Orthodontic Practice US Spring 2022 Vol 13 No 1 by MedMark, LLC

Bracket & Alignment Systems

4 CE Credits Available in This Issue*

Spring 2022 Vol 13 No 1

orthopracticeus.com

Aligning with CandidPro™:

a forward-thinking orthodontic system Fixed lingual retention: the gold standard or a relic of orthodontics past? Dr. Amy Jackson

Simplifying the deimpaction of mandibular second molars Drs. Larry W. White and Francesca Scilla Smith

Practical considerations for utilizing Prescription Drug Monitoring Programs — a primer Nikki Sowards, PharmD Michael O’Neil, PharmD Tyler Dougherty, PharmD

PROMOTING EXCELLENCE IN ORTHODONTICS

Meeting the growing demand for clear aligners

Dr. Lynn Hurst

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INTRODUCTION

Spring 2022

Volume 13 Number 1

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 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 Laurence Jerrold, DDS, JD, ABO Marc S. Lemchen, DDS Edward Y. Lin, DDS, MS Thomas J. Marcel, DDS Mark W. McDonough, DMD Randall C. Moles, DDS, MS Elliott M. Moskowitz, DDS, MSd, CDE Rohit C.L. Sachdeva, BDS, M.dentSc Gerald S. Samson, DDS Margherita Santoro, DDS Shalin R. Shah, DMD 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 Board Bradford N. Edgren, DDS, MS, FACD Fred Stewart Feld, DMD Gregori M. Kurtzman, DDS, MAGD, FPFA, FACD, FADI, DICOI, DADIA Justin D. Moody, DDS, DABOI, DICOI Lisa Moler (Publisher) Mali Schantz-Feld, MA, CDE (Managing Editor) Lou Shuman, DMD, CAGS

© MedMark, LLC 2022. 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 Endodontic Practice US or the publisher.

A new frontier in clear aligner orthodontics

rthodontics is at a crossroads. Our patient base is growing; our clinical expertise is crucial. Research shows that around 75% of Americans could benefit from orthodontic treatment, and the long-term oral and systemic health downsides to delaying or forgoing treatment are becoming increasingly clear. Clear aligners, specifically, dramatically expanded the number of patients who are able to access and afford orthodontic treatment while simultaneously enabling clinicians to effectively treat even more patients. Yet these advances are still not keeping pace with the growing demand for straighter, healthier teeth. That’s one reason why I helped found Candid in 2017 — and why I’m so thrilled to share how Candid is paving the way for clinicians across the United States to meet the growing demand for orthodontic treatments. Candid recently announced that we’ve pivoted away from our direct-to-consumer business and are now solely focused on the CandidPro™ service to democratize clinical access to the latest orthodontic standards — while sunsetting our directto-consumer product. We’re bringing everything we’ve developed over the past 5 years — stellar patient experience, cutting-edge aligner designs, industry-leading treatment planning technologies, smart-patient acquisition strategies, and a strong, memorable brand — to clinicians across the U.S. looking for a better clear aligner system. As the U.S. clear aligner market is expected to grow to $6.17 billion by 2028, my concern is that we will find ourselves unable to fully address this tsunami of demand. If we’re unable to meet our patients’ desires, they will find alternative avenues to get the treatment they want. We have to get smarter about scaling our practices, or we risk losing those potential patients to subpar services — potentially resulting in irreversible damage. We need to take the reins and solidify our role, as clinicians, as the primary source of truth in orthodontic treatment. The good news: our patients are more informed than ever — and most of them want a local doctor overseeing their case. Though the Internet has produced some of our stiffest competition, it’s also helped patients learn more about why straight teeth are beneficial for their long-term well-being. Some patients are comfortable working with a fully remote, direct-to-consumer solution, but our research at Candid shows that of those who did not pursue remote clear aligner therapy, approximately 80% did not because they preferred to have a local clinician involved in their treatment. I’m inviting you to join us to meet this unique moment for our field. With CandidPro, we can address the growing demand for clear aligners conveniently and efficiently. I acknowledge that at its current stage, CandidPro may not be the first choice for your most complex cases. However, it will give you the opportunity to spend more time on those patients and the auxiliaries they often require. Stay tuned as we have a roadmap with more exciting technological advancements over the horizon. I’ve shared more details about CandidPro in this issue of Orthodontic Practice US. We’re taking a page from the book of the great Wayne Gretzky and “Skating to where the puck is going to be, not where it is.” I hope you’ll give it a read and reach out to our team with any questions you may have.

Lynn Hurst, DDS, MS, FACD, received his BA from Southwestern University and his Doctor of Dental Surgery with Honors from the University of Texas Health Science Center at San Antonio. He has also earned a Specialty Certificate in Orthodontics and Dentofacial Orthopedics from the University of Oklahoma Health Sciences Center and has completed his Phase III board certification. Dr. Hurst has actively practiced orthodontics for over 30 years, developing the principles behind Candid’s patent-pending CandidRx™ along the way. He is a cofounder of Candid and serves as Chief Dental Officer.

ISSN number 2372-8396

orthopracticeus.com

Volume 13 Number 1

TABLE OF CONTENTS

PUBLISHER’S PERSPECTIVE

Don’t just survive — thrive!

Lisa Moler, Founder/CEO, MedMark Media............................... 6

TECHNIQUE

COVER STORY

Aligning with CandidPro™: a forward-thinking orthodontic system

Dr. Lynn Hurst explains the benefits of this affordable and accessible orthodontic system

Bending superelastic archwires — the missing constituent of orthodontic therapy Dr. Suhail A. Khouri discusses the clinical benefits of wire bending ...............................................................16

TECHNOLOGY

Let the dentist know what you can do

Cover image courtesy of CandidPro.

Dr. Robert Kaspers notes that interaction between dentists and orthodontists can result in more effective treatment.................... 22

RESEARCH

TECHNIQUE

Simplifying the deimpaction of mandibular second molars

Drs. Larry W. White and Francesca Scilla Smith offer a technique to simplify a complex and lengthy procedure Orthodontic Practice US

Volume 13 Number 1

Which is the best treatment modality for space closure — orthodontic, restorative, or prosthetic? Drs. Vishal Parashar, Rupali Balpande, Amil Sharma, Snehal Markandey, Neetish Shriram Chavhan, and Gayatri Deshmukh survey doctors about their preferred course of treatment ........................................................ 30

Control in Motion Rely on the Carriere® MOTION 3D™ Appliance to do the heavy lifting for you, and simplify and shorten your brackets cases. MOTION 3D Appliances correct AP discrepancies and stimulate initial tooth movement. This fosters easier transitions into larger wires earlier in treatment using Carriere M-SERIES™ Wires, less time in braces, and shorter overall treatment times. By resolving the most difficult part of treatment at the beginning, when patient compliance is at its highest, you can achieve a Class I platform in 3 to 6 months, shortening the total treatment time by up to 6 months in Carriere SLX ® 3D Self-Ligating Brackets.

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TABLE OF CONTENTS

CONTINUING EDUCATION

Practical considerations for utilizing Prescription Drug Monitoring Programs (PDMPs) — a primer CONTINUING EDUCATION

Fixed lingual retention: the gold standard or a relic of orthodontics past? Dr. Amy Jackson discusses retention as an important part of orthodontic treatment................ 42

Nikki Sowards, PharmD; Michael O’Neil, PharmD; and Tyler Dougherty, PharmD; discuss how prescription drug monitoring programs play an important role in monitoring controlled substances

PRODUCT PROFILE

............................................................... 46

Keys to the kingdom — unlocking opportunity with practice data ............................................................... 48

Spark™ Aligners set new standard in orthodontics

Gaidge

*Paid subscribers can earn 4 continuing education credits per issue by passing the 2 CE article quizzes online at https://orthopracticeus.com/category/continuing-education/

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

Orthodontic Practice US

Volume 13 Number 1

Uncover Your Practice Performance

AVERAGE CASE ACCEPTANCE IN U.S. ORTHODONTIC PRACTICES IN 2021

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PUBLISHER’S PERSPECTIVE

Don’t just survive — thrive!

Published by

hen preparing my first message of 2022, I was looking for inspiration. I found a quote by author Richelle E. Goodrich, which said, “Revitalized, I find the strength to battle new tomorrows.” She added, “This year, I survived. Next year, I will thrive!” Revitalization is a key to continuing to grow and prosper in the coming years. It means to give new life or vitality. Here at MedMark, revitalization is exactly what we concentrate on every day — for our readers and our authors and, ultimately, for our patients. For our spring issue, our page design has changed. That is part of our revitalization. Our articles and topics will conLisa Moler tinue to motivate. But you will also find: Founder/Publisher, MedMark Media • Easier-to-read bold headlines and a humanist, more legible typeface • More color and a fresh color palette with new accent colors • More reader-friendly text and column width • More bookshelf-friendly size — the publication now is easier to store for long-term reference Our cover story by Dr. Lynn Hurst talks about the CandidPro™ system and its simple-to-use, automated technology that eliminates the unnecessary visits, refinements, and extended treatment times, which can happen with many other types of aligners. A CE by Dr. Amy Jackson discusses the benefits and drawbacks of fixed lingual retention. A CE by Nikki Sowards, PharmD; Michael O’Neil, PharmD; and Tyler Dougherty, PharmD; shows how dentists can utilize state prescription drugmonitoring programs (PDMPs) to inform clinicians and identify “red flags” when prescribing controlled substances. Take the quizzes for these CEs and obtain 2 CE credits each! In his technology article, Dr. Robert Kaspers discusses the benefits of a a CBCT scan for formulating an accurate diagnosis. While we all are laser-focused on succeeding and expanding our options this year, we also should remember the importance of practicing empathy and kindness. Stories of these past 2 years of the COVID-19 pandemic taught us all that everybody has a personal and professional story that has deeply impacted their lives. Some share these challenges with the world, and some prefer to keep them personal; but in the light of what we have all gone through, part of the revitalization of 2022 will be to recognize that we need each other’s support to move forward. There are many ways to practice kindness in the dental world. Be a mentor to another dentist who has questions on technique or materials that work for you. Motivate a colleague who is just starting out or is restarting. Use your social media to be an inspiration. Call peers and suggest they read an interesting article that will help move their practice forward. Tell a few people in your personal life that you are proud of them. Revitalization means so much, especially this year, and MedMark is proud to be a catalyst for positive change. For our readers, our articles and webinars can help you gain or change perspective and move in new directions. For manufacturers and innovators, our marketing services can bring you the attention you deserve and the recognition you seek. Our motto this year is “Renew in 2022!” With our combined experience and insights, we can stride into the future together. For this issue, we put a new spin on the quote at the beginning of this perspective. “Last year, I survived. This year, I will thrive!” To your best success, Lisa Moler, Founder/Publisher, MedMark Media Orthodontic Practice US

Volume 13 Number 1

Publisher Lisa Moler lmoler@medmarkmedia.com Managing Editor Mali Schantz-Feld, MA, CDE mali@medmarkmedia.com Tel: (727) 515-5118 Assistant Editor Elizabeth Romanek betty@medmarkmedia.com National Account Manager Adrienne Good agood@medmarkmedia.com Sales Assistant & Client Services Melissa Minnick melissa@medmarkmedia.com Creative Director/Production Manager Amanda Culver amanda@medmarkmedia.com Marketing & Digital Strategy Amzi Koury amzi@medmarkmedia.com Digital Marketing Assistant Hana Kahn support@medmarkmedia.com Webmaster Mike Campbell webmaster@medmarkmedia.com eMedia Coordinator Michelle Britzius emedia@medmarkmedia.com Social Media Manager April Gutierrez socialmedia@medmarkmedia.com

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COVER STORY

Aligning with CandidPro™: a forward-thinking orthodontic system Dr. Lynn Hurst explains the benefits of this affordable and accessible orthodontic system

chieving a healthy smile that patients can be proud of — whether in terms of functional, clinical, or cosmetic correction — ideally should have as many barriers removed as possible. Yet approximately 75% of Americans could still benefit from orthodontic treatment.1 Compounding this imbalance, the U.S. orthodontic market is forecast to continue growing at a compound annual growth rate of 16.4% to an astonishing $6.17 billion by 2028, tripling the size of the current market.2 Manufacturers continue to innovate, bringing new solutions to address contemporary orthodontic challenges. In recent years, two major forces driving change have been reducing treatment time and improving comfort, with major strides having been made on both fronts. However, nothing has remotely approached the impact of direct-to-consumer (DTC) orthodontics. Scarcely more than a water-cooler topic a few years ago, as of 2020, DTC orthodontics has captured 32.2% of the U.S. market.3 This seismic shift in treatment delivery is being driven by a multitude of factors, but two have been identified as predominant. A recent study published in the American Journal of Orthodontics and Dentofacial Orthopedics (AJODO) identified consumers today as being influenced by cost and convenience more so than any other factors, including perceived quality of care.3 This unmet and growing demand for orthodontic treatment, coupled with expectations of convenience and low cost, signals a need for a new and innovative approach to efficiently correct malocclusions while maintaining high clinical standards.

Figure 1: Current U.S. population that could benefit from orthodontic treatment

Figure 2: CandidMonitoring™ device

Coordinating versus competing

on advanced biomechanics as opposed to attachments and an expansive full-arch technique over interproximal reduction (IPR). Consumer expectations regarding convenience and cost were achieved through incorporating, at no extra charge, CandidMonitoring™ remote telehealth service and hardware. The business model was remarkably successful, with revenues steadily increasing. Naturally, as a technology-based company, all things were measured, studied, and improved upon. Business intelligence and market surveys revealed that while cost and convenience were king, another major influence was impacting treatment acceptance — patients’ strong desire for a local provider to be involved with their treatment. In late 2020, CandidPro™ launched as a division of its parent company building upon the affordable, accessible, remote oversight to include direct and local clinical supervision. This new model put an emphasis on partnering with doctors versus competing with them. With a brand name that was trusted, thousands of 5-star reviews and the No. 1-rated teledentistry app in the app

In 2017, Candid launched as a DTC aligner manufacturer with a mission to improve access and affordability to specialist-driven orthodontic care. All treatment plans were designed by orthodontic specialists and guided by CandidRx™, a patent-pending treatment philosophy built over a 30-year period on the concepts of Damon, McLaughlin, Bennet, Trevisi, and Tweed. This prescription is minimally invasive in nature with a focus

Lynn Hurst, DDS, MS, FACD, received his BA from Southwestern University and his Doctor of Dental Surgery with Honors from the University of Texas Health Science Center at San Antonio. He’s also earned a Specialty Certificate in Orthodontics and Dentofacial Orthopedics from the University of Oklahoma Health Sciences Center and has completed his Phase III Board Certification. Dr. Hurst has actively practiced orthodontics for over 30 years, developing the principles behind Candid’s patent-pending CandidRx™ along the way. He is a cofounder of Candid and serves as their Chief Dental Officer.

Orthodontic Practice US

Volume 13 Number 1

COVER STORY

CandidRx™, and then returned to the doctor of record to request any modifications or to approve. Once the treatment plan is approved, clinicians can elect to have the aligners shipped to their office or go directly to the patient’s home, thereby eliminating even the insertion appointment. Everything is provided for the patient to begin treatment entirely remotely, and the doctor of record will be notified when his/her patient’s first scan is submitted.

store, uptake was quick.4 Today’s post-COVID-19 clinician evidently needed no convincing regarding the power and freedom that virtual consults provide. Fast-forward 12 months, and CandidPro had surpassed all projections and stretch-goals. In fact, CandidPro has grown 10 times in both case volume and revenue since Q3 of 2021.5 This has ultimately culminated in the recent January 2022 announcement that Candid is shutting down its DTC aligner business to focus strictly on the rapid growth of its professional CandidPro product.5

Practice building

The technology

This new tele-orthodontic treatment option is an exciting way to add a clear aligner service to an existing practice without requiring the purchase of any new equipment or expensive training. For those already offering clear aligner therapy, the transition to CandidPro requires little to no staff training to get started. Becoming a CandidPro partner comes with many perks. You will be assigned a dedicated account manager to help you identify opportunities in your practice to engage more patients while improving your case presentation and case acceptance rates. A practice immersion is scheduled over a 2-day period to observe, collaboratively design, and deliver an individual practice blueprint for success. Turnkey marketing support is included to help share the message internally within your practice as well as externally with a portfolio of assets designed for email, web, social media, and print marketing. The CandidPro doctor locator helps patients identify practices near them that have incorporated this new convenience-focused technology.

CandidPro is designed from the ground up based on clinical efficiency. Simple-to-use, automated technology eliminates many of the pitfalls responsible for the unnecessary visits, refinements, and extended treatment times common with legacy aligner systems. Finishing a case in as few as two office visits has now become an achievable reality. Carbon L1 commercial large format printers yield hyper-accurate 3D-molds surpassing benchmarks for orthodontic standards up to 600%.6,7 The aligner material used is next-generation Zendura™ FLX tri-layer polyurethane. The advanced properties of this newer polymer are a natural fit for teledentistry applications in three ways. First, the outer layer of the CandidPro aligner is designed for stain resistance, leading to improved esthetics and compliance in the event of an extended aligner wear interval.8 Second, initial force levels are 40% lower than other aligner materials leading to improved comfort and again maximizing compliance in the days surrounding aligner changes.8 Third, the real magic comes days later, evidenced by significantly greater retained force levels helping to fully express prescribed movements.8 Ironically, refinements and extra visits can actually be caused by a patient’s strict adherence to their prescribed treatment plan. Consider a patient instructed to advance aligners at a fixed but arbitrary interval, such as every 7 days, 10 days, or 14 days. This is common practice, yet it does not factor in many other critical variables. Medications, age, bone metabolism, and type of movement are just some of the variables known to affect aligner tracking. Fortunately, CandidMonitoring allows you to instruct patients to advance aligners only after adequate tracking with the treatment plan has been confirmed, rather than according to a rigid schedule that doesn’t adapt to biological and behavioral variables.9 Clinicians are able to enjoy visibility of treatment progress at every aligner stage, offering unprecedented oversight into compliance, tracking, and hygiene.

Benefits for every organization CandidPro represents a potentially game-changing opportunity for orthodontists who may not have embraced aligner therapy in its earlier days and feel too far behind to catch up. Orthodontists currently offering modalities and auxiliaries with premium lab fees based on advanced case complexity may consider CandidPro clear aligners to save time or expense on their

Figure 3: Candid — a brand built on trust and quality

The process CandidPro’s simplicity and customizable nature lead to increased same-day starts. Patients begin treatment with a simple consultation on their malocclusion. If the patient elects to proceed with treatment, records are taken. This involves collecting basic contact info, medical/dental history, the ABO-recommended eight photo array, as well as an X-ray and intraoral digital scan. It is worth noting that while digital scans are preferred, and all scanners are accepted, CandidPro is compatible with PVS impressions. Once all records have been taken, the case is submitted through the doctor portal. Treatment plans are developed under orthodontic supervision and the clinical framework of the orthopracticeus.com

Figure 4:. CandidApp

Volume 13 Number 1

COVER STORY

Figure 5: Aligner kit shipped to office or patient’s home

Figure 6: CandidPro™ system

routine cases. This could allow more time for collaboration and planning on their most complex cases. Prosthodontists can lean into CandidPro’s orthodontic specialist oversight while designing their patients’ complex multidisciplinary treatments. DSOs are finding that the CandidPro model delivers a host of tangible benefits. One of the hallmark strengths of a DSO is its ability to quickly pivot administrative and clinical support across its distributed network of locations. For the orthodontic patient, this has the potential to occasionally manifest as conflicting instructions or information received at aligner checks. CandidPro addresses this issue in the following three ways: 1. Treatment planning is standardized, centralized, and performed by state-licensed orthodontic specialists. 2. Aligner checks are performed remotely. 3. Communications are delivered with consistent instructions and an established escalation framework through the CandidApp. Together, these features drive consistency, predictability, and clinical continuity of care. Regardless of practice model, providers of orthodontic treatment are motivated to maximize patient compliance with treatment instructions. Therefore, some providers may be concerned that remote treatment monitoring may decrease their oversight of oral hygiene and appliance wear, particularly with removable appliances. Interestingly, oral hygiene, compliance with instruction, and clinical performance have each been shown to improve among patients utilizing modern app and AI-based telehealth technologies.10-13 In addition to reducing office visits, remote patient management technology has proven to truncate orthodontic treatment time as well.14 Whether operating as a solo practitioner or enterprise DSO, and whether considering business efficiencies or clinical standards, this model offers benefits for all.

The future is now Generation Z is in treatment with Gen Alpha gearing up to enter phase I now. With a projected threefold increase in the U.S. orthodontic market by 2028, there is no better time than now to familiarize with some of the latest technological advances in orthodontic treatment. The majority of today’s orthodontic patients were born with a smartphone in the room. Their first photo was likely digitally shared and remotely viewed within Orthodontic Practice US

seconds of birth. They expect convenience and demand value. They prioritize experience-related purchases that allow them to feel more socially connected. The team at CANDID has assembled a suite of intuitive technology that delivers what consumers want and practitioners need — time freedom and a better experience. The future of orthodontics is now. OP

REFERENCES 1.

American Association of Orthodontic Specialists (AAO) https://www3.aaoinfo.org/_/ press-room/ Accessed February 7, 2022

Fortune Business Insights. Medical Device / U.S. Orthodontics Market. https://www. fortunebusinessinsights.com/u-s-orthodontics-market-104039 Accessed February 7, 2022.

Okuda B, Tabbaa S, Edmonds M, Toubouti Y, Saltaji H. Direct to consumer orthodontics: Exploring patient demographic trends and preferences. Am J Orthod Dentofacial Orthop. 2021;159:210-216.

Apple App Store. CandidApp: Remote Monitoring. https://apps.apple.com/us/app/ candidapp-remote-monitoring/id1503232181. Accessed February 7, 2022.

“Candid, a pioneer in the clear aligner industry, closes its DTC offering and doubles down on its B2B CandidPro service” Candid Care Co. CISION PR Newswire. 24 Jan. 2022, https://www.prnewswire.com/news-releases/candid-a-pioneer-in-the-clear-alignerindustry-closes-its-dtc-offering-and-doubles-down-on-its-b2b-candidpro-service-301466235.html. Press release. Accessed February 7, 2022.

Etemad-Shahidi Y, Qallandar OB, Evenden J, Alifui-Segbaya F, Ahmed KE. Accuracy of 3-Dimensionally Printed Full-Arch Dental Models: A Systematic Review. J Clin Med. 2020;9(10):3357.

Carbon Inc. Carbon DLS Accuracy for Engineering Materials. https://www.carbon3d. com/resources/dls-101/carbon-dls-accuracy-for-engineering-materials/. Accessed February 7, 2022.

Bay Materials Inc. Introducing Zendura FLX. https://cdn.shopify.com/s/files/1/0084/ 9302/files/Zendura_FLX_brochure_2.26.21.pdf?v=1641782611. Accessed February 7, 2022.

Dental Monitoring SAS. How Dental Monitoring works. https://dental-monitoring.com/ dental-monitoring/. Accessed February 7 ,2022.

10. Zotti F, Dalessandri D, Salgarello S, et al. Usefulness of an app in improving oral hygiene compliance in adolescent orthodontic patients. Angle Orthod. 2016;86(1):101-107. 11. Farhadifard H, Soheilifar S, Farhadian M, Kokabi H, Bakhshaei A. Orthodontic patients’ oral hygiene compliance by utilizing a smartphone application (Brush DJ): a randomized clinical trial. BDJ Open. 2020;20;6(1):24. 12. Thurzo A, Kurilová V, Varga I. Artificial Intelligence in Orthodontic Smart Application for Treatment Coaching and Its Impact on Clinical Performance of Patients Monitored with AI-TeleHealth System. Healthcare. 2021;9(12):1695. 13. Bingham JM, Black M, Anderson EJ, et al. Impact of Telehealth Interventions on Medication Adherence for Patients with Type 2 Diabetes, Hypertension, and/or Dyslipidemia: A Systematic Review. Ann Pharmacother. 2021;55(5):637-649. 14. ]Li X, Xu ZR, Tang N, et al.. Effect of intervention using a messaging app on compliance and duration of treatment in orthodontic patients. Clin Oral Investig. 2016;20(8): 1849-1859.

Volume 13 Number 1

Treat more patients. Save more time. Earn more revenue.

Expert-designed, clinician-approved candidpro.com

TECHNIQUE

Simplifying the deimpaction of mandibular second molars Drs. Larry W. White and Francesca Scilla Smith offer a technique to simplify a complex and lengthy procedure Introduction Nothing slows the completion of orthodontic therapy as the failure of impacted mandibular second molars to erupt or achieve eruption through surgery and subsequent orthodontic intervention. Still, surgical intervention adds to the cost, trauma, and duration of treatment for the patient and doctor. Many clinicians have suggested several approaches to this continuing problem, and this article will review some of those techniques as well as illustrate a recent development that holds great promise in simplifying this difficult and time-consuming chore.

Figures 1A-1C: 1A. Deimpactor spring. 1B. Deimpactor in place. 1C. Deimpactor activated

Previous techniques Pool1 introduced an innovative and simple method of uprighting semi-impacted mandibular second molars in the 1970s; however, the second molar needs to have a measure of eruption, so the mechanism can be placed (Figures 1A, 1B, and 1C). At the dawn of bracket bonding in 1977, Rubin2 developed a technique that also required partial eruption of the ectopic erupting mandibular second molar. This took advantage of early bonding materials, and he was able to bond an auxiliary uprighting spring to the occlusal surface of the molar (Figure 2). In 1987, Orton and Jones3 suggested another tack for uprighting semi-impacted mandibular second molars that relied on the ability to bond a tube on the partially erupted second molar and, essentially, reversed the uprighting spring assembly of Rubin (Figure 3). One of the most novel ways of deimpacting ectopic erupting mandibular second molars was developed by Dr. Bach4 (Figures 4-8). Dr. Bach has created a nonsurgical method for uprighting ectopic molars that has an elegance and simplicity heretofore unseen. It neither requires special instrumentation nor depends on laboratory construction of a special appliance. Although the ectopic molar appears to contact the tooth it abuts, there is a

Figure 2: An illustration of the Rubin uprighting spring that bonded to the occlusal surface of a partially erupted mandibular second molar

Figure 3: An illustration of the Orton-Jones uprighting spring that bonded to the occlusal surface of the first molar and inserted into a tube bonded to the partially erupted mandibular second molar

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.

space between the two teeth that Dr. Bach exploits in an unusually effective manner. He depends on a highly flexible wire — usually a CuNiTi .016 — to elevate the ectopic molar with the following approach by inserting the short NiTi wire vertically along the distal marginal ridge of the first molar so that it clears the mesial marginal ridge of the impacted second molar. He then bends the visible vertical wire over the occlusion of the first molar and secures it with some compomer; e.g., Band Loc®, (Reliance Orthodontic Products).

Francesca Scilla Smith, DDS, MS, was born and raised in Arezzo, Italy. She graduated summa cum laude at 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.

Orthodontic Practice US

Volume 13 Number 1

Bringing Transformative Technology to Orthodontics Brius Technologies is a forward thinking innovation company on a mission to improve the orthodontic experience for the patient and the orthodontist.

Not braces Not aligners Independent Movers™

This patented biomechanical approach allows for independent and simultaneous movement and is hidden behind the teeth. Bespoke design leverages artificial intelligence to pre-program the precise moment and force for each tooth of each patient. The result is effective, efficient and aesthetic treatment.

TECHNIQUE

Figures: 4 and 5: 4. NiTi wire secured to anchor molar and placed beneath the marginal ridge of the ectopic molar. 5. X-ray of the impacted mandibular second molar

Figure: 7: Eight weeks of therapy

Figure: 6: NiTi wire is bonded to the occlusal surface of the mandibular first molar and engages the ectopic molar below its marginal ridge

Figures: 8 and 9: 8. Sixteen weeks of therapy. 9. A NiTi compressed open-coil spring uprights and pushes the partially erupted ectopic mandibular second molar distally

Dr. Bach uses wires as small as .013 CuNiTi but no larger than .014 x .025 CuNiTi and leaves the wire in until the target molar uprights, and he then bonds a tube to it. With the advent of miniscrews and bone plates, clinicians5,6 have developed multiple ways of using them as anchorage to upright and retract the impacted molar. Most of the techniques previously described require surgical uncovering or, at a minimum, the partial eruption of the impacted molar. Once either of those occurs, an attachment can be bonded, and several methods can retract the tooth. A popular and simple method is to add a NiTi open-coil spring to push the ectopic molar distally (Figure 9).

A new technique for uprighting and erupting ectopic molars

Figure 10: The piggybacked .014 NiTi wire (red) overlays the principal archwire (white) and extends distally approximately the width of the ectopic second molar

The technique described in this article offers an additional way of uprighting and retracting the molar without resorting to surgery and is similar in concept to the Bach technique, but avoids the occlusal bonding of the NiTi wire to the first molar. A .014 NiTi wire is piggybacked to the principal wire in the posterior quadrant (first molar, first and second premolars) and ligated with stainless steel wires plus O-rings (Figures 10-13). This wire extends beyond the first molar by the approximate width of the ectopic second molar. The clinician then holds the secured .014 NiTi with a hemostat or pliers and pushes it below the crown of the first molar, which will allow it to contact the mesial surface of the impacted molar’s crown (Figure 12). The panograph X-rays in Figures 12 and 13 illustrate the effect this wire had on the impacted molars in 5 weeks.

Figure 11: The piggybacked .014 NiTi wire (red) overlays the principal archwire (white) and is placed below the crown of the first molar so that it contacts the mesial surface of the second molar

Orthodontic Practice US

Summary The avoidance of surgery and a complete orthodontic solu-

Volume 13 Number 1

TECHNIQUE

tion to upright and erupt ectopic molars offers patients and doctors several advantages: • Avoids considerable trauma for the patient. • Avoids extra expense to orthodontic therapy. • Avoids the incomplete uncovering of the ectopic molar that can make the bonding of attachments difficult to impossible to do. • Avoids secondary uncovering. • Offers a relatively painless and rapid resolution to an ordinarily slow and difficult procedure. Orthodontic clinicians can apply this therapy without needing additional supplies. The auxiliary .014 NiTi wire securely

attaches to the principal wire and has little opportunity of breakage or loosening. One final caveat for clinicians — will this new method prove efficacious and efficient for every patient with ectopic erupting mandibular molars? Probably not. Still, based on the limited but impressive results so far, we remain optimistic about its potential to simplify one of the most complex and lengthy procedures that orthodontists encounter. OP REFERENCES 1.

Pool H. Orthodontic Pearls: A Clinicians Guide. White LW (ed). Taylor Publishing Co.; 2012.

Figures 12 and 13: 12. The initial panograph X-ray shows the unerupted and mesially inclined second molars. 13. The follow-up panograph X-ray shows the second molars’ 5-week response to the piggyback wires that acted as springs against the second molars. Note how the .014 NiTi wires touch the second molars

Rubin RM. Uprighting impacted molars. J Clin Orthod. 1977;11(1):44-46.

Orton H, Jones S. Correction of mesially impacted lower second and third molars. J Clin Orthod. 1987;21:176-181.

Bach RM. Non-surgical uprighting of mesially impacted lower molars. J Clin Orthod. 2011;45(12):679-681.

Tseng YC, Chen CM, Chang HP. Use of a miniplate for skeletal anchorage in the treatment of a severely impacted mandibular second molar. Br J Maxillofac Surg. 2007;46(5):406-407.

Zhen J, Liu CH, Zhang WX, et al. Uprighting deeply impacted mandibular second with miniscrew anchorage. J Clin Orthod. 2019;53(7):405-413.

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Volume 13 Number 1

TECHNIQUE

Bending superelastic archwires — the missing constituent of orthodontic therapy Dr. Suhail A. Khouri discusses the clinical benefits of wire bending Introduction

Mechanical and clinical benefits of wire bending

When superelastic archwires entered orthodontic practice, their 100% spring-back elastic property created the lightest and most consistent force delivery range, which exceeds by far the elasticity increase obtainable by wire bending. They revolutionized teeth alignment without loop bending. But the impossibility of bending those brittle wires posed the challenge of finding a special tool to activate them.1,2 This triggered the development of Bendistal pliers in 1995.3 These special pliers can insert permanent V-bends that activate those unbendable wires in all directions, leading to evolution of the new V-bend technique, which opened new potential in orthodontic therapies.4-11

The following factors determine levels of archwire elasticity, magnitudes, and continuity of force-delivery: 1. Metallurgic alloy structure of archwire exhibits its own specific level of elasticity. 2. Cross-sectional thickness. Wire that has a thinner cross section has a longer elasticity level and range than thicker wire, and vice versa. 3. Length of a wire. Longer wire has a higher level of elasticity and longer spring-back range than short ones, and vice versa. 4. Bending a wire extends its elasticity, creating lighter, more consistent force that moves teeth faster with less root resorption. 5. Bendability of a wire. Wire bending into appliances allows applying those forces in all directions.9,10 The structural elasticity properties of superelastic archwires negates the need for the four benefits of wire bending; however, their bending remains urgently needed to apply their lightest and most consistent forces in all directions on teeth. Bendistal and Omni pliers were specifically designed just to satisfy the fifth objective and resolve this mostly important requisite.11

How elasticity of wires creates and delivers orthodontic forces

Orthodontic force is created from the energy stored by deflecting an elastic wire to a position just before its deformation point. This force will be delivered to teeth when the deflected wire returns to its original position. Bending archwires into loops, helices, and springs aims primarily at extending the elasticity range of the distant part of the bent wire that will be engaged in the bracket’s slots. The position of this distant part of already bent wire, before being engaged in brackets, becomes the targeted final position of the teeth. So, the distance from the target position and the bracket, the bent part of the wire to be tied to, is called “activation range.” It is the same range of extended spring-back range after appliance bending. The “deactivation range” is the same spring-back range. The pushing or pulling force starts acting on tooth/teeth, consistently moving the teeth all the way until the elastic range expires, and the teeth reach the target position.

Measuring archwire’s elasticity The force magnitude required to deflect a wire a certain distance before it deforms is called “Load.” This maximum distance a wire can be deflected while maintaining full spring-back to its predefection position, is called “Deflection.” This is the distance along which orthodontic force is generated, delivered, and moves teeth with one adjustment. Relating the force magnitude over that distance makes the Load/Deflection ratio (L/D) ratio — the mathematical parameter that describes and measures the wire’s level of elasticity9 in gm, cm, or oz/inch. The lower value of this ratio indicates the wire’s higher elasticity that delivers lighter and more consistent force and moves teeth a longer distance with a single activation. A higher value of that ratio indicates that such wire has a lower level of elasticity, delivers stronger force magnitude, moves teeth a shorter distance, and requires frequent tying adjustments. Each wire’s metallurgic structure possesses its own level of elasticity (L/D rate) that distinguishes it from other kinds of wires.

Suhail A. Khouri, DDS, is a Diplomate of the American Board of Orthodontics (1988). He graduated from the orthodontic program at the University of Connecticut in 1980, taught at the University of Connecticut and King Saud University, and later served as a consultant orthodontist at King Faisal Specialist Hospital, Saudi Arabia (1980-1988). He maintained a private practice in Saint Louis, Missouri, from 1991 until he retired in 2015. Dr. Khouri is the inventor and developer of the new Bendistal pliers, (USA patent number 5, 395,236 March, 7, 1995), the first and only pliers that bend and activate the brittle unbendable superplastic archwires. Its clinical use simplified many old orthodontic treatment techniques with highly efficient new ones. He is also the inventor and developer of the Omni pliers (USA, patented 2015), which replace all shapes and functions of the two-paired Bendistal pliers into one pair of pliers. Dr. Khouri is the developer of the new and advanced V-bend technique that simplified many known challenging orthodontic malocclusions. He has published many articles and lectured about this technique in the United States and overseas.

Orthodontic Practice US

Properties of superelastic wires • Are brittle and unbendable (break upon acute sharp bend angle) and lose activation when bent in an obtuse angle. • Have a 100% spring-back elasticity range that can move teeth the longest distance with just one tying adjustment.

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TECHNIQUE

V-bends can bend distal ends, tip back molars, and step-up/stepdown, and intrude/extrude teeth. Transversely oriented V-bends activate archwires extraorally for step out/in, and arch expanding bends. The Omni Pliers is a new generation of Bendistal pliers that combines the exact jaw shapes and versatile functions of both pairs of Bendistal pliers into one pair of pliers.

• Have the lowest L/D rate value ever produced (delivers the lightest and most consistent force delivery). • Maintain full activation range upon full wire-to-brackets engagement.7,10 • Move teeth the longest distance with least number of adjustments in fastest treatment time.12,13

Description of the Bendistal and Omni pliers (Figure 1)

Which bends can activate NiTi wires? Because of the brittleness and superelasticity of NiTi wires, traditional pliers make bends that are shallow, quickly spring back, and lose their force-delivering ability. Inserting a permanent bend in those nonmalleable wires requires that the pliers’ bending jaws be V-shaped, not round. Bendistal and Omni pliers’ jaws design makes the bending of NiTi wires possible. The crucial requirements for inserting the successful bends in superelastic archwires follow: 1. Inserting a permanent V-bend capable of delivering light and consistent force requires that the tip of the bend must be sharp. 2. The angle of the V-shaped bend must be not too acute to break the brittle wires or too obtuse to lose its force-delivering activation. 3. The bend must hold on after forcefully engaging bent wire in bracket slots. 4. V-bends must be inserted correctly at the first attempt. Attempting to repair a wrong bend will break the archwire, requiring replacement.

Bendistal pliers’ jaws make a 45° angle to its long axis for easy intraoral manipulation and accessibility behind molar tubes. Each plier has two jaws — the occlusal jaw has a V-shaped trench, and the gingival jaw has a V-shaped gingival wedge that fits snugly in it to insert the lasting bends. A simple squeeze of those jaws will produce an optimal unbreakable activating bend. The two pairs of pliers insert V-bends in superelastic archwires in four quadrants of mouth, without annealing, breakage, or over twisting. One pair of pliers is designated to insert bends in the upper left and lower right mouth quadrants (UL-LR); and the other pair bends NiTi archwires in the upper right and lower left mouth quadrants (UR-LL). Engraved letters on both pairs of pliers help clinicians identify the correct pair that bends the archwire in the intended quadrants. Placing the pliers’ jaws around tied archwires determines the orientation of the inserted V-bend and its mechanical effect on the segments of teeth. Also, the location of the bend on the archwire determines the direction and planes of teeth segment movements as well. Vertically oriented intraoral

Inserting correct bends in straight NiTi wires (Figure 2) Bendistal and Omni pliers’ jaws were optimally designed to insert successful unbreakable lasting V-bends, which do not dissipate upon bracket tying. Orienting these bends in the correct locations — the wire’s line and imaginary plane that moves teeth in the planned path — poses a challenge. This requires observing certain specific rules that instruct the correct orientation of the pliers’ jaw snout to lines and planes of archwires. These rules ensure inserting the correct bends that activate to apply their forces in the prescribed paths of teeth movements (Figure 2). Round and rectangular wires tend to slip during the bending process due to their elasticity and brittleness. This difficulty can be overcome by grabbing the wire in a correct orientation with a firm grip before squeezing plier jaws. If the wire slips after a loose grip, the bend will activate the wire in a wrong path of tooth movement. Rules that ensure inserting correct V-bends in all planes follow: 1. The pliers’ jaws must grab the wire with a firm grip at a right angle (Figure 2C) 2. If the wire slips while bending due to lose grip, the bend will result in an obtuse or acute angle, activating the wires in a wrong direction and moving the teeth in unwanted oblique planes (Figures 2A and 2B).

Figure 1: Each of the two-paired Bendistal pliers set (left) have opposite jaw configurations that determine the V-bend direction it places on an archwire. The engraved letters on each pair identifies the two mouth quadrants each pair of Bendistal pliers serves. The one-paired Omni pliers (right) has two occlusal V-shaped trenches and one double-sided rhomboidal-shaped gingival wedged jaw, which produce opposite directional bends replacing the two pairs of Bendistal pliers

Inserting correct vertical intruding bends in preformed NiTi archwires (Figures 3 and 4)

Figures 2A-2C: Illustrates UL-LR pliers’ occlusal jaw placed under straight wire during the bending process. 2A and 2B. Wrong wire-to-jaw snout angles resulting in deflecting bent parts of the wires in wrong direction (in red) and planes, away from wire’s straight-line continuity. 2C. Shows the correct 90° angle of wire-to-snout relationship that deflects the bent part of the wire in line and in a plane with the rest of the wire’s line

Orthodontic Practice US

When inserting intrusion vertical bends in maxillary preformed NiTi archwire in the upper left quadrant, follow these rules: 1. Place the occlusal jaw of UL-LR Bendistal pliers under and in line with the imaginary archwire’s plane.

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TECHNIQUE

2. Pointing the tip of pliers’ jaws down or up to the archwire plane will deflect bent wire in a wrong oblique unwanted plane (Figures 3A and 3B). 3. Incorrect angle relation of the pliers’ snout to the archwire plane deflects wire in an incorrect intruding V-bend (Figures 3A and 3B). 4. Only observing the 90° angle rule to wire line, with jaws’ snout in line with archwire’s plane, produces correct intruding bend (Figure 4C).

Inserting transverse bends To insert correct transverse V-bends that activate NiTi wires, the pliers’ snout must make a 90° angle to the archwire’s imaginary plane. At the same time, the snout should make a right

Figures 3A-3C: Inserting intrusive V-bends on maxillary preformed archwires. 3A. When occlusal jaw of Bendistal or Omni pliers is placed under the archwire plane, making an obtuse anterior angle with the line of the archwire, the resulting V-bend deflects wire up, but out in a wrong plane (in yellow). 3B. When the occlusal jaw snout makes acute angle with wire line, the bent part deflects up but in a wrong inward plane to archwire’s plane and line. 3C. The correct grip right angle between snouts to wire line will deflect the wire correctly and in a vertical plane to the archwire’s plane. For horizontal V-bends, step-in/step-out and crossbite midline bends, the snout of the pliers’ jaws should make a right angle with the imaginary plane of the preformed archwire. Otherwise, the wire deflection will cause extrusion or intrusions of the affected teeth in unwanted oblique directions

angle with the archwire’s line sideways and anterio-posteriorly. Those two requirements ensure inserting bends in line with the archwire’s plane and wire’s line. Any deviation from that rule results in activating the bends in a different plane than the archwire’s. These bends are used to correct crossbites (expanding and constricting dental arches). Such bends include midline bends, canine constrictive or expanding bends, step-out, step-in bends, and mushroom bends (Figure 4A-4C).

Types of vertical intraoral V-bends After clinicians master the preceding bending rules, extraorally, they can insert correct V-bends intraorally to activate tied NiTi archwires in the vertical direction. These bends include cinch-back bends without annealing; molar tip-back, anchorage, and space-regaining bends for second premolar eruption; and intrusion bends for anterior and posterior teeth segments (Figures 5A and 5B). When making intraoral V-bends, clinicians must observe all previously mentioned rules for correct lasting bends in a plane perpendicular to the archwire’s plane. Any oblique tilt of the pliers’ jaws before squeezing the pliers’ jaws will result in a wrong wire deflection that moves teeth in an unwanted oblique direction. For both mandibular and maxillary molar’s cinch-back, tip-back, and incisor segments intrusion, place the pliers’ occlusal jaw occlusal to the wires; and gingival jaw gingival to the wire. All intrusive bends produced must always have their sharp tip point occlusally. Reversing jaws, positions will result in forward molars tipping and incisor teeth extrusion, which may be used in closing open bites.

Discussion This article introduces, for the first time, guidelines and instructions to help clinicians insert correct bends in those known-unbendable wires, and orient them in relation to archwire’s lines and imaginary planes to move teeth in the exact prescribed paths of movements. OP REFERENCES

Figures 4A-4C: Samples of types of V-bends possible in superelastic archwires. 4A. Shows crossbite, midline expanding, and constricting bends. 4B. Shows transverse bends: step-out/step-in, and mushroom bends. 4C. Shows vertical bends: cinch-back; step-up/step-down, and intrusion bends

Figures 5A-5C: Shows examples of V-bends that turn regular tied NiTi archwires into instant and effective appliances without customizing multilooped-bends necessary in stainless steel archwires. 5A. Shows possibility of placing intraoral bends in distal end behind molar tube and molars tip-back bends in NiTi archwires, which helps erupt second premolars. 5B. Shows the intrusive effect of V-bends inserted intraorally behind canine areas of maxillary and mandibular archwires. In this case, the activated archwires were left in place for an extended period of time, resulting in overtreatment. 5C. Shows insertion of extra V-bends in both maxillary and mandibular archwires to tipback molars and protects their anchorage, and helps erupting blocked second premolars. This force system’s intrusion of incisors and extrusion of canines and premolars enhance teeth disengagement, which allows easy mandibular incisors retraction and Class III treatment without orthognathic surgery

Orthodontic Practice US

Nakano T, Hotokezaka H, Hashimoto M, et al. Effects of different types of tooth movements and force magnitude on the amount of tooth movement and root resorption in rats. Angle Orthod. 2014;84(6):1079-1085.

Khier SE. Bending properties of superelastic and nonsuperelastic nickel-titanium orthodontic wires. Am J Orthod Dentofacial Orthop. 1991;99(4):310-318.

Khouri SA. The Bendistal pliers: a solution to distal end bending of superelastic wires. Am J Orthod Dentofacial Orthop. 1998;114(6):675-676.

Burstone CJ, Koenig HA. Creative wire bending—the force system from step and V bends. Am J Orthod Dentofacial Orthop. 1988;93(1):59-67.

Quick AN, Lim Y, Loke C, et al. Moments generated by simple V-bends in NiTi wires. Eur J Orthod. 2011;33(4):457-460.

Lopez I, Goldberg J, Burstone CJ. Bending characteristics of nitinol wires. Am J Orthod. 1979;75:(5):569-675.

Miura F, Mogi M, Ohura Y, Karibe M. The superelastic Japanese NiTi alloy wire for use in Orthodontics, Part III. Studies on the Japanese NiTi alloy coil springs.. Am J Orthod Dentofacial Orthop. 1988;94(2):89-96.

Miura F, Mogi M, Okamoto Y. New application of superelastic NiTi rectangular wire. J Clin Orthod. 1990;24(9):544-548.

Goldberg A.J, Morton J, Burstone CJ. The flexure modulus of elasticity of orthodontic wires. J Dent Res. 1983;62(7):856-858.

10.

Jiang JG, Han YS, Zhang YD, et al. Spring back mechanism analysis and experiment on robotic bending of rectangular orthodontic wire. Chin J Mech Eng. 2017;30:1406-1415.

11.

Khouri SA. Using the Bendistal Pliers for Correction of Common Orthodontic Problems. World J Orthod. 2002;3(2):172-174.

12.

Ronay F, Kleinert W, Melsen B, Burstone CJ. Force system developed by V bends in an elastic orthodontic wire. Am J Orthod Dentofacial Orthop. 1989;96(4):295-301.

13.

Weltman B, Vig KWL, Fields HW, Shanker S, Kaizar EE. Root resorption associated with orthodontic tooth movement: a systematic review. Am J Orthod Dentofacial Orthop. 2010;137(4):462-476.

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TECHNOLOGY

Let the dentist know what you can do Dr. Robert Kaspers notes that interaction between dentists and orthodontists can result in more effective treatment

nfortunately, dental schools do not educate general dentists on why certain patients need orthodontists. And aligner companies’ marketing has done a phenomenal job in informing general dentists about how easy it is to move teeth with aligners. Unfortunately, the dentist is not educated to the limitations of aligners in treating the three dimensions (anterior-posterior, transverse, and vertical). Diagnosis is everything when it comes to getting a successful orthodontic result. With the advent of CBCT scans, analysis of the three dimensions is easier than ever. With the proper imaging for accurate diagnosis, Figure 1: Diagnosis flow chart general dentists and orthodontists can recognize which patients can benefit from aligner therapy and which need an orthodontic specialist for the more effective treatment for the patient. The diagnosis flow chart (Figure 1) displays all the areas that a 3D radiograph can explore and gain valuable information to complete an accurate diagnosis. Without a CBCT scan, the dentist or orthodontist has no idea if the condyles are properly seated in the glenoid fossa. What may appear “clinically” to be an easy adjustment with an aligner may actually be a clinical symptom of a much bigger concern. The patient in Figure 2 had braces by an orthodontist and, unfortunately, began having headaches and pain with her masseter muscles. The CBCT scan showed both condyles to be in a retruded-and-down condylar position. Because the orthodontist did not take a CBCT scan on the patient, he was unaware that Figure 2: Patient after braces. CBCT scan shows both condyles in a retrudedand-down condylar position the patient was fulcrumming around posterior interferences to achieve maximum intercuspation. The advent of 3D technology has allowed the clinician to detect vertical discrepancies in a patient’s occlusion. Prior to the CBCT scan, the clinician could determine the patient’s condylar position by mounting the case on a SAM II articulator utilizing a CPI (condylar position indicator).1 However, the process was too labor-intensive requiring a highly skilled clinician. An increase in the vertical dimension of the superior joint space informs the clinician that the patient is fulcrumming around a posterior interference. Roth defined the fulcrum as a condition in which the condyle distracts away from the eminence when the mandible closes into maximum intercuspation.2 When we talk about the “vertical dimension,” we must address it in two areas:

Robert Kaspers, DDS, received his Doctorate of Dental Surgery with honors from the University of Michigan. He then completed specialty training in orthodontics at the Northwestern University Dental School and earned a Master of Science degree in Radiology. While in Ann Arbor, Dr. Kaspers worked with Dr. Major Ash on research projects pertaining to temporomandibular dysfunction. Dr. Kaspers has lectured to hundreds of dentists and orthodontists on diagnosis and treatment for both orthodontic and TMD cases. He is the founder of the Five Condylar Positions©, which has helped make diagnosing and treatment planning easier for the practitioner. He is the founder of ProActive Orthodontics, and it is his desire to help the profession understand the advantages of the CBCT scan machine so that diagnosis of orthodontic cases can be made more easily and more accurately. Currently, Dr. Kaspers maintains a private orthodontic and TMD practice in Northbrook, Illinois.

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TECHNOLOGY

1. the vertical dimension with the condylar position in the glenoid fossa 2. the vertical dimension in the patient’s occlusion The patient pictured in Figure 2 had both condyles in a retruded-and-down position, which means there was an increase in the superior joint space. Loading the temporomandibular joints properly with a bite plate seated the condyles in the glenoid fossae. However, changing the vertical discrepancy in the glenoid fossa will change the vertical dimension in the patient’s occlusion. One affects the other as you can see in Figure 3. Seating the condyles with a properly constructed bite plate produced an anterior open bite. Most importantly, an orthodontist must inform the dentist that correction of the “fulcrum effect” must be achieved in adult patients by properly loading the temporomandibular joints throughout orthodontic therapy. Without maintaining a seated condylar position throughout treatment, the patient will attempt to acquire maximum intercuspation for stability. If patients are allowed to “fulcrum around a posterior interference” during their orthodontic therapy, there is an excellent chance that the clinician will not acquire a seated condylar

position at the end of treatment. The clinician must understand that an oral appliance such as a bite plate, splint, or a custom NTI may be utilized to help maintain a seated condylar position and a healthy musculature during orthodontic therapy (Figure 5). Intrusion of the maxillary molars can eliminate the fulcrum point and allow the mandible to auto-rotate closed. An MRI scan of an adult fulcrumming around a posterior interference will usually show an increase in tissue surrounding the disc. The body does not leave a void when the condyle distracts away from the eminence. Instead, it fills the void with tissue, which will maintain the “retruded-and-down” position. Hand manipulation may get the clinician close to seating the condyle within the glenoid fossa, but the condyle will not remain seated as the tissue influences the position of the condyle. The MRI scan (Figure 4) shows both temporomandibular joints of a patient possessing discs that are at the 12:00 position. The patient’s right condyle is in a centered-and-down condylar position, while the left condyle is forward on the eminence. The MRI scan shows the anterior joint space twice as wide with the centered-and-down condylar position as compared to the condyle forward on the eminence. The information gained from an MRI scan is extremely helpful in verifying disc position as well as whether or not inflammation is present within the joint complex. However, the CBCT scan is more helpful to the orthodontist because the clinician can assess whether or not the condyle is seated in the glenoid fossa as explained by Ikeda3 but can also evaluate how the condylar position affects the patient’s occlusion and vice versa. The two CBCT scans in Figures 6 and 7 were taken 2 minutes apart with and without a maxillary occlusal splint. The patient had been receiving splint therapy for months, and the CBCT scan verified a seated condylar position (Figure 6). A second CBCT scan was taken immediately after the first scan to evaluate the vertical Figure 3: Changes in the condylar position will produce changes in the patient’s occlusion

Figure 4: MRI scan

Figure 5: With an oral appliance

Orthodontic Practice US

Volume 13 Number 1

TECHNOLOGY

discrepancy. The maxillary occlusal splint was removed, and the patient was asked to close down into maximum intercuspation (Figure 7). These two CBCT scans clearly show the clinician how a scan can become a “functional radiograph.” By taking the CBCT scan in MIP, the clinician gets to see how the patient’s occlusion and musculature can influence the condylar position. Having an understanding of the condylar position helps the orthodontist treat the dentist’s patients to a seated condylar position. Correction of the vertical discrepancy shown in this last patient cannot be corrected with aligner therapy. Dentists need to be informed by their orthodontists that intrusion mechanics should be utilized to correct the vertical dimension. If your referring dentists do not possess a CBCT scan, you should take them out to lunch, so you can show them how the CBCT scan can help diagnose their patients correctly. OP

Figure 6: With the maxillary occlusal splint

REFERENCES 1.

Cordray FE. Three-dimensional analysis of models articulated in the seated condylar position from a deprogrammed asymptomatic population: a prospective study. Part 1. Am J Orthod Dentofacial Orthop. 2006;129(5):619-630.

Roth RH, Rolfs DA. Functional occlusion for the orthodontist. Part II. J Clin Orthod. 1981;15(2):100-123.

Ikeda K, Kawamura A. Assessment of optimal condylar position with limited conebeam computed tomography. Am J Orthod Dentofacial Orthop. 2009;135(4):495-501.

Figure 7: Without the maxillary occlusal splint

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RESEARCH STUDY

Introduction Spacing is a main concern that can hamper the patient’s esthetics. Space closure, whether in the anterior or the posterior region, is a major concern. Spacing in the anterior region might affect the self-esteem of the patient, and spacing in the posterior region might hamper the function and become traumatic, ultimately damaging the gingiva and the oral structures.

Figure 2: Case No. 1 — patient showing generalized spacing

Aims and objectives To compare and evaluate the perspective of the general dentist to treat space closure — orthodontic, restorative, or prosthetic.

Materials and methods

Figure 1: Questionnaire

Two patient images — case No. 1 and case No. 2 (one male and one female) — with different types of spacing were provided to a set of 30 general dentists to evaluate the type of modality that they would prefer to use for the closure of the spaces.

Statistical analysis and results A total of 161 general dentists participated in this survey. Vishal Parashar, BDS, MDS, is a private practitioner in Mumbai, India. Rupali Balpande, BDS, MDS, is a private practitioner in Nagpur, India. Amil Sharma, BDS, MDS, is a senior lecturer in the Department of Conservative Dentistry and Endodontics, Maharana Pratap College of Dentistry and Research Center, Gwalior, Madhya Pradesh, India. Dr. Sharma is a private practitioner and consultant endodontist in Gwalior, Madhya Pradesh. Snehal Markandey, BDS, received his degree from Government Dental Hospital and College (GDC), Aurangabad, India. Neetish Shriram Chavhan, BDS, MDS, is a senior lecturer in Department of Conservative Dentistry and Endodontics, VYWS Dental College and Hospital, Amravati, India. Gayatri Deshmukh, BDS, MDS, Department of Conservative Dentistry and Endodontics, VYWS Dental College and Hospital, Amravati, India (postgraduate student)

Orthodontic Practice US

Figure 3: Case No. 2 — patient showing spacing in the upper anterior region

These general dentists’ experience in practicing dentistry ranged from 1 to 26 years.

Discussion The results for case No. 1 have shown that majority of the dentists believed that the space closure could be performed using the orthodontic method, which accounted for around 57.14% of the responses. The results for case No. 2 have shown that the majority of the dentists believed that space closure can be performed using a restorative procedure, which accounted for about 49.68% of the responses.

Conclusion The research study concluded that the majority of general dentists would opt for the orthodontic method of space closure when the spacing is more generalized. For very minor spacing or a midline diastema, general dentists prefer restoration as a method of treatment.

Introduction Excess space in the dental arch is diagnosed as generalized spacing or a local divergence. This is often observed in the maxillary anterior region as median diastema, traumatic loss of central incisors, or congenital absence of lateral incisors. Spacing in the posterior region of the jaw may be due to congenitally missing

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RESEARCH STUDY

tooth/teeth or excessive proclination of the anterior teeth, which causes drifting of the posterior teeth into the available spaces and impaction of adjacent tooth. Interdental spacing in the anterior or the posterior regions of the mouth can present a challenge to the attending clinician for restoring esthetics and function. In such instances, an interdisciplinary approach is necessary to evaluate, diagnose, and resolve esthetics.1 Perception is “the process or result of becoming aware of objects, relationships, and events by means of the senses, which includes such activities as recognizing, observing, and discriminating.2 Once the etiology is known, a decision must then be taken whether to utilize a multidisciplinary approach or to simply close the spaces by means of direct and/or indirect restorative treatment.3

Table 1: Case No. 1 — dentists’ responses SR. NO.

Treatment modality

Dentists’ responses

% of responses

Orthodontic

57.14%

Restorative

14.28%

Prosthetic

28.57%

Table 2: Case No. 1 — bar graph representing dentists’ responses for treatment modality

Aims and objectives

Table 4: Case No. 1 — dentists’ responses

To compare and evaluate the perception of the general dentist to determine how space closure can be treated — orthodontically, restoratively, or prosthetically.

Materials and methods In this era of modernization and technology, communication has taken a fast-forward step through the availability of various communications methods, including social media like WhatsApp, Facebook, and Twitter, among others. Other methods include various search engines — e.g., Google, Bing, Wiki.com, and other mass media devices such as computers, cellphones, and tablets. A questionnaire was created using the Google form (Figure 1). This form consisted of intraoral frontal photographs of two patients (Figures 2 and 3). One patient consisted of generalized spacing, and the other patient consisted of a midline spacing. This form was circulated among general dentists across the state of Maharashtra, India, using mass media and social media applications — e.g., WhatsApp, Facebook Messenger, and general SMS. The dentists were provided with the questions, which included their choice of treatment modality for space closure, and were asked to mention the reason for selecting the specific treatment.

Statistical analysis and results A total of 161 general dentists participated in this survey type of research study. Their experience in practicing dentistry ranged from 1 to 26 years; they belonged to various locations throughout Maharashtra, India. A comparative study was done for the received values from the various general dentists represented by a simple bar graph for the maximum and the minimum responses obtained.

Table 3: Case No. 1 — bar graph representing dentists’ responses to the selection of a particular factor for the specific treatment

SR. NO.

Factor

Dentists’ responses

% of responses

Time

21.11%

Cost

7.78%

Esthetic

103

38.14%

Stability

32.96%

Table 5: Case No. 2 — dentists’ responses SR. NO. 1. 2. 3.

80Treatment modality

Dentists’ responses

% of responses

Orthodontic

29.81%

49.68%

20.49%

60Restorative Prosthetic

Table 6: Case No. 2 — bar graph representing dentists’ responses for treatment modality

Table 8: Case No. 2 — dentists’ responses

SR. NO.

Time Table 7: Case No. 2 — bar graph representing dentists’ responses to the selection of a particular factor for the specific treatment

Orthodontic Practice US

Volume 13 Number 1

Factor

1. Time Esthetic

Dentists’ responses 116 Stability

% of responses 21.56%

Cost

19.36%

Esthetic

125

30.63%

Stability

28.43%

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RESEARCH STUDY

For case No. 1 (Figure 2), which included the preference of the treatment modality to be used for the closure of the space, the majority answered with preference for the Orthodontic (Table 1 and Table 2) modality. For the same question, the reason for the selection of a particular modality indicated that most of the general dentists reasoned Esthetics (Table 3 and Table 4) and Stability (Table 3 and Table 4) to be the major criteria. Similarly, for the next patient — case No. 2 (Figure 3) — the majority of the general dentists suggested that the patient would benefit from Restorative (Table 5 and Table 6) treatment. The reason for this modality selection was Esthetics and Time (Table 8).

was indicated by orthodontic treatment, which was actually done using restorative treatment.3 Subjects voted for space closure with orthodontic treatment as the most attractive smile, and the similar cases received a higher response by dental professionals as compared to the patients and laypeople. Treatment, absence of diastema, and symmetry were the most accepted characteristics by all categories of respondents. Extensive literature is available that discusses the perception concept and the ways to treat it according to various departments — including prosthetic, cosmetic, and orthodontic closure of spaces. This literature indicates that perception of space closure is a multidisciplinary approach.9-20

Discussion

Conclusion

The results for case No. 1 have shown that majority of the dentists believed that the space closure could be performed using the orthodontic mean, which accounted for around 57.14% of the response. The reason of selection of this mode was esthetics and stability, which accounted for 38.14% and 32.96%, respectively. The results for case No. 2 have shown that majority of the dentists believed that space closure could be performed using the restorative procedure, which accounted for about 49.68% of the responses. The reason that the majority of clinicians voted for the selection of this technique was Esthetics, which accounted for 30.63% of responses, and for time, which accounted for 21.56% of the responses. A review of the past literature noted a difference of opinion among the group of people selected, whether it be students, dental professionals, or laypeople. Differences in responses to viewing a particular case created a wide variety of opinions for the same case. Ribeiro, et al., (2004) performed a study with the help of a questionnaire format to understand the perceptions of 20 dentists, 20 dental students, and 20 laypeople about the use of sedatives in a dental environment.4 The study concluded that only a few participants in any of the three categories felt confident about the topic. The group consisting of laypeople were optimistic, while dentists and students showed insufficient exposure to the subject at school. Mota and Pinho (2015) performed a study to understand the perception toward a smile in maxillary lateral incisor agenesis (MLIA) cases treated by protracting a canine.5 The most attractive results for MLIA treatment showed that unilateral dental and gingival reshaping was most significant. The subjects in all of the groups felt that simple reshaping of the tooth structure was more than sufficient for Esthetics. When the images of the unilateral and bilateral MLIA were analyzed together, the study found that dental and gingival reshaping was more attractive than the unmodified one. The Taibah study (2018) explored dental patients’ perception toward dental professionalism and then compared their views to dental professionals’ views.6 Patients’ and dentists’ views toward dental professionalism and professional behavior was found to vary in certain aspects. These differences in the opinion must be addressed and understood to provide for better dental treatment in the future. The Rosa, et al., (2013) study sought to understand the difference in opinions among various subjects on the images of the patients’ altered smiles due to missing maxillary lateral incisors with or without treatment.7 An interdisciplinary approach, combining restorative treatment along with orthodontic treatment, has also been mentioned in the literature as a procedure for space closure.8 The literature shows case reports whereby space closure Orthodontic Practice US

General dentists showed a different perception for space closure, whether it be in the anterior or the posterior region of the oral cavity. The majority of the general dentists opted for orthodontics as a method of space closure when the spacing is more generalized. For very minor spacing or a midline diastema, general dentists preferred selecting restoration as a method of treatment. From the research study presented here, major spacing, esthetics, and stability are the deciding factors; however, for minor spacing, esthetics and time are the major factors. Ultimately, any treatment is the dentists’ decision after taking into consideration the patients’ requirements and needs. OP REFERENCES 1.

Park JH, Tai K, Kanao A, Takagi M. Space closure in the maxillary posterior area through the maxillary sinus. Am J Orthod Dentofacial Orthop. 2014 ;145(1):95-102.

APA Dictionary of Psychology: “Perception.” https://dictionary.apa.org/perception. Accessed January 13, 2022.

Goyal A, Nikhil V, Singh R. Diastema closure in anterior teeth using a posterior matrix. Case Rep Dent. Published online October 13, 2016. doi: 10.1155/2016/2538526. Accessed January 13, 2022.

Costa LR, Dias AD, Pinheiro LS, et al. Perceptions of dentists, dentistry undergraduate students, and the lay public about dental sedation. J Appl Oral Sci. 2004;12(3):182-188.

Mota A, Pinho T. Esthetic perception of maxillary lateral incisor agenesis treatment by canine mesialization. Int Orthod. 2016;14(1):95-107.

Taibah SM. Dental professionalism and influencing factors: patients’ perception. Patient Prefer Adherence. 2018;12:1649-1658.

Rosa M, Olimpo A, Fastuca R, Caprioglio A. Perceptions of dental professionals and laypeople to altered dental esthetics in cases with congenitally missing maxillary lateral incisors. Prog Orthod. 2013;14:34.

Hwang SK, Ha JH, Jin MU, Kim SK, Kim YK. Diastema closure using direct bonding restorations combined with orthodontic treatment: a case report. Restor Dent Endod. 2012;37(3):165-169.

Proffit WR, Fields HW Jr, Sarver DM. Contemporary Orthodontics. 4th ed. Mosby; 2007.

10.

Misch CE. Contemporary Implant Dentistry. 2nd ed. Mosby; 1999.

11.

Van der Geld P, Oosterveld P, Van Heck G, Kuijpers-Jagtman AM. Smile attractiveness: self-perception and influence on personality. Angle Orthod. 2007;77(5):759-765.

12.

Klages U, Zentner A. Dentofacial aesthetics and quality of life. Semin Orthod. 2007;13(2): 104-115.

13.

Miller CJ. The smile line as a guide to anterior esthetics. Dent Clin North Am. 1989;33(2): 157-164.

14.

Thomas M, Reddy R, Reddy BJ. Perception differences of altered dental esthetics by dental professionals and laypersons. Indian J Dent Res. 2011;22(2):242–247.

15.

Mokhtar HA, Abuljadayel LW, Al-Ali RM, Yousef M. The perception of smile attractiveness among Saudi population. Clin Cosmet Investig Dent. 2015;7:17-23.

16.

Abu Alhaija ES, Al-Shamsi NO, Al-Khateeb S. Perceptions of Jordanian laypersons and dental professionals to altered smile aesthetics. Eur J Orthod. 2011;33(4):450-456.

17.

Mehl C, Wolfart S, Vollrath O, Wenz HJ, Kern M. Perception of dental esthetics in different cultures. Int J Prosthodont. 2014;27(6):523-529.

18.

Isiksal E, Hazar S, Akyalçin S. Smile esthetics: perception and comparison of treated and untreated smiles. Am J Orthod Dentofacial Orthop. 2006;129(1):8-16.

19.

Oesterle LJ. Shellhart WC. Maxillary midline diastemas: a look at the causes. J Am Dent Assoc. 1999;130(1):85-94.

20.

Romero MF, Babb CS, Brenes C, Haddock FJ. A multidisciplinary approach to the management of a maxillary midline diastema: A clinical report. J Prosthet Dent. 2018. 119(4):502-505.

Volume 13 Number 1

AUTHOR GUIDELINES

How to submit an article to Orthodontic Practice US Orthodontic Practice US is a peer-reviewed, quarterly 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.

ance 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:

Submitting articles

Journals: (Print) White LW. Pearls from Dr. Larry White. Int J Orthod Milwaukee. 2016;27(1):7-8.

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 2,400 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 orthodontics. 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

Pictures/images

(Online) Author(s). Article title. Journal Name. Year; vol(issue#):inclusive pages. URL. Accessed [date]. Or in the case of a book: Pedetta F. New Straight Wire. Quintessence Publishing; 2017. Website: Author or name of organization if no author is listed. Title or name of the organization if no title is provided. Name of website. URL. Accessed Month Day, Year. Example of Date: Accessed June 12, 2011. Author’s name: (Single) (Multiple) Doe JF Doe JF, Roe JP

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Volume 13 Number 1

CONTINUING EDUCATION

Practical considerations for utilizing Prescription Drug Monitoring Programs (PDMPs) — a primer Nikki Sowards, PharmD; Michael O’Neil, PharmD; and Tyler Dougherty, PharmD; discuss how prescription drug monitoring programs play an important role in monitoring controlled substances Introduction Although not first-line therapy, prescription opioids play an important role in the management of acute dental pain. However, all medications carry risks, which in the case of opioids can lead to misuse, physiologic dependence, and diversion. Additionally, opioid use disorder may lead to overdose and death. According to the CDC, from 1999 to 2019, an estimated 247,000 deaths in the United States were attributed to overdoses involving prescription opioids.1 In dental practice, the majority of opioids prescribed are immediate-release formulations with a higher potential for misuse and diversion.2 Data also suggests that dentists prescribe more opioids than considered necessary

Nikki Sowards, PharmD, earned her Doctor of Pharmacy degree in 2012 from the University of Tennessee College of Pharmacy in Memphis, Tennessee. She completed a PGY-1 Pharmacy Practice residency in Knoxville, Tennessee. Dr. Sowards joined South College School of Pharmacy as an Assistant Professor in 2013. In 2015, Dr. Sowards worked as a Director of Hospital Pharmacy in Knoxville, Tennessee. Dr. Sowards is currently an Assistant Professor of Pharmacy Practice at South College School of Pharmacy. She practices at Blount Memorial Hospital where she focuses on pharmacy operations and pharmacy management.

This self-instructional course for dentists aims to present an overview of prescription drug monitoring programs (PDMPs) and their considerations for use in dental practice.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions by taking the quiz online at orthotpracticeus.com to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify key components of the PDMP. • Outline steps to access the state’s PDMP. • List reasons how utilizing the PDMP can protect dental practices. • List limitations to the PDMP. • Complete a query utilizing the PDMP to evaluate a patient’s controlled substance record. CREDITS

Michael O’Neil, PharmD, received his Doctor of Pharmacy from the University of North Carolina at Chapel Hill, North Carolina. Dr. O’Neil has extensive experience in pain management, substance misuse, and medication diversion. Dr. O’Neil was editor and lead author for the American Dental Association’s book titled The ADA Practical Guide to Substance Use Disorders and Safe Prescribing, published in 2015. Dr. O’Neil has served as a consultant for prescription drug misuse and diversion for several entities including the Federal Drug Enforcement Agency. He is currently Professor and Chair of Pharmacy Practice at South College School of Pharmacy in Knoxville, Tennessee.

2 CE

for managing postprocedural acute pain.3 Over the past 10 years, many medical and dental boards as well as professional organizations have recommended or required routine use of prescription drug monitoring programs (PDMPs). The American Dental Association recommends dentists register and utilize their state’s PDMP to promote the safe and appropriate use of controlled substances.4 Currently, all 50 states have implemented a PDMP, and dental practitioners may access the following link for more information related to their state PDMP: https://www.pdmpassist. org/State.5,6 Dental practitioners must be fully knowledgeable of their own state’s PDMP. This article will serve as a primer and

Tyler Dougherty, BA, PharmD, BCACP, received his Bachelor of Arts degree in Biochemistry from Maryville College in 2011 and his Doctor of Pharmacy degree from the University of Tennessee College of Pharmacy in 2015. He completed a postgraduate residency at South College School of Pharmacy in 2016. Dr. Dougherty is a Clinical Community Pharmacist and Assistant Professor of Pharmacy Practice where he specializes in community pharmacy practice and teaches ethics and pharmacy law. Dr. Dougherty is an invited speaker for healthcare professionals teaching ethics and law with emphasis on medication management.

Orthodontic Practice US

Educational aims and objectives

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CONTINUING EDUCATION

give a general overview for dental practitioners to optimize utilization of their state’s PDMP.

Use of the PDMP by dental practitioners Historically, data has indicated that out of 805 members of the National Dental Practice-Based Research Network, only half of respondents reported having accessed a PDMP. Both lack of awareness and lack of knowledge regarding its use were the most common reasons cited for not using the database. Of those individuals who did report utilizing the PDMP, 33.5% indicated that their usage led them not to prescribe an opioid, while 25.5% reported usage led them to prescribe fewer opioid doses. Figure 1: An example report from the Tennessee Controlled Substance Monitoring Database of dispensed Overall, the findings of this research controlled substances for a mock patient did suggest that a majority of dentists do find the PDMP helpful in their decision-making regarding the prescribing of controlled substances. Table 1: Commonly Used Names and Acronyms for PDMPs Many states now mandate prescribers access the PDMP prior CSD Controlled Substance Database to prescribing controlled substances in defined circumstances.4

PDMP basics Prescription Drug Monitoring Programs (PDMPs) store outpatient controlled prescription medication information and are designed to track these prescriptions through an internet-accessed database maintained at the state level. Classes of controlled substances required to appear in the PDMP are determined by individual states. Of note, PDMPs are commonly referred to in a variety of ways depending on the state of origin. Table 1 lists commonly used terminologies that are equivalent to the PDMP. The main components of the PDMP include tracking of a patient’s prescribed controlled prescriptions, prescriber tracking of prescriptions utilizing their DEA number, and surveillance/ monitoring systems to detect trends and allow for statistical analysis. Controlled substances dispensed by community pharmacies and outpatient clinics are entered into the patient’s prescription record. When these prescriptions are dispensed, information associated with the prescription is uploaded to the PDMP at a time determined by the state with many pharmacies and clinics uploading at the immediate point-of-sale or dispensing. The PDMP report contains the patient’s name, date of birth, any addresses associated with that patient, and any prescriptions for controlled substances that have been dispensed by a pharmacy or outpatient clinic. Specific information typically available for each prescription follows: • medication name • medication strength • quantity filled • number of days’ supply • the prescriber’s DEA number • the date the prescription was written orthopracticeus.com

CSMP

Controlled Substance Monitoring Program

CSMD

Controlled Substance Monitoring Database

CSMPD

Controlled Substance Monitoring Program Database

PMP

Prescription Monitoring Program

PDMP

Prescription Drug Monitoring Program CSMD=CSMP=CSMPD=PMP=PDMP

• the prescription number • the pharmacy that filled the prescription. Some PDMPs are more advanced and may contain additional information such as total daily morphine milligram equivalents (MME), dispensed naloxone, and payment type.6,7 Figure 1 represents a typical report generated from the state of Tennessee PDMP. This database is maintained by the Tennessee Board of Pharmacy, which is a division of the State’s Public Health Department.8 It is critical for practitioners to recognize that information uploaded to the PDMP comes directly from pharmacies or outpatient clinic records. Medication information is entered into the pharmacy’s or clinic’s computers by a variety of personnel. None of this data is ever validated prior to being uploaded to the PDMP other than by personnel entering the data. Any entry errors by practitioners, pharmacists, technicians, or staff get uploaded to the database. Therefore, it is critical to recognize that the PDMP report is not evidence of a crime and should be used only as a starting point to verify potential concerns or “red flags” found in the report. The PDMP ultimately serves to inform clinical practice and improve prescribing. When utilized in a timely manner, PDMPs can prevent dangerous combinations of medications, limit pre-

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CONTINUING EDUCATION

scribing of unnecessary or duplicate prescriptions, and prevent doctor shopping as well as other types of medication diversion.

Accessing PDMPs Accessing PDMPs requires the prescriber to register with the state organization responsible for managing the database. Like most internet-based restricted sites, passwords are initially assigned by the regulating body and can be changed to a more convenient password later by the user. The database should only be accessed to evaluate a specific provider’s patient records “near time” of the scheduled appointment unless the prescriber is investigating potential fraud or diversion. Information provided in the PDMP must be handled the same as other patient information, which requires following all requirements of The Health Insurance Portability and Accountability Act (HIPAA).9 Accessing the PDMP to ascertain information about friends, families, other practitioners, or patients not part of the prescriber’s immediate practice is usually considered a violation of state and federal law that may result in prosecution. Prescribers are not usually obligated to provide patients with a copy of their PDMP report. However, if a copy of the report is placed in a patient’s medical record, the patient or insurance agencies may have access to the report. Additionally, caution should be used when placing the PDMP report in the chart since it potentially may contain another patient’s information depending on how the patient’s information was queried. Access to the PDMP is restricted to prescribers, pharmacists, the DEA, and law enforcement entities executing a warrant or who are part of a defined drug task force. However, most states allow the PDMP registered user to grant access to PDMP records to a limited number of users in the practice. In most cases this requires the user to use the registrant’s password. Ultimately, the PDMP registrants are responsible for any queries by any allowed users that use their password even if it is not for legitimate purposes. When “allowed users” leave the practice, passwords must be changed immediately to prevent misuse of the database. Some states now identify “allowed users” through special registrations linked to the PDMP registrant or allow support staff to have their own login code.10 Many medical practices and pharmacies have a separate login to the state’s PDMP that is often utilized by everyone in the practice. It is key that every licensed user use his/her own login to access the PDMP. Multiple users put the practice and individual login owners at risks for violations made by individuals using the facility’s login information inappropriately. Many patients live in areas that border multiple states, allowing patients to access practitioners and pharmacies in different states. Some states’ PDMPs provide a link to other nearby states’ PDMP. To date, there is not a single, nationally controlled PDMP that integrates all patient information for all 50 states.

For example, a patient named “Michael O’Neil” should not be entered as “Mike O’Neil” or vice versa. To avoid missing records that may have been entered using an abbreviated name, a more advanced search can be easily performed by using only the first initial of the patient’s first name and his/her last name. Caution is warranted when this method is used since any person named “O’Neil” whose first name starts with the letter “M” and has the exact birthdate will appear in the results. Spellings and datesof-birth must be exact; otherwise, they will not be found in the report. Dental practitioners should also be vigilant for the potential for multiple patients who have the same last name and date of birth. The timeline of the search is also required. For practitioners treating an active patient, searches generally only need to go back 6 months to 1 year because practitioners are making a real-time clinical decision. When investigating patients for potential fraud or diversion, longer time periods may be warranted. Although patient addresses can be entered, patients frequently move, and listing a specific address in the query may limit the findings in the report. Errors entered into patient profiles that end up in the PDMP usually require a formal request to the PDMP managing agency to correct the misinformation. Simply changing the information in the patient profile will not change the information in the PDMP. Once the PDMP report has been generated for the designated patient and the defined timeline, select the most recent prescription listed, and track on the timeline any medications within the same medication class. Look for any potential “red flags.” Repeat this process for any additional medications.

Identifying and evaluating “red flags” A “red flag” may be defined as any observation that provokes the user of the PDMP to evaluate the need, safety, or legitimacy of a prescribed medication. Identifying a “red flag” does not mean to immediately refuse to prescribe, but rather to ask questions and verify information before prescribing. Ultimately, refusing to prescribe often becomes a common action by the prescriber if controversial information is identified and verified.11

Table 2: Common Potential “Red Flags” Patients traveling extremely long distances between dental practicehome-pharmacy Early refills Utilizing multiple prescribers (emergency medicine, dental practices, hospitals, private practices) Out-of-state patients Random, escalating-de-escalating doses of opioids or benzodiazepines Common “cocktails” consisting of opioids, benzodiazepines, muscle relaxants, and sedative hypnotics

Querying the PDMP After logging into the PDMP, the patient’s name and date of birth must be entered. Ideally this information should come from a government-issued identification such as a driver’s license, but this sometimes is not possible. The patient’s proper name should be used. Nicknames or abbreviated names should be avoided. Orthodontic Practice US

Morphine-Equivalent Daily Doses (MEDD) exceeding 90 mg/day Patients presenting “old” dental injuries as “new” injuries Utilizing only cash payments for medications

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CONTINUING EDUCATION

When reviewing the PDMP, general observations that may be identified as “red flags” include the following: early medication refills, duplicate medications, utilization of multiple pharmacies or multiple providers, extremely long distances traveled from a patient’s home-pharmacy-dental practice, persistent use of similar medications, including random escalating-de-escalating doses, variation in products, and concerning medication combinations, also commonly referred to as “cocktails.” Table 2 lists common “red flags” that may require further questioning.11,12

Limitations to the PDMP Equally as important to the information provided in the PDMP is the information not found in the PDMP that potentially impacts prescribing. The PDMP report will not reflect any verbal changes that have been communicated to the patient such as increasing usage of a prescription. As previously mentioned, errors may occur when prescriptions are processed then uploaded to the database. Because Veterans Administration Medical Center patients receiving medical care are under federal regulation, prescriptions for controlled substances, including methadone and buprenorphine products, are not required to be reported to the PDMP. However, some Veterans Administration Medical Centers do voluntarily report to the PDMP. The PDMP does not usually contain patient diagnosis for the medications prescribed. Finally, all PDMPs are subject to the variety of connectivity issues that commonly occur with accessing information through an internet connection.

Reporting suspected diversion or fraud behavior When suspicious findings in the PDMP have been confirmed to be attempts to divert controlled substances or commit fraud, most states require reporting to a specific drug enforcement agency. This may include the dental practitioner’s local police department, regional drug task force, or regional DEA office. The DEA requires the reporting of any suspicious activities surrounding controlled substances. Regardless, specific information

including the time, date, patient’s name, address, date of birth, suspected illegal activity, medications indicated, and the verification process used to confirm the information in the PDMP should be reported. All information collected surrounding the suspected case should be documented in the patient’s medical record.13

Best practices Recommendations to help optimize a dental practitioner’s use of the PDMP include: • Logging in to the PDMP often to stay familiar with passwords and to stay current with any PDMP changes. • Training staff to run the PDMP report and to have the report ready for review when your patients arrive. • Maintain positive relations with local pharmacies and law enforcement since they are frequently the first to identify potential problems and can help protect your practice. • Evaluate PDMP reports every 6 months with your office manager using your DEA registration number to identify fraudulent prescriptions that have been issued using your DEA number. • Evaluate the PDMP for any brand new patient requiring a controlled substance.

Summary In summary, PDMPs are an effective tool for detecting and deterring controlled substance fraud and diversion. Querying the PDMP requires exact name and date of birth. “Red flags” require further questioning and verification before prescribing or refusing to prescribe since information contained in the PDMP is not evidence of a crime. Sharing of PDMP login passwords should be limited. Although there are some limitations to PDMP, most information is accurate. Dental practitioners prescribing controlled substances should access the PDMP to stay familiar with their passwords and to be kept up-to-date on major changes to their state’s PDMP. Confirmed suspicions or fraud or diversion must be reported per state and federal laws. IP

REFERENCES 1.

Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2020. http://wonder.cdc.gov. Accessed 1/7/22

McCauley JL, Hyer JM, Ramakrishnan VR, et al. Dental opioid prescribing and multiple opioid prescriptions among dental patients: administrative data from the South Carolina prescription drug monitoring program. J Am Dent Assoc. 2016;147(7):537-544.

Maughan BC, Hersh EV, Shofer FS, et al. Unused opioid analgesics and drug disposal following outpatient dental surgery: a randomized controlled trial. Drug Alcohol Depend. 2016;168:328-334.

McCauley JL, Gilbert GH, Cochran DL, et al. Prescription Drug Monitoring Program Use: National Dental PBRN Results. JDR Clin Trans Res. 2019;4(2):178-186.

Herion P, office GP, Marshall Cof J. Missouri becomes 50th state to introduce Prescription Drug Monitoring Database. KOMU 8. https://www.komu.com/news/state/missouri-becomes-50th-state-to-introduce-prescription-drug-monitoring-database/article_6e944f90-c7b8-11eb-a6ff-8742499b65dd.html. Published June 7, 2021. Accessed January 7, 2022.

State PDMP Profiles and Contacts. https://www.pdmpassist.org/State. Accessed January 7, 2022.7. Appriss, Inc. - Tennessee state government - tn.gov. https://www.tn.gov/content/dam/ tn/health/healthprofboards/csmd/TNDataCollectionManual.pdf. Accessed January 7, 2021.

Image Courtesy Tennessee Department of Public Health.

Health Insurance Portability and Accountability Act of 1996 (HIPAA). Centers for Disease Control and Prevention. https://www.cdc.gov/phlp/publications/topic/hipaa.html#:~:text=The%20Health%20Insurance%20Portability%20and,the%20patient’s%20consent%20or%20knowledge. Published September 14, 2018. Accessed January 7, 2022.

FAQ’s. https://www.tn.gov/health/health-program-areas/health-professional-boards/csmd-board/csmd-board/faq.html. Accessed January 7, 2022.

10. Prescription Medication Diversion: Detection and Deterrence. J Calif Dent Assoc. 2019;47(3):180-181. 11. O’Neil M, Winbigler B, Sowards A. Detection and Deterrence of Substance Use Disorders and Drug Diversion in Dental Practice. In: The ADA Practical Guide to Substance Use Disorders and Safe Prescribing. 143-149; 2015:144-147. 12. Suspicious orders report system (sors). https://www.deadiversion.usdoj.gov/sors/index.html#:~:text=On%20October%2023%2C%202019%2C%20DEA,115%2D271). Accessed January 7, 2022.

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CONTINUING EDUCATION

Continuing Education Quiz Practical considerations for utilizing Prescription Drug Monitoring Programs (PDMPs) — a primer SOWARDS/O’NEIL/DOUGHERTY

1. According to the CDC, from 1999 to 2019, an estimated _________ deaths in the United States were attributed to overdoses involving prescription opioids. a. 50,000 b. 134,000 c. 247,000 d. 456,000

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 16 CE credits for only $149; call 866579-9496, or visit https://orthopracticeus.com/subscribe/ to subscribe today. n To receive credit: Go online to https://orthopracticeus.com/continuingeducation/, click on the article, then click on the take quiz button, and enter your test answers.

2. Currently, ________ have implemented a PDMP. a. 16 states b. 34 states c.. 46 states d. all 50 states

AGD Code: 157 Date Published: February 22, 2022 Expiration Date: February 22, 2025

3. Of those individuals who did report utilizing the PDMP, ________ indicated that their usage led them not to prescribe an opioid, while 25.5% reported usage led them to prescribe fewer opioid doses. a. 33.5% b. 52% c. 65% d. 71%

2 CE CREDITS

ally considered a violation of state and federal law that may result in prosecution. a. friends and families b. other practitioners c. patients not part of the prescriber’s immediate practice d. all of the above

4. The main components of the PDMP include tracking of a patient’s prescribed controlled prescriptions, prescriber tracking of prescriptions utilizing their _______ , and surveillance/monitoring systems to detect trends and allow for statistical analysis. a. Social Security number (SSN) b. DEA number c. driver’s license number d. Employee Identification Number (EIN)

8. For practitioners treating an active patient, searches generally need to go back _______ because practitioners are making a real-time clinical decision. a. 6 months to a year b. 2 to 3 years c. 4 to 5 years d. 6 to 10 years

5. It is critical for practitioners to recognize that information uploaded to the PDMP comes directly from _______. a. pharmacies or outpatient clinic records b. the patient c. the insurance company d. the pharmaceutical manufacturer

9. A “red flag” may be defined as any observation that provokes the user of the PDMP to evaluate the _____ of a prescribed medication. a. need b. safety c. legitimacy d. all of the above

6. When utilized in a timely manner, PDMPs can prevent _________. a. dangerous combinations of medications b. limit prescribing of unnecessary or duplicate prescriptions c. prevent doctor shopping as well as other types of medication diversion d. all of the above

10. As part of “best practices” process: Evaluate PDMP reports every ______ with your office manager using your DEA registration number to identify fraudulent prescriptions that have been issued using your DEA number. a. 3 months b. 6 months c. 9 months d. 12 months

7. Accessing the PDMP to ascertain information about _______ is usu-

To provide feedback on 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.

Orthodontic Practice US

Volume 13 Number 1

LEAVE YOUR RETAINER HEADACHES BEHIND We understand better than anyone how retainer issues steal valuable chair time, create additional workload and all while creating no meaningful revenue. Now, imagine those headaches gone, experience an increase in your top-line revenue without over working your team with retainer issues.

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CONTINUING EDUCATION

Fixed lingual retention: the gold standard or a relic of orthodontics past? Dr. Amy Jackson discusses retention as an important part of orthodontic treatment

etention is the unspoken, fairly unmonitored phase of orthodontic therapy, and arguably one of the most important parts of orthodontics. There is no perfect tool for retention based on the fact that every tool, even permanent retainers, requires some type of compliance and monitoring. This article will discuss permanent and removable retention as well as some recent articles on fixed lingual retainers, their success rates, types of wires, and suggestions for your practice.

Educational aims and objectives

This self-instructional course for dentists aims to discuss the benefits and drawbacks of fixed lingual retention.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions by taking 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 the challenges of fixed retention and relapse. • Identify some principles for prevention of inadvertent tooth movement. • Recognize the type of patients that should receive a lingual retainer. • Realize some ways to prevent inadvertent tooth movement. • Identify some benefits to certain types of materials that would be beneficial for the maxillary lingual system. • Realize the need for clear retainers in certain instances. CREDITS

Orthodontic retention Teeth, particularly around the necks of the teeth, tend to revert to their original position due to stress in periodontal fibers (interdental and dentogingival fibers). The goal of orthodontic retention is to keep the teeth in their new aligned place. However, unless adequate retention is planned and followed after the cessation of active orthodontic therapy, relapse is certain. Orthodontic recurrence can be avoided with proper treatment planning and occlusal and soft tissue care. Unfortunately, patient compliance tends to decline as therapy advances, thus jeopardizing the gains made throughout treatment.1

2 CE

Fixed lingual retention Several long-term studies have demonstrated a strong tendency for relapse of anterior alignment after orthodontic treatment. For this reason, permanent retention has been popularized to combat this negative consequence.2,3 At the height of popularity of lingual retainers, the majority were only bonded to the canines, but it has been shown that a higher percentage of patients with fixed retainers secured only to the canines will have incisor irregularity at 5 years after treatment than if the retainer wire is bonded to the incisors as well.4 However, bonding to all teeth incorporated with the fixed retainer has its own inherent

Figures 1A and 1B: Construction of the most frequently used wire materials: 1A. 3-strand round twisted. 1B. Rectangular 8-strand braided wire

problems mostly due to a high-bond failure rate simply because of the additional teeth added to the equation. A recent article looked at the survival rates of the fixed wires in patients with 3-strand round twisted (RT) versus 8-strand rectangular braided (RB) fixed retainers bonded to all six anterior teeth in the mandible (Figures 1A and 1B). The retainers were all placed by one experienced, blinded operator. The investigators collected data when retainers were placed at 3, 6, 12, 18, and 24 months after end of treatment and monitored their time to fail. The researchers found a high failure of retainers in the 2 years of the study. For example, they found that during their 2-year follow-up, 37 of 66 (56.1%, RT group) and 32 of 66 (48.5%, RB group) retainers failed at least once. They concluded that the overall risk for first-time failure was high

Amy B. Jackson, DDS, MS, is a Board-certified orthodontist in private practice for over 15 years, and runs four practices in San Antonio, Texas. She began her dental career in Houston where she attended The University of Texas Health Science Center. During her time there, she was recognized by the UT Health Science Center with the Dental Public Health Award for community service and was awarded a Summer Research Fellowship from the AADR and the Barnard G. Sarnat Award in Craniofacial Biology from the IADR. Dr. Jackson continued her specialty training for orthodontics at The University of Texas where she completed a master’s degree through the periodontal department and was awarded the AAED’s research grant for her work with midpalatal implants. Disclosure: Dr. Jackson is the founder of Retainers for Life®. She does not have any financial or other relationship with Reliance Orthodontic Products.

Orthodontic Practice US

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CONTINUING EDUCATION

and amounted to 52.3% (56.1% in the RT group and 48.5% in the RB group).5 The occasional unexpected tooth movement created by a lingual retainer was the subject of a paper by Shaughnessy, Profit, and Samara,6 who reviewed examples and discussed the most likely causes. They suggested that no single fixed retainer type was immune to unexpected tooth movement, but tooth movement was more likely to occur with flexible wires.6

Prevention of inadvertent tooth movement

Prevention of unwanted tooth movement follows these two basic principles: 1. Detailed, precise delivery of the lingual wire so that it is secure and passive when bonded 2. Regular observation of retainer pads and wire integrity7 Shaughnessy, Profit, and Samara recommend when bending or adapting a wire with flexibility for lingual delivery, fabricating on a working model to provide better adaptation to the lingual surfaces, and decreasing the chance of placing an active bend in the retainer. Another good technique is using a carrier to avoid distorting it with pressure from fingers and floss.6 Dead soft wires can be adapted to the teeth with burnishing or finger pressure. This is also better fabricated on a model but can be done intraorally. Dead soft wires are an ideal choice for patients with tricky lingual anatomy (Figures 2A and 2B).6 Patients with lingual retainers should be seen regularly in the initial retention period by their orthodontist for the first 2 years when bond failure rates are greatest. The bond failure rate is lower in the 3- to 5-year posttreatment period.8 Removable retainers should be fabricated to provide protection against lingual mishaps such as broken bonds and wire breakage. This can be provided by vacuum-formed retainers with block out under the wire.7

Figures 2A and 2B: Dead soft wire completely intact, with skewing of the arch form in multiple planes of space, facial tipping of the right canine, and torque of the right lateral incisor and central incisor in opposite directions. 2A. Buccal view. 2B. Occlusal view

Table 1: Mention Retention Often Discuss retention at the consultation, and bring it up frequently throughout active treatment and again at appliance removal and retainer consultations. •

Beginning of treatment

•

6 months before end of treatment

•

6 weeks before debond

•

Debond appointment

•

Post-debonding consult

Practical tips

Retention should be considered at the treatment planning stage, when the clinician is able to focus on the pretreatment rotations and malocclusion. Retention should be discussed at the consultation, revisited frequently throughout active treatment, and again at appliance removal and retainer consultations.

Use of fixed lingual retainers

Fixed retainers come in a variety of styles. The most popular wires are a multi-strand wire bonded on the anterior teeth Figure 3: Lower-bonded retainer with multi-strand wire (Figure 3). Because they are fixed, fixed retainers are generally comfortable; however, they are linked to a high likelihood of long-term failure as we discussed previously. Combining knowledge of the literature with empirical evidence, in my practice, patients receive a lingual retainer when: • Patient requests or demands them • Pretreatment maxillary diastema is greater than 2 mm • Pretreatment lower crowding is greater than 5 mm A. B. • Anterior teeth have compromised roots • Canines are impacted or ectopic Figures 4A and 4B: 4A. Interproximal space between the lower premolar and first molar. • In a closed posterior space, a tooth was moved 4B. Reinforced closure using a modified bonded retainer with an omega-style loop that into an edentulous area (Figure 4) allows for cinching using a three-prong plier orthopracticeus.com

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CONTINUING EDUCATION

Materials

The patient is informed that the removable

Currently, for my maxillary lingual system, I retainers are nighttime for a lifetime, or as long personally use Retainium® (Reliance Orthodontic Products, Itasca, Illinois), which is a titanium as they want to keep their teeth straight. molybdenum alloy wire. For cases involving crowding or impacted cuspids, it is utilized canine-to-canine. For diastemas, I place the wire lateral-to-lateral with a 45-degree bend (Figure 5). I like this material for the maxillary arch because it is flat (027” x .011” ribbon), helping to avoid occlusal excursive movements and strong to resist breakage from direct occlusal forces. It also flexes interproximally, is nickel-free, MRI-compatible, and adaptable. In the mandibular arch, I prefer using Bond-A-Braid® (Reliance Orthodontic Products, Inc. Itasca, Illinois), a .027” x .011” ribbon that is a dead soft 8-strand braided wire and adapts very easily to the lingual surfaces. In conversations with Paul Gange, owner of Reliance®, he prefers the Retainium over Bonda-Braid because it is single-stranded and stronger. Personally, I Figure 5: Flat (027” x .011” ribbon) lateral-to-lateral with a 45-degree bend find the Retainium more difficult to conform to the anatomy of itored and taught how to care for them, keep them clean, and the teeth. how to spot bond failures and wire breakage. It is a prudent to All of my lingual systems are accompanied by clear plasaccompany fixed wires with removable retainers. tic retainers from Retainers For Life®.9 Emphasis is given during Consider retention at the treatment-planning stage when the patient and parent instructions that one does not go without the malocclusion is not obscured by tooth movement. Discuss retenother, and patients need the removable retainer along with the tion at the treatment consultation, bring it up frequently throughpermanent retainer for four important reasons: out active treatment, and highlight it again during debonding 1. The permanent retainer can break, and if it does, it is and post-debonding consults. often unknown or unnoticed by the patient. If and when Make retention a priority rather than an afterthought in your this happens, the patient has a tool in his/her possession therapy. that keeps the teeth from shifting. Be aggressive with retention, especially in the first year of 2. With the permanent retainer secure and intact, teeth can therapy, because periodontal ligament fibers and gingival tissues still micro-move, and the removable retainer will fight take about 1 year to entirely restructure. against unwanted micro-movement. Keep in mind that it is not the type of retainer that appears to 3. Any teeth unsecured by a permanent retainer will need be the most important factor, but rather the patient’s cooperation a retention system, and often, occlusal interdigitation and willingness to use it. Providing easily accessible, affordable alone will not keep back teeth from moving. removable retainers has been key to my success. OP 4. Segment of teeth attached to the lingual wire can still move en masse. When fabricating the clear plastic retainers, attention should REFERENCES be paid to the following: 1. Richter DD, Nanda RS, Sinha PK, Smith DW, Currier GF. Effect of behavior modifica• Ensure that they cover the second molars tion on patient compliance in orthodontics. Angle Orthod. 1998;68(2):123-132. • Ensure that they do not bounce 2. Joondeph DR. Stability, retention and relapse. In: Graber LW, Vanarsdall RL Jr, Vig KW. • Ensure that they don’t pinch the gum tissue or hang very (eds.) Orthodontics: current principles and techniques. 5th ed. Elsevier; 2012. far past the clinical crown, as not to cause gum recession. 3. Zachrisson BU. Important aspects of long term stability. J Clin Orthod. 1997;31:562-583. I also incorporate lingual bite ramps into my clear retainers 4. Renkema AM, Renkema A, Bronkhorst E, Katsaros C. Long-term effectiveness of canine-to-canine bonded flexible spiral wire lingual retainers. Am J Orthod Dentofafor patients that started with greater than an 80% overbite and a cial Orthop. 2011;139:614-21. tongue reminder for those patients with myofunctional therapy 5. Wegrodzka E, Kornatowska K, Pandis N, Fudalej PS. A comparative assessment of needs. failures and periodontal health between 2 mandibular lingual retaienrs in orthodontic patients. A 2-year follow-up, sinlge practice-based randomized trial. Am J Orthod The patient is informed that the removable retainers are Dentofacial Orthop. 2021;160(4):494-502. “nighttime for a lifetime,” or as long as they want to keep their Shaughnessy TG, Proffit WR, Samara SA. Inadvertent tooth movement with fixed lin6. teeth straight. As part of the Retainers For Life® 9 system, there gual retainers. Am J Orthod Dentofacial Orthop. 2016;149(2):277-286 is also an affordable replacement plan in place, and a plan 7. Renkema AM, Al Assad S, Bronkhorst E, et al. Effectiveness of bonded lingual retainfor relapse, and that protocol and pricing is reviewed with the ers in controlling relapse of the lower incisors. Am J Orthod Dentofacial Orthop. 2008;134(2):179e1-8. patient before treatment is complete.

In summary There is still a place for permanent retainers, but patients should be educated about the failure rates. They should be monOrthodontic Practice US

Renkema AM. General introduction In: Renkema A.M. ed. Permanent retention from a long-term perspective, PhD Thesis. Nijmegen, The Netherlands: Radboud UMC; 2013:10-26. ISBN 978-909027866-7.

Retainers For Life® www.myretainerforlife.com patient site – www.afterorthorevenue. com doctor site -15900 La Cantera Pkwy, Suite 20260, SanAntonio TX 78256 .

Volume 13 Number 1

CONTINUING EDUCATION

Continuing Education Quiz Fixed lingual retention: the gold standard or a relic of orthodontics past? JACKSON

1. Teeth, particularly around the necks of the teeth, tend to revert to their original position due to ___________. a. stress in periodontal fibers (interdental and dentogingival fibers) b. stress in the patient’s life c. fixed lingual retention d. using removable retention

2. At the height of popularity of lingual retainers, the majority were only bonded to the canines, but it has been shown that a higher percentage of patients with fixed retainers secured only to the canines will have incisor irregularity at ______ after treatment than if the retainer wire is bonded to the incisors as well. a. 1 year b. 2 years c. 5 years d. 7 years 3. Shaughnessy, Profit, and Samara recommend when bending or adapting a wire with flexibility for lingual delivery, fabricating on a working model to _________. a. provide better adaptation to the lingual surfaces b. decrease the chance of placing an active bend in the retainer c. avoid additional visits d. both a and b 4. Patients with lingual retainers should be seen regularly in the initial retention period by their orthodontist for the first ______ when bond failure rates are greatest. a. 6 months b. 2 years c. 4 years d. 5 years

AGD Code: 370 Date Published: February 22, 2022 Expiration Date: February 22, 2025

2 CE CREDITS

7. The author incorporates lingual bite ramps into clear retainers for patients that started with greater than a/an ________ overbite and a tongue reminder for those patients with myofunctional therapy needs. a. 20% b. 50% c. 80% d. none of the above 8. The patient should be informed that the removable retainers are ______ or as long as they want to keep their teeth straight. a. daytime only b. nighttime for a lifetime c. all day and all night d. only at times when the patient feels that the teeth are moving

5. Retention should be _________. a. discussed at the consultation b. revisited frequently throughout active treatment c. discussed at appliance removal and retainer consultations d. all of the above

9. When educating patients about failure rates of permanent retainers, the patient should be monitored and taught how to care for their retainers as well as how to ______. a. keep them clean b. spot bond failures c. spot wire breakage d. all of the above

6. When fabricating the clear plastic retainers, attention should be paid to ensure that they _________. a. cover the second molars b. do not bounce c. do not pinch the gum tissue or hang very far past the clinical crown, as not to cause gum recession d. all of the above

10. The author suggests that orthodontists should ______, especially in the first year of therapy, because periodontal ligament fibers and gingival tissues take about 1 year to entirely restructure. a. be aggressive with retention b. avoid retention c. not suggest retention d. only use removable retainers

orthopracticeus.com

Volume 13 Number 1

PRODUCT PROFILE

Spark™ Aligners set new standard in orthodontics

park™ Aligners are manufactured by Ormco™ — a global leader in innovative orthodontic products with 60 years of expertise, R&D, and high manufacturing standards. Ormco has helped doctors treat more than 20 million patients in more than 140 countries. Spark’s Approver software is designed to give doctors more control and flexibility, while Spark’s advanced aligner technology and TruGEN™ material enable more sustained force retention* and better surface contact with the tooth*. Spark Aligners are also clearer, more comfortable, and stain less than the leading aligner brand*, and have smoother, polished edges for enhanced patient comfort.* These features may explain why 100% of patients recently surveyed said they would recommend Spark Aligners to a friend.*

Force retention, surface contact, and manufacturing technology

Spark™ Clear Aligner features

Spark’s TruGen™ material provides more sustained force retention* and improved contact surface compared with the leading aligner brand.* When touching the same tooth, Spark Aligners have 19% better surface contact than the leading aligner brand.* The superior force retention and surface contact of the Spark aligner is due to its manufacturing technology. Spark Aligners are made with 80%* better printing resolution and a more uniform surface texture than the leading aligner brand.*

Finishing, refinements, and attachment bonding TruGen XR™, Spark’s new, more rigid material, is optimally designed for finishing and refinements.* TruGen XR™ is equivalent to the finishing wire option of traditional braces* and is available for all refinements at no additional charge. Doctors can obtain results without resorting to optimized attachments. Spark’s beveled attachments conform to a patient’s oral anatomy, matching the surface of each tooth for a more uniform attachment surface.* In addition, according to study results published in Applied Sciences MDPI, the Spark™ Aligners attachment template was 3X more effective than the leading competitor’s attachment template in preventing attachment bonding failures:** • 87.5% of Spark Aligners patients had NO attachment bonding failures versus only 27.5% on patients using the leading aligner competitor.** This randomized controlled trial concluded that the Spark™ template is more effective in transferring attachments to the tooth surface than the leading aligner brand’s template, resulting in less time and effort in removal and cleanup.** Orthodontic Practice US

Powerful Approver software for better control and workflow Spark’s proprietary Approver software is designed to give orthodontists start-to-finish control for more efficient and effective treatment planning. CBCT integration lets orthodontists import and visualize CBCT patient data,* request multiple treatment plans and compare them,* while posterior Bite Turbos can be added to address complex cases.* Spark Approver software can also benefit practice workflow. Orthodontists may select their preferred scanner, remote monitoring and virtual consult services.

Treating younger patients Spark Aligners also give doctors added support in treating younger patients with mixed dentition.* Spark Approver software is designed to improve treatment of interceptive cases.* Spark Approver software technicians are trained in established Spark clinical protocols for Kids and Teens to help ensure proper arch development for erupted and ectopic teeth. Ormco continues its 60-year tradition of excellence and innovation in orthodontia with the Spark Clear Aligner System. Designed and manufactured for optimal doctor flexibility and control, and patient comfort,* Spark Aligners are clearer, more comfortable, and have better surface contact than the leading brand.* Spark’s powerful Approver sofware is designed to help doctors better visualize and organize their treatment plans. The Spark Clear Aligner System is setting a new benchmark in clear aligners now and for the future. Learn more about Spark Aligners at Ormco.com/Spark or by calling 800-854-1741. OP *Data on file. **Source article: https://www.mdpi.com/1198216 This information was provided by Spark™ Aligners by Ormco™.

Volume 13 Number 1

GREATER CONTROL AND flexibility Featuring a host of new industry-leading innovations, Spark Aligners’ are designed to give orthodontists even CBCT Integration

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Learn more at ormco.com/spark

PRODUCT PROFILE

Gaidge Keys to the kingdom — unlocking opportunity with practice data Do you know your practice performance data? When running a practice, every orthodontist must be not only a doctor, but also a CEO who drives the business forward through operations, marketing, strategy, and goals. With so many departments and moving pieces in a practice, this task can feel daunting. Knowing where to start when it comes to setting goals and telling your team where to focus is the first challenge that not only orthodontists face, but also any business leader. The first place to begin must be understanding current performance, and the only way to know versus guess is to look at your data. Do you track new patient phone calls and marketing dollars? What do you know about your treatment efficiencies and repair rates? What about starts from your observation pool, accounts receivable, or insurance delinquency? Making informed business decisions in a practice is critical to ongoing success, but without understanding your key performance indicators (KPIs), it’s a challenging and risky endeavor.

How are you currently gathering practice data? Do you have team members pulling reports, creating spreadsheets, and manually entering data points? Or perhaps after hours, you sift through reports provided through your practice management system and analyze the information? Manually gathering all your important practice metrics can be a huge investment of time for you and your team, and it’s immediately outdated. Data must be synthesized and easily digestible in order to gain insights and make the right decisions on where to focus your efforts moving forward. Your time should not be spent gathering data, but instead leveraging automation and tools that give you what you need to quickly determine where to focus resources and where not to.

Data visualizations that provide clear, actionable insights Custom-designed for orthodontists, Gaidge — a business intelligence software company — provides significant time-savings and automation for up-to-date information on your practice. Gaidge streamlines the process of measuring and analyzing your practice performance data in one comprehensive platform. By synthesizing thousands of calculations that are pulled from your practice management system, Gaidge displays easy-to-read dashboards and charts, so you can see the entire health of your practice in one tool. The features of Gaidge Analytics include: • 80-plus practice health metrics on your critical KPIs • 35-plus practice reports displayed in simple graphs and charts • 9 custom dashboards to view your complete practice health, including data for productions and collections, accounts receivable and delinquency, exams and starts, observation, schedule, and treatment efficiency • Access to national and regional comparison data from over 1,700 locations to see how you rank and help set meaningful goals for your practice • Seamless integration with the 6 leading practice management systems • Track performance across multiple practice locations and roll up for a corporate view • Ability to access your Gaidge data through the Gaidge Mobile app Learn more at www.gaidge.com, or call 1-800-287-3396. OP This information was provided by Gaidge.

Orthodontic Practice US

Volume 13 Number 1

Transform Your Practice with TruDenta Our diagnostic technologies and FDA-cleared therapeutic procedures provide pain relief and rehabilitate force imbalances for new and existing patients with sleep apnea, chronic migraines and headaches, tinnitus, and other neck/jaw pain.

Each drug-free treatment plan is tailored to address the individual patient’s symptoms, and includes the use of several tested technologies, including ultrasound, photobiomodulation, microcurrent, and muscle manipulation.

Reap ROI With Your Investment Dental practices that provide TruDenta see nearly 389 percent in return on investment and $1,500 per hour for doctor chair time.

As Seen On

Request a Consultation Today! 855-770-4002 | Trudenta.com/doctors/

The future of teen treatment is clear

95% of experienced Invisalign® orthodontists agree it’s the future of teen treatment.1 Experienced Invisalign orthodontists can treat nearly 70% of teens seeking treatment with Invisalign clear aligners.1 With technology like Mandibular Advancement and SmartForce® attachments, you get the control and predictability you expect while your teen patients get the smiles they want. Learn more about the technology behind more than 2 million teen smiles at Invisalign.com/provider/teen.

1. Data from a survey of 78 orthodontists (from NA, EMEA, APAC) experienced in treating teenagers (minimum of 40 cases, prior 8 months) with Invisalign clear aligners, regarding teenagers with permanent dentition; doctors were paid an honorarium for their time. © 2021 Align Technology, Inc. All Rights Reserved. Align, the Align logo, Invisalign, the Invisalign logo, SmartForce®, among others, are trademarks and/or service marks of Align Technology, Inc. or one of its subsidiaries or affiliated companies and may be registered in the U.S. and/or other countries. | MKT-0006346 Rev A