Orthodontic Practice US Fall 2023 Vol 14 No 3 by MedMark, LLC

orthopracticeus.com

Tweakz®

Fall 2023 Vol 14 No 3

4-in-1 Ortho Care Tool

3D Printing / TMD & Sleep n 4 CE Credits Available in This Issue*

For Braces

For Aligners

Applications of 3D printing in orthodontics Dr. Sunny Jisun Lee

The five finger approach to sleepwake complaints Dr. David E. McCarty

Tumultous times, tough conversations: the Internet's influence on communication

OrthoNu — Reinventing patient experiences and practice efficiencies

Pat Mc Bride, PhD, CCSH

PROMOTING EXCELLENCE IN ORTHODONTICS

Dr. Sima Yakoby Epstein

Empower your patients today!

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INTRODUCTION

Fall 2023 n Volume 14 Number 3 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 2023. 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.

ISSN number 2372-8396

Let compassion be your superpower

am honored to write the Cover Story in this issue of Orthodontic Practice US. In that article on page 8, I mention that one of the reasons I chose orthodontics was a terrible accident when I was 13 years old. My orthodontist not only treated my dental injuries but also helped me to navigate through my fears. There are several ways orthodontists can help young patients triumph through treatment after trauma. Explain upcoming procedures: Children need to feel that you understand their situation. The patient has no idea of the wonderful procedures that are available to orthodontists today. Assure him/her that you know what happened, and you Sima Yakoby Epstein, DMD have a plan. When explaining, divide the treatment plan into understandable chunks of information. (For example, “The first month, we will focus on your healing by doing this. The second month, you will get your braces. Third and fourth month, you will start to see a difference in your smile.”) This is called creating “the Hope Chart” — it clarifies and also gives them the energy and the wherewithal to keep moving forward when they feel so helpless. Relate to the patient: Make sure the patient realizes that you are a part of their team. If the accident was serious, that team may include a medical internist, as well as an oral surgeon or prosthodontist. The orthodontist in some cases becomes the heart of the team — making certain decisions and keeping all collaborators in the loop of the processes and scheduling. Ask the patient specifically what they need from you — what goals do they want to accomplish? This gives you more opportunity to let them know what they must do to reach those goals, like wearing their elastics. The goals will give them some form of control over the outcome. Control is very important when the patient feels helpless and vulnerable. Taking control over their own outcomes is a life lesson that will serve them well over the years. Meet with the parents: Parents need to have the same perspective as you about treatment and timing. Involved parents can be supportive and encourage compliance. This also will give the parents the confidence to ask you for help if their child loses enthusiasm and becomes non-compliant. The child’s disciplined routine is key to reaching their goal. Give them some tools to help them succeed: I founded OrthoNu because I found that orthodontic patients often didn’t have the tools to help them care for their braces or aligners or to handle certain emergencies. Having Tweakz reduces their anxiety over a sharp wire or broken bracket because they have a professional-grade dental pick, applicators and removers for dislodged brackets, rubber bands, and even a diamond dental file so ulcerations don’t develop. They feel enough anxiety about treatment; it’s important to make as much of the orthodontic journey as seamless as possible. Do your research: With complicated scenarios, be prepared to think outside of the box. CBCT, obviously, is a great diagnostic tool to find out about skeletal trauma and dysfunction. Some types of artificial intelligence (AI) may be enlightening regarding outcomes for patients who have had such trauma previously, and the possible treatment plans or collaborations that would help you reach success. Sometimes, life comes full circle. I am fortunate to be able to talk in hindsight about my dental trauma. It is so powerful to have experienced what traumatized patients feel and to help them heal from physical and emotional pain. Even if you have not experienced trauma, let compassion be your superpower, like it is for me, and help young patients overcome their most challenging times. Warm regards, Sima Yakoby Epstein, DMD

orthopracticeus.com

Volume 14 Number 3

TABLE OF CONTENTS

PUBLISHER’S PERSPECTIVE

Staying informed and safe

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

COVER STORY

OrthoNu — Reinventing patient experiences and practice efficiencies

Dr. Sima Yakoby Epstein explains how OrthoNu can redefine oral care for patients in orthodontic treatment

Achieving accuracy and consistency of IDB without the tray

Dr. James “Jep” Paschal describes his experience with trayless indirect bonding

Orthodontic Practice US

Tumultous times, tough conversations: the Internet’s influence on communication Pat Mc Bride, PhD, CCSH, discusses how the online world can affect the orthodontic practice...............................................15

Cover image of Dr. Sima Yakoby Epstein courtesy of OrthoNu.

TECHNIQUE

PRACTICE DEVELOPMENT

Volume 14 Number 3

CONTINUING EDUCATION

Applications of 3D printing in orthodontics

Dr. Sunny Jisun Lee outlines how 3D printing can benefit the orthodontic practice.....................18

TABLE OF CONTENTS

PRODUCT PROFILES

Introducing: Spark™ Release 14! Discover our latest doctorinspired innovations...................30

Transforming oral health

CONTINUING EDUCATION

SPOT PAL™ introduces a gamechanging approach to tongue training.......................................... 32

The five finger approach to sleep-wake complaints

Innovating with digital technology

Dr. David E. McCarty offers a collaborative patient-centered problem-solving tool for a complex world

.........................................................34 PRODUCT PROFILE

DentalMonitoring

PRACTICE DEVELOPMENT

Beyond the pandemic Casey Bull discusses the lasting impact of virtual consultations in orthodontics.................................36

Driving growth and profitability in the modern orthodontic practice in three phases — Monitor, Measure, and Master. ................. 38

PRODUCT PROFILE

Laser-sintered appliances: now in stainless steel Christian Saurman points out some advantages of NEOLab’s new offering...................................... 40

*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 14 Number 3

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PUBLISHER’S PERSPECTIVE

Staying informed and safe

ecently, I saw a movie called “The Sound of Freedom,” the story of Tim Ballard, a federal agent who quits his job with the Department of Homeland Security to start his own independent team to rescue child trafficking victims. One of the movie’s executive producers is Tony Robbins. Tony has been a mentor and inspiration to me. The movie was emotional and moving for me, watching (as Tony describes on his website), “the harrowing experiences faced by victims of human trafficking and the relentless dedication of those fighting to dismantle these dark criminal networks, which continue to enslave millions of children globally each year.” Lisa Moler Human trafficking is not just a movie. The U.S. DepartFounder/Publisher, ment of Homeland Security (DHS) notes, “Every year, milMedMark Media lions of men, women, and children are trafficked worldwide — including right here in the United States. It can happen in any community, and victims can be any age, race, gender, or nationality.” Violence, manipulation, false promises of well-paying jobs, and even the promise of romantic relationships can lead to imprisonment of these innocent, frightened victims. DHS adds, “Language barriers, fear of their traffickers, and/or fear of law enforcement frequently keep victims from seeking help, making human trafficking a hidden crime.” At-risk victims may be hiding in plain sight. Dental professionals may not realize that patients who visit their offices may be impacted by this terrible crime. Because of signs and symptoms of human trafficking, dentists may be able to help a victim of human trafficking during the course of the dental visit. Several states mandate that dentists need a human trafficking continuing education course to renew their licenses. In these courses, dentists learn details such as: • Work-settings that may employ trafficking victims. • Physical and psychological clues that the patient may be being trafficked. • Some key words that the victim or perpetrator may say to the dentist to avoid being identified as a trafficking situation. • Reasons why a victim may try to avoid being identified. • Oral injuries that may indicate a trafficking victim. • Resources for intervention specialists in human trafficking. • What steps the clinician can take if the patient is identified as a trafficking victim. The DHS says that in helping these victims, the healthcare professional also needs to pay careful attention to the safety of themselves and their teams. They warn, “Do not attempt to confront a suspected trafficker directly or alert a victim to any suspicions. It is up to law enforcement to investigate suspected cases of human trafficking.” Back to our fall issue, for our CEs, Dr. Sunny Jisun Lee outlines the benefits of 3D printing and offers some tips on getting started. For those considering adding sleep therapies to their practices, Dr. David E. McCarty’s CE gives a high-five to “The five finger approach to sleep-wake complaints,” a way of communicating the complex topic of sleep medicine to patients. Our Cover Story, by Dr. Sima Yakoby Epstein, discusses how to add compassion to orthodontics and redefine how orthodontists treat emergencies and reduce patients’ stress by putting some helpful and innovative products in their goodie bags. In my Publisher’s Perspective column, I always share topics that are important to my growth not just as a publisher and entrepreneur, but also as a human being. Human trafficking is an outrageous and evil crime. Take a CE class on this topic to know warning signs and also to stay safe. Human trafficking “exists nationwide — in cities, suburbs, and rural towns — and possibly in your own community,” says DHS. Be aware, smart, and cautious — as you help patients to survive and thrive. To your best success, Lisa Moler Founder/Publisher, MedMark Media Orthodontic Practice US

Volume 14 Number 3

Published by

Publisher Lisa Moler lmoler@medmarkmedia.com Managing Editor Mali Schantz-Feld, MA, CDE mali@medmarkmedia.com Tel: (727) 515-5118 National Account Manager Adrienne Good agood@medmarkmedia.com Tel: (623) 340-4373 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 eMedia Coordinator Michelle Britzius emedia@medmarkmedia.com Social Media Manager April Gutierrez socialmedia@medmarkmedia.com Digital Marketing Assistant Hana Kahn support@medmarkmedia.com Website Support Eileen Kane webmaster@medmarkmedia.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Toll-free: (866) 579-9496 www.medmarkmedia.com www.orthopracticeus.com Subscription Rate 1 year (4 issues) $149 https://orthopracticeus.com/subscribe/

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COVER STORY

OrthoNu — Reinventing patient experiences and practice efficiencies Dr. Sima Yakoby Epstein explains how OrthoNu can redefine oral care for patients in orthodontic treatment

ow can orthodontists show patients that they care about them? Adding technology to our practices is certainly helpful in improving our clinical skills, but how do we create the best experience for patients even after they leave the office? That means showing them that we care about the situations that make them uncomfortable, inconvenienced, vulnerable, or stressed during their time in treatment.

Sima Yakoby Epstein, DMD, founder of OrthoNu, holds a Doctorate of Medicine in Dentistry and Clinical Orthodontics from the University of Pennsylvania School of Dental Medicine. She completed her residency at New York Presbyterian and taught Advanced Esthetic Dentistry at New York University. She has more than 10 years of professional orthodontic experience, including working as a cosmetic dentist in New York City.

Orthodontic Practice US

Volume 14 Number 3

COVER STORY

Reinventing the goody bag

It’s really important to make sure that your

One of the ways orthodontists connect to patients are taking care of their teeth properly patients is by our goody bags. Patients excitedly look inside the bag that is supposed to hold some throughout treatment — and they can do it products that will help them through treatment — better if they have the right tools.” but often all they find are a toothbrush and some plastic flossers. They leave the office and then are surprised, confused, and frustrated about all of the That’s so much more hygienic and safer than using nail clippers ways that they have to problem-solve about their braces or that previously were used to clip someone’s toe or finger nails. aligners and of the emergencies that may create painful probThe Dislodged Bracket and Elastic Remover removes broken or lems for them or their children. This is one of the reasons that dislodged brackets (self-ligating or conventional) and food from I created OrthoNu — to change the way we address patients’ hard-to-reach areas and between teeth. The Rubber Band Applipain points, discomfort, and anxiety and also to improve their cator removes and replaces rubber bands with ease, so no one perception of us in the process. has to stick their unwashed fingers in their mouth at work or at Depending on oral hygiene, a patient’s microbiome is conschool. And now, you can save your nail file for your nails. The stantly shifting. When constant inflammatory state is added to Diamond Dental File helps smooth out rough spots on brackets, the situation, as is the case with braces or aligner wearers, the hooks, and bands that can cause ulcerations. result can be cavities, periodontal disease, and an influx of bacThe Tweakz for Aligners 4-in-1 tool kit includes a Dental Pick teria from having metal, ceramics, or plastics in the mouth. It’s to remove food from hard-to-reach areas and between teeth. The really important to make sure that your patients are taking care Elastics Applicator removes and replaces rubber bands in an of their teeth properly throughout treatment — and they can do easy and sanitary way. The Aligner Remover can remove retenit better if they have the right tools. tive aligners. (No more breaking nails or chipping polish when removing a tough aligner.) Patients can put that emery board Convenient self-care solutions back in their bag because the Diamond Dental File helps smooth Tweakz for Braces and Aligners are science-driven and set out rough spots on composite attachments or aligners that can the tone for patient care. Adult patients and parents face inevicause ulcerations. table unforeseen problems that happen with braces or aligners. These two products will make so many aspects of braces and During the many emergencies that can happen with braces, aligners easier and less stressful. The small carrying case (that parents have to deal with an uncomfortable child, without any comes with a mirror) can easily fit in a purse, pocket, or backsolution except to call for an emergency visit. For braces, 99% pack, with all the tools needed right at your fingertips. Tweakz of emergencies are broken brackets and sharp distal ends. And clinical-quality material is easy to just wipe down with an alcofor aligners, 92% of emergencies are rough edges and removal hol wipe, wash with soap and water, or throw into the top rack of overly retentive trays. of the dishwasher. Tweakz for Braces addresses these issues. The Flush Distal While avoiding emergency visits makes parents happy, End Cutter eliminates the sharp wires, and the wire cutter holds reducing unexpected chairtime also helps the practice finances. the cut piece so it doesn’t fall in their mouth or down their throat.

orthopracticeus.com

Volume 14 Number 3

COVER STORY

Chris Bentson, Partner at Bentson Copple and Associates, says, “Most orthodontic visits are due to a device problem causing discomfort that is in the interest of the patient to resolve as quickly as possible, yet many of these could be resolved by the patient on their own well enough to wait for the next scheduled visit. At an average cost to the practice of $300 per visit, empowering patients to resolve bracket and wire problems on their own, eliminating the need to come into the office, can have financial and operational benefits to the practice.”

Continuing to redefine orthodontic care OrthoNu continues to innovate. We are dedicated to introducing other products that help the microbiome of the mouth. It’s a fact that sometimes, braces just don’t feel good. We are developing other solutions for the pain points of braces created with products that contain functional ingredients. Two products that will debut by winter of 2023 and that have never been offered before will increase the comfort of braces and aligners. A healthy oral microbiome is encouraged by all of the products that will be produced by OrthoNu. Ingredients are anti-microbial, anti-inflammatory, beneficial for the gingiva, and able to remineralize teeth and keep that enamel strong throughout treatment. On a mission to reinvent the goody bag, OrthoNu is creating other products that address pain, discomfort, oral hygiene, cleaning, and demineralization. We want to give the patient options for the issues that really happen during their time of treatment, to develop products that kids and parents appreciate and want to use in an easy and seamless way. Our goal is to be recognized in the industry for creating a pipeline of products that are the new standard of care. Eighteen products are in the OrthoNu innovation pipeline, two of which are in collaboration with the University of Pennsylvania dental/medical/engineering schools, and a part of a 3-year development process. Currently, we already have three patents and approximately 14 patents pending. Most of these products will be rolled out in 2024. By putting these products in the goody bag, orthodontists are saying to patients, “I’m giving you this as a gift, because I want you to know that when there’s a problem, you have a tool to solve it, and we support you until you can come to the office.” If parents want more than is provided in the goody bag, they can go to OrthoNu online and set up a subscription for whatever works for that patient, or the orthodontist can sell the products in the office.

Orthodontic inspiration When I was in a car accident, at 13 years old, I sustained many injuries. One caring and compassionate orthodontist guided me throughout the treatment process. I remember how Orthodontic Practice US

important it was to understand what was happening to me and what to expect. Because I was a child of immigrant parents, they didn’t always understand the terminology. If that orthodontist had not provided that emotional and clinical support throughout the whole process, I probably wouldn’t have come out of it unscathed. There was a lot of trauma involved, not only because I was a teenager, but also because of my extensive esthetic issues — teeth that were different sizes and different lengths, having braces and surgery, and other complicated procedures. It was a very challenging time, and although my parents were well-meaning, they sometimes did not know how to handle certain situations, many of which were painful for me. Later on, this doctor inspired me to realize that I and other orthodontists have the opportunity to help people in my situation every single day. In a moment of vulnerability, the most beautiful gift a clinician can ever give someone is helping them when they’re struggling. It could be something simple as saying to a patient in discomfort, “I have something for you. Don’t worry; you’re going to be okay. Everything is set up so that you can succeed.” Orthodontists already have the clinical skills to help patients succeed, and in the goody bag, OrthoNu can supply the products that help every patient to be better prepared to be successful in their care. OP

10 Volume 14 Number 3

Orthodontic Self-Care Solutions for Real Life The average practice experiences 8-10 costly emergency visits every day, with each visit costing the ofﬁce $100 on average. Broken brackets and cutting distal ends are 99% of the Braces emergencies. For aligners, rough edges and removal of overly retentive trays account for 92% of aligner emergencies. In total, these breakthrough visits can cost an ofﬁce over $300,000 a year. Keep disruptions to a minimum for your practice and your patients!

Tweakz® for Braces

4-in-1 Ortho Care Tool & Travel Case 2 Dislodged Bracket & Elastic Remover

3 Diamond Dental File

1 Rubber Band Applicator

Tweakz® for Aligners

4-in-1 Ortho Care Tool & Travel Case 2

1 Aligner Removal

3 Rubber Band Applicator Dental Pick

4 Diamond Dental File

Upper Arm

Spring Lower Arm

4 Flush Distal End Cutter

Travel Case with Mirror

NEW OrthoNu® Tweakz® for Braces and Aligners are patient-friendly, professional-grade stainless steel tools designed to address the most common orthodontic emergencies.

Order now at OrthoNu.com

TECHNIQUE

Achieving accuracy and consistency of IDB without the tray Dr. James “Jep” Paschal describes his experience with trayless indirect bonding

erhaps like me, many of you have tested IDB over the years but ultimately decided against it. I have been testing IDB and fully customized IDB systems for close to 20 years now. While many of these devices were clinically viable, the lag time between a commitment to start and initial bonding, the inconsistency of the bonding process itself, and the overall cost always proved to be hurdles too significant to overcome. Recently my stance has changed. The first time I saw the appliance called Monolithic™ by Braces On Demand™, I was captivated. The appliance is a fully customized bracket system that offers “trayless” indirect bonding. That means I get the visualization and feel of direct bonding with the accuracy and consistency of IDB without the challenges inherent to tray techniques. Trayless indirect bonding is the answer to both the time-to-delivery dilemma and the cost hurdle, while providing a superior delivery system for a fully customized appliance. My team has been impressed with the ease of bonding that patients also appreciate. Everything fits exactly as it was prescribed and designed. The occlusal indexes and supports are easily removed, and we’ve had no debonds during bracket placement. We’ve never worked with an appliance that’s as problem-free and can deliver as quickly. The brackets are 3D printed from a photocured polymer that is crystal clear; this gives them the durability required in the oral environment while also being safe for use on the lower arch without the risk of enamel wear. We have bonded a myriad of different esthetic brackets over the years and have never had a bracket look as transparent as this one does on the teeth. So far, they’ve been stain-free, something we do not typically see with other esthetic brackets.

How trayless IDB works Traditional indirect bonding trays present a variety of challenges to adoption because they require an exacting bonding protocol to minimize bracket failures. Too much adhesive or primer, and you risk bonding the tray to the bracket or tooth.

James “Jep” Paschal, DMD, MS, FACD, lectures to doctors, staff, and residents worldwide on the most advanced orthodontic trends, techniques, and technologies that improve patient care. He is also recognized as a leading expert on incorporating 3D printing into orthodontic practices. Disclosure: Dr. Paschal is an investor in and the Chief Clinical Officer for Braces On Demand, where he oversees the clinical aspects of product development. He maintains practices in both Madison and Greensboro, Georgia.

Orthodontic Practice US

Figure 1A: 3D print Monolithic on a Formlabs Form 3B or 3B+ within 24 hours of case approval, or order for delivery and receive your patient’s case within one week

Figure 1B: Bite registration framework offers full access to pad when applying adhesive. No tray to avoid or risk bonding to

Too little adhesive, and you compromise the bond strength of the bracket to the tooth. Monolithic replaces the tray with a custom bite registration structure (i.e., occlusal index). This placement structure is not merely a jig. It’s a one-piece, custom occlusal index with fully customized brackets precisely oriented to one another via a 3D-printed framework. Every unit is individualized to fit the facial contours and occlusal surfaces of each tooth so that each bracket slot is properly oriented in its ideal position based on the patient’s final digital setup that you approve. Once the segments are positioned intraorally, you have direct clinical access to the bracket. You can apply an ample amount of adhesive to fill the pad, seat the bracket against the tooth, clean up the flash, and visually inspect the bracket positioning before curing it (Figure 1).

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TECHNIQUE

In this regard, the procedure has many of the familiar advantages of direct bonding. There are distinct benefits to having direct visualization and access to each bracket. With this indirect system, my team and I

can, for the first time, see that each bracket is properly positioned and seated on the tooth. With other IDB techniques, if the tray is not completely seated, or if a bracket shifts in its well, bracket placement is compromised and won’t be discovered until the tray is removed or later in treatment after the inaccurate placement is expressed. With trayless indirect bonding, adhesive curing is faster and more consistent due to the translucent resin material and the direct access the assembly permits since no tray material hinders light transmission. Bonding times are drastically reduced, and there are significant efficiencies that could be gained when bonding can be delegated to clinical assistants. The advantages in multi-doctor practices would likewise be notable in terms of bracket placement accuracy and consistency.

The digital workflow

Figure 1C: Press the bracket to the tooth, express excess adhesive, and remove flash

Figure 1D: Visually inspect bracket position before curing. No tray to penetrate through or remove

Figure 1E: Registration framework releases comfortably with light finger pressure. Scan the QR code to watch a video of Dr. Paschal Bonding Monolithic (https://youtu.be/ XvCTMEKzSmY)

Orthodontic Practice US

The digital workflow begins with the patient scan that’s uploaded to the DIBS AI® planning software platform integrated with Braces On Demand. You receive the initial setup within 24 hours of submission. After refining and/or approving the digital setup, the next step depends on whether you print your cases in-office or choose to have them printed for delivery. If you choose the latter, mail delivery will take approximately 1 week. In addition, you will receive a second set of appliances to serve as backup. If you are 3D printing in-office on your Formlabs Form 3B or 3B+ printer, you will receive the .STL file within 24 hours of case approval. I have used several different printers in my office and have found the Formlabs Form 3B line of printers excel at providing both the accuracy and surface finish needed for manufacturing orthodontic brackets. With in-office 3D printing, we can cut patient start times from commitment to bonding to approximately 1 week from the usual 4 weeks with other customized bracket systems. For those who choose to have cases delivered, you can reduce your commitment-to-start times to approximately 2 weeks. Doctors recognize the advantage of such an improved timeline, which capitalizes on patients’ enthusiasm at the outset of treatment.

Conclusion Orthodontists recognize the significance of precise bracket placement: fewer wire bends and fewer repositioning appointments for easier and more timely case finishes — all of which improve efficiency and ultimately profitability. Those of us who have employed customized appliances can also attest to their benefits. Trayless bonding combines these two vital aspects of orthodontic treatment into one appliance that is a boon to prompt bondings with a fully customized appliance. It fits seamlessly into our digital workflow. Moreover, the clarity of the brackets makes them beautiful on the teeth. The system can save significant doctor time during bondings, and for those looking to delegate the bonding appointment, it is a reliable technique for trained assistants to manage. It offers accurate, consistent, and fully visualized bracket positioning in a simple and convenient trayless delivery system that addresses the challenges of traditional IDB. OP

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PRACTICE DEVELOPMENT

Tumultous times, tough conversations: the Internet’s influence on communication Pat Mc Bride, PhD, CCSH, discusses how the online world can affect the orthodontic practice

he Internet and social media has forever changed the way we obtain and use healthcare information for ourselves and our families. It is commonplace for dentists and orthodontists to have made significant modernization in their offices to utilize website and social media platforms to educate, engage, and attract patients. The downstream effect of these changes means that the quality and style of communication and information “pushed” out to the public has significantly more intrinsic influence on patients’ perceptions about specific dental issues, possible therapy interventions they may want or need, and the skill set of the dentist or orthodontist in particular. With just a few clicks, impressions from images, content, or posted reviews can modify patients’ decisions or shift perceived credibility in a provider or a treatment plan that has been discussed or already embarked upon. Not surprisingly, the largest proportion of patients using the Internet to obtain dental and orthodontic information are urban and suburban dwellers versus rural patients. This issue of inequity remains a universal problem across most of medicine and dentistry, and is not mitigated simply by income, but also by access to Internet services and quality care demographically and geographically. Doubtless, this implies that providers in urban or suburban areas will be more heavily impacted by and have more challenges dealing with patients empowered or in some cases viewed as entitled by online health information, blog commentaries, reviews, podcasts, and misinformation. Gone are the days when patients and families acquired “intel” from friends, relatives and neighbors about their local care providers. With the Internet, information comes from all angles, at high speed, from multiple, and often conflicting, sources. There is no

Pat Mc Bride, PhD, CCSH, has spent 38 years as a full time clinician, educator, and author in the fields of dentistry, respiratory medicine, and dental sleep medicine. Her extensive experience in clinical, laboratory, research, and educational arenas has led to the development of interdisciplinary care model delivery systems used in collaboration by physicians and dentists around the globe. Pat has a unique ability to intervene in the interstices of global systems, developing protocols which can be translated across demographics and cultures into improved clinical outcomes. In addition to teaching and writing, Pat continues to work hands on in the patient care arena. Serving the underserved and marginalized patient remains a passion and priority for her. She sits on numerous Boards such as the AAPMD and is the Executive Director for The Foundation for Airway Health. She has one grown daughter who shares her passion for social justice and education, serving as a sixth grade teacher in the inner city Oakland.

orthopracticeus.com

end to what people can find if they dig deep enough. It is like watching multiple channels on multiple screens, all at once. Trying to digest too much information at once can be stressful and overwhelming to most individuals. Orthodontic treatment is lengthy, and the path can be bumpy as difficulties can arise throughout treatment concerning adherence to protocols, patient and parental expectations, communication breakdowns and misunderstandings, possible switching of providers, social anxiety, and concerns for temporary facial changes by the child, and a host of other possible issues. Unless the practitioner becomes the communication leader, the door is open for questioning, concerns, and doubts. Now more than ever, it is essential that the practitioner and patient create a relationship of collaborative trust and open exchange before, during, and after treatment. At its very best, the Internet has the potential to be one of the very best self teaching platforms, as long as the information accessed is appropriate, creditible, and verifiable. The easy availability of dental and orthodontic treatment information is not an issue per se; the real dilemma is the authenticity of the information.“There is no system introduced on the Internet to check whether information is reliable or not. Patients don’t check the source or authenticity of content, and a big chunk of online information isn’t regulated. The common user believes anything they read online.”1 This can lead to confusion, anger, loss of credibility for the dentist or orthodontist who may not agree with the information the patient considers to be accurate, and/or failure to meet patients’ expectations based on the information they’ve acquired and believe is 100% correct. There is no means available for balancing the dichotomy of information and opinions.

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Also, the information can be incomplete, based With just a few clicks, impressions from images, on insufficient scientific evidence or misleading, particularly in regard to online support groups, content, or posted reviews can modify patients’ where sensational anecdotes and unbalanced decisions or shift perceived credibility in a views are common.2 As evidenced by a recent television news exposé on the failures of an adult provider or a treatment plan that has already expansion appliance for sleep apnea, parents of been discussed or embarked upon. young children were misled into believing that all pediatric orthodontic devices should be FDA approved. The sensationalization of the reporting and massive Internet blogging led to many anxiety-ridden and issues develop — they’ll be back, and it’ll cost a whole lot more sometimes hostile calls to orthodontists across the country from to undo the damage. parents fearful that their children were being harmed by treatOr, what about the child in expansion therapy whose parents ment — that their child was not actually undergoing. read in a mommy blog about “this great other” appliance for Internet and social media use by patients, and parents in their child? They announce without understanding how it actuparticular, affects professional and parent communication and ally might affect their child’s clinical issues or treatment, that relationships bidirectionally “by leading to more equal commu“this is a better way to go,” then try to direct a major change nication between the patient and provider, and harmonious relain treatment plan, expecting no change in costs for treatment tionships on the one hand, and increased switching of providers, already in place for several months. You’ll be running towards and suboptimal interaction between the patient and provider on the fire extinguisher to put out your hair. the other.”3 So, it can be a bit of a minefield for providers. Every provider wants to be “that someone” people come to Providers and patients are increasingly caught in the crosssee and obtain treatment from. Communicating well through fire of miscommunication in the prevailing battle between traobstacles and barriers may very well help your practice thrive ditional orthodontic treatment plans which include extraction even if the conversations are difficult, contentious, or stressful. and retraction treatment provision, and the rapidly growing Understanding there are some general barriers running across movement of providers who embrace whole-health dentistry. most demographics including the disabled and underserved Whole-health orthodontics focuses on airway development, may help in planning and executing meaningful conversations. quality sleep and breathing, improved overall functioning, and It should be no surprise that regardless of how much inforrobust brain and body development to improve the trajectory of mation people acquire, there is always fear of the unknown. every child towards achieving their optimal potential. They may not know you, or whether you are there to supply Internet blogs, podcasts, and websites providing conflicting a wide variety of treatment options or only “what you do.” information does empower patients and families, but it also creThere is a general mistrust of healthcare providers post-COVID, ates a lot of communication chaos. Empowerment can be a douwhich no amount of education and reassurance can completely ble-edged sword as we all know. Knowledge empowers patients assuage. Cost or perceived costs compared to others may force to ask comprehensive questions and make decisions with better a conversation where patients demand justification for fees. Or, understanding of the risks and benefits of any particular treatpatients may have conflicting opinions obtained from previous ment. On the down side, it can be confused with entitlement provider consultations or from conflicting ideologies/methodolwhich places the providers in the uncomfortable position of ogies they have read or watched online, through podcasts and defending their methods or treatment recommendations to the blogs. How can you reassure them that what you say and offer is patient. This disempowers the entire concept of collaborative valid for them personally, even if a previous provider told them, communication. for example, that early intervention for their child has no merit? Regardless of whatever camp you are in as a provider, comThere will always be concern for “What if it all goes wrong? Or munications with your patients across all areas of dentistry and wrong, again?” particularly orthodontics under the influence of the Internet is Unfortunately, when people have had harmful prior treatchallenging. An understanding of some of the hidden obstacles ment or no treatment, foundational anxiety may subconsciously to transparent and collaborative communication can help ease make them want to direct care. This is when real empathy and anxiety and provide a solid foundation for potentially tough honesty from you and your staff is paramount. If the patient’s conversations. For example: everyone knows that thousands of issues are beyond your skill set or confidence, honest assesspatients have sought clear aligner treatment — online with no ment of your ability to help may be an initial disappointment, dentist involved — for a few hundred dollars rather than seek the but appreciated in the end. There is no shame in admitting that care of qualified professionals who will safeguard their dental, you don’t know what you don’t know, cannot or will not do what occlusal, and periodontal health while aligning the teeth. Why? you do not do, and hold whatever beliefs you have to be true. Because those individuals don’t want the hassle of dealing with What about the question of time? Time or the lack of it, or “going to” the dentist — it’s cheaper, gets mailed to the door, patients’ sense of entitlement to it can be a real deal buster. A and saves time. On the front end, that’s absolutely correct. On patient/family who has an hour or longer consultation, then the back end, it’s like the patient who declines a necessary root goes home and fires off an email with 50 questions requesting canal. When it all goes sideways, the bite is off, or periodontal immediate, detailed reply because they feel entitled to it, is Orthodontic Practice US

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going to take an inordinate amount of everyone’s time. Boundaries regarding communications in all forms need to be set. Your office must have a written protocol regarding communications of this nature that the patients must agree to from the start. It can also be implemented with existing patients to help control the floods of emails into the office. The protocol should include what is appropriate content for an email, how to be clear and identifiable to protect privacy and follow HIPAA guidelines, who in the office will be reading and or replying to emails, and when a charged online additional consultation may be required to answer detailed or lengthy questions.4 The Internet is a remarkable thing, and the beauty of a well-educated dental or orthodontic patient or parents is that the flow of information can be as easy or hard as everyone wants to make it. Use that number one skill you have — listen, listen, listen, then reply with honesty and empathy to all questions. Allow that there can/will be disagreement in philosophy or desire, or plan, and decide collaboratively if what you offer and how you offer it is in sync with the patients’/parents’ expectations, ability to commit to, pay for, and understand. If parents are uncomfortable or unwilling to accept your observations, allow for a graceful exit, offer other resources such as referral to specialist pediatrician, ENT, or sleep medicine MD if appropriate.

Remember if a child is the patient, including them in every aspect of the conversation that is appropriate to their development and understanding is also crucial. They are, after all, the ones going through treatment, and must be on board. Allow for time to digest your thoughts and treatment plan prior to asking for commitment. Encourage second or even third opinions if parents seem unsure. If your team is relational and not transactional, it will allow for everyone to be sensitive to needs both expressed or unexpressed of all concerned. And finally, you need not be a casualty of Internet and social media over-consumption by patients and families. Educate where you can, clarify where you must, and always do what’s right for them and for you. If you do so and communicate in a way that quiets the “noise,” you and your patients will be in a great place to move down whichever treatment pathway is best for all. OP REFERENCES 1.

Ijaz R. How technology affects doctor-patient relationship? Health Works Collective. https://www.healthworkscollective.com/how-technology-affects-doctor-patientrelationship/. Updated June 8, 2018. Accessed August 1, 2023.

Benigeri M, Pluye P. Shortcomings of health information on the Internet. Health Promot Int. 2003 Dec;18(4):381-386.

Smailhodzic E, Hooijsma W, Boonstra A, Langley DJ. Social media use in healthcare: A systematic review of effects on patients and on their relationship with healthcare professionals. BMC Health Serv Res. 2016 Aug 26;16(1):442.

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CONTINUING EDUCATION

Applications of 3D printing in orthodontics Dr. Sunny Jisun Lee outlines how 3D printing can benefit the orthodontic practice

he utilization of 3-dimensional printing in dental settings has experienced significant growth in recent years. In particular, its implementation in orthodontic offices has gained attention due to its extensive and versatile range of applications. The extent to which an orthodontist incorporates 3D printing into their practice naturally depends on factors such as software, printing technology, available human resources, and importantly, their treatment philosophy. The applications highlighted in this article reflect only a portion of what 3D printers can achieve in orthodontics. Nonetheless, they can serve as a guiding example for those who are starting or expanding their in-house lab, regardless of its size.

Selecting a printer Choosing the right printer has an enormous financial and clinical impact on the office. The following should be considered: • Cost • Time-efficiency • Accuracy • Print volume for practice One thing to note is that although different types of printing technologies do influence the accuracy of 3D printed models, it does not make a significant change in clinical outcomes1 — in other words, you can use any known type of 3D printer and trust that they will render clinically acceptable models. However, we will later address other factors that will affect the clinical outcomes. The two most popular printing technologies in current orthodontics are undoubtedly laser-stereolithography (SLA) and digital light processing (DLP) — both being relatively affordable but not compromising on accuracy. They belong to the vat polymerization printer category, which involves using liquid resin and a curing light to solidify the resin. Between these two, DLP is considered to

Sunny Jisun Lee, DDS, MBA, graduated from University of the Pacific Arthur A. Dugoni School of Dentistry and completed an orthodontic program at Roseman University of Health Sciences, where she also received a degree in business administration. She currently practices at Orthodontic Specialists of Green Bay, a private office in Green Bay, Wisconsin, alongside two other orthodontists. She serves as a Component Advocacy Liaison for the state of Wisconsin for the recently launched AAO National Advocacy Network. Her focus in treatment encompasses contemporary orthodontic techniques and addressing airway and TMJ concerns. Disclosure: Dr. Lee does not have any financial or other relationship with the products mentioned in the article. Special thanks to Dr. Ed Y. Lin and lab manager Paula Kaminski for reviewing the article.

Orthodontic Practice US

Educational aims and objectives

This self-directed educational course for dentists provides information for those who have interest in building or expanding their knowledge regarding applications of in-house 3D printing.

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: • Identify the elements involved in choosing a 3D printer in orthodontics. • View examples of how a combination of 3D printing and digital orthodontics can be used, and identify where and how to increase the capacity of your 3D printing lab and adapt digital orthodontics. • Review the current research behind 3D printing in orthodontics. • Identify the future prospects for 3D printing in orthodontics.

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Figure 1: Diagram showing differences between laser SLA and DLP printers in projecting image from light source3

offer a better balance between cost and efficient printing.2 Faster than laser-SLA, DLP’s speed comes from the fact the digital light projector projects the given cross-sectional area all at once (Figure 1). Having an advanced laser chip (e.g., a true 4k processing chip) that provides high pixel density reduces the stair-stepping effect, ensuring a smooth surface and increased clarity. When evaluating the cost-benefit analysis, one must consider additional costs associated with printers. Both laser-SLA and DLP printers require an alcohol wash and post-cure process. Resin is

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Table 1: Implications of 3D Printed Models Created Off Printed Models

Software Used

Hardware Used

Additional Resources

In-house Aligners

uLab

Biostar® Scan with LCD Display

Good Fit Technologies GT FLEX PRO .025 (template)

Digital Dental CNC Milling Machine (trimming)

Good Fit Technologies GT FLEX PRO .030 (aligners)

Biostar Scan with LCD Display

Bay Materials Zendura .030” (Ph I retainers, finishing aligners and retainers)

Retainers (Ph I and Ph II/ Comprehensive Treatments)

uLab (processing and set trim height)

Banded Metal Appliances (Nance, rapid molar expanders, lower lingual holding arch)

uLab (processing)

Fixed lingual retainer (with a putty jig)

YOAT FixR (processing)

Digital Dental CNC Milling Machine (trimming)

Bay Materials Zendura .030” (finishing aligners and retainers)

Bay Materials Zendura .040” (retainers for bruxors)

Orion LZR 60 (welding)

Autodesk MeshMixer (processing) YOAT Bender II

16x16 deadsoft SS AW (G&H Orthodontics) Manually made putty jig

typically sold in liters, and manufacturers usually recommend purchasing resin from the same brand for warranty and proper servicing. Lastly, servicing cost and period are commonly overlooked, but keep in mind that most printers will require regular maintenance and may need occasional emergency servicing. Therefore, high-volume practices will benefit from owning more than one working printer. Those who own smaller practices or have longer turnover time for resin use should pay attention to the expiration date and shelf life for resin. Our offices use DLP printers: Desktop Health’s Envision TEC Vida2 and Envision One as well as the Einstein Pro XL. As mentioned above, the Pro XL with an advanced DLP chips claims to mitigate the stair-stepping effect by precisely managing the light intensity along the contours of a design (Figure 2). Considering its pricing range of $15k-40k, it is likely that they are positioned at a higher range compared to what most dental offices have. Again, it becomes imperative to carefully assess the cost and benefits when selecting a printer.

Figures 2A-2C: 2A. Modulating the intensity of light in individual pixels along the edge; 2B) during the intermediate stages of the growth process, and 2C. after the complete polymerization of the resin4

models for aligner purposes.6 Although my office has been printing arches horizontally, we are currently testing the vertical orientation for increased printing efficiency.

Indirect bonding (IDB) trays

Products of 3D printing Models

• The choice of software for model processing is an important consideration as some software provides more features than others. Having a consistent system in place leads to higher efficiency and reduces confusion for staff. Please refer to the section “Further Implications of Printed Models” for a list of software and hardware we utilize. • When it comes to determining the appropriate layer height for a clinically acceptable printed model, research consistently demonstrates that a 100-μm layer is superior to 25-μm or 50-μm layers.5 Therefore, a 100-μm layer height seems to be the minimum when deciding on the layer height for printing. • Current research suggests the orientation of printed arches does not significantly affect the accuracy of 3D-printed orthopracticeus.com

• Despite research findings, multiple-tray printing (MTP) appears to be the clinical winner. Single-tray printing (STP) has demonstrated fewer errors in bracket positioning compared to MTP7 — however, STP faces two big challenges in the clinic. First, removing a single tray that covers the entire arch after curing becomes difficult for patients who present crowding and/or buccal inclination of incisors. Second, if IDB was performed poorly, it may result in failure and debonding of the entire arch instead of small segments (Figure 3). These challenges make MTP a more practical and clinically feasible option for many orthodontic practices. • IDB software from other companies may draw attention for their unique features — such as a channel that allows cleaning up around brackets or ability to selfprocess trays.

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Figure 4: Digital Dental CNC Milling Machine to trim aligners and retainers. Picture taken in our practice Figure 3. Two-segmented upper tray (top) and lower tray (bottom) fabricated in my practice. Picture taken in our practice

In-house aligners • The impact of trim design on tooth movement with aligners is widely acknowledged.8 In my office, we have a specific approach to trim design. Instead of utilizing a scalloped design, we trim most aligners to a height of 0.5 mm above the gingiva to prioritize patient comfort. For patients who require non-compliance or have challenging tooth movements, we increase the trim height to 0.75 mm. In cases of gingival recession or abfraction, aligners are trimmed at the cemento-enamel junction (CEJ). • To mark the trimline, we employ uLab software, although it should be noted that manual marking introduces the potential for human error. For the actual trimming process, we rely on a milling machine specifically designed for trimming aligners and retainers. This enables our staff to efficiently and effectively prepare the aligners, ensuring a precise and comfortable fit for our patients.

Retainers • Ph I retainers cover U2-2 and U6’s with palatal coverage. All other retainers are made with a full coverage of dentition, and acrylic can be added for bite ramps as needed. A thicker material, Zendura 040”, is used for bruxers.

Banded Metal appliances • The utilization of 3D printers for fabricating in-house metal appliances offers an opportunity to further enhance the capacity of the orthodontic lab. With the use of 3D printers, the fabrication process becomes more scalable. Orthodontic Practice US

Figure 5. Sample case on MeshMixer for processing models for banded appliances

• Software like Autodesk MeshMixer eliminates the need to remove excess model material around the molars with a handpiece. This not only increases efficiency but also simplifies the processing of banded metal appliances. • We fabricate various metal appliances — Nance, rapid molar expanders, and lower lingual holding arch.

Fixed lingual retainer • Although not made directly off a printed model, having a physical model (arch can be segmented and printed to save resources and effort) allows for fabrication of a jig. All the provider or assistant have to do is to place the jig that holds a fixed lingual retainer, bond and cure with flowable resin (Figures 4 and 5).

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Figure 6: Machine-bent fixed retainer with a man-made jig. Picture taken in our practice

Figure 7: Placing the fixed retainer intraorally using the jig. Picture taken in our practice

The extent to which an orthodontist incorporates 3D

Advanced implications of 3D printing

printing into their practice naturally depends on factors

Although my office does not employ the tools below regularly, they are certainly generating discussions among orthodontists. It is important for orthodontists to stay informed about these advancements to explore their potential benefits and applications.

such as software, printing technology, available human resources, and importantly, their treatment philosophy. and excitement, we will need to see clinical studies to determine the viability of direct-printed aligners.11 OP

CAD/CAM-designed metal or resin appliance • 3D metal printers are costly but will be a great addition if patient demand and volume are sufficient, and an in-house lab has the capacity to justify the purchase. 3D-printed, metal-banded appliances do not require separators, which saves providers’ and patients’ time and have great retention. • CAD/CAM-designed resin appliances hold promise for significant implications in orthodontic settings, but further research, particularly concerning FDA-approved resin materials and protocol, is needed to fully tap into their future.

REFERENCES 1.

Tsolakis IA, Gizani S, Panayi N, Antonopoulos G, Tsolakis AI. Three-Dimensional Printing Technology in Orthodontics for Dental Models: A Systematic Review. Children (Basel). 2022 Jul 23;9(8):1106.

Pereira ABN, Almeida RC, Marassi C, Abdo Quintão CC, Carvalho FAR. Do low-cost 3-dimensional printers produce suitable dental models? Am J Orthod Dentofacial Orthop. 2022 Jun;161(6):858-865.

Frey S. Laser SLS vs DLP vs masked SLA 3D printing technology. The Ortho Cosmos. March 23, 2017. https://theorthocosmos.com/laser-sla-vs-dlp-vs-masked-sla-3d-printing-technology-compared/. Accessed July 13, 2023.

Desktop Health. Desktop Einstein Pro XL Dental 3D Printer. https://health.desktopmetal.com/3d-printers/einstein-pro-xl/. Accessed July 13, 2023.

Loflin WA, English JD, Borders C, Harris LM, Moon A, Holland JN, Kasper FK. Effect of print layer height on the assessment of 3D-printed models. Am J Orthod Dentofacial Orthop. 2019 Aug;156(2):283-289.

McCarty MC, Chen SJ, English JD, Kasper F. Effect of print orientation and duration of ultraviolet curing on the dimensional accuracy of a 3-dimensionally printed orthodontic clear aligner design. Am J Orthod Dentofacial Orthop. 2020 Dec;158(6):889-897.

Yoo SH, Choi SH, Kim KM, Lee KJ, Kim YJ, Yu JH, Choi YI, Cha JY. Accuracy of 3-dimensional printed bracket transfer tray using an in-office indirect bonding system. Am J Orthod Dentofacial Orthop. 2022 Jul;162(1):93-102.e1.

Cowley DP, Mah J, O’Toole B. The effect of gingival-margin design on the retention of thermoformed aligners. J Clin Orthod. 2012 Nov;46(11):697-702; quiz 705.

Tartaglia GM, Mapelli A, Maspero C, Santaniello T, Serafin M, Farronato M, Caprioglio A. Direct 3D Printing of Clear Orthodontic Aligners: Current State and Future Possibilities. Materials (Basel). 2021 Apr 5;14(7):1799.

Direct-printed aligners and retainers • Up until 2021, there were no marketed and approved materials specifically for direct printing of aligners — thickness of printed aligners was not transferred accurately as software design, and figuring out the post-curing process affecting resin property was not established.9 The AAO 2023 conference in Chicago featured presentations on direct-printed aligners, highlighting the introduction of Forastadent’s Graphy system — their resin advertised as the world’s first direct-print aligner material.10 A recent study conducted with their resin material, Forastadent Tera Harz™ TC-85DAP 3D Printer UV Resin, demonstrated improved accuracy and trueness of aligners compared to thermoformed aligners. Despite the buzz orthopracticeus.com

10. Graphy. Forestadent®. https://www.forestadent.com/en-us/products/aligner/produktdetail/graphy-3/. Accessed July 13, 2023. 11. Koenig N, Choi JY, McCray J, Hayes A, Schneider P, Kim KB. Comparison of dimensional accuracy between direct-printed and thermoformed aligners. Korean J Orthod. 2022 Jul 25;52(4):249-257.

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Continuing Education Quiz Applications of 3D printing in orthodontics LEE

1. The extent to which an orthodontist incorporates 3D printing into their practice naturally depends on factors such as software as well as ___________. a. printing technology b. available human resources c. treatment philosophy d. all of the above

2. Choosing the right printer has an enormous financial and clinical impact on the office. The following should be considered: _________. a. Cost and time efficiency b. Accuracy c. Print volume for practice d. all of the above

AGD Code: 370

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. Date Published: September 28, 2023 Expiration Date: September 28, 2026

2 CE CREDITS

3. One thing to note is that although different types of printing technologies do influence the accuracy of 3D-printed models, it does not make a significant change in clinical outcomes — in other words, you can use any known type of 3D printer and trust that they will render clinically acceptable models. a. True b. False

7. Those who own smaller practices or have longer turnover time for resin use should pay attention to _______. a. the expiration date of the resin b. the shelf life for resin c. the size of the in-office lab d. both a and b

4. Laser-stereolithography (SLA) and digital light processing (DLP) belong to the ________ category, which involves using liquid resin and a curing light to solidify the resin. a. vat polymerization printer b. multiple-tray printing c. FixR printing d. BioStar processing

8. When it comes to determining the appropriate layer height for a clinically acceptable printed model, research consistently demonstrates that a ________ layer is superior to 25-μm or 50-μm layers. a. 60-μm b. 70-μm c. 100-μm d. 125-μm

5. Faster than laser-SLA, DLP’s speed comes from the fact that the digital light projector _________. a. increases the stair-stepping effect b. projects the given cross-sectional area all at once c. is not selective d. has a low pixel density

9. (Regarding trim design with aligners) Instead of utilizing a scalloped design, the author trims most aligners to a height of ______ above the gingiva to prioritize patient comfort. a. 0.3 mm b. 0.5 mm c. 0.75 mm d. 0.80 mm

6. Servicing cost and period are commonly overlooked, but keep in mind that most printers will require regular maintenance and may need occasional emergency servicing. Therefore, high-volume practices ________. a. will benefit from owning more than one working printer b. should not consider getting a 3D printer c. should only get a model that does not require regular maintenance d. should only get a model with advanced DLP chips

10. (Regarding trim design with aligners) For patients who require noncompliance or have challenging tooth movements, we increase the trim height to _________. a. 0.65 mm b. 0.75 mm c. 0.85 mm d. 0.95 mm

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

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The five finger approach to sleep-wake complaints Dr. David E. McCarty offers a collaborative patient-centered problem-solving tool for a complex world The complexity of sleep apnea Because it arises from multiple overlapping anatomic, physiologic, and functional deviations from optimum, with variable representation of obstructive versus central apnea processes, the entity known as “Sleep Apnea” is best characterized as a complex phenomenon1 for which there is no “one-size-fits-all” solution.2 What’s more, clinical management of breathing- and airwayrelated pathology requires navigation of countless non-apnea contributors to sleep-wake complaints, nesting the complexity of the breathing/airway issues within the complexity of a larger spectrum of sleep-provocative disease. “Complex” environments differ from “complicated” ones by virtue of their unpredictability. For example, the cockpit of a 747 can be considered a “complicated” environment. Sure, there are scads of dials and knobs, but with the right training, you’d know just what to do to get a predicable result from that machine: you’d take off, you’d fly, and you’d land, and it would be predictable. On the other hand, a “complex” environment involves variables that may be hidden to the problem-solvers, responses to therapy being less predictable. Compared to an aircraft cockpit, a “complex” environment is more like a Brazilian rainforest.3 Complicated environments tend to run efficiently with expert, top-down management styles. On the other hand, complex environments require a different mindset, one which is receptive to new information and intentionally collaborative.3 To explore this, let’s go to war…

Gen. Stanley McChrystal, Al Qaida in Iraq, and the Team of Teams In his bestselling book Team of Teams, Stanley McChrystal (U.S. Army Gen, retired) describes his real-world approach to complexity and his successful strategy to harness true collaboration among America’s most elite strike forces: Navy SEALS, Army Rangers, Army Delta Force, and Air Force Special Tactics.4 Under McChrystal’s command, this consortium faced a devious and dangerous enemy called Al Qaida in Iraq in the early 2000s. In short, he found that these elite forces had difficulty merging their efforts at first — the squads seemed to compete with one another in the field and had trouble predicting one another’s

David E McCarty, MD, FAASM, is a Sleep Medicine clinician, author, cartoonist, and podcast creator/host. He is the co-author of Empowered Sleep Apnea: A Handbook for Patients and the People Who Care About Them, and the creator and co-host of Empowered Sleep Apnea: THE PODCAST.

orthopracticeus.com

Educational aims and objectives

This self-directed educational course for dentists aims to demonstrate how to communicate the complex topic of sleep medicine to patients by using the Five Finger Method.

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: • Identify the concept of the Five Finger Approach as a functional and actionable method. • Realize the parts of the sleep-wake regulation Two Process Model that could lead to circadian misalignment. • Recognize how pharmacologic factors can play a part in sleep-wake complaints. • Realize that medical factors and psychosocial/psychiatric factors play a part in sleep/wake complaints, and they must be discovered by collaboration with the patient. CREDITS

2 CE

contingencies. Instead of enhancing one another’s efforts, squads often squabbled and defended their internal honor. He described the phenomenon as feeling like the coach of a soccer team of exclusively world-class players, all of whom happened to play the game with blinders on. McChrystal understood that he wouldn’t be able to command his way out of his predicament. He realized he needed to create an environment where collaboration would arise naturally. To do this, he introspectively asked what would make a good soccer team. His answer included two elements: 1. Team-members needed to share an understanding of the playing field — what it looked like, what the rules were, and how things fit together — in other words, all players possessed a “shared consciousness” of the complexity of the situation. 2. Team-members had to experience “lateral connectivity” — a term which for McChrystal basically boiled down to a combination of “trust” and “empathetic connection.” Trust empowers an upfield player to kick the ball to an empty spot downfield, born of an empathetic bond with her teammate — whom she knows is fast enough to get there, and carries the shared consciousness that that’s where she’s expected to be.

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To enhance team-wide shared-consciousness, McChrystal created an open-command-post mission control center, with planning stages open to all key members of the mission: even translators, drivers, and non-military governmental agencies like the CIA and FBI. As a leader, he was present, active, and available. Very few details were deemed “need to know.” To enhance lateral connectivity, McChrystal instituted a cross-team embedding program — a SEAL would embed with the Rangers, for example, or a Delta would fly with Special Tactics. Ultimately, McChrystal’s “Team of Teams” would go on to eliminate their most dangerous target, the charismatic radicalized leader of Al Qaida in Iraq, Abu Musab al-Zarqawi, a success McChrystal attributed to collaboration and field-empowered decision-making: “At the core of the Task Force’s journey to adaptability lay a yin-and-yang symmetry of shared consciousness, achieved through strict, centralized forums for communication and extreme transparency, and empowered execution, which involved the decentralization of managerial authority.” 4

Complexity, collaboration, and Dave Snowden’s Cynefin Framework Dave Snowden is a social scientist who specializes in making sense of complexity.5,6 He popularized the concept of collaborative decision-making in the business world and continues to consult for titans of industry.7 The following passage — taken from an essay Snowden wrote for Harvard Business Review in 2007 — observes breakthroughs when a leader is receptive to new information: “Instructive patterns … emerge if the leader conducts experiments that are safe to fail. That is why, instead of attempting to impose a course of action, leaders must patiently allow the path forward to reveal itself. They need to probe first, then sense, then respond.”3 What Snowden describes here is essentially responsive listening, echoing the foundational ethos of patient-centered medicine. When he advises leaders to conduct “experiments that are safe to fail,” clinicians recall the scientific basis for the old-fashioned “N of 1” clinical treatment trial.8 Substitute “examine-diagnose-treat” for “probe-sense-respond,” and the parallel to patient-centered medicine is clear.

Figure 1A: Five Finger Approach (from McCarty 20109)

1. circadian misalignment 2. pharmacologic factors 3. medical factors 4. psychiatric/psychosocial factors 5. primary sleep medicine diagnoses.9 When used as a collaborative bedside tool, this framework helps patients participate in their own problem-solving by promoting a shared consciousness for the complexity that’s being deconstructed. When each domain is collaboratively explored by provider and patient, the partnership can identify actionable sources of suffering, discomfort, and dissatisfaction with the sleep-wake experience that otherwise would remain unseen and unaddressed.10 To properly explore the first two domains (circadian misalignment and pharmacologic factors), we’ll need to review some basic concepts of circadian neurobiology and clinical epidemiology. First, let’s look at circadian misalignment.

Exploring circadian misalignment

Arguably, skillful navigation of complexity is the “art” of clinical practice. McChrystal’s wartime experience and Snowden’s work on complexity sense-making both suggest a method behind the “art,” with a receptive and collaborative posture at its foundation. It follows that providers best able to collaborate with their patients will be most successful navigating through medically complex terrain. The challenge we face is to communicate the complexity of the landscape of sleep medicine to our patients in an understandable and practically useable way.

The competing drives for “sleep” and “wake” can be summarized using a framework that’s called the Two Process Model of sleep-wake regulation.11 The two processes governing “sleep” and “wake” are called Process S (the “S” stands for a concept known as “sleep pressure”) and Process C (the “C” stands for “circadian”). When the circadian drive to promote wakefulness is misaligned with the desired timeframe for sleep, the sleep-wake experience becomes problematic. It’s common for evening environmental variables to contribute to a delay in circadian sleep phase — creating a type of “social jet lag” which manifests as sleep-onset insomnia and morning grogginess. The complexity of these topics can be easily shared with patients, as will be explained below.

The Five Finger Approach

Process S: Fumes in the Attic

Complexity requires collaboration

The “Five Finger Approach” is a patient-centered collaborative clinical tool which organizes the complexity of problemsolving sleep-wake complaints into five functional and actionable domains: Orthodontic Practice US

The concept of Process S can be easily explained by using the concept of “fumes in the attic.”12 The longer we’re awake, and the more active we are, the more “fumes” will build up in our “attic.” When “fumes” get too thick, we get sleepy, bleary-eyed, brain-

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Figure 1B: “Fumes in the Attic” cartoon (from McCarty & Stothard 202212)

fogged. When we fall asleep, fumes clear out — it’s as if we’ve opened up all the windows in the attic to allow a cross-breeze to ventilate all those fumes away! The cartoon in Figure 1B illustrates the concept with a bit of whimsy.

Process C: Circadian Maintenance of Alertness The deep brain neuronal structures keeping us awake are collectively referred to as the “Ascending Reticular Activating System” — “ARAS” for short. Stimulating these neurons makes us feel more awake. Damaging or blocking these neurons makes us feel sleepy, due to unopposed activity from Process S. The neurons of the ARAS are programmed to fire at different levels, depending on the time of day, a process regulated by the seat of our circadian rhythm, the suprachiasmatic nucleus (SCN).13 Toward the end of the day, during roughly the 3 hours before our usual prolonged nocturnal sleep interval, the ARAS fires at high levels. This makes sense, because by the end of the day, there’s a lot of sleep pressure (i.e.: Process S, i.e.: “fumes”) hanging around. At that point, the ARAS must work hard to counterbalance the fumes, so it dials way up.13 This is the “second wind” our patients might recognize, in the early evening. Researchers of circadian sleep biology have termed this timeframe in the circadian cycle the “forbidden zone” because biologically, it’s difficult for one to sleep during this timeframe of robust ARAS activity.14 Delaying the “forbidden zone” contributes to “social jet lag” symptoms, like sleep-onset insomnia and morning grogginess.15 Teaching about circadian biology is enhanced with the use of visual aids, such as the interactive wheel shown in Figure 2. orthopracticeus.com

Figure 2: Circadian Rhythmo-Wheel (from McCarty & Stothard 202212). A bedside tool for teaching patients about circadian biology. The usual prolonged sleeping interval — the “circadian sleep phase” — is shown in blue (~10 p.m. to 6 a.m.). The “forbidden zone” is shown in orange (~7 p.m. to 10 p.m.). A free downloadable and interactive version of this tool is available at https://www.empoweredsleepapnea.com/circadian-rhythmo-wheel

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Patients are often surprised to learn that common environmental variables in the timeframe of the “forbidden zone” — not just electric lights, but also social stimuli, such as eating, excitement, and exercise — all promote a subsequent delay in the sleep phase, thus compounding “social jet lag” misalignment symptoms.

Exploring pharmacologic factors Prescription medications and social drugs (like nicotine, caffeine, alcohol, and, increasingly, marijuana) can have profound influences on sleep and wake. That’s why a diligent, non-judgmental pharmacologic review is essential in any investigation of an individual’s sleep-wake complaints.

How does one decide if a medication or drug is playing a role in a patient’s sleep-wake complaints? Evidence-based medicine pioneers, Sackett, et al., recommend a studied evaluation of whether there’s a repetitive signal in the published literature suggesting that the agent in question can cause the type of harm you’re worried about, coupled with a temporal sequence of exposure and outcome that makes sense for the narrative you’re dealing with.14 This bit of detective work is enhanced when patients understand the nature of the search and are deputized as active agents in the problem-solving process.10 A list of common pharmacologic factors affecting sleep-wake is listed in Table 1.

Table 1: Common Pharmacologic Factors Affecting Sleep-Wake Drug Class

Common Examples – Generic Names (Trade Names)

Effect on SLEEP and WAKE

Metoprolol (Toprol XL)

Beta blockers promote insomnia and can disturb dreams. Disturbances in REM sleep can lead to nightmares or even to to the disquieting experience of dreaming while seemingly awake (hallucinations). Lipophilic beta blockers cross the blood-brain barrier more readily and are more likely to provoke sleep disturbances.

Cardiovascular Drugs Beta Blockers

Labetalol

Note that beta blockers can also contribute to daytime WAKE-related symptoms of generalized lethargy and fatigue.

ACE inhibitors

Lisinopril, Ramipril

This drug class can increase airway irritability, leading to disruptive coughing that can disturb sleep. The upper airway irritability may worsen obstructive sleep apnea pathology.

Statins

Atorvastatin, Rosuvastatin, Simvastatin

Statins may provoke insomnia with or without causing muscle pain. If you get muscle pain with statins, this can also interfere with sleep. Note that statin-induced muscle pain can also color the lens by which WAKE is viewed, leading to fatigue and poor exercise tolerance.

Mental Health Drugs Selective serotonin reuptake inhibitors (SSRIs)

Fluoxetine, paroxetine, sertraline

SSRIs contribute to “restless legs” symptoms (higher doses = worse effects). SSRIs can also increase the likelihood of dream enactment behavior, which is another way of saying “moving around while you dream.” When dream enactment behavior happens for no good reason, it’s called REM Sleep Behavior disorder. SSRIs can cause insomnia as an adverse effect (fluoxetine is famous for this). Alternatively, SSRIs can also cause WAKE-related symptoms of grogginess or sedation (paroxetine is famous for this).

Serotonin and Norepinephrine Reuptake Inhibitors

Venlafaxine, desvenlafaxine

All of the above that we just mentioned about SSRIs is true for this drug class. The norepinephrine reuptake inhibition is particularly provocative for insomnia, restless legs symptoms, and dream enactment behavior.

Norepinephrine and Dopamine Reuptake Inhibitors

Bupropion

Think of this drug class as being an amplifier for the ARAS, and you’ll then understand why insomnia is one of the most common adverse sleep-related effects.

Tricyclic antidepressants

Amitriptyline, imipramine, protriptyline

All tricyclics can provoke restless legs symptoms and signs (like periodic limb movements of sleep). They also can be sedating, and in seniors they can cause difficulty with memory, due to an anticholinergic side effect profile.

CNS Stimulants

Methylphenidate (Ritalin), amphetamine/dextroamphetamine (Adderall)

Stimulants are famous for causing sleep-onset insomnia. The longer-lasting the formulation, and the later it is taken in the day, the more likely it will be to interfere with transitioning to sleep.

Bupropion is the only antidepressant that doesn’t provoke restless legs.

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Table 1 Continued Drug Class

Common Examples – Generic Names (Trade Names)

Effect on SLEEP and WAKE

Pulmonary / Rheumatology Drugs Beta-2 Agonists

Albuterol, salmeterol

These inhalers tend to rev you up! Expect an increase to your pulse, and difficulty with getting to sleep, lasting for as long as the drug is active.

Corticosteroids

Prednisone, methylprednisolone

Corticosteroids can cause many problems with your sleep. Difficulty getting to sleep, waking up too early, and abnormal dreams have all been described.

Anticonvulsant Drugs Gabapentinoids

Gabapentin, Pregabalin

Drugs in this class are technically “anticonvulsants” but they’re mostly prescribed for reasons other than seizures. They are often used to manage chronic pain, headache syndromes, fibromyalgia, and symptoms of WED. They are sedating, in general, and can be considered “hypnotics” (sleeping pills). Of importance, these drugs can contribute to next-day sedation when dosed at bedtime!

Social Drugs Nicotine

Nicotine is not friendly to sleep, if used regularly. Pharmacologically, nicotine is a CNS stimulant, so it will interfere with sleep while the drug is active. The other side of the coin with nicotine is the physical and psychological discomfort that comes from withdrawal, which generally begins about an hour after the last dose, for heavy users. That sensation is also a potent stimulus for insomnia. Old-school smoking is particularly irritative to the upper airway and is likely to worsen obstructive pathology.

Alcohol

Alcohol worsens the propensity for Sleep Apnea, particularly obstructive pathology. Though it may help you fall asleep faster, sleep worsens as your blood alcohol content drops, and second-half-of-night sleep is generally rocky and poor-quality. Alcohol hangover symptoms can confound interpretation of daytime neurobehavioral impairment.

Cannabis (THC)

THC is the psychoactive component of marijuana. Depending on the strain, it may be activating or sedating. THC users may experience withdrawal symptoms of anxiety and insomnia, which can lead to a self-perpetuating problem.

Caffeine

Caffeine can interfere with sleep for as long as the drug is in the system. Caffeine can mask daytime impairment symptoms, leading to a sudden “crash” in energy when the drug is metabolized away.

(adapted from McCarty & Stothard, 2022)

Exploring the last three domains

The “Five Finger Approach” is a patient-centered

The last three domains of the Five Finger collaborative clinical tool which organizes the comApproach are 3. Medical Factors plexity of problem-solving sleep-wake complaints 4. Psychosocial/Psychiatric Factors 5. So-called “Primary Sleep Medicine into five functional and actionable domains. diagnoses” The final domain is the mental location to file our patient’s “known sleep diagnoses” and to question whether other common diagnostic labels might have been overlooked. 2. Complicated environments benefit from the efficiency of a Strategically, these three domains are methodically addressed top-down management style, run by an expert. with the patient similarly to the first two, striving to engage 3. Complex environments benefit from collaborative deciSnowden’s mindful “probing” as a first step. In each setting, the sion-making responses to unpredictability. This requires process involves engaging the patient, probing collaboratively an approach of intentional probing and receptivity to whether elements in that domain could be a factor contributing change plans as new information arises. to their personal concerns, and then collaboratively exploring 4. Collaborative teamwork requires: 1. a shared consciouspotential solutions. ness of the system’s complexity and 2. lateral connectivity (i.e., trust and empathetic connection) between team-members. What we’ve learned 5. In a patient-centered clinical relationship, the patient is a 1. Sleep Apnea — and the practice of Sleep Medicine — is member of the team. not complicated, it’s complex! There’s a difference! orthopracticeus.com

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6. “Root cause” complexity for sleep-wake complaints can be deconstructed with a “five-finger” collaborative exploratory tool: 1. circadian misalignment, 2. pharmacologic factors, 3. medical factors, 4. psychosocial/psychiatric factors, and 5. primary sleep medicine diagnoses. 7. Communicating and strategizing collaborative understanding of the first (circadian misalignment) and second (pharmacologic factors) domains requires a basic familiarity with simple concepts of sleep-wake/circadian biology and clinical epidemiology. These concepts are worthy of further study, as mastery improves the ability to characterize this complexity for our patients. OP

REFERENCES

Kurtz CF, Snowden DJ. The new dynamics of strategy: Sense-making in a complex and complicated world. IBM Systems Journal. 2003;42(3): 462-483.

Cognitive Edge Ltd & Cognitive Edge Pte. The Cynefin Company and The Cynefin Centre, Conwyll, Singapore, Wilmington. https://thecynefin.co/. Accessed June 13, 2023.

Sackett DL, Haynes RB, Tugwell P, Guyatt GH. N of 1 Trials: Selecting the Optimal Treatment with a Randomized Trial in an Individual Patient. In: Clinical Epidemiology: A Basic Science for Clinical Medicine (2nd Ed). Boston: Little Brown & Co.;1991:223-238.

McCarty DE. Beyond Ockham’s razor: redefining problem-solving in clinical sleep medicine using a “five-finger” approach. J Clin Sleep Med. 2010 Jun 15;6(3):292-296.

10.

McCarty DE. Sometimes, You’re the One. OR: The Story about How the Five Finger Approach Found a Problem That Had Never Been Described and How it Changed Wendy’s Life. In: Dave’s Notes the official blog of Empowered Sleep Apnea: Published online November 18, 2022. Accessed August 1, 2023. https://www.empoweredsleepapnea.com/daves-notes/ sometimes-youre-the-one.

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Borbély AA, Daan S, Wirz-Justice A, Deboer T. The two-process model of sleep regulation: a reappraisal. J Sleep Res. 2016 Apr;25(2):131-143.

12.

McCarty DE, Stothard E. Empowered Sleep Apnea: A Handbook for Patients and the People Who Care About Them. Pennsaukin Township, NJ: BookBaby Press;2022.

13.

Gabehart RJ, Van Dongen HPA. Circadian Rhythms in Sleepiness, Alertness, and Performance. IN: Kryger, Roth, Dement, eds. Principles & Practice of Sleep Medicine, 6th Ed. Elsevier Press, 2017:388-395.

McKeown P, O’Connor-Reina C, Plaza G. Breathing Re-Education and Phenotypes of Sleep Apnea: A Review. J Clin Med. 2021 Jan 26;10(3):471.

McCarty DE. There is No OSFA: How the Many Moving Parts of Sleep Apnea Demands Precision Medicine. Dental Sleep Practice. Spring 2023;10(1): 18-20.

14.

Strogatz SH, Kronauer RE, Czeisler CA. Circadian pacemaker interferes with sleep onset at specific times each day: role in insomnia. Am J Physiol. 1987 Jul;253(1 Pt 2):R172-178.

Snowden DJ, Boone ME. A leader’s framework for decision making. A leader’s framework for decision making. Harv Bus Rev. 2007 Nov;85(11):68-76, 149.

15.

McChrystal S, Collins T, Silverman D, Fussell C. 2015. Team of Teams: New Rules of Engagement for a Complex World. New York: Portfolio/Penguin Books; 2015.

Stothard ER, McHill AW, Depner CM, Birks BR, Moehlman TM, Ritchie HK, Guzzetti JR, Chinoy ED, LeBourgeois MK, Axelsson J, Wright KP Jr. Circadian Entrainment to the Natural Light-Dark Cycle across Seasons and the Weekend. Curr Biol. 2017 Feb 20;27(4):508-513.

16.

French S. Cynefin, statistics and decision analysis. Journal of the Operational Research Society. 2013. 64:4, 547-561.

Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Deciding Whether Your Treatment Has Done Harm. IN: Clinical Epidemiology: A Basic Science for Clinical Medicine (2nd Ed). Boston: Little Brown & Co.;1991: 283-304.

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a new YouTube series: Nexus Connexus. This series will embody our Nexus Dental Systems’ vision and mission WATCH NOW to inspire others https://www.youtube.com/ to take action and @NexusDentalSystems be informed. We are all extensions of this great cause and your efforts can benefit so many!

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Continuing Education Quiz The five finger approach to sleep-wake complaints McCARTY

1. The competing drives for “sleep” and “wake” can be summarized using a framework that’s called the ________ of sleep-wake regulation. a. Two Process Model b. Circadian Cycle c. Jet Lag Model d. Probe-Sense-Respond Model 2. The deep brain neuronal structures that are _________ are collectively referred to as the “Ascending Reticular Activating System” — “ARAS” for short. a. causing us to to sleep b. keeping us awake c. causing daytime drowsiness d. creating brain fog 3. Toward the end of the day, during roughly the ________ before our usual prolonged nocturnal sleep interval, the ARAS fires at high levels. a. 1 hour b. 2 hours c. 3 hours d. 4 hours 4. Delaying the _________ contributes to “social jet lag” symptoms, like sleep-onset insomnia and morning grogginess. a. “forbidden zone” b. suprachiasmatic nucleus rhythm c. Circadian interval d. Snowden framework 5. Patients are often surprised to learn that common environmental variables in the timeframe of the “forbidden zone” — not just electric lights, but also social stimuli, such as _________ promote(s) a subsequent delay in the sleep phase, thus compounding “social jet lag” misalignment symptoms. a. eating b. excitement c. exercise d. all of the above 6. Prescription medications and social drugs (like nicotine, caffeine, alcohol, and, increasingly, marijuana) can have profound influences on sleep and wake. a. True b. False 7. Evidence-based medicine pioneers, ________, recommend a studied

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 866-579-9496, 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. AGD Code: 730 Date Published: September 28, 2023 Expiration Date: September 28, 2026

2 CE CREDITS

evaluation of whether there’s a repetitive signal in the published literature suggesting that the agent in question can cause the type of harm you’re worried about, coupled with a temporal sequence of exposure and outcome that makes sense for the narrative you’re dealing with. a. Snowden, et al. b. Sackett, et al. c. Cynefin, et al. d. McKeown, et al. 8. (According to Table 1) This drug class can increase airway irritability, leading to disruptive coughing that can disturb sleep. a. ACE inhibitors b. Beta-2 Agonists c. CNS Stimulants d. Statins 9. _________ benefit from collaborative decision-making responses to unpredictability. a. Complicated environments b. Probing environments c. Complex environments d. Psychoactive environments 10. “Root cause” complexity for sleep-wake complaints can be deconstructed with a “five-finger” collaborative exploratory tool: 1. circadian misalignment, 2. Pharmacologic factors, 3. medical factors, 4. psychosocial/psychiatric factors, and 5. primary sleep medicine diagnoses. a. True b. False

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29 Volume 14 Number 3

PRODUCT PROFILE

Introducing: Spark™ Release 14! Discover our latest doctor-inspired innovations

rmco is excited to announce Spark Release 14 which includes a host of doctor-inspired innovations designed to increase efficiencies while allowing for even more flexibility and control. “Ormco has a legacy of continuous, doctor-inspired innovation. And it shows in this new release. As an Ormco insider, I can attest to the fact that Spark is listening to us doctors. Each release is designed to make our lives better, to give us better patient care, and improve our patient interaction to help us with efficiency. I am thrilled with the direction that we’re going together.” – Dr. Jeff Summers

Spark Approver Web Supported by Google Chrome and Microsoft Edge, the new web-based version of Spark Approver works on any Internet-connected computer, with no software installation or updates required. With Spark Approver Web, doctors now can easily save patient files securely in the cloud to access or modify them anywhere and anytime.

Spark Approver Software Updates • Passive Aligner Editing feature allows doctors to add or change the number of passive aligners and instantly approve a case. • TruRoot CBCT Collision Alert system supports more predictable treatment by automatically highlighting root surface areas that touch or penetrate cortical bone. • Updated Web Scan Hold Resolution allows for accurate visualization of the actual trimline in Spark Approver and serves up detailed information for quick resolution of issues and minimized scan-matching errors. “Ormco and Spark are constantly improving the Spark Approver software. With the TruRoot Collision Alert System, I can now plan a patient’s treatment with a better understanding of where the roots are in the bone especially in relationship to

the cortical plate,” explains Dr. Richard Lee. “This allows me as a provider to plan cases better and have more practical, tailored aligners for my patients.”*

Optimized open platform with seamless DEXIS IOS integration The optimized open platform now seamlessly integrates Spark and DEXIS IOS Solution, allowing practitioners to capture patient information with one click and making it easier to submit aligners. New cases are automatically created on the Spark DTX portal, giving doctors quick access to STL files and enabling them to launch the Spark Approver software directly from their browsers.

Flexibility in material choice Doctors also now have the option to select TruGEN™ or TruGEN XR™ on all primary Spark product orders. Both TruGEN materials offer the same advanced force retention, clarity, stain resistance, and material thickness that orthodontists prefer. With its added rigidity and higher initial force, TruGENXR offers an ideal material choice for expansion and finishing movements.*

Integrated Hooks update Winning 2nd place in the first-ever New Products Showcase Award at the 2023 AAO conference, Spark Aligner’s Integrated Hooks feature continues to provide the durability and versatility doctors need for a wide range of aligner treatments, including heavy-weight options. Integrated Hooks now also offers enhanced patient comfort and esthetics with three retention attachment sizes (small, medium, and large). Learn more about the latest Spark release at https://ormco. com/en-us/spark-r14-update. OP *Data on file

This information was provided by Ormco.

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*Data on file. Drs. Bicknell, Anghileri, Frost and Bovenizer are paid consultants for Ormco. The opinions that are quoted in this material are those of the doctors. Clinicians should use their own judgment in treating their patients. MKT-23-0355 ©2023 Ormco Corporation

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challenging issues in dentistry, such as breaking non-nutritive sucking habits, correcting tongue thrusts, and teaching proper tongue posture on the palate. By facilitating natural arch expansion, promoting nasal breathing, and enhancing the overall quality of life, SPOT PAL contributes to the comprehensive well-being of our patients, especially children.” SPOT PAL differentiates itself by taking a holistic approach to oral health. It serves as a transformative tool that goes beyond traditional oral appliances. Committed to revolutionizing oral health, SPOT PAL aims to empower individuals by optimizing their oral function and overall well-being. The role that the tongue plays in an individual’s overall health is often underestimated. SPOT PAL encourages coordination and strengthening of the tongue which leads to a tongue-up posture, which promotes a stronger airway, enhanced swallowing, and improved sleep. SPOT PAL is for all ages and is customized to each individual and their needs. The device is not recommended for individuals with braces. A 3D scan or dental impression is required to ensure a proper fit. The specific design of the wearer’s SPOT PAL will be determined by factors such as age, oral habits, and oral symptoms. You can wear the device, day or night, but it is not recommended while eating. All SPOT PALs are 3D printed and come with several tongue exercise videos to help jumpstart your wellness journey. However, SPOT PAL is best used when in conjunction with a myofunctional therapy program. SPOT PAL can be purchased at thespotpal.com. OP This information was provided by SPOT PAL.

32 Volume 14 Number 3

THE NATION'S FIRST TONGUE TRAINING APPLIANCE!

OTPAL.C P O ES

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A custom-fit oral appliance designed to teach proper tongue resting posture resulting in:

Reduced sleep disordered breathing Improved articulation of lingual alveolar and palatal sounds. Minimized symptoms associated with TMJ/D

Why recommend Spot Pal?

To support the long term success of your patients!

Tongue Function

Increases lingual strength, range of motion and tongue-jaw dissociation to maximize airway space, and proper posture.

TONGUE POKES

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Habit Breaking

Eliminates extraneous force on the dentition and/or palate to support natural growth and development of facial structure.

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PRODUCT PROFILE

Innovating with digital technology

hen new technology is introduced, innovative users will develop novel techniques for implementing it. Here are a few:

Dr. Bill Layman, Straighten Up Orthodontics Virtual Treatment Letter As part of a strategy to develop a strong referral base of restorative dentists, Dr. Layman creates a treatment plan from the STL files the dentist captured in-office. In addition to creating and sending a treatment video, he prints an articulated model of the final occlusion and provides it to the dentist. This improves communication between allied specialists and the patient, showing the value of orthodontic work in the restorative case. If a picture is worth a thousand words, a 3D model is worth infinitely more. Results? A 90% patient conversion rate and less time spent writing and deciphering. The treatment plan is already created so ordering the aligners is easy.

Dr. Deborah Solomon, Smile Health Orthodontics Try-Before-You-Commit Aligners Dr. Solomon prescribes aligners for most of her Phase I cases and is impressed with her young patients’ compliance. When a parent isn’t sure their child will wear aligners consistently, she offers to let them try aligners and will switch them to braces at no extra charge. She places an order for a few stages without

Orthodontic Practice US

committing to a comprehensive treatment and without the risk of wasting boxes of unused aligners. Results? Her patients are so excited to have aligners that most diligently follow instructions. The efficient aligner workflow easily compensates for a few compliance failures.

Dr. Jeremy Manuele, Hamilton and Manuele Orthodontics Chairside Refinements Even with proper aligner compliance, some movements don’t express as predicted. In these cases, Dr. Manuele’s assistant will pull up the uDesign® treatment plan chairside and compare it to the patient’s teeth in real-time. They add any additional movements or overcorrection stages that are needed without having to take a new scan and work up a traditional refinement. Dr. Manuele verifies the changes and orders these additional aligners before the patient even leaves the office. Results? By eliminating traditional refinements, valuable time is saved. Chairside refinements are performed “on the go,” ensuring efficient progress in the patient’s treatment while reducing the doctor’s after-hours computer work. uLab®. How will you innovate? OP This information was provided by uLab.

34 Volume 14 Number 3

uLab® offers new “Just Right” pricing for orthodontists. Now available with download of uDesign® 7.3 ◌ See treatment plan before you commit to a bundle ◌ Software calculates the most economical option ◌ Can’t choose? Mix and match à la carte with bundles

uLab case bundles include: uAssist™ Service

24, 48 or Unlimited Aligner Options

Standard Shipping

À La Carte Option

Custom Packaging

Retainers & Templates

N AVA OW I CU LABL PAC STOM E KAG ING

Scan the QR Code to learn more about our bundle options.

www.ulabsystems.com/request-a-demo

Bundles are for 3-years of continuous treatment for one patient. uLab Systems, Inc. 7005 Appling Farms Parkway, Suite 103 | Memphis, TN 38133 | 1-866-900-8522 | www.ulabsystems.com © 2023 uLab Systems, Inc. All Rights Reserved. uLab Systems, uAssist, uView and uSmile are trademarks and uDesign and uLab are registered trademarks of uLab Systems, Inc. MAR-0001425 Rev 1

PRACTICE DEVELOPMENT

Beyond the pandemic Casey Bull discusses the lasting impact of virtual consultations in orthodontics

he rapid adoption of virtual consultations in orthodontic practices during the peak of the COVID-19 pandemic was undeniably transformative. Serving as a safe and convenient method for patients to interact with practices remotely, this innovative approach became essential for maintaining patient communication and care continuity. While virtual consultations witnessed a surge in popularity during the pandemic, some practices have scaled back or removed them as the world returns to normalcy. However, the benefits of virtual consultations remain significant, making them a valuable tool for modern orthodontic practices.

Addressing new patient scheduling backlog and patient satisfaction

A primary reason for implementing virtual consultations is to address the challenges posed by extended new patient appointment wait times. Practices experiencing overbooked schedules with wait times exceeding 2 weeks often encounter elevated no-show and cancellation rates, leading to lost opportunities for conversion and production. Virtual consultations present a practical solution, allowing patients to be “seen” sooner and alleviating patient frustration caused by long waiting periods. Engaging with potential patients during the lead-capture phase, where they submit inquiries and photos, enables practices to establish early communication and nurture prospects from the outset. This proactive approach empowers patients to gain insights into their orthodontic needs and explore treatment options. As patients develop a clearer understanding of their treatment journey, they become more invested and are more likely to commit to further steps, which leads us to another key benefit of virtual consultations — increased conversion rates.

Increased conversion rates

Practices that have embraced virtual consultations have observed a substantial boost in their in-office consultation conversion rates. By providing preliminary treatment plans and fee estimates during virtual consultations, practices put themselves in a position to be seen as empowering patients to make informed decisions without “gatekeeping” fees and doctor time. This transparency and flexibility instill confidence in prospective

Casey Bull is the Global Director of Content and Community at The Invisible Orthodontist (TIO), where she drives efforts to provide member practices with marketing and business management expertise. With an MBA from Pepperdine University, Casey began her career in 2014 at Dr. Alexander Waldman’s renowned Beverly Hills orthodontic practice. During her tenure there, she developed practice management processes, including tracking and reporting systems, management frameworks, treatment plans, and marketing programs. Casey’s dedication to advancing patient-centric care and practice excellence makes her a leading figure in the orthodontic industry.

patients, leading to a higher likelihood of converting them into committed patients when they do visit the office. Virtual consultations offer patients the convenience of obtaining essential treatment information while ensuring they feel comfortable and in control of their decision-making process. When patients are well-informed and actively engaged, they are more likely to move forward with their orthodontic journey, ultimately leading to increased conversion rates and improved patient commitment. Without virtual consultations, treatment coordinators should be experiencing a 65%-75% in-office consultation conversion rate. Once virtual consultations are implemented, the in-office conversion rate increases to in excess of 90%. It essentially weeds out the shoppers and ensures in-office doctor time is reserved for high quality patients.

Recommended workflow for virtual consultations

To ensure the seamless integration of virtual consultations into the practice, a well-defined workflow is essential. Following this recommended workflow can maximize efficiency and patient satisfaction:

Step 1: Determine who will receive this offer • Is it something that is offered exclusively to selected patient segments, like adult new patients calls that are digital referrals without a dentist on file? • Is it offered to patients only when the in-office consultation backlog is over 2 weeks long? Is it advertised on the website and on ads but not something promoted in the practice?

Step 2: Identify how you capture the information and photos • Virtual Consultation widget like SmileSnap or SmileMate • Landing Page with photo upload feature

Step 3: Photo evaluation and follow-up If needed, follow up to obtain suitable photos.

Orthodontic Practice US

36 Volume 14 Number 3

PRACTICE DEVELOPMENT

responsibilities include: • Tracking lead status and following up promptly • Ensuring timely and attentive engagement with patients throughout the consultation process • Utilizing CRM systems and email marketing to maintain patient engagement efficiently • Managing reception rates by monitoring patients appropriately • Coordinating applicable email campaigns and marketing blasts • Ensuring effective communication via various channels, such as phone, text, email, and video calls • Providing a seamless and comfortable virtual shopping journey for patients at different stages of the buying process By assigning a dedicated VTC to handle virtual consultations, practices can ensure a patient-centric approach that enhances the overall experience and boosts conversion rates. The VTC’s involvement is crucial in building patient trust, maintaining engagement, and streamlining the virtual consultation process for optimal success. As practices continue to navigate the post-pandemic landscape, it is crucial to recognize that virtual consultations were never just a temporary fix. Rather, they represent the future of orthodontics — an approach that puts patients at the forefront of their own treatment journey. By prioritizing this patient-centric model, practices can build strong patient relationships, enhance treatment acceptance rates, and solidify their position in their community as a leader in orthodontic care. OP

Step 4: Treatment options communication Call or email the treatment options, including a quote and estimated treatment duration.

Step 5: Virtual consultation Schedule a video call via Zoom, SmileSnap, FaceTime, WhatsApp, Doxy.me, or another platform.

Step 6: In-office appointment • Conduct a dental examination. • Obtain scans or records. • Begin the treatment. Important: You want to give the impression that your practice is easy to work with. If you have to follow up too many times for quality photos during the first lead-capture phase, consider skipping this step altogether. The goal is to increase conversion rates, not deter someone from becoming a patient because your process is too rigid. Not having photos will, of course, limit the detail you will be able to cover during a virtual consultation call, but getting the patient on the call can allow the practice to start to build that patient-practice relationship. Instead of focusing on fees, this would be a good time to focus on understanding the patient’s dominating buying motive, appliance preferences, and reviewing what being a patient at your specific office looks like.

Responsibilities of a Virtual Treatment Coordinator (VTC) The role of the Virtual Treatment Coordinator (VTC) is crucial in ensuring the success of virtual consultations. The VTC’s

Orthodontic Practice US Webinars LEARN about the lastest techniques and technology from industry leaders with our free live and archived educational webinars. Our online seminars are a convenient way to access great information and upskill. Check out our most recent webinars: •

Your Ultimate Orthodontic Workflow from Start to Finish with host Dr. Paul Trotter

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How a Digital Workflow and Remote Monitoring Made Me a “Better Version of Me” with host Dr. Joshua Adcox

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Orthodontic Trends: How to Better Leverage Practice Data with host Ryan Moynihan

WATCH NOW at https://orthopracticeus.com/webinars/ Connect. Be Seen. Grow. Succeed. | www.medmarkmedia.com

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37 Volume 14 Number 3

PRODUCT PROFILE

DentalMonitoring Driving growth and profitability in the modern orthodontic practice in three phases — Monitor, Measure, and Master.

entalMonitoring is a patented remote solution empowering orthodontists to provide dynamic treatment and optimize costly in-person appointments. Using the unique ScanAssist system, patients take weekly scans of their teeth during treatment. Scans are completed at the patients’ convenience using their smartphones and the ScanBox pro. ScanAssist guides patients through remote scanning, equipping doctors with the most accurate intraoral notifications to use in scheduling and treatment planning. The ScanBox pro is a patented device making accurate intraoral scanning easy and convenient for patients. The DentalMonitoring software analyzes the scans for 130+ automated intraoral observations and automatically notifies orthodontic providers about treatment progress. The list of monitored intraoral conditions includes patient hygiene, bracket tracking, wire passivity, aligner fit, and tooth movement, all of which doctors use to finish treatment with excellent results. In the Monitor phase, staff and patients are trained to use the system and will experience immediate positive results. Patients can appreciate the ease and convenience of the remote monitoring system while clinicians find relief in their busy schedules as they use the data and analytics to improve workflows. The practice is now fully prepared for every appointment, which reduces stress and improves profitability. DentalMonitoring streamlines communication between the patient and the doctor. In-app messaging helps patients get answers to their questions quickly and easily, which improves compliance and encourages good habits. DentalMonitoring is suitable for all orthodontic treatments, phases, and dental appliances. This means that every patient can benefit from our patented technology, and the remote solution fits into every practice. Furthermore, DentalMonitoring has engineered an open API making it possible to integrate the digital remote monitoring workflow into any patient management system, eliminating redundancies for the clinical and front office staff. Once DentalMonitoring has been firmly established into a practice’s workflow, they have reached the Measure phase. Staff and doctors will use the data in DM Insights to explore Orthodontic Practice US

what is happening during treatment at the practice level. DM Insights uses the information generated during remote monitoring to show practice trends across time. As practices engage with their data, it becomes possible to identify repeat issues and develop creative solutions. In the Master phase, DentalMonitoring becomes the center of an optimization flywheel. A practice uses DentalMonitoring and DM Insights to improve the patient experience and increase profitability. The practice will transition from standard appointment intervals to dynamic scheduling. Appointments are scheduled at the optimal time, never before and never after a patient needs in-office intervention, which is validated by clinical information in the remote scans. This means unnecessary appointments that don’t require clinical intervention are eliminated, and necessary appointments are scheduled at the right time. This frees up time in the schedule to grow the practice and train staff. OP This information was provided by DentalMonitoring.

38 Volume 14 Number 3

Discover ScanAssist, the AI-Guided Scan Process in the DentalMonitoring app. Automated detection of 130+ intraoral observations for all orthodontic treatments.

PRODUCT PROFILE

Laser-sintered appliances: now in stainless steel Christian Saurman points out some advantages of NEOLab’s new offering

nnovation is at the forefront of our day-to-day at NEOLab, both in ensuring that we have brought the most sophisticated techniques to the quality of our appliances and in the planning and structure behind our many solution-based products. Our goals are high impact to your bottom line, whether that’s in time, convenience, or efficiency, and one of our most illustrative solutions is 3D-Printed Metal (SLS) appliances. NEOLab is proud to announce that we are now laser sintering in stainless steel, bringing important additional features to this already advantageous workflow. Stainless steel is a tried-and-true material in the orthodontic world for a reason — its low biocompatibility risk and high durability make it an obvious choice for a variety of traditional appliance applications. The same is certainly true for the more cutting-edge versions of these same devices: CAD-designed and laser-sintered 3D appliances. These appliances come standard with serious time-saving attributes: the intentional design of bands to avoid interproximal and subgingival interference, eliminating the need for spacers or to wait for eruptions, and our patent-pending design process which often includes the appliance framework, eliminating potential breakage points caused by welded joints. Where the introduction of CAD processes alone has provided these significant benefits, the incorporation of stainless steel heaps on even more advantages: 1. Stainless steel brings an inherent flexibility to your designs, allowing for chairside adjustment of bands and their relationship to the occlusal surface. 2. With previous CAD iterations, any components requiring functionality had to be completed by hand and welded to SLS chromium cobalt bands. The flexibility of stainless steel allows for the digital design of more appliance components, such as adjustment loops. By designing and printing the entire appliance, welded joints — and their potential breakage points — are largely eliminated.

Since 2001, Christian Saurman has pioneered innovation and solution-based service at NEOLab. His tenacity for orthodontics propels the industry forward in continual improvement, and his passion for the people behind the appliances helps NEOLab keep a patient-centric focus every day.

3. Stainless steel bonds most efficiently to itself, rather than to another chemical composition (such as chromium cobalt), ultimately resulting in stronger bonds whenever welding is required. 4. Most orthodontic cements are primed for bonding to stainless steel, and utilizing appliances sintered in stainless steel maintain ideal bonding conditions. 5. The layered printing process of SLS results in a natural etching, which is significantly enhanced through the use of stainless steel, creating an optimized bonding surface. SLS stainless steel is available now on any of your preferred fixed-appliance designs. NEOLab has been a consistent technology leader among orthodontic laboratories and has been a foundational member of the industry since 1976. Our technology-driven approach made us a standout example through the incorporation of intraoral scanners and 3D printing, which has carried us now into the design and production of 3D-printed appliances. NEOLab is a prime laboratory partner for orthodontists nationwide, providing a full support system to their staff, patients, and treatment plans, whether they are well-versed in digital appliances or are just beginning the journey. For more information, visit www.neolab.com. OP This information was provided by NEOLab.

Orthodontic Practice US

40 Volume 14 Number 3

FOUR DAY TURNAROUND

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WWW.DYNAFLEX.COM | 800-489-4020 Faster Delivery Time Includes Defend® Retainer Cases Only. Cases Must Be Submitted Via DynaFusion® Digital Rx System. Cases Needing Other Appliances In Addition To Defend®, Or Require Resets And Pontics, Will Be Subject To Our Standard Turnaround Times. *If Brace Erase Is Requested, There Will Be An Additional Charge And Removal Of The Archwire Will Be Required. 091523 © 2023 DynaFlex®, Lake St. Louis, MO 63367. Printed In U.S.A.