

ORTHODONTIC PRACTICE CE

Dr. Lloyd Taylor illustrates a technique for impacted cuspids Figure 1: Gold Mesh Pad with swivel and chain

S

urgical attachments to impacted teeth requiring eruption into the dental arch have gone through a long and tortuous evolution. The majority of the procedures are performed on impacted cuspids since they are often the last teeth to erupt into the dental arch. The following describes the development leading to Gold Mesh Pads: 1. Lasso made of .012" wire was looped around the cuspid cervix after bone and soft tissue were removed. The wires of the lasso were twisted tightly to form a loop for elastic traction. Many of these lassoed cuspids were later extracted because of ankylosis due to the removal of some periodontal membrane resulting in alveolar bone fusing to root cementum.

2. Tunnel was cut through bone to the uncovered cuspid. A crown form was sutured in the tunnel while it epithelialized. These teeth eventually erupted after many years, which enormously extended orthodontic treatment time.

Figure 2B: Swivel feature allows the chain to rotate a full 360° around the Gold Mesh Pad. The swivel permits the chain to be tied in any desired direction

Figure 2D: Bendable feature shows that the Gold Mesh Disk (once cut to ideal shape) is easily bent with any plier to conform to any surface. This provides perfect adaptation for bonding

Figures 2E and 2F: 2E. Adhesive is placed on the undersurface of the Gold Mesh Disk. When the disk is placed on the tooth, the adhesive will extrude through and around the mesh. 2F. Light cure polymerizes the adhesive that flows into the etched enamel and also locks around the mesh wires. The Gold Mesh Disk will remain bonded throughout the eruption process

Figures 2G and 2H: 2G. Chain has a 1” length, which is adequate for all surgical procedures. For this double impaction, the Gold Mesh Pads have been trimmed and bent for maximum surface contact on tiny cuspid incisal edges. 2H. Gold is exceptionally well tolerated under the gingiva. Here the gold chain is tied to a loop on an archwire trapeze, which provides a vector for cuspid eruption

Figure 2I: Links are sequentially cut off leaving 1/8” space from the last link to be tied to the archwire with .025” elastic thread. Here there is only 1 link left on the swivel as the cuspid erupts!

Lloyd R. Taylor, DDS, received his DDS degree from Fairleigh Dickinson Dental School. He first completed a 3-year residency in Oral and Maxillofacial Surgery and Anesthesiology and was Chief Resident at the Albert Einstein College of Medicine/Jacobi Hospital in New York City. Dr. Taylor then completed a 3-year Fellowship in Orthodontics at the Harvard School of Dental Medicine. He also completed an additional 3-year Fellowship in Orthodontic Teaching and Research at the Forsyth (Harvard) Dental Center. Dr. Taylor has practiced both Oral Surgery and Orthodontics in North Hollywood, California, for more than 50 years.

Disclosure: Dr. Taylor is both the founder and president of OrthoSource since 1985.

Volume 11 Number 5

Figure 2C: Cutting the Gold Mesh can be easily trimmed to fit any shaped surface. An orthodontic hard wire cutter is ideal for this purpose

Figure 2A: The tips of a mini tweezer fit perfectly into the swivel providing a secure hold and precise placement of the Gold Mesh Disk

3. Pin allowed access to be cut through enamel to dentin for a tiny drill to prepare a hole to screw in an eyelet pin. The eyelet was tied for eruption.

Unfortunately, the damage to the tooth crown was difficult to repair, eyelets were difficult to tie, and often pulpal damage occurred.

4. Acid etch bonded brackets and buttons, eliminating crown damage and ankylosis, but attachments were often lost requiring repeated surgeries.

It was difficult to light-cure adhesives under solid attachments.

5. Gold Mesh Pads with swivel eyelets and gold chain have become the standard treatment for the eruption of impacted teeth. With proper bonding and surgical technique coupled with gentle elastic force, teeth erupt efficiently and with controlled direction. OP Orthodontic practice 31

STEP-BY-STEP

Historical evolution of Gold Mesh Pad with swivel and chain for impacted cuspids

SERVICE PROFILE

COVID-19 impact on practice values — short and long term Chip Fichtner discusses how orthodontists can add liquidity and a strong growth partner to their practices

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he effects of COVID-19 on dental practices nationally have been well publicized. However, many orthodontists are not fully aware of how it has impacted practice values in the short term and what the potential effects are in the long term. Fortunately, many groups that invest in orthodontic practices as silent partners have actually accelerated their activity levels during COVID-19. Great orthodontists can still monetize a part of their practice for cash now.

We have completed tens of millions of dollars in transactions since March 16. Many larger orthodontic practices can still achieve 2019 bubble level values from Invisible Dental Support Organizations (IDSOs) monetizing a part of their practice. For a brief moment, doctors can liquify some of what is probably their largest single asset for cash at the low 2020 federal tax rates.

The IDSO business model is to purchase a percentage, typically 60% to 90% of a growing practice for cash up front. The doctor retains an ownership interest in either the practice or the IDSO or both. Doctors continue operating their practice under the doctors’ brand, team, and strategy for years or decades in the future, but with a known exit when they are ready. In the current economic climate, liquidity has become very attractive to doctors of all ages, and there are many operating benefits in addition to cash in your pocket now.

While IDSOs shrewdly attempt to deal directly with orthodontists on these transactions, the smart doctors seeking to maximize value with the right partner will engage an advisor. Attracting multiple bidders increases both short- and long-term value and ensures a properly structured transaction. Every IDSO is different, and every transaction is

Chip Fichtner is the founder of Large Practice Sales, which specializes in Invisible DSO transactions for large practices of all specialties.

The company has completed more than $100 million of transactions in the past 6 months.

Learn more at www.findmyorthodonticidso.com.

32 Orthodontic practice

Doctors continue operating their practice under the doctors’ brand, team, and strategy for years or decades in the future, but with a known exit when they are ready.

customized to meet the doctors’ personal and business goals, both short and long term.

The benefits of having an IDSO partner Many doctors value their sole ownership structure and have no desire to attract a partner. They believe that the world will continue as is, and that they can weather any storm alone. This may be true for some, but we know cases where an IDSO has partnered with a local orthodontist, and the other orthodontic practices in the community have declined significantly. An IDSO that also owns the pediatric dentists in town can change the referral dynamics overnight by partnering with an orthodontist. IDSO partnership is in some cases a defensive move.

One of the offensive tactics deployed

by IDSOs’ partner practices are their professional, direct-to-patient marketing.

An IDSO that owns interests in dozens or hundreds of orthodontic practices across the country has a very highly focused and experienced in-house marketing team that is helping all of their orthodontist partners. When they partner with one of your

competitors, marketing dynamics in your town will change.

Due to their size, many IDSOs will purchase supplies more efficiently, including clear aligners of all brands. Their team benefits packages will typically provide better coverage at lower cost, and some have very impressive internal recruiting groups.

By design, an IDSO partner seeks doctors who want to remain as the leaders and owners of their practices for years or decades. While the average age of LPS clients is about 50 years old, younger doctors are discovering that IDSOs can provide growth capital and management expertise for rapid expansion. The right IDSO can help doctors grow their practices via acquisitions of competitive or complementary practices in which they will be owners, as well as the retained interests in their original practice.

In the coming economic turmoil, liquidity and a strong growth partner may be very valuable resources for any doctor. The process to learn the potential value of your practice with an IDSO partner is confidential and at no cost or obligation. You have nothing to lose by learning more about this attractive strategy. OP Volume 11 Number 5

Now is the Time To Monetize Part of Your Practice Value Invisible Dental Support Organizations (IDSO) buy 60% to 90% of your practice for cash up front. You remain as owner, operating under your brand with your team. Stay for five to 20+ years with a known exit. Silent partners provide you with the resources to grow your practice bigger, better, faster, more profitably and compete more effectively.

Recent Orthodontic Practice Transactions One-Doctor Practices: 2.4X Collections 2.6X Collections 3.5X Collections 2.1X Collections (Covid Era)

Two-Doctor Practices: 1.7X Collections 2.1X Collections 3.4X Collections

Three-Doctor Practices: 2.2X Collections 3.0X Collections

DONâ&#x20AC;&#x2122;T GET CAUGHT IN THE NEXT WAVE ALONE WATCH OUR WEBINAR ON DEMAND: COVID-19 UPDATE Why IDSOs are Accelerating Partnerships With Great Doctors Earn One CE. Lecture by Chip Fichtner, Principal

19 D I V O C

To schedule a confidential call, and get a FREE practice value analysis, call 844-734-8533 or Email OPUS@LargePracticeSales.com Webinar On Demand at FindMyOrthodonticIDSO.com

PRODUCT PROFILE

Empower ® 2 Clear Self-Ligating brackets

A

merican Orthodontics introduces Empower® 2 Clear Self-Ligating brackets, a smartly redesigned enhancement of its esthetic bracket. Empower 2 Clear still offers the versatility and ease of self-ligation in a durable, esthetic, around-the-clock solution and improves treatment options by continuously implementing advanced technology.

Engineered from the ground up for performance and beauty, the polycrystalline material is formulated to deliver uncompromising strength. Empower 2 Clear brackets are designed using state-of-the-art CAD modeling and computerized simulation resulting in improved mechanical strength, leveraging the patented technology found in the Empower 2 Metal Bracket. Through extensive internal lab testing, American Orthodontics has also refined the debonding predictability of its patented Quad Matte™ technology — all without compromising the esthetic clarity of the bracket.

The robust bracket body design of Empower 2 Clear enhances durability without sacrificing tie-ability. The clip is now 20% thicker than the prior offering, providing increased wire seating force and reduced clip deformation. The trident shape of the clip offers better rotational control and helps seat wire during closure while adding a visual cue to confirm clip closure. Reduced binding friction results from the redesigned wire-slot chamfers, while opening and closing is enhanced through improvements in the clip track.

Empower brackets were the first in the industry to offer the versatility of either interactive or passive bracket designs in one unified system with coordinated in/outs. In the interactive bracket, the clip passively captures smaller wires and actively engages larger wires for lower ligation force early in treatment, and exceptional torque and rotation control during working and finishing stages. In the passive bracket, the clip passively captures all wire sizes for lower ligation forces throughout treatment. This Dual Activation System provides the best of both worlds — interactive and passive brackets in one unified system with excellent anterior control, improved posterior freedom play, and the time-saving benefits of self-ligation.

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Empower® 2 Clear Self-Ligating bracket

Luno® Debond Tool

The various options available with the Dual Activation System of Empower afford great versatility as extensive prescription, wire, hook, and pad options allow development of a system unique to the treatment style of the orthodontist.

To complement Empower 2 Clear, AO has also introduced its new Luno® Debond Tool. With a simple, intuitive mesial-distal rocking motion, the new Luno® Debond Tool is specifically designed to debond ceramic or esthetic brackets such as Empower 2 Clear and Radiance Plus, the cosmetic twin bracket from American Orthodontics created from a single crystal of pure grown sapphire.

The new Luno® Debond Tool retains the bracket upon debond from the tooth surface and will remove brackets while leaving the archwire intact.

“One of the great benefits of this new tool is it does not require any removal of flash prior to debond,” says AO Product Manager

Lindsey Cadoo. “The feedback we have received from our users has been extremely positive.”

Just like every Luno® cutter, bender, and plier, the Ceramic Debond Tool is precision manufactured to effectively prevent corrosion and is tested beyond industry standards. Each Luno® instrument is laser engraved with lot numbers and wire specifications to assist in quality control and to ensure it is the right instrument for the right job. The smooth polished surface with a patented two-tone finish provides optimum comfort while in the hand of the dentist and in the mouth of the patient. With a focus on ergonomics, Luno® is ideal for orthodontists and patients alike.

Please contact your AO Representative for additional information. OP This information was provided by American Orthodontics.

Volume 11 Number 5

FOLLOW US ON

WELCOME TO THE FAMILY In addition to the ifit 1st Molar tube and 2nd Molar tube, American Orthodontics is excited to add the ifit Convertible and the ifit Mini 2nd Molar tubes to the ifit family.

Convertible Tube • Featuring an all-in-one convertible tube with an incorporated engineered “cap” - Converts when needed and not before

Mini 2nd Molar Tube • Features a wraparound pad which can be used for partially erupted molars • Overall Mesial-Distal width of 2.5 mm

• Tie-wing undercuts accommodate all elastomerics

Please See Your AO Sales Rep for Details ©2020 AMERICAN ORTHODONTICS CORPORATION +1 920 457 5051 | AMERICANORTHO.COM

PRODUCT PROFILE

The universal language of business Suzanne Wilson, Chief Marketing Officer of Gaidge, discusses how to keep a pulse on essential performance metrics in your business

A

s a business owner, keeping track of your money is the most fundamental part of business. The inflow and outflow of cash is the lifeblood of the business and the single ingredient that differentiates those who keep the doors open and those who cannot. The orthodontics industry reports one of the lower overhead percentages among dental providers, with orthodontic practice overhead ranging from 49% to 60%. Knowing your fixed and variable overhead expenses directly impacts what you take home or how much you have left over to make investments. None among us can thrive unless our minds are dialed in to the flow of our money, and the key to profitability and growth is knowing the numbers.

Gaidge is a tool that helps practice owners keep a pulse on their essential performance metrics, providing the information required to run their businesses better. In one comprehensive software platform, orthodontists have access to quickly review their key performance indicators across all areas of the practice with easy-to-understand charts, summaries, trends, industry benchmarks, and practice comparisons.

Now introducing the new Overhead Expense Tracker™ The Overhead Expense Tracker™ is now available as an add-on module that will feature automated reporting of your expenses, including budget tracking, profitability, benchmarks, and trends. This further enhances your ability to see a clear, end-to-end picture of your practice’s business performance conveniently in one cloud-based platform.

We have consulted industry experts such as Bentson Copple & Associates and others during our development to ensure we aligned with common practices that would bring value to both practice owners and their accounting partners. Your accounting software houses your financial transactions, and your accountant or bookkeeper are Suzanne Wilson joined Gaidge as the Chief Marketing Officer in September 2018. She has held leadership positions in operations, marketing, and business development in the oral care industry over the past 20 years. She earned her Bachelor of Arts in English and an Executive MBA from the University of Utah. To learn more, visit https://www.linkedin.com/in/suzanne-wilson-8a158b1a/.

36 Orthodontic practice

regularly managing, advising, and helping you leverage tax optimization. With Gaidge Overhead Expense Tracker, you can now easily retrieve and review your expense detail whenever desired. Gaidge’s security permissions allow you to control each user’s access, which means sensitive data remains secure, but it also means you have the ability to grant access to your accountant to share views and simplify communications.

Controlling overhead represents a wealth of opportunity for increasing net income.

Having a simple view and easy access to monitor what’s happening brings visibility on a regular basis rather than waiting for quarterly, biannual, or annual reviews. In addition, having the budgeting tool with the progress tracker allows you to keep tabs on spending, detect areas of concern, and have better chances of hitting your profitability goals throughout the year.

Once activated, the Overhead Expense Tracker will automatically pull practice accounting data directly from QuickBooks® Online and upload the information into Gaidge with added charts, new metrics, trends, summary reports, and budgeting tools, making it easier than ever to review, plan, and control your overhead. It features three tabs that show your Overhead Summary in a standard table

format with net collections for projected profitability, your Overhead Budget that includes your month-to-date and year-to-date spending in comparison to the budget you’ve set, as well as Overhead Reports displaying visual charts that show your expense categories broken down and calculated with related trends and Gaidge metrics.

The module is fully integrated and automated with QuickBooks® Online, including pulling through retroactive adjustments. For offices using other accounting software, Gaidge also offers a file upload and manual entry option.

Contact us today for a free online demo via email at Info@gaidge.com, visit www. gaidge.com, or call (800) 287-3396. OP REFERENCES 1. Wharton Executive Education. Do you speak the language of business? https://execed.wharton.upenn.edu/thoughtleadership/wharton-at-work/2013/07/language-of-business/. Posted July 13, 2013. Accessed July 31, 2020.

2. Blatchford B. You choose your overhead. Dental Economics. https://www.dentaleconomics.com/practice/ overhead-and-profitability/article/16393116/you-chooseyour-overhead. Posted February 1, 2004. Accessed July 31, 2020.

3. White C. How to Manage Overhead Percentages in the Practice. Orthotown. https://www.orthotown.com/magazine/ article/5814/how-to-manage-overhead-percentages-inthe-practice. Posted March 2016. Accessed July 31, 2020.

This information was provided by Gaidge.

Volume 11 Number 5

Francesco Pedetta, MD, DDS 2020, Quintessence Publishing Co.

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r. Francesco Pedetta, a devotee of Dr. Larry Andrews, has assembled in this paperback opus an amazingly large collection of excellent illustrations to guide readers in understanding this new approach to the use of the Straight Wire Appliance© (SWA). The instrumentation has not changed; that is, the bracket metrics, antirotational additives, power arms, and extraction anti-tipping features still exist as originally planned. What has changed is the diagnosis and treatment planning that it now relies upon — a variant of the venerable Steiner Box, which mathematically clarifies the space available and space needed for resolving malocclusions.

The New Straight Wire relies on establishing an optimum position for the maxillary incisor by relying on the glabella line, an idea that Dr. Andrews began developing 4 decades ago. A line drawn from glabella perpendicular to the Frankfort horizontal plane ostensibly touches the facial surface of the maxillary central incisor, establishes an optimal position for the maxillary incisor, and subsequently creates the anterior limitation for the entire dentition. Dr. Pedetta contends this measurement is the same for all races.

Although the brackets do not differ in the New Straight Wire, the recommended wires greatly differ as it uses more round wires to tip the teeth rather than move them bodily with edgewise wires. Seemingly, this avoids putting the roots of the teeth against the cortical plates of their osseous confinements and reduces root resorption.

When this technique advocates the use of edgewise wires, it commends .018 x .025 dimensioned wires in a .022 bracket, which allows 18° of rotation and thus little threedimensional control.

Dr. Pedetta believes that the bulk of Class II corrections must come from retraction of the maxilla, and he subsequently advocates the use of extraoral traction via the headgear supplemented during the day with Class II

Volume 11 Number 5

This beautifully illustrated text offers what readers have come to expect from Quintessence Publishing Co. — that is thick durable pages, readable fonts, and impressive artwork with clear and unequivocal narratives. elastics so as to keep a continuous force against the teeth. He contends that teeth must have continuous force to move.

Dr. Pedetta displays some misunderstandings regarding functional therapy by stating it started with Frankel’s work in 1969.

Functional appliances preceded that date by more than a half century. Further, Dr. Pedetta states that while these appliances work, they do so entirely by restricting maxillary growth and are indicated only in patients with maxillary protrusions. This belief varies

considerably from the work by Pancherz, DeVincenzo, Valant, and many others.

This beautifully illustrated text offers what readers have come to expect from Quintessence Publishing Co. — that is, thick durable pages, readable fonts, and impressive artwork with clear and unequivocal narratives. It suffers from a lack of bibliographies and clinical therapies that could validate the theory of the New Straight Wire. OP Review by Dr. Larry White.

Orthodontic practice 37

BOOK REVIEW

New Straight Wire: Strategies and Mechanics for a Programmed Approach to Orthodontic Treatment

INDUSTRY NEWS Gaidge, LLC, Gainesville, Georgia, announces new virtual appointment metrics Gaidge released an update to its software platform that now includes virtual consultation metrics and appointment tracking.

The addition will be automatically available and included for all Gaidge accounts at no additional charge. The initial release has been mapped for CS OrthoTrac and Dolphin Management software programs with the next release scheduled to include the remaining practice management software (PMS) partners. The Gaidge platform’s powerful features are automated with nightly uploads to give clients unprecedented visibility into the practice’s performance, essential business metrics, and goals. Gaidge is fully integrated with the leading practice management systems for seamless operations and no additional data entry.

Gaidge clients can now track their virtual consultations in the following areas: • Exams and new patients • Origin of starts • Pretreatment observation • Between phases observation • Schedule statistics • Repair detail • Retention appointments Virtual consultations and virtual visits can increase opportunities to connect with patients as well as minimize the need for in-person visits for routine checks, triage, and observation.

For more information, existing Gaidge users can contact support@gaidge.com and email info@gaidge.com.

Rhinogram and DynaFlex® announce collaboration to enhance remote patient care through integration of telehealth platform Rhinogram, a leader in cloud-based, HIPAA-compliant, telehealth solutions, announced a strategic alliance with DynaFlex®, manufacturer and distributor of product and digital solutions for the orthodontic and dental industries.

Through this collaboration with Rhinogram, DynaFlex® will now offer their client network with the ability to provide virtual visits for patients as well as communicate in real-time via simple texts (SMS) and multimedia texts (MMS) — giving dental and orthodontic practices the ability to better engage with patients while streamlining workflows.

Rhinogram enables providers to securely communicate with patients via two-way texting at any time from their mobile device to address appointment requests, clinical questions, refill requests, medical records access, and more. The Rhinogram platform also provides facilitation of virtual visits with patients in real-time. Rhinogram seamlessly integrates with most EHR and PMS systems, synchronizing secure, encrypted patient communication into clinical workflows. It also includes a quick message-triage to appropriate team members, allowing the scheduling team to handle appointments, billing staff to field financial and insurance queries, and freeing clinical team members to address care concerns. The complete history of SMS messages is archived in the patient’s communication record, allowing practitioners to quickly and conveniently reference past communication with their patients. Patients do not have to download an app or log into a portal to communicate with their clinician or office staff.

For more information, visit www.rhinogram.com.

AAO supports orthodontic innovation with investment in KLOwen™ braces The American Association of Orthodontists (AAO) is taking another step forward in supporting the orthodontic profession by investing in advancing the specialty and patient care via its Innovation and Transformation Fund. The fund, which can be used to develop new products and services for orthodontists and patients by building, partnering, or investing, made its second move by investing $50,000 in KLOwen™ Custom Braces System — an in-office, same-day, custom-bracket solution. Custom Braces System uses the newest technologies, including 3D printers and custom-shaped braces. According to KLOwen Braces, the system can work on any orthodontic case, even those requiring functional appliances, expansion, or surgery. By leveraging a unique software platform, the solution automatically places the ideally shaped bracket for each tooth out of a kit of 27 pieces. Then, using 3D-printed indirect bonding (IDB) trays, brackets are bonded precisely where approved on the software, completing the customization. By filling the slot completely, the system allows the wires to be more completely expressed, eliminating or greatly reducing wire bending or bracket repositioning.

For more information, visit https://klowenbraces.com/.

38 Orthodontic practice

Volume 11 Number 5

MMG Fusion — the all-in-one software suite working to market, manage, and grow dental practices — has released its Unified Communication tool, the second of four products being released within the new MMG Manage suite of services. The Unified Communication tool (UC) was designed, tested, and continually improved by dentists and dental staff within MMG Fusion’s affiliated San Francisco group practice. Unified Communications is the central communication hub for all internal and external practice interactions. UC’s efficiencies generate more time for both the practice and the patient.

UC replaces the practice’s hardware phone system with an advanced VoIP system capable of helping staff better connect and collaborate externally with patients and internally with each other. Advanced phone routing, customizable answering options, transferring, and full integration with other MMG Fusion tools make UC’s VoIP system the most advanced on the market. UC uses artificial intelligence to capture important patient data directly from the web-chat feature and load it into the patient record. The patient record is then converted into a patient pop that is automatically presented anytime the patient is being communicated with. When combined with the MMG’s AI-driven Task Manager tool, the UC engine gives the team a central location to collaborate and ensures that all necessary tasks are assigned, tracked, and completed. MMG also replaces office phone, text, and chat systems with one intelligent Unified Communication tool.

For more information, visit www.mmgfusion.com.

RMO provides Dentsply Sirona/GAC customers equivalent orthodontic products upon exit

Aligner producer ClearCorrect expands partnership with 3Shape to elevate patient experience and simplify provider workflow ClearCorrect, a Straumann Group brand and manufacturer of clear aligners, will elevate its partnership with 3Shape, a developer and manufacturer of 3D scanners and software. The expanded partnership will include seamless integration that will allow for a simplified connection between ClearCorrect and 3Shape TRIOS®, resulting in faster, more efficient results — enabling providers to create a better patient experience and a flexible workflow. Expansion of services stemming from this partnership include a 3Shape TRIOS Treatment Simulator, which will allow for patients to see their current smile alongside results offered by ClearCorrect aligners and/ or whitening treatment. In addition to the new simulator, providers can also now pair their TRIOS scanner to their ClearCorrect account and upload the scans to their patient’s case page. In addition, a free on-demand learning and continuing education course about the new 3Shape integration functionalities will be available for 3Shape users and their teams.

For more information, visit tps.clearcorrect.com.

Volume 11 Number 5

Rocky Mountain Orthodontics® (RMO®) offers an array of comparable products for Dentsply Sirona/GAC orthodontic customers as that company announces its exit from the traditional business as reported in the company’s 2020 Second Quarter Report. To assist Dentsply’s orthodontic appliance customers, RMO is offering a buyback program to U.S. and Canadian doctors looking for alternative sources of brackets, bands, tubes, and wires. RMO offers the following products that are equivalent to those being discontinued

by Dentsply Sirona: • FLI® Buccal Tubes vs. Resolve Buccal Tubes • Truform vs. Snap-Fit® molar bands • Alpine SL® and Alpine SL® Clear vs. In-Ovation® self-ligating brackets • FLI® Clear and Signature III vs. Ovation® ceramic brackets • Orthonol®, Thermaloy® (+), FLI® esthetic & Copper NiTi vs.

Accu-Force wires • Trioforce Preformed Natural Arch Wire vs. BioForce® Arch Wire For more information, visit www.rmortho.com.

Orthodontic practice 39

INDUSTRY NEWS

MMG Fusion announces the launch of Unified Communications: part of the MMG Manage suite of services

INDUSTRY NEWS Sensei name introduced as new brand identity for care management platform The software-as-a-service solution, known as Carestream Dental’s “Care Management Platform,” is getting a new brand identity.

Sensei Cloud combines powerful imaging, practice management, clinical workflows, and intuitive design into one platform that offers anytime, anywhere access. The name Sensei was chosen because the word conveys the sense of a trusted guide. By analyzing practice data, Carestream Dental’s software can report on key performance indicators (KPIs) and provide actionable steps that practices can take to improve patient engagement and revenues. In addition to clinical data, business performance metrics and analytics are a key feature of the platform. With Sensei Cloud, owners and office managers can make smarter business decisions based on actionable reporting that summarizes how a practice is performing. This high-level business-focused view makes it ideal for practices with multiple locations or DSOs and provides industry-leading opportunities for benchmarking and multi-practice management.

For more information visit carestreamdental.com.

Smile Stream Solutions announces Tom Macari as CEO

GTech Clean for high-frequency touchpoints Keeping dentist offices and equipment clean is normally a top priority, but during the coronavirus pandemic, it has become critical to help keep patients and workers safe and healthy, especially when they use high-frequency touchpoints such as door handles, chairs, and counters. Having to hire professional cleaners to disinfect every nook and cranny in the building can get costly, but dentist offices can use GTech Clean to quickly and efficiently kill 99.9% of bacteria and viruses on surfaces, including COVID-19, influenza, mildew, mold, and more. The EPA-approved spray leaves a microscopic barrier on hard and soft surfaces that continues to kill bacteria and viruses for up to 5 days. Any dentist officer worker or in-house cleaning team can use GTech Clean: Fog the area to disinfect the surface, and let it air-dry — no need to dilute the solution prior to use or wipe it away after spraying the surface.

For more information, visit http://gtechclean.com/.

40 Orthodontic practice

Smile Stream Solutions announced the appointment of Tom Macari as Chief Executive Officer. He joins the company with 26 years of experience in the orthodontic marketplace, throughout which time he has held positions from sales to executive leadership for larger organizations such as Dentsply/GAC and GC Corporation, to entrepreneurial companies like MidAtlantic Ortho.

Smile Stream Solutions, Inc. is a privately owned company that delivers innovative product and service platforms meant to enhance the vitality of orthodontic care providing practices around the world.

For more information, visit smilestreamsolutions.com, or email Tom Macari directly at tmacari@smilestreamsolutions.com.

Share your good (ortho) news!

Submit your press release for consideration to managing editor Mali Schantz-Feld via email at Mali@medmarkmedia.com.

Volume 11 Number 5

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