Orthodontic Practice US - July/August 2014 Issue - Vol5.4 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews

Dr. Harold F. Menchel

Practice profile

Dr. Jeffrey Sessions

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TMJ arthritis 2014: Essentials for the orthodontist Part 1

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A 40-year odyssey in an orthodontic practice

Dr. Ron Roncone

The importance of nasal breathing and its effect on the direction of mandibular growth Dr. Nelson J. Oppermann

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July/August 2014 – Vol 5 No 4

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EDITORIAL ADVISORS Lisa Alvetro, DDS, MSD Daniel Bills, DMD, MS Robert E. Binder, DMD S. Jay Bowman, DMD, MSD Stanley Braun, DDS, MME, FACD Gary P. Brigham, DDS, MSD George J. Cisneros, DMD, MMSc Jason B. Cope, DDS, PhD Neil Counihan, BDS, CERT Orth Eric R. Gheewalla, DMD, BS Dan Grauer, DDS, Morth, MS Mark G. Hans, DDS, MSD William (Bill) Harrell, Jr, DMD John L. Hayes, DMD, MBA Paul Humber, BDS, LDS RCS, DipMCS Laurence Jerrold, DDS, JD, ABO Chung H. Kau, BDS, MScD, MBA, PhD, MOrth, FDS, FFD, FAMS Marc S. Lemchen, DDS Edward Y. Lin, DDS, MS Thomas J. Marcel, DDS Andrew McCance, BDS, PhD, MSc, FDSRCPS, MOrth RCS, DOrth RCS Mark W. McDonough, DMD Randall C. Moles, DDS, MS Elliott M. Moskowitz, DDS, MSd, CDE Atif Qureshi, BDS Rohit C.L. Sachdeva, BDS, M.dentSc Gerald S. Samson, DDS Margherita Santoro, DDS Shalin R. Shah, DMD (Abstract Editor) Lou Shuman, DMD, CAGS Scott A. Soderquist, DDS, MS Robert L. Vanarsdall, Jr, DDS John Voudouris (Hon) DDS, DOrth, MScD Neil M. Warshawsky, DDS, MS, PC John White, DDS, MSD Larry W. White, DDS, MSD, FACD CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day BDS, VT Julian English BA (Hons), editorial director FMC Dr. Paul Langmaid CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-in-chief Private Dentistry Dr. Chris Potts BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon

PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com MANAGING EDITOR | Mali Schantz-Feld Email: mali@medmarkaz.com Tel: (727) 515-5118 ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkaz.com EDITORIAL ASSISTANT | Mandi Gross Email: mandi@medmarkaz.com NATIONAL ACCOUNT MANAGER | Michelle Manning Email: michelle@medmarkaz.com NATIONAL ACCOUNT MANAGER | Adrienne Good Email: agood@medmarkaz.com CREATIVE DIRECTOR/PRODUCTION MANAGER | Amanda Culver Email: amanda@medmarkaz.com PRODUCTION ASST./SUBSCRIPTION COORD. | Jacqueline Baker Email: jbaker@medmarkaz.com

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The Differences That Unite Us

recently came across a curious paradox that’s inherent to the practice of orthodontics. It’s not just something that some of us might have experienced in the past, but something that we all experience every day since we became orthodontists. I’d like to share this insight with you, and then reveal how I think this contradiction actually helps each one of us elevate the level of care that we provide. Plus, I’d like to offer you a personal invitation to what is going to be the most significant event in orthodontics in the coming year. So let’s get down to it! The other day I was putting the final touches on the — in my opinion Dr. Antonino G. Secchi — remarkable roster of speakers we’ve got lined up for the 2015 Orthodontic World Congress. I was looking at this incredibly diverse group of individuals — and considering how each one took it upon him or herself to not only explore a specific aspect of orthodontics, but to then reach out to the rest of the orthodontic community to share their knowledge. That’s when it struck me: orthodontics is a profession driven by singularly driven individuals. Yet it’s also a profession that relies heavily upon the concepts of team and community in order to thrive. Think about that for a second. Every orthodontist I know is an individual who is driven by an absolute passion that drives him/her to excel. They have an insatiable need to be the best. But they also have the ability to function as a part of a collective; to recognize that they are all parts of a larger community. In short, they are humble enough to be a part of a team. All of that, plus they are willing to share the knowledge they’ve invested a lifetime accumulating. Is it any wonder we’re such a well-rounded group of individuals? As you know, I’m involved with a program called the CCO, the Complete Clinical Orthodontics. The group is made up of some of the most driven, knowledgeable, and clinically proficient professionals I’ve ever met. They are the top of the top. But at the same time, they all know that they’re standing on the intellectual shoulders of the orthodontic giants who came before them. So they all take time out of their demanding schedule to be a part of the orthodontic community and share all of the knowledge they’ve worked so hard to acquire. This paradox, to be “the best at what they do” while at the same time going out of their way to share what makes them the best, is what makes me so proud to be a part of the orthodontic community. It’s one of the many differences that unite us as individuals and as a community. In closing, I hope you’ll accept my personal invitation to be a part of the gathering that inspired this letter. The Orthodontic World Congress is going to be the most inspired gatherings of talent I’ve ever been a part of. This multi-day event will look at the business decisions that impact us all, and then the clinical aspects of how we can make it work. The featured speakers will include Jonah Berger, Steve Curtain, and Jon Acuff, plus orthodontic luminaries such as Dr. Ben Burris, Dr. Ryan Tamburrino, Dr. Martin Palomo, Dr. Julia Garcia-Baeza, Dr. Rebecca Bockow, Dr. Raffaele Spena, and yours truly. So if you’re driven to be the best, and also want to be a part of a team and a community dedicated to enhancing the whole of orthodontics, then I urge you to be a part of the Orthodontic World Congress in San Diego. I’m sure that you, your team, and your colleagues will be glad you did. Dr. Antonino G. Secchi

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© FMC 2014. All rights reserved. FMC is part of the specialist publishing group Springer Science+Business Media. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Orthodontic Practice US or the publisher.

Volume 5 Number 4

Antonino Secchi, DMD, MS, is Clinical Assistant Professor and Former Clinical Director of the Department of Orthodontics at the University of Pennsylvania. Dr. Secchi received his DMD, Certificate in Orthodontics, and a Master of Science in Oral Biology from the University of Pennsylvania. Dr. Secchi is the founder of the “Complete Clinical Orthodontics System” (CCO System™), which he teaches to orthodontists not only in the USA but throughout the world. Dr. Secchi has an established practice in Devon, Pennsylvania.

Orthodontic practice 1

INTRODUCTION

July/August 2014 - Volume 5 Number 4

TABLE OF CONTENTS

Case study

The importance of nasal breathing and its effect on the direction of mandibular growth

Practice profile Dr. Jeffrey Sessions

Dr. Nelson J. Oppermann discusses nasal breathing as an essential component to optimal orthodontic results.............................................16

This orthodontist’s mission is exceptional service and exceptional experience

Orthodontic insight A 40-year odyssey in an orthodontic practice

Dr. Ron Roncone explains the PhysioDynamic System (PDS) ....................................................... 22

Orthodontic concepts

Case study

Treating completely blocked canines and full step Class II malocclusion

Dr. Todd Bovenizer presents a full step Class II malocclusion with blocked-out canines utilizing light open coil springs and elastics with the Damon™ System’s Damon™ Q brackets

BioDigital Orthodontics: Management of patients with Class 2 malocclusion — extraction (III): part 10

In the 10th part of this series, Drs. Rohit C.L. Sachdeva, Takao Kubota and Kazuo Hayashi focus on treatment of patients with Class 2 malocclusion with SureSmile® ......................................27

ON THE COVER Cover photo courtesy of Drs. Rohit C.L. Sachdeva and Takao Kubota. Article begins on page 27.

2 Orthodontic practice

Volume 5 Number 4

A Two Day Exploration of All Things Ortho in Gorgeous San Diego, California!

Where: Loews Coronado Bay Resort, San Diego, CA

When: Feb. 18 - 21, 2015

The DENTSPLY GAC Orthodontic World Congress is dedicated to bringing top quality professional and clinical development to further the advancement and discussion within the orthodontic community. This yearâ&#x20AC;&#x2122;s meeting will feature sessions on a range of topics from Contagious Marketing to Contemporary Transverse Diagnosis. The conference will include notable speakers, workshops tailored for orthodontists and staff, group discussions, and a half-day tactical session on implementation of practice differentiators for your staff. The 2015 Annual Meeting brings together orthodontists from around the world for two days of meetings, insightful speakers, recreation and plenty of networking time that we are sure will create a community of valuable relationships. Keynote Speakers: Jonah Berger Steve Curtain Jon Acuff

Featuring: Thursday 2/19 Dr. Ben Burris Dr. Lou Shuman

Featuring: Friday 2/20 Dr. Antonino Secchi Dr. Ryan Tamburinno Dr. Martin Palomo

Dr. Julia Garcia-Baeza Dr. Rebecca Bockow Dr. Raffaele Spena

We look forward to seeing you in California!

Visit www.mygcare.com

TABLE OF CONTENTS

Research

White spot lesion treatment alternatives: an in-office trial and survey Drs. Bethany R. Middleton, Donald J. Rinchuse, and Thomas G. Zullo investigate current trends of treatment alternatives for white spot lesions ...................................................... 46

Continuing education Airway development and prevention of obstructive sleep apnea in children

Dr. Juan-Carlos Quintero discusses obstructive sleep apnea in younger patients

Technology

eXceed™ — the “GPS approach” to orthodontic bracket placement Vladimir Lucenko, director of operations, IT, for Exact Invest OU, addresses precision bracket placement...................................... 52

Legal Matters

2014 employment law updates every dentist should know Ali Oromchian examines some changes that can affect practices ......................................................55

TMJ arthritis 2014: Essentials for the orthodontist Part 1

Dr. Harold F. Menchel discusses epidemiology, pathophysiology, diagnosis, and management of osteoarthritis

4 Orthodontic practice

Volume 5 Number 4

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PRACTICE PROFILE

Dr. Jeffrey Sessions This orthodontist’s mission is exceptional service and exceptional experience What can you tell us about your background? I grew up in Oregon, attended Oregon State University for my undergrad education and Oregon Health and Science University in Portland for my dental training. During my junior year, I decided that I wanted to be an orthodontist. While fulfilling my orthodontic requirement at OHSU, I had an exceptional instructor from the orthodontic department who motivated me toward pursuing orthodontics as a specialty. I very much liked that orthodontic treatment is elective and that patients not only need, but also want our service. I wished to step out of my comfort zone, so I applied to several programs and was accepted into Indiana University’s residency program in Indianapolis where I received my orthodontic certificate and Master’s degree in dentistry. Since this was a 2-year program, I immediately started on the research needed for my Master’s thesis that dealt with changes in the nose and lips relative to extraction and non-extraction therapy. During the summer of 1997, I returned to Oregon, and I started my practice in Lake Oswego, Oregon.

Why did you decide to focus on orthodontics? My first order of business when I started practice was not only to learn how to be the best orthodontist I could be, but also to build the very small practice that I bought. My staff and I worked primarily on internal marketing as opposed to external advertising to gain patients. Making our patients’ experiences exceptional and their appointments fun was our initial approach to creating growth. Hiring staff that were not only talented but were beyond friendly to my patients was a must. I believe any orthodontist’s biggest challenge is how to stand out among his/her immediate neighbors or competition. I felt that customer service and creating a positive experience at every visit were my “niche.” I realize that there are many niches that can be utilized, but exceptional service and an exceptional experience were — and continue to be — my mission. 6 Orthodontic practice

Dr. Jeffrey Sessions, Sessions Orthodontics, Lake Oswego, Oregon Volume 5 Number 4

PRACTICE PROFILE What systems do you use? After several years in practice, I was inspired and excited by technology. Besides customer service, I felt that I could stand out and improve our patients’ healthcare delivery by being an early adopter of technology. Even though this seems rather insignificant, digital photography for patients was one of the first “new” technologies. I can remember, with a smile, the large and heavy first digital cameras available to orthodontists. The next technology that I thought was here to stay forever was the digital pano. I loved having panos available at each chair with a click of a mouse without having to ask the front office to “pull” a pano from a patient chart in the filing cabinet. Being able to refer to a pano instantly when I needed to talk to a parent about treatment was (and still is) pracDr. Jeffrey Sessions introduces AcceleDent with SoftPulse Technology to patient Madison Root tice changing. The next huge innovation was digital models. In my original location in Lake Oswego (every inch of our 1,600 square-foot office was utilized), I knew that moving into digital models would eliminate the need to store models on-site or in a nearby storage unit. I also knew that designing and moving into a new Dr. Jeffrey Sessions, Madison Root and her father, Ashton Root office soon would not have space devoted technology would absolutely allow me or wasted to model storage. As a benefit to to offer my patients exceptional treatpatients, I could show them models to answer ment planning. questions instantly on the chairside computer One of the most recent technolomonitor. My one dilemma with digital models gies that makes me excited for the was the need for an impression that had to future of orthodontics is the introducbe shipped where it would be scanned. tion of accelerated tooth movement. My answer came at the Washington, D.C., The AcceleDent® unit is the most American Association of Orthodontists ® clinically viable method available to meeting where iTero had introduced a fast our patients. I still can picture one of and viable in-office scanner. This improved my Invisalign® patient’s face when he the patient experience since records no commented about finishing in half the longer involved an alginate impression expected treatment time by using during a patient’s first experience in an orthhis AcceleDent for just 20 minutes odontic office. At this very same meeting, I each day. He was smiling so big also moved into 3D imaging by purchasing and asked, “Why wouldn’t everyone an i-CAT® cone beam. I was convinced that use this device?” I’ve recently 3D would be the standard of care in orthoprescribed an AcceleDent unit to dontics in the next decade. Again, I wished one of my teen patients, Madison to be an early adoptor so that my patients Root, who became a local celebrity would benefit immediately. I had always felt over the last holiday season. Madison that it was unsatisfactory to talk with a patient was selling mistletoe in downtown about an ectopic cuspid without knowing Portland to help offset the cost of her how close it was to neighboring roots and if braces. Due to Madison’s determined, Dr. Sessions checking progress on Madison Root root resorption was present. I knew that this

I realize that there are many niches that can be utilized,

but exceptional service and an

exceptional experience were —

and continue to be — my mission.

8 Orthodontic practice

Volume 5 Number 4

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PRACTICE PROFILE entrepreneurial spirit, several news organizations and media outlets reported her story. This coverage helped my patient to sell enough mistletoe to pay for her entire treatment! I am very excited to provide AcceleDent to accelerate Madison’s case as she is missing lower bicuspids, and we will be closing a considerable amount of space. I am hoping that more and more of my patients chose to incorporate this into their treatment.

Professionally, what are you most proud of? Like many orthodontists, I have helped my profession by serving as an officer and committee member at the county and state levels in addition to the Pacific Coast Society of Orthodontists. Over the years,

straightening my patients’ teeth, correcting their bites, and giving them beautiful smiles have been very rewarding to me and my staff. There is nothing better than seeing a parent’s and/or patient’s smile when they have finished treatment.

What is the future of orthodontics and dentistry? Looking forward, I think that an orthodontic practice has to stay at the top of its game. In addition to all of the things that you can do to enhance the patient experience within the walls of a practice, patients are researching orthodontic care and our practices via the Internet. Managing a practice website and staying up-to-date on new technology are more important now than ever.

Managing a practice website and staying up-to-date on new technology are more important now than ever.

What are your hobbies, and what do you do in your spare time? Just when I think nothing else will change in my profession, I am often pleasantly surprised with things that spark my interest and that will help make our patient experience better. Another nice aspect of our profession is that orthodontics allows me plenty of free time to enjoy my family, to golf, and to travel. These types of activities re-energize me and allow me to bring my “A game” to the office on a daily basis. I think that any person thinking about going into healthcare should consider orthodontics to fulfill their life’s goals and aspirations. OP

Top 10 Favorites 1. 2. 3. 4. 5. 6.

Practicing orthodontics Spending time in Hawaii Golfing with friends Boating in the Caribbean Cycling on my road bike Listening to live music and concerts 7. Eating out at good, fun restaurants 8. A good red wine 9. Running, walking, exercise 10. Reading a good book

Dr. Sessions with his staff 10 Orthodontic practice

Volume 5 Number 4

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CASE STUDY

Treating completely blocked canines and full step Class II malocclusion Dr. Todd Bovenizer presents a full step Class II malocclusion with blocked-out canines utilizing light open coil springs and elastics with the Damon™ System’s Damon™ Q brackets

valuation and treatment of Class II malocclusion can present a challenge to the practitioner. One must consider the facial ramifications, as well as skeletal and dental characteristics. This particular case presented with severe crowding that further complicated the diagnosis and treatment planning. This case exemplifies a challenge in multiple planes of space, A-P, transverse, and vertical. The following case will illustrate how I implemented the combination of variable torques of Damon™ Q, with NiTi coil spring, and early elastic therapy to avoid extraction of maxillary premolars. The ending result was a well-developed transverse arch with ideal incisal inclination.

Case presentation Diagnosis A 13.6-year-old, healthy adolescent male with no significant dental history presented Class I skeletal and full step Class II with severe maxillary crowding, including 100% blocked out cuspids. He presented with a reasonably straight profile with a retruded, flat maxillary lip. In fact the lower lip protruded beyond the maxillary lipline. This therefore led to a slight obtuse nasolabial angle. Looking at the patient’s profile, I felt that extracting teeth could negatively impact his facial features over time, and his parents wanted to avoid extracting teeth if possible. Using passive self-ligation (the Damon System) gives me the tools necessary to treat this

Dr. Todd S. Bovenizer was certified by the American Board of Orthodontics in 2006 and re-certified by taking another optional clinical exam in 2010. He serves as a Director for the North Carolina Association of Orthodontists and is on the adjunct faculty with the UNC School of Dentistry in Chapel Hill. Dr. Bovenizer is also a contributing editor for the Southern Association News. Additionally, he is a member of The College of American Board of Orthodontics, American Dental Association, Southern Association of Orthodontists, North Carolina Association of Orthodontists, and Southern Wake Dental Institute.

12 Orthodontic practice

This case is a reminder that orthodontists should not simply consider the aspect of teeth and the easiest treatment result. One must look at the patient’s unique facial esthetics and determine the appropriate use of extraction therapy.

non-extraction, with simple predictable treatment mechanics that become reproducible with other adolescents with similar malocclusions. Treatment plan In assessing the case, I wanted to enhance the profile and employed facialdriven treatment planning. Patient had upright maxillary incisors and a retrusive maxillary lip line. I focused on the patients’ facial esthetics today and considered the future growth throughout life. As most clinicians would agree, a non-extraction treatment approach must be considered with extreme care in these case selections. To do so, I selected maxillary and mandibular Damon Q low torque brackets on U/L 2-2 and standard torque on the U/L 3’s. I have been using the Damon™ System for 7 years and have depended on the passive self-ligating appliance with high-technology archwires to treat these difficult cases — where multiple planes of space are being developed at once. NiTi open coil springs were utilized at ½ bracket activation to open space for the maxillary canines. Additionally, it was decided to depend on light short Class II elastics to aid in the correction of Class II and also help with anchoring the maxillary arch. The maxillary incisors were very upright, and the transverse needed to be developed. The

patient’s maxillary molars were also rotated along the palatal root. The lack of binding aided my transverse adaptation of the molars and allowed me to open up space for the maxillary canines while at the same time maintaining the axial inclination of the maxillary incisors. The incisors remained upright, which is completely stunning. Treatment progress To start treatment, an in-office indirect bonding system was used to bond the Damon Q low torque appliances. I used NiTi open coil spring upper 4-2 bilaterally to open space very gently on round CuNiTi wires. From there, I employed short Class II elastics U4-L6 bilaterally, 3/16” 2 oz. for fulltime wear. It was decided to stay in round CuNiTi for approximately 1 year on the maxillary arch with gentle activation of the open coil spring. 3/16” 2 oz. Quail elastics were used the entire time to keep forces light. During the next 11 months, there were five treatment appointments where I paid very close attention to the transverse development and the axial inclination of the maxillary incisors which as I mentioned were one of the primary focuses of every appointment to ensure that proper angulation/inclination was maintained and in proper alignment with his facial features. At 14 months, I used a soft tissue diode laser to uncover the maxillary canines. At this Volume 5 Number 4

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CASE STUDY

Figure 2: Progress pan

Figure 1: Initial records

point, the patient was in a Class I buccal segment with adequate space to incorporate these teeth into the arch. The axial inclination of the maxillary incisors was near ideal, and we were still using round wire in the maxillary arch. At this time, the buccal segments were Class I, and case management was well under control. In fact, it only took three more appointments to remove all appliances. As I mentioned, roughly 8 months into treatment, the buccal segments were approximately Class I with only 2 oz. shorty elastic wear. Of extreme importance, and I have witnessed it case after case and with careful diagnosis, bracket placement and selection is crucial to ensure meticulous control of the case. In this case, the first year was spent in round NiTi wire without excessive incisal proclination (Figure 1). Finishing As most clinicians are aware, to treat a mutually protected socked-in occlusion from a full cusp start is very tough. With careful planning and light activation of open coil springs and short Class II elastics, finishing was controlled and easy to provide. After roughly 12 months, the case was a sockedin Class I. Therefore, the patient spent the next 11 months in rectangular NiTi and finishing wires, 19 x 25 TMA and 16 x 25 SS on lower. Archforms were periodically checked on the arch symmetry guide manufactured for Damon archforms to protect the beautifully created Damon archform. 14 Orthodontic practice

Figure 3: Final records

Results After 23 months of treatment, nonextraction therapy was obtained. The patient completed treatment with more uprighted buccal segments and transverse development influencing a broad smile. Additionally, we achieved an improvement on profile with lip support and nasiolabial angle. The final images display a very nice inter-incisal angle, obtained with appropriate axial inclination of the maxillary incisor. Since using the Damon System, I feel I can treat complex cases more efficiently and differently than with traditional systems. In this particular case, I was able to take advantage of the low force, low friction environment to begin opening space at bonding. There was 100% space loss for these teeth,

yet we were able to develop the transverse and create room for the cuspids. Not only was room created, but the Class II was corrected at the same time â&#x20AC;&#x201D; without flaring the maxillary incisors. Previously, this patient would have required a maxillary expander then braces to hopefully open space, often resulting in flaring the incisors. This case is a reminder that orthodontists should not simply consider the aspect of teeth and the easiest treatment result. One must look at the patientâ&#x20AC;&#x2122;s unique facial esthetics and determine the appropriate use of extraction therapy. Each treatment plan should strategically cater to the individual patient, as some begin with incisal protrusion, and therefore lip imbalance, to warrant extraction therapy. OP Volume 5 Number 4

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ORTHO2

CASE STUDY

The importance of nasal breathing and its effect on the direction of mandibular growth Dr. Nelson J. Oppermann discusses nasal breathing as an essential component to optimal orthodontic results Introduction The effect of breathing patterns on facial growth of children has been well documented. Many articles indicate that nasal obstruction leads to respiration changes, which can influence the facial development pattern.1-4 Linder-Aronson5 described the facial characteristic of “mouth-breathing individuals,” by the following: • an incompetent lip seal • a narrow upper arch • retroclined mandibular incisors • increased anterior face height • steep mandibular plane angle • retrognathic mandible He also noticed that patients with large adenoids, due to breathing through the mouth, had a lower tongue position and unbalanced forces from the cheeks and tongue when compared to normal mouth breathers. Linder-Aronson observed that a lower mandibular position led to an extended head posture. Cephalometrically, a large anterior face height and increased mandibular plane angle can be noted in mouth-breathing patients, as well as short mandible ramus heights. Linder-Aronson6 found changes in skeletal and dental variables toward normal after adenoidectomies. Growth of the mandibular ramus and condylar process of adenoidectomy patients was found to be greater than that in the control subjects7 due to the Dr. Nelson J. Oppermann obtained his Orthodontics Specialty Certificate in 1993 from the Sao Paulo State Dental Association and a Master’s Degree with an oral sciences focus in orthodontics in 2003 from Sao Leopoldo Mandic Dental School, Campinas, Brazil. Dr. Oppermann has been involved with the Bioprogressive and Sectional Mechanics Studies. His connection to Dr. Robert Ricketts years ago and his presence in several studies on these subjects help this development. Dr. Oppermann’s knowledge in growth and development of the human craniofacial complex, together with Dr. Ricketts’ cephalometric analysis and diagnostics system, gives another perspective to treatment planning. He is also involved as adjunct speaker professor at the Department of Orthodontics at the University of Illinois at Chicago. Apart of those attributions, Dr. Oppermann is an active and enthusiastic professor and lecturer, having visited many countries for teaching.

16 Orthodontic practice

Figure 2 Figure 1: August 18, 2001

Figure 3

alteration in tongue position and autorotation of the mandible. However, a decrease in the mandibular plane angle requires more growth in posterior face height/ramus height than anteriorly. The intrusion of maxillary teeth may be possible with the use of intrusive devices or maxillary impaction surgery. Mandibular growth, when adenoidectomy is performed on severe nasopharyngeal obstruction individuals, was significantly greater when compared to control group 5 years after surgery8. Based on these findings, it is imperative for the orthodontists to detect patients’ breathing patterns at an early age and refer them to an otorhinolaryngologist to perform the appropriate treatment. This case report shows a mouthbreathing patient before treatment and 2 years after the adenoids were surgically removed. The patient completed comprehensive orthodontic treatment. Follow-up records until adulthood are presented.

Significant Considerations Condition Class II malocclusion Severe Overjet Skeletal Class II Adenoid blockage of the airway?

Reason due to the lower molar due to the mandible & maxilla Possible

Facial Pattern: Mesofacial Factors Interincisal Angle Convexity Lower Facial Height A6 Molar Position to PTV B1 to A-Po Plane B1 Inclination to A-Po Facial Depth Facial Axis Maxillary Depth Mandibular Plane to FH Mandibular Arc

Measured Value 121.0 dg 6.7 mm 45.5 dg 9.7 mm -0.3 mm 16.2 dg 84.6 dg 84.4 dg 91.8 dg 24.7 dg 29.4 dg

Norm 132.7 dg 2.6 mm 45.0 dg 10.1 mm 1.0 mm 22.0 dg 86.0 dg 90.0 dg 90.0 dg 26.6 dg 25.2 dg

Clinical Deviation -1.9 2.0 0.1 -0.1 -0.6 -1.4 -0.5 -1.6 0.6 -0.4 1.0

Figure 4

Diagnosis and treatment plan /case presentation A 7-year-old mouth breathing female patient presents with a Class II div 1 malocclusion, convex profile (Figure 1 and Figure 2). The lateral cephalometric radiograph shows noticeably large adenoid tissue present and a downward tip of the occlusal plane (Figure 3). Volume 5 Number 4

CASE STUDY

Figure 5: March 31, 2004

Figure 6

Figure 7

Figure 9: June 23, 2004 Figure 8

Figure 12: Left - June 23, 2004; Right - September 29, 2004

Figure 10: August 25, 2004

Figure 11: September 29, 2004

The lateral tracings were done by Rocky Mountain速 Orthodontics Data Services速 (RMODS速), and the patient was diagnosed with a large overjet, skeletal Class II condition with the mandible rotated clockwise when compared with the mean norms. Immediately, the patient was referred to an otorhinolaryngologist for evaluation of the upper airway condition and to communicate the appropriate treatment plan. After the adenoidectomy, the patient

disappeared resulting in 2 years and 6 months of no orthodontic work within this time frame. New records were taken (Figure 5 and Figure 6). The malocclusion remained similar, but the profile improved. The functional occlusal plane improved (observe the T2 lateral ceph radiograph) with tipping back the posterior and raising the anterior, thus, facilitating the forward movement of the mandible (Figure 7). T1 and T2 before and after comparison can be seen in Figure 8.

Volume 5 Number 4

Figure 13: October 23, 2004

The mandible changed growth direction (Figure 23), and the mandible condyles grew in a healthier direction (Figure 24). Figures 9 to 21 exhibit the treatment mechanics and follow-up appointments until adulthood at age 21. Notice the profile changes through the years in Figure 22. Orthodontic practice 17

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CASE STUDY

Figure 14: November 12, 2004

Figure 15: February 14, 2005

Figure 17: March 28, 2008

Figure 16: June 20, 2005

Figure 18: October 13, 2008

Figure 19: October 31, 2011

Figure 20: March 30, 2013

Final tracings and superimpositions at 21 years old can be seen in Figure 25 and Figure 26.

Discussion

Figure 21

20 Orthodontic practice

Figure 22

In order to express the maximum mandibular growth potential, it is imperative that the patient is able to breathe through his/her nose. This is the key in Class II cases where the mandible is retropositioned and growing downward. Redirecting the growth of the mandible in a sagittal direction by counterclockwise rotation is fundamental to reducing the convexity and obtaining a more pleasant profile. The growth can be controlled by carefully monitoring the vertical aspect of the case, allowing for ramus growth. Additional outcomes are a decompressing of the temporomandibular joint (TMJ)9 Volume 5 Number 4

CASE STUDY

Figure 24

Figure 23

Significant Considerations Condition Bimaxillary Protrusion Severe Skeletal Class II Adenoidectomy performed. Adenoid blockage of the airway?

Reason due to the mandible & maxilla Probably not

Facial Pattern: Brachyfacial # Factors Interincisal Angle Convexity Lower Facial Height A6 Molar Position to PTV B1 to A-Po Plane B1 Inclination to A-Po Facial Depth Facial Axis Maxillary Depth Mandibular Plane to FH Mandibular Arc

Measured Value 117.4 dg 5.8 mm 43.5 dg 17.8 mm 3.2 mm 29.0 dg 87.0 dg 85.4 dg 92.5 dg 18.9 dg 32.2 dg

Figure 25

Norm 130.0 dg 1.0 mm 45.0 dg 18.0 mm 1.0 mm 22.0 dg 88.6 dg 90.0 dg 90.0 dg 24.2 dg 29.2 dg

Clinical Deviation -2.1 2.4 -0.4 -0.1 0.9 1.8 -0.5 -1.3 0.8 -1.2 0.8

Figure 26

and preventing molar growth and extrusion. Monitoring the preceding conditions closely will allow the functional occlusal plane to react positively, which is a sign that the mandible is moving in the correct direction.

Conclusion The overall function, specifically, nasal breathing, is imperative to obtain the best orthodontic results, independent of the treatment plan and appliances used. OP

REFERENCES 1. Freng A. Restricted nasal respiration, influence on facial growth. Int J Pediatr Otorhinolaryngol. 1979;1(3):249-154. 2. Dunn GF, Green LJ, Cunat JJ. Relationships between variation of mandibular morphology and variation of nasopharyngeal airway size in monozygotic twins. Angle Orthod. 1973;43(2):129-135. 3. Bresolin D. Shapiro PA, Shapiro CC, Chapko MK. Dassel S. Mouth breathing in allergic children: its relationship to dentofacial development. Am J Orthod. 1983;83(4):334-340. 4. Sassouni V, Friday GA, Shnorhokian H, Beery QC, Zullo TG, Miller DL, Murphey SM, Landay RA. The influence of perennial allergic rhinitis on facial type and a pilot study of the effect of allergy management on facial growth patterns. Ann Allergy. 1985;54(6):493-497. 5. Linder-Aronson S. Adenoids. Their effect on mode of breathing and nasal airflow and their relationship to characteristics of the facial skeleton and the denition. A biometric, rhino-manometric and cephalometro-radiographic study on children with and without adenoids. Acta Otolaryngol Suppl. 1970;265:1-132. 6. Linder-Aronson S. Effects of adenoidectomy on dentition and nasopharynx. Am J Orthod. 1974;265:1-15. 7. Woodside DG, Linder-Aronson S, Lundstrom A, McWilliam J. Mandibular and maxillary growth after changed mode of breathing. Am J Orthod Dentofacial Orthop. 1991;100(1):1-18. 8. Kerr WJ, McWilliam JS, Linder-Aronson S. Mandibular form and position related to changed mode of breathingâ&#x20AC;&#x201D;a five-year longitudinal study. Angle Orthod. 1989;59(2):91-96. 9. Burke G, Major P, Glover K, Prasad N. Correlations between condylar characteristics and facial morphology in Class II preadolescent patients. Am J Orthod Dentofacial Orthop. 1998;114(3):328-336.

Volume 5 Number 4

Orthodontic practice 21

ORTHODONTIC INSIGHT

A 40-year odyssey in an orthodontic practice Dr. Ron Roncone explains the PhysioDynamic System (PDS)

s orthodontists, we are very aware of the incredible changes that have occurred in the profession. Yet even though these changes have occurred, many issues are still debated. Case (extraction) versus Angle (nonextraction); Wuerpel could not draw the “ideal” face as Angle had requested. It is too subjective. Stallard’s view of joint position and occlusion versus multiple areas; the Steiner analysis, based on one case, still used today has been joined by over 100 other analyses; non-tipped, non-torqued, and non-angulated brackets versus multiple types of pre-adjusted appliances; non selfligating versus self-ligating brackets; active versus passive, and so on. The author’s orthodontic odyssey has included treatment of more than 32,000 patients with many very successful results but also many failures. The old days seemed so simple — a lot of work for the orthodontist — but simple. All of the advancements that we enjoy today have made orthodontics more complicated — easier for the orthodontist — but complicated. For more than 30 years, my quest has been to simplify functional After receiving his undergraduate degree from Marquette University, Dr. Ron Roncone pursued graduate study in physiology and neuroanatomy at the Medical College of Wisconsin (Marquette School of Medicine) while simultaneously earning his dental degree from the same university. His CV includes postdoctoral certificates from the Harvard School of Dental Medicine and the Forsyth Dental Center, a Teaching Fellow at Harvard School of Dental Medicine, and Assistant Professor of Orthodontics at the University of Maryland School of Dentistry. Dr. Roncone belongs to Alpha Sigma Nu National Jesuit Honorary Fraternity and Omicron Kappa Upsilon National Dental Honorary Fraternity. Dr. Roncone’s practice in San Diego County, California, specializes in adult treatment (esthetics, surgical, and TMD) as well as “early” treatment for children. He is a respected and frequent lecturer, having taught more than a thousand seminars around the globe. His impressive list of technical innovations and the Physio Dynamic philosophy, includes reduced treatment time, a minimal number of appointments (between 6-8 for 90% of patients), and long intervals between patient appointments (8-12 weeks), which he introduced in 1989 through the use of titanium wires and the development of a unique prescription for bands and brackets. Dr. Roncone is President and CEO of Roncone Orthodontics International. ROI offers practice management courses, a library of 15 manuals, and individualized consulting programs which include: scheduling, marketing, patient enrollment, clinical efficiencies, training, and financial management.

22 Orthodontic practice

orthodontic treatment while giving the patients what they most wanted — esthetic treatment accomplished in a timely manner. At times efficiency and esthetics are at odds. At times, esthetics and overhead are at odds. Difficult choices have to be made between superb esthetics and profitability. The epitome of esthetic orthodontics is obviously lingual treatment. Lingual orthodontics proved to be very difficult. Indirect, custom bases, high lab fees, size of brackets, placement of archwires, and difficulty in finishing were only some of the problems. Lingual has become much easier than in previous years because the brackets are smaller; they can be self-ligating, and wires can be pre-formed. Our European and Asian colleagues have worked diligently over the last 30 years to obtain more accurate bracket placement. Aligners also offer a high degree of esthetic treatment but can be very expensive to the practice and the ultimate bottom line. My decision is to offer lingual and aligners where appropriate but to add at a minimum at least 1.5 times the lab fee to the typical patient fee for the cost of a labial fee. So what has this 40-year journey taught me that I can offer to patients? How do we simplify the vast majority of orthodontics? The SEA Principle is basic to our orthodontic practice. We need to use three areas available to us. The first is Science. What is in the literature that is practical and proven? What has been shown in the laboratory that can be applied to human anatomy and physiology? The second area we have available to us is our Experience. What have we observed hundreds or thousands of times in our treatment of patients? It is the author’s opinion that the vast majority of emphasis should be placed in this area. The last area of this SEA Principle is Artistry. How do we give the patient the very best artistic finish? This obviously would include the very best facial, smile, and tooth esthetics genetically possible. If science is the foundation of what we do for our patients, then it stands to reason that what we do must be based on physiology,

anatomy, and function. What can we do to allow muscles, bone, teeth, and periodontal complex to be in harmony and equilibrium? It is certainly not in attempting to force the above factors to function where we would like them to function! Our job is to remove impediments to proper muscle, bone, tooth, and periodontal development and function. Mechanics does not trump physiology. We should be attempting to achieve a physiologic orthodontic result. This thought has led to the development of the PhysioDynamic System (PDS). This system is based on reducing the complexities surrounding treatment of each patient to relatively simple parts. There are six interdependent areas that must be followed sequentially. This certainly is not to say that this is the only way to practice orthodontics. Superb orthodontics is being performed all over the world using many different techniques. However, if you could see 90% of your patients in 6-8 total appointments; if this 90% only needed 2-3 wires in each arch; if you could eliminate the vast majority of errors, emergencies, re-dos, and unnecessary appointments; if you could finish this 90% of your patients in 13-16 months with a functional finish; would that be interesting to you? The PhysioDynamic System (PDS) — This system of orthodontic practice has at its core, “Simplifying the Complex.”

PhysioDynamics is… More patient-centric: • Shorter appointment visits and frequencies — 6-8 total visits for 90% of patients. • Significantly less discomfort for patients. Internal studies show a discomfort level which averages 4 on a scale of 1-10. This is a subjective scale asked of thousands of patients between 1988 and 2013. • Reduced treatment times — 13-16 months for 90% of patients. • Esthetic treatment and results, utilizing the PhysioDynamic QuicKlear® and BioQuick® LP SL brackets (Forestadent USA, Inc.), and the Volume 5 Number 4

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ORTHODONTIC INSIGHT Roncone PDS Prescription, developed for both functional and esthetic tooth position. Focused on integrated physiological finishes: • Relaxed musculature • A natural joint position • Superb functional occlusions Centered on the proper use of friction: • Interactive slot-to-wire relationships using PhysioDynamic interactive QuicKlear and BioQuick LP bracket. • Proper wire metallurgies lead to more optimum force levels. • The importance of the correct wire diameters being used in the specific stages of treatment. Larger round wires not smaller at the start of treatment and are kept in place for a minimum of 6 months. • Simplified wire sequencing. • Coordinated archforms achieving more functional treatment results. The Roncone PhysioDynamic Quick System: • Encompasses a prescription for each tooth designed for both functional and esthetic placement. • Eliminates the need for anchorage devices such as TPAs, TADs, headgear, etc. in all but a few cases. • Allows for physiologic control of periodontial fibers allowing them to stay physiologically “flexed” and not over taxed. • Greatly enhances control of the vertical dimension. • Addresses all 28 reasons for relapse. Specific Adjuncts as Integral to the PDS: • Correct use of anterior turbos. • Correct anatomical and functional archforms. • PDS titanium springs with precise forces. • Utilizing Beta looped wire to achieve ideal vertical control as well as A-P. • Absolute, precise placement of brackets on teeth. • Virtual elimination of emergencies and SOS visits (under 1% of all patient visits) The esthetic finish is centered on: • Tooth position — horizontally, vertically, and axially • Smile line • Individual tooth esthetics • Full arch natural smiles • Functional occlusion 24 Orthodontic practice

The Six Steps of the PhysioDynamic System (PDS) are: 1. Achieving full muscle relaxation of head, neck, and face. This is absolutely essential. It is not in any way related to the use of pulse machines or electromyography. It is relatively simple to achieve. 2. Superb diagnosis using a checklist method and attention to the “Diagnostic Dozen.” 3. The PDS Prescription using self-ligating brackets for maximum efficiency only. 4. Precise bracket placement with JSOP® jigs. 5. Three distinct stages of treatment. Knowing when you are finished greatly reduces relapse. 6. Post-removal finishing for function and esthetics.

PhysioDynamic System (PDS) Wires Let’s discuss a few key elements of the PDS; the wires and the three stages of treatment. There has been much discussion about size and force of wires. Which wires move teeth faster? Do smaller diameter wires work better? With rare exception, all wires used in the Roncone PhysioDynamic System are Titanium Alloy Wires. The combination of larger diameter, specific force level PDS Wires (thermal and super elastic) in Stage 1, along with larger heat activated rectangular “quality control” wires (for Stage 2) and finally PDS Beta Titanium finishing wires for Stage 3 — combined with the active clip — produces superb results and rapid tooth movement. In order to correct rotations, obtain proper archform, and correct the Curve of Spee, a single large diameter or two smaller diameter wires in the slot at the same time are used for a minimum of 6 months. Contrary to what has become popular in recent years, the use of small diameter wires does not move teeth more quickly or with improved directional forces. The role of reducing friction and its relationship to more rapid tooth movement has not been proven. In fact, Experience has shown the opposite. Larger diameter wires such as a .018 H.A. wire or twin .014 SE wires are, in the author’s opinion, much more effective in correcting rotations, obtaining correct archform, and leveling the Curve of Spee. The twin wires have been used in my practice for 40 years. An article published by Dr. Jim Ackerman, a superb orthodontist, teacher, and researcher in the early 1970s highlighted the use of two .012 stainless steel arches in a .022 slot. This concept has been mainstay in our practice. In

1988, stainless steel wires were replaced with twin Niti wires. Since that time, appointment intervals were dramatically increased. Wires — Stage 1 (6 months) • For mild to moderate tooth displacement, a PDS Thermal .018 wire is used. • For moderate to severe tooth displacement, two (2) PDS superelastic SE .014 wires are placed in the slot simultaneously. These create a much more optimally directed force level. The large diameter wire or two small diameter wires in the slot at the same time are critical to quickly moving teeth. The wires are placed, checked in 12-14 weeks, and the patient is not seen again for another 12 weeks. Only then is a rectangular second stage wire placed. Figures 1-4 show progression of tooth movement over approximately 6 months. On many occasions, tooth alignment occurs within 8-10 weeks. The wires should still be kept in place for 6 months to correct the Curve of Spee and to achieve proper archform. A huge additional advantage of a large diameter single wire or twin smaller wires is the root parallelism which occurs during the initial 6 months of treatment. Wires — Stage 2 (6-10 weeks) After achieving Stage 1 goals with round titanium wires which are kept in place for 6 months, an .020 x .020 heat-activated wire is placed. The purpose of this wire is one of quality control. This wire will almost fill the slot in the vertical. This allows the orthodontist to check bracket placement. Incisal edges and marginal ridges should be perfect. This wire is left in place for 6 weeks. If bracket placement was proper, the .020 x .020 HA wire is removed, and Stage 3 wires are placed. If tooth position is not ideal, then appropriate brackets are changed, the same wire is replaced for 4 weeks, and then, Stage 3 begins (Figure 3). Wires — Stage 3 (4-6 months) The final wires are .019 x .025 Beta titanium. The flex in these wires versus stainless steel allows the teeth to fit more easily. The upper arch has a “P” or Snoopy loop distal to the lateral incisors. If adjustments are needed for torque or anterior guidance, they can easily be done intraorally. Figure 4 shows the lower arch with an .019 x .025 Beta PDS wire. If necessary, elastics can be worn during this stage. Volume 5 Number 4

Figure 2: 11 weeks later

Figure 3: PDS .020 x .020 Niti at 23 weeks

Case study (see below)

Treatment plan: • Full bond upper and lower 7-7 with 20/20 molar tube upper right first molar and 20/12 molar tube upper left first molar. • Molar rotation with PDS 20/20 molar bracket right side • 6 Total appointments including bonding and removal

13.5 years old Unilateral Class II 6 mm O.J. Impinging O.B. Figure 4: PDS .019 x .025 Beta Ti at 29 weeks

Figures 5-7: Start Date — upper and lower .018 PDS heat-activated wires

Figures 8-10: 12 weeks after initial bonding. Upper right first molar rotating distally (tube has 20° of rotation). Notice upper premolar cusps are now on the distal slope of the lower premolar cusps. No elastics have been worn yet

Figures 11-13: 6 months after initial bonding .019 x .025 PDS Beta “P” looped upper and .019 x .025 PDS Beta Ideal lower (Stage 2 – 020 x 020 wires not needed) Short Class II elastics for 11 weeks on the right side Volume 5 Number 4

Orthodontic practice 25

ORTHODONTIC INSIGHT

Figure 1: PDS twin .014

ORTHODONTIC INSIGHT

Figures 14-16: Removal, total treatment time: 13 months, 2 weeks

Last, let’s discuss one of the Auxiliaries of the PD System:

Anterior bite turbos Why are they important? There are several important reasons for their use: • When lower posterior are bonded, bite forces do not cause loose brackets. • To disclude (separate) posterior teeth. This allows: Lower posterior teeth to erupt very easily to correct the COS where appropriate. If posterior teeth occlude during treatment, muscular forces will

always depress teeth into the apical area of the root. Even if fullsize stainless steel wires are used, muscular forces will “win.” The turbos will allow these voids at the apices of teeth to fill in with bone. The turbos are kept in place for many months (9-12). This eliminates relapse of overbites. • Eliminates the significant occlusal forces that occur during tooth contact. (The average person swallows between 1,700-2,400 times per day.) • The elimination of posterior tooth contact during treatment suppresses

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26 Orthodontic practice

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Volume 5 Number 4

In the 10th part of this series, Drs. Rohit C.L. Sachdeva, Takao Kubota and Dr Kazuo Hayashi focus on treatment of patients with Class 2 malocclusion with SureSmile® Introduction In previous articles, the application of SureSmile® technology in management of patients with Class 2 malocclusions with non-extraction therapy was discussed.1,2 The aim of this article is to discuss the treatment of Class 2 patients requiring extraction therapy with SureSmile. Generally speaking, the management of patients with Class 2 requiring extractions follows clinical pathways similar to those described earlier for Class 1 extraction patients.3,4 At the beginning of treatment, Virtual Diagnostic Simulations (VDS) are performed to assess arch length deficiency, extraction decisions, Bolton discrepancy, anchorage requirements and strategies, archform, and establish a visual shared space to enable communication with a patient and to monitor the progress of care.1-12 Also, the VDS helps the clinician in establishing a framework for the design and selection of the orthodontic appliance system. This is based upon the nature of the planned spatial movement of the dentition.6-9 As is, for Class 1 extraction treatment, a major consideration in the use of SureSmile precision therapeutics necessitates the proactive assessment of the appropriate stage during the care cycle when the archwire is most effective and efficiently used. Most commonly, these archwires are used during the final stage of treatment after all spaces have been closed and are used to correct (as per Dr. Sachdeva): a. For bracket placement and prescription errors. b. To coordinate arches. c. As correction for mismanaged closure of space, which often manifests as loss of torque control, tipping of teeth adjacent to extraction sites, and rotations. d. For strategically regaining anchorage. The precision SureSmile archwire may also be engaged prior to the extraction space Volume 5 Number 4

being entirely closed. This requires taking a therapeutic scan when about 2-3 mm of extraction site remains. Final space closure is completed on the SureSmile archwire. This therapeutic strategy commonly gives a head start to the finishing phase of treatment and often shortens treatment by about 3 months when compared to using the archwire after all the space has been closed.2,5 When minimal crowding exists, a SureSmile precision archwire can be designed for sliding mechanics to close space. Preferential slide lines i.e., straight segments, can be designed into the archwire to minimize any possible collisions between archwire bends and brackets during sliding.13 Additionally, compensating curves can be placed in the archwire, e.g., Reverse Curve of Spee, to control the tipping of teeth and overbite during space closure. However, this approach to managing space closure is rarely used since other orthodontic mechanisms are available that provide better control of the segments during space closure.2,13 It should also be noted that more often than not a revision SureSmile precision archwire needs to be designed to achieve a desirable outcome with this approach to treatment.6-9 The following patient histories are used to demonstrate some of the clinical therapeutic strategies discussed previously.

Patient KS Patient KS, a 19-year-old female, presented with a Class 2 division 1 malocclusion (Figure 1). The Virtual Diagnostic Model (VDM) is shown in Figure 2A is more representative of the severity of the malocclusion than the intraoral photographs where the image is slightly distorted because of the viewing angle (Figure 1). It was decided to extract the upper first bicuspids in the upper arch to correct the Class 2 malocclusion and treat to a Class 2 molar and a Class 1 canine relationship. The lower arch was treated non-extraction, and some

lower interproximal reduction was planned to minimize the advancement of the lower incisors that would result during alignment and leveling. The Virtual Diagnostic Simulation (VDS) and the associated displacements are shown in Figures 2B and 2D. Patient KS was bonded with Sankin Clear Bracket SL (Dentsply-Sankin, Dentsply International Inc.) with slot width .0220”. All the space was closed with conventional therapy using both sliding mechanics and retraction loops. The lower arch was aligned and leveled simultaneously. Space consolidation was achieved in 8 months, at which point a Therapeutic scan and associated X-rays were taken (Figure 3). The Virtual Therapeutic Model (VTM), Virtual Target Setup (VTS), and the SureSmile precision archwires were designed as shown in Figure 4. Upper and lower .019” x.025” CuNiTi SureSmile precision archwires were selected for detailing the occlusion, and these were installed 6 weeks post therapeutic scan (Figure 5). The patient was seen 8 weeks later, at which time nighttime wear of elastics was recommended (Figure 6). The patient was debonded 4 weeks later. Upper and lower fixed retention was delivered (Figure 7), and Rohit C.L. Sachdeva, BDS, M Dent Sc, is the cofounder and Chief Clinical Officer at OraMetrix, Inc. He received his dental degree from the University of Nairobi, Kenya, in 1978. He earned his Certificate in Orthodontics and Masters in Dental Science at the University of Connecticut in 1983. Dr. Sachdeva is a Diplomate of the American Board of Orthodontics and is an active member of the American Association of Orthodontics. He is a Clinical Professor at the University of Connecticut and Temple University and the Hokkaido Health Sciences Center Japan. In the past, he held faculty positions at the University of Connecticut, Manitoba, and the Baylor College of Dentistry, Texas A&M. Dr. Sachdeva has over 80 patents, is the recipient of the Japanese Society for Promotion of Science Award, and has over 160 papers and abstracts to his credit. Visit Dr. Sachdeva’s blog on http://drsachdeva-conference. blogspot.com. All doctors are invited to join the “Improving Orthodontic Care” discussion blog. Please contact improveortho@ gmail.com for access information.

Orthodontic practice 27

ORTHODONTIC CONCEPTS

BioDigital Orthodontics: Management of patients with Class 2 malocclusion — extraction (III): part 10

ORTHODONTIC CONCEPTS it was recommended that patient have the lower third molars extracted. Figure 8 shows a superimposition of the Virtual Diagnostic

Model (VDM) against the Virtual Final Model (VFM). Note how closely the planned movement matches the final.

Figures 1A and 1B: Patient KS. 1A. Initial intraoral records of patient presenting with a Class 2 division 1 malocclusion. 1B. Initial X-rays VDM

VDS

VDS (white) Vs VDM (green)

Figures 2A-2D: Patient KS. 2A.Virtual Diagnostic Model (VDM). 2B.Virtual Diagnostic Simulation (VDS) shows the upper first bicuspids extracted in the upper arch to correct the Class 2 malocclusion and treat to a Class 2 molar and a Class 1 canine relationship. The lower arch was treated non-extraction, and some lower interproximal reduction was planned to minimize the advancement of the lower incisors as a result of alignment and leveling. 2C. VDM (green) vs. VDS (white). 2D. Shows the nature and magnitude of displacements of the dentition

Figures 3A and 3B: Patient KS. 3A. Mid-treatment intraoral photos were taken at 9 months into active treatment. 3B. Mid-treatment X-rays VTM

VTS

Figures 4A-4C: Patient KS. 4A.Virtual Therapeutic Model (VTM). 4B.Virtual Target Setup (VTS) with SureSmile precision archwire designed. 4C. SureSmile precision archwire viewed against VTM 28 Orthodontic practice

Volume 5 Number 4

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ORTHODONTIC CONCEPTS

Figure 5: Patient KS. Upper and Lower .019â&#x20AC;? x.025â&#x20AC;? CuNiTi SureSmile precision archwires installed 6 weeks post therapeutic scan for detailing the occlusion

Figure 6: Patient KS. The patient was seen 8 weeks later and recommended nighttime wear of elastics

VFM

Figures 7A-7C: Patient KS. 7A. Final intraoral photos taken at debond 12 weeks post SureSmile wire insertion and 13 months from start of treatment. 7B. Final X-rays. 7C. Virtual Final Model VDS (white) Vs VDM (green)

Figure 8: Patient KS. VDS (white) versus VFM (green). Note how closely the planned movement matches the final 30 Orthodontic practice

Patient TE Patient TE, a 17-year-old male patient presented with a Class 2 malocclusion and an impacted upper left second bicuspid. The initial patient records are shown in Figure 9. It was planned to extract the upper left second bicuspid and the upper right first bicuspid to treat to a Class 2 molar and Class 1 canine relationship. The lower arch was planned non-extraction (Figure 10). Note the minimum tooth displacement associated with the plan (Figure 10D). In the upper arch, posterior anchorage and intermolar archwidth was maintained with a transpalatal arch. Canine retraction was started with a retraction force generated by a ligature archwire. Note the ligature Volume 5 Number 4

A therapeutic scan was taken 5 months from the start of treatment (Figure 13). Note approximately 2.5 mm of space remains to be closed distal to the upper right canine. In spite of the use of an upper transpalatal arch and light forces, the buccal segment tipped forward during space closure (Figure 13B). The Virtual Therapeutic Model (VTM) is shown in Figure 14A. The Virtual Target Setup (VTS) and the associated SureSmile precision archwire design are shown in Figures 14B and 14C. Also, note the slide designed in the upper archwire distal to the upper right canine to complete the space closure on Figure 14C. Upper and lower .017” x .025” CuNiTi AF 35°C SureSmile precision archwires were installed 6 weeks post therapeutic scan. Note by this time, the upper space was substantially closed (Figure 15). Furthermore, the patient was asked to wear short Class

2 elastics to augment the correction of the tipped upper buccal segments. The patient was seen 8 weeks later, at which point, the tipping of buccal segments appeared to have corrected substantially. Residual space was closed with power chain (Figure 16). The patient was debonded 4 weeks later (Figure 17). Note the root correction in the canine and buccal segments (Figure 17B). The Virtual Final Model (VFM) is superimposed on the Virtual Diagnostic Simulation (VDS) and shows how well the treatment outcome corresponded to the plan (Figure 18). An upper fixed retainer and lower Essix® retainer were used for retention.

Figures 9A and 9B: Patient TE. 9A. Initial intraoral records of patient presenting with a Class 2 malocclusion with an impacted upper left second bicuspid. 9B. Initial X-rays VDM

VDS

VDS (white) Vs VDM (green)

Figures 10A-10D: Patient TE. 10A.Virtual Diagnostic Model (VDM). 10B. Virtual Diagnostic Simulation (VDS) shows the extraction of the upper left second bicuspid and the upper right first bicuspid to treat to a Class 2 molar and Class 1 canine relationship. The lower arch was planned non-extraction. 10C. VDM (green) vs. VDS (white). 10D. Shows the nature and magnitude of displacements of the dentition. Note the minimum tooth displacement associated with the plan Volume 5 Number 4

Orthodontic practice 31

ORTHODONTIC CONCEPTS

should have been tied on the labial to help derotate the canine (Figure 11). Six weeks later, sliding mechanics on an .016” AF 27°C archwire in the upper arch was initiated to close the extraction site. The lower arch was partially bonded to initiate rotational correction of the bicuspids. The lower anteriors were not engaged with a continuous archwire. This was done to prevent the initial side effect of the constriction of the intercanine width and the potentially skewing of the lower left (Figure 12). At the next appointment (6 weeks later), the patient was fully bonded (Tomy Clippy-C a.k.a., In-Ovation® C by GAC International bracket with slot width .0180”) in the lower arch, and .016” x .022” CuNiTi AF 35°C were installed both in the upper and lower arch. Retraction of the upper right canine continued with sliding mechanics on this archwire.

ORTHODONTIC CONCEPTS

Figure 11: Patient TE. Post extraction treatment mechanics in the upper arch. The upper anchorage and intermolar archwidth maintained with a transpalatal arch. Canine retraction started with a retraction force generated by a ligature archwire. Note the ligature should have been tied on the labial to help derotate the canine

Figure 12: Patient TE. Six weeks later, sliding mechanics was used on upper arch with .016” AF 27°C archwire to close extraction site. Lower arch partially bonded to initiate rotational correction of the bicuspids. Note: Lower anteriors were not engaged to prevent the initial side effect of constriction of the intercanine width and potentially skewing of the lower left buccal segment as a result of the use of a continuous archwire

Figures 13A and 13B: Patient TE. 13A. Mid-treatment intraoral photos were taken at 5 months into active treatment. 13B. Mid-treatment X-rays. Note approximately 2.5 mm of space remains to be closed distal to the upper right canine. In spite of the use of an upper transpalatal arch and light forces, the buccal segment tipped forward during space closure VTM

VTS

Figures 14A-14C: Patient TE. 14A.Virtual Therapeutic Model (VTM). 14B. Virtual Target Setup (VTS) with SureSmile precision archwire designed. 14C. SureSmile archwire viewed against VTM

Figure 15: Patient TE. Upper and lower .017” X .025” CuNiTi AF 35°C SureSmile precision archwires were installed 6 weeks post therapeutic scan. Note by this time the upper space was substantially closed. Patient to wear short Class 2 elastics to augment correction of tipped upper buccal segments 32 Orthodontic practice

Figure 16: Patient TE. Patient was seen 8 weeks later at which point the tipping of buccal segments appeared to have corrected substantially. Residual space was closed with power chain Volume 5 Number 4

Figures 17A-17C: Patient TE. 17A. Final intraoral photos taken at debond 12 weeks post SureSmile wire insertion and 9.5 months from start of treatment. 17B. Final X-rays. Note the root correction in the canine and buccal segments achieved. 17C. Virtual Final Model VDS (white) Vs VDM (green)

Figure 18: Patient TE. The superimposition of VDS (white) Vs VFM (green) shows how well the treatment outcome corresponded to the plan

Patient MI Patient MI, a 14-year-old female, presented with very poor oral hygiene and a Class 2 malocclusion with a deep overbite and severe crowding in both the upper and lower arch (Figure 19). The Virtual Diagnostic Model (VDM) was used to plan treatment as seen in the Virtual Diagnostic Simulation (VDS) (Figures 20A and 20B). It was decided to extract the upper first bicuspids, the lower left second bicuspid, and right first bicuspid and treat to a Class 1 relationship. Note the high anchorage requirements for the upper arch (Figures 20C and 20D). Treatment started with separate canine retraction in the upper arch. Space closure in the upper arch was designed with the goal of preserving anchorage. Palatal temporary Volume 5 Number 4

anchorage devices in conjunction with a modified transpalatal arch were used to maintain the position of the upper buccal segments. Also, note the TPA design was slightly modified with a cantilever extension arm to tip the upper bicuspids buccally (Figure 21). Three months into treatment, the entire upper arch was bonded and alignment in the upper arch initiated with a .016” AF 35°C CuNiTi archwire. At the next appointment 5 months from the start of treatment, an upper utility arch was engaged to begin correcting the deep overbite with the intrusion of the upper anterior segment (Figure 22). Once the overbite was partially corrected, 7 months into treatment, the lower arch was bonded and

The ability to design and fabricate targeted SureSmile precision archwires to affect greater control of orthodontic tooth movement impacts the care cycle favorably. a .016” x .022” CuNiTi AF 35°C alignment archwire engaged (Tomy CLIPPY-C, aka, In-Ovation C by GAC International bracket with slot width .0180”). The treatment progress at 9 months is shown in Figure 23. At this point in treatment, power arms were crimped on a .017” x .025” CuNiTi AF 27° upper archwire distal to the canine to continue with upper space closure. The lower archwire remained unchanged. The 12-month treatment progress intraoral images are shown in Figure 24. Note: The lower arch is substantially leveled. Upper anchorage is well preserved, and some residual space remains distal to the upper right canine. The patient had a therapeutic scan taken 13.5 months into treatment (Figure 25). The Virtual Target Setup (VTS) Orthodontic practice 33

ORTHODONTIC CONCEPTS

VFM

ORTHODONTIC CONCEPTS and the SureSmile precision archwire were designed (Figures 26B and 26C). Upper and lower .017â&#x20AC;? X .025â&#x20AC;? CuNiTi precision archwires were installed 4 weeks later, and the patient was asked to wear light Class 2 elastics (Figure 27). Note there was some loss in overbite correction. The patient was seen 4 weeks later and asked to continue

with Class 2 elastic wear (Figure 28).The patient was debonded after 4 weeks (Figure 29). The total treatment time for patient MI was 16.5 months. Note. the superimposition of the Virtual Digital Simulation (VDS) against the virtual final model (VFM) shows close approximation between the plan and the final result (Figure 30).

In retrospect, at least 3-4 months in treatment time could have been possibly saved if leveling and alignment in the lower arch had begun earlier.

Figures 19A-19B: Patient MI. 19A. Initial intraoral records of patient presenting with a Class 2 malocclusion with a deep overbite and severe crowding. 19B. Initial X-rays VDM

VDS

VDS (white) Vs VDM (blue)

Figures 20A-20D: Patient MI. 20A. Virtual Diagnostic Model (VDM). 20B. Virtual Diagnostic Simulation (VDS) shows the simulation to extract the upper first bicuspids, the lower left second bicuspid, and right first bicuspid and treat to a Class 1 relationship. 20C. VDM (green) vs. VDS (white). 20D. Shows the nature and magnitude of displacements of the dentition

Figure 21: Patient MI. Extraction with separate canine retraction in the upper arch. Space closure in the upper arch designed to preserve anchorage. Palatal temporary anchorage devices in conjunction with a modified transpalatal arch were used to maintain position of upper buccal segments. Note: TPA design was slightly modified with a cantilever extension arm to tip the upper bicuspids buccally 34 Orthodontic practice

Figure 22: Patient MI. At the next appointment, 5 months from the start of treatment, an upper utility arch was engaged to begin correcting the deep overbite with the intrusion of the upper anterior segment Volume 5 Number 4

Figure 24: Patient MI. The 12-month treatment progress intraoral images. Note: the lower arch is substantially leveled. Upper anchorage is well preserved, and some residual space remains distal to the upper left canine.

Figures 25A-25B: Patient MI. 25A. Mid-Treatment intraoral photos were taken at 13.5 months into active treatment. 25B. Mid-treatment X-rays VTM

VTS

Figures 26A-26C: Patient MI. 26A. Virtual Therapeutic Model (VTM). 26B. Virtual Target Setup (VTS) with SureSmile precision archwire designed. 26C. SureSmile archwire viewed against VTM

Figure 27: Patient MI. Upper and lower .017” X .025” CuNiTi SureSmile precision archwires were installed 4 weeks later. Patient was asked to wear light Class 2 elastics. Note there was some loss in overbite correction Volume 5 Number 4

Figure 28: Patient MI. Patient was seen 4 weeks later and asked to continue with Class 2 elastic wear Orthodontic practice 35

ORTHODONTIC CONCEPTS

Figure 23: Patient MI. The treatment progress at 9 months. At this point in treatment, power arms were crimped on a .017”x.025” CuNiTi AF 27° upper archwire distally to the canine to continue with upper space closure. The lower archwire remained unchanged

ORTHODONTIC CONCEPTS

Figures 29A-29C: Patient MI. 29A. Final intraoral photos taken at debond 8 weeks post SureSmile wire insertion and 16.5 months from start of treatment. 29B. Final X-rays. C. Virtual final model VDS (white) Vs VFM (green)

Figure 30: Patient MI. The VDS (white) Vs VFM (green) shows close approximation between the plan and the final result.

Conclusions The focus of the last series of papers and this has been on the treatment of patients with of Class 2 malocclusion with SureSmile. It is important to recognize that a successful treatment outcome is based upon a correct diagnosis at the start of treatment. Planning tools that SureSmile technology offers such as the decision support system enables an orthodontist to efficiently and effectively plan different treatment scenarios and define a measurable path to achieve the treatment goal. In addition, the visual interface provides a vital resource to communicate with patients. The ability to design and fabricate targeted SureSmile precision archwires to affect greater control of orthodontic tooth movement impacts the care cycle favorably. 36 Orthodontic practice

It should be noted that the orthodontist needs to develop appropriate skills to use the technology effectively, and SureSmile is not “push button” in orthodontics. The orthodontist drives the treatment and not the technology. Lastly, the selection and proper use of auxiliaries and appropriate management of the patient using sound biomechanical principles while respecting the constraints of the biological system need to be actively considered to achieve desirable treatment outcomes in a timely manner. OP Acknowledgments The authors are most thankful to Dr. Sharan Aranha, BDS, MPA, and Maya Sachdeva for their assistance in the preparation of this manuscript.

REFERENCES 1. Sachdeva R, Kubota T, Moravec S. BioDigital othodontics, Part 1: Management of Class 2 Non–Extraction Patients: Part 8. Orthodontic Practice US. 2014;5(2):11-16. 2. Sachdeva R, Kubota T, Hayashi K. BioDigital orthodontics, Part 2: Management of Patient with Class 2 malocclusion Non–Extraction: Part 9. Orthodontic Practice US. 2014;5(3):29-41. 3. Sachdeva R. BioDigital orthodontics: Management of Class 1 Non–Extraction Patient with “Fast–Track”©– six month protocol: Part 5. Orthodontic Practice US. 2013;4(5)18-27. 4. Sachdeva R, Kubota T, Hayashi K. BioDigital orthodontics. Management of Class 1 Non–Extraction Patient with “Standard–Track”©– nine month protocol: Part 6. Orthodontic Practice US. 2013;4(6):16-26. 5. Sachdeva R, Kubota T, Hayashi K. BioDigital orthodontics: Management of space closure in Class I Extraction Patients with SureSmile: Part 7. Orthodontic Practice US. 2014;5(1):14-23. 6. Sachdeva R. BioDigital orthodontics: Designing customized therapeutics and managing patient treatment with SureSmile technology: Part 2. Orthodontic Practice US. 2013;4(2):18-26. 7. Sachdeva R. BioDigital orthodontics: Diagnopeutics with SureSmile technology: Part 3. Orthodontic Practice US. 2013;4(3):22-30. 8. Sachdeva R. BioDigital orthodontics: Outcome evaluation with SureSmile technology: Part 4. Orthodontic Practice US. 2013;4(4):28-33. 9. Sachdeva R. BioDigital orthodontics: Planning care with SureSmile Technology: Part 1. Orthodontic Practice US. 2013;4(1):18-23. 10. White L, Sachdeva R. Transforming orthodontics: Part 1 of a conversation with Dr. Rohit Sachdeva, Co-founder and Chief Clinical Officer of Orametrix Inc. by Dr. Larry White. Orthodontic Practice US. 2012;3(1):10-14. 11. White L, Sachdeva R. Transforming orthodontics: Part 2 of a conversation with Dr. Rohit Sachdeva, co-founder and chief clinical officer of Orametrix Inc. by Dr. Larry White. Orthodontic Practice US. 2012;3(2):6-10. 12. White L, Sachdeva R. Transforming orthodontics: Part 3 of a conversation with Dr. Rohit Sachdeva, co-founder and chief clinical officer of Orametrix Inc. by Dr. Larry White. Orthodontic Practice US. 2012;3(3):6-9. 13. Sachdeva RCL, Kubota T, Hayashi K, Uechi J, Hasuda M. BioDigital Orthodontics, Part 9. Management of space closure in Class I Extraction Patients with SureSmile: Part 1. Journal of Orthodontic Practice (Japan). 2012.

Volume 5 Number 4

Dr. Juan-Carlos Quintero discusses obstructive sleep apnea in younger patients

bstructive sleep apnea (OSA) is a debilitating disease resulting in greater loss of life expectancy (LLE) and diminished quality of life (QOL), affecting anywhere from 3% to 7% of the U.S. population.1 The prevalence of OSA is higher in some subpopulations such as obese adults.2 Comorbidities include cardiovascular disease, renal disease, diabetes, depression, and motor vehicle accidents among others.1 The number of patients being diagnosed with OSA is increasing at an alarming rate of 15% per year likely due to increased patient and doctor awareness. From an economic perspective, the estimated annual costs of obstructive sleep apnea and its related comorbidities is estimated to be between $65 billion and $165 billion a year, according to a 2010 report published by the Harvard Medical School.3 Treatment modalities include weight loss, positional therapy, nasal decongestion, oral appliances, CPAP, soft tissue surgery — uvulopalatopharyngoplasty (UPPP), orthognathic surgery in the form of maxillo-mandibular advancement (MMA) or mandibular advancement (MA) —

Educational aims and objectives

The aim of this article is to inform readers of the rationale and potential of preventing OSA in children at risk through proven methods of airway development and evolving diagnostic aids.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 45 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Realize the prevalence of OSA in certain populations. • Understand the involvement of the airway in OSA. • Identify some screening modalities used in diagnosing OSA. • Recognize some treatment options for OSA.

and tracheotomy. But perhaps the most effective and least invasive modality is the one infrequently discussed in the scientific circles: prevention in children through airway development.3,4,5,6,7 Part 1 of this article will explore the rationale and potential of preventing OSA in children at risk for OSA through proven methods of airway development and evolving diagnostic aids. Early screening and understanding of growth and development is critical in identifying pediatric patients at

risk for OSA or for developing future OSA as adults. Breathing is a function of craniofacial anatomy and the resultant airflow resistance caused by the collapse of the structures surrounding the upper airway (Figure 1), such as the tongue. The larger the size of the pharyngeal airway, or more specifically, the larger the minimum cross sectional area (MCA) of the airway, the less collapse or obstruction that occurs during sleep when voluntary muscles such as the tongue become flaccid. Recent studies have correlated facial dentofacial morphology with airway volume, and airway dimensions have logically been correlated to risk factors for OSA.4,5,6 Furthermore, recent advances in imaging technology have made ultra-lowdose cone beam computerized tomography (CBCT) such as the new i-CAT® FLX from Imaging Sciences International and everyday imaging of the airways possible with dose

Juan-Carlos Quintero, DMD, MS, received his dental degree from the University of Pittsburgh in Pennsylvania and his degree in Orthodontics from the University of California at San Francisco (UCSF). He also holds a Master of Science degree in Oral Biology. He has served as national president of the American Association for Dental Research-SRG, is a faculty member at the L.D. Pankey Institute, and an attending professor at Miami Children’s Hospital, Department of Pediatric Dentistry, as well as immediate past president of the South Florida Academy of Orthodontists (SFAO). He currently practices in South Miami, Florida. His academic interests include applications of 3D craniofacial imaging and airways in orthodontics. Figure 1

Volume 5 Number 4

Orthodontic practice 37

CONTINUING EDUCATION

Airway development and prevention of obstructive sleep apnea in children

CONTINUING EDUCATION exposure less than a panorex and as low as 8 µSv14,15 (Figures 2, 3, and 4). The applications and implications of this technology in the screening and prevention of OSA in the pediatric population are enormous. It is now possible to screen children with small airways who either have OSA, are at risk for OSA, or are at risk for developing OSA later in life, and treat accordingly.

Case Report The following is a case study of an 8-year-old female patient who presented for an orthodontic evaluation with a chief concern of “wanting a prettier smile.” During the initial interview, it was revealed that the patient was a chronic mouth breather and a regular snorer. The parents also reported a lethargic disposition during the day with inattentiveness at school and disinterest in sports. At the time of the exam, the patient appeared to be breathing only through her mouth and had signs of venus pooling (“droopy eyes”). A 3D diagnostic session was completed consisting of photographs (Figure 5) and a low-dose CBCT taken on an i-CAT machine using 16 x 13 cm field of view and a 4.9-second exposure time. The evaluation revealed crowding with impacted maxillary canines in the mixed dentition, with a constricted arch form (Figure 6). The CBCT radiographic study showed an extremely narrow pharyngeal airway with an MCA of 47 mm2 (Figure 7). The patient also presented with adenoid hyperplasia encroaching upon the pharyngeal airspace. The treatment plan consisted first of ENT management in the form of adenoidectomy with coblation of turbinates followed by 10 months of orthodontic Phase I dual arch expansion treatment. Specifically, the patient received a Rapid Maxillary Expander off of a 2 x 6 bracket system in the upper arch

Figure 2

Figure 3

Figure 4

Figure 6

Figure 5

38 Orthodontic practice

Figure 7

Figure 8

Volume 5 Number 4

Figure 9: Left, before treatment; right, after treatment

in daytime sleepiness, an improvement in academic performance, and increased athletic activity — all signs of better sleep and oxygenation.

Discussion Orthognathic surgery in the form of maxillomandibular advancement has been shown to be the definitive treatment for patients suffering from obstructive sleep apnea. Several studies have demonstrated a 100% success rate of OSA through MMA, when compared to CPAP or oral appliances, using AHI scores through polysomnograms as the measuring tool.16, 17, 18 This is because Grauer, et al., and others have reported that pharyngeal airspace dimensions are a function of jaw position.4,5,6 It would seem only reasonable to equally expect enlargement of the pharyngeal airspace in children concurrent with the forward growth of the craniofacial complex. Just as the airway is enlarged in nongrowing patients when the face is surgically positioned forward through MMA, so can the airway be enlarged through proper interprofessional collaboration (in this case with an ENT physician) when facial-growth-friendly

orthodontics are applied in children, as is demonstrated in this case report.

Conclusions In children, airway issues must be identified and treated as early as possible. Delays in treatment can only delay the suffering of the family and the child. Proper screening using ultra-low-dose CBCT imaging and early management through inter-professional collaboration with ENTs, pediatricians, and allergists during the growing years of the face may prevent OSA in future generations, by promoting healthy growth of the craniofacial complex, and thus pharyngeal airway development, during childhood. OP Follow Dr. Quintero’s blog on airway development on www.airwaydevelopment.com.

REFERENCES 1. Chiong TL. Sleep Medicine Essentials. Hoboken, NJ: WileyBlackwell; 2009. 2. Punjabi NM. The epidemiology of adult obstructive sleep apnea. Proc Am Thorac Soc. 2008;5(2):136-143. 3. The Price of Fatigue: The Surprising Economic Costs of Unmanaged Sleep Apnea. Harvard Medical School. The Harvard Medical Division of Sleep Medicine. December 2010. 4. Grauer D, Cevidanes LS, Styner MA, Ackerman JL, Proffit WR. Pharyngeal airway volume and shape from cone-beam computed tomography: relationship to facial morphology. Am J Orthod Dentofacial Orthop. 2009;136(6):805-814. 5. Abdelkarim A. A cone beam CT evaluation of oropharyngeal airway space and its relationship to mandibular position and dentocraniofacial morphology. J World Fed Orthod. 2012;1(2):e55-e59. 6. El H, Palomo JM. Airway volume for different dentofacial skeletal patterns. Am J Orthod Dentofacial Orthop. 2011;139(6):e511-521.

Figure 10: Left, before treatment, MCA=47 mm2; right, after treatment MCA=210 mm2

Pirelli P, Saponara M, Guilleminault C. Rapid maxillary expansion in children with obstructive sleep apnea syndrome. Sleep. 2004;27(4):761-766.

Villa MP, Malagola C, Pagani J, Montesano M, Rizzoli A, Guilleminault C, Ronchetti R. Rapid maxillary expansion in children with obstructive sleep apnea syndrome: 12-month follow-up. Sleep Med. 2007;8(2):128-134.

9. Villa MP, Rizzoli A, Miano S, Malagola C. Efficacy of rapid maxillary expansion in children with obstructive sleep apnea syndrome: 36 months of follow-up. Sleep Breath. 2011;15(2):179-184. 10. Guilleminault C, Quo S, Huynh NT, Li K. Orthodontic expansion treatment and adenotonsillectomy in the treatment of obstructive sleep apnea in prepubertal children. Sleep. 2008;31(7):953-957. 11. Marino A, Ranieri R, Chiarotti F, Villa MP, Malagola C. Rapid maxillary expansion in children with Obstructive Sleep Apnoea Syndrome (OSAS). Eur J Paediatr Dent. 2012;13(1):57-63. 12. Cistulli PA, Palmisano RG, Poole MD. Treatment of obstructive sleep apnea syndrome by rapid maxillary expansion. Sleep. 1998;21(8):831-835.

Figure 11: Left, before treatment with adenoids; right, after treatment without adenoids

13. Miano S, Rizzoli A, Evangelisti M, Bruni O, Ferri R, Pagani J, Villa MP. NREM sleep instability changes following rapid maxillary expansion in children with obstructive apnea sleep syndrome. Sleep Med. 2009;10(4):471-478. 14. Ludlow JB, Walker C. Assessment of phantom dosimetry and image quality of i-CAT FLX cone-beam computed tomography. Am J Orthod Dentofacial Orthop. 2013;144:802-817. 15. Quintero JC. New study may change the face of orthodonitcs. Orthodontic Practice US. 2014;5(1):41-43. 16. Prinsell JR. Maxillomandibular advancement surgery in a sitespecific treatment approach for obstructive sleep apnea in 50 consecutive patients. Chest. 1999;116(6):519-529. 17. Riley RW, Powell NB, Guilleminault C, Stanford University Medical Center, CA. Obstructive sleep apnea syndrome: a surgical protocol for dynamic upper airway reconstruction. J Oral Maxillofac Surg. 1993;51(7):742-749.

Figure 12: Left, before treatment; right, after treatment

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18. White PD, Wooten V, Lachner J, Guyette RF: Maxillomandibular advancement surgery in 23 pts with OSA syndrome. J Oral Maxillofac Surg. 1989;47:1256.

Orthodontic practice 39

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and a lower removable Schwartz expander followed by a 2 x 6 bracket system. Final Phase I records were taken consisting of photographs and a low dose CBCT. Figure 9 shows the facial changes before and after treatment, 12 months apart. Figures 10 and 11 show the changes in the pharyngeal airway volume and cross-sectional areas following adenoidectomy, coblation of turbinates, and Phase I orthodontic expansion. Figure 12 shows the resolution of the ectopically positioned permanent maxillary canines. Note the more upright and vertical positions of the canines. Post treatment, the mother reported a dramatic improvement in the patient’s overall health, level of alertness, a reduction

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TMJ arthritis 2014: Essentials for the orthodontist, Part 1 Dr. Harold F. Menchel discusses epidemiology, pathophysiology, diagnosis, and management of osteoarthritis

n industrialized societies, osteoarthritis (OA) is a leading cause of physical disability, increases in health care usage, and impaired quality of life.1,2,3 TMJ arthritis is a common presentation in orthodontic practice, especially with the increase in adult orthodontic treatment.4 However, arthritis can occur at any age, and it should not be overlooked in infants, children, and adolescents. It is essential that the orthodontist understand the 2014 evidence base and underlying mechanisms of the disease and its prevalence. Diagnostic criteria are presented, as well as management of associated acute and chronic pain, and associated occlusal changes. Appliance therapy and sequencing of treatment are critical to treatment success. Medical, physical, and surgical approaches will be discussed for the orthodontic patient. This article is introductory and is the first in a series. Case histories will be presented in future articles to illuminate the material presented here. The following are some examples of occlusal changes associated with arthritis. These cases will be presented and detailed in this series of articles.

Educational aims and objectives

The aim of this article is to discuss the epidemiology, pathophysiology, diagnosis, and management of TMJ osteoarthritis.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 45 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Realize the underlying mechanisms of the disease and its prevalence. • Identify some forms of arthritis. • Define some necessary determinants for diagnosis of TMJ OA. • Recognize the pathophysiology of TMJ OA. • Realize forms of diagnosis, and management of TMJ OA.

Introduction Evidence of TMJ arthritis can be seen in skeletal and anthropological studies dating back to Paleolithic specimens.5 TMJ arthritis is a common disorder. There is reduced prevalence of bony changes in prehistoric populations (most probably related to life expectancy), but in examination of modern exhumed remains, the prevalence of TMJ arthritic changes is 22%-32%.6,7 This prevalence is 2:1 (female: male). In orofacial pain practices, prevalences of 30% have been reported.8 Recent CBCT imaging studies confirm this prevalence.9 The prevalence is higher in Angle Class II populations; however, this

may be due to resulting occlusal changes from OA.

Forms of arthritis There are over 100 different types of arthritis but most common is osteoarthritis, (OA) related to mechanical stress.10 This is the most common form of arthritis, and we will focus mostly on this in these articles. Other forms of arthritis (rheumatoid, psoriatic, gouty, etc.) are caused by antigen-antibody reaction, metabolic disease, hormonal imbalance, blood breakdown products in joints, genetics, and direct infection of joints. They, however, are present in less than 1% of the population, while OA of all forms presents in the majority of the population.

Prevalence of TMJ Arthritis/Arthrosis by Malocclusion CBCT Angle Class

Figure 1: A. Example of healthy TMJ. B. Advanced osteoarthritis. C. Typical intrachondral cyst formation in right TMJ.

20%

73.2%

Figure 2: Examples of occlusal changes associated with condylar changes in patients. A. Psoriatic arthritis (PA). B. Rheumatoid arthritis III 46.6% (RA). C. Idiopathic condylar cesorption (ICR). D. Metastatic carcinoma. Figure 3: Higher incidence of TMJ OA in Class II5 E. Bilateral osteoarthrtis. F. Osteochondritis dessicans

Dr. Harold Menchel is a well-known worldwide educator on orofacial pain. He is adjunct faculty at Nova Southeastern Dental School in Fort Lauderdale, Florida, educating both undergraduates and graduate residents. He is also director of Orofacial Pain education at Larkin Teaching Hospital in Coral Gables, Florida. Dr. Menchel is in private practice in Coral Springs, Florida, limiting his practice to orofacial pain and sleep-disordered breathing.

40 Orthodontic practice

Risk Factors for Arthritis Age Trauma Genetics

Obesity (fat metabolism?) Joint surgery Septic infection

Gender (estrogen metabolism) Joint laxity

Figure 4: The above are common risk factors for all OA. Notice that joint laxity (hypermobility) is listed. Certain genetic disorders (e.g., Ehler-Danlos Type I) with hypermobility may predispose to OA1 Source: Arthritis Rheum 2007;56:984-994 Volume 5 Number 4

Milam, et al., proposed a hypothesis for the etiology of TMJ OA relating it to mechanical stress. This stress could come from microtrauma (e.g., bruxism) or macrotrauma, (direct injury).12.13.14,15 The pressure on joints from excessive forces cause hypoxia in the synovial circulation, and then on release of the pressure, capillary reperfusion occurs, initiating localized joint destruction through direct mechanical damage, release of free radicals, neurogenic inflammation, and eventual destruction of joints by cytokinemediated release of destructive metalloproteinases (MMPs).16,17,18,19,20 There are 28 known proteases implicated in joint destruction, all which require zinc as a co-factor, and six have been identified in diseased human TMJs.21 Blood in joints from injury can initiate the Fenton reaction, releasing further destructive free radicals. Although the exact mechanisms of OA have not been elucidated, it is notable that the progress of the disease cannot be changed, (as in rheumatoid arthritis) by blocking the factors identified in joint destruction, although pain may be reduced with short-term use. For example, although cytokine blockers are effective in altering the course of destruction in rheumatoid arthritis (RA), they have no long-term effect in OA.10 The most recent hypotheses on the etiology of OA are focused on a hampered repair mechanism in patients with defective DNA, gene polymorphisms, or mutations for certain anabolic factors. It is hypothesized that in asymptomatic patients, mechanical stress does cause physiologic joint changes, but normal repair occurs with no pathology.21,22,23,24,25 In the patient lacking reparative and inhibitory mechanisms, the equilibrium is upset leading to pathology and joint degeneration. It is also known that with aging, the reparative capability of joints decreases.

Disc displacements and arthritis/ arthrosis Longitudinal studies with MRI have demonstrated an association between disc displacement with and without reduction and TMJ OA. In cases of disc displacement with reduction, the odds of the patient developing degenerative changes are increased twofold, and in disc displacement without reduction, the risk factors are almost 5 times the normal population.26.27,28, 29 The presence or absence of joint effusions in patients with reducing discs also affects the course of OA. Both Volume 5 Number 4

imaging and clinical studies estimate that active OA “flare” has a course of 3.6 years before the disease becomes quiescent.30,31 In the past, there were proponents of surgical disc repositioning to prevent further osteoarthritic degeneration. There is no support for this in the literature.

value of CT imaging is limited, and if further imaging is necessary, an MRI may provide more information.36,37,38

Oxidative Stress: Hypoxia-Reperfusion (in OA)

Clinical examination, diagnosis, and management of TMJ OA Orthodontists should screen patients of all ages for joint changes. Many asymptomatic patients can have evident significant arthritic changes easily seen in panorex or lateral TMJ films in open and closed position. CT or CBCT is the gold standard for diagnosis of bony changes and can detect subtle changes in joint morphology. CT is the most accurate measurement of joint size and joint space.32,33,34,35 Disadvantages of CT • Higher radiation than other studies • Necessity to take 2 studies to determine open and closed TMJ position • No visualization of soft tissues (disc position) • No visualization of soft tissue inflammatory changes (joint effusions) • No visualization of bone marrow inflammation If there are obvious bony changes on panorex and transcranial radiographs, the

Figure 5: Milam’s hypotheses state that osteoarthritis is a localized inflammatory disease related to mechanical stress and pressure on joints causing ischemic injury

Blood in Joints

Figure 6: Hemoglobin breakdown products leading to production of the free radical species ferrule ion leading to further joint destruction

Anabolic Repair Mechanisms

Figure 7: Pathophysiology of osteoarthritic joint destruction caused by mechanical stress according to Milam, et. al., 1995. The release of destructive-free radicals create a cytokine-mediated mechanical cascade leading to release of metalloproteinase enzymes (MMPs) destructive to joints and causing neurogenic inflammation and pain

Figure 8: Reparative joint processes. Insulin growth factor (IGF) and transforming growth factor (TGF-β) all generate new tissue formation. Tissue inhibitor of metalloproteinases (TIMPs) and plasminogen activator inhibitor antigen PAI-1) all block destructive enzymes. Lycopene superoxide dismutase (LSOD) is an endogenous antioxidant scavenging free radicals

Figure 9: The Panorex above showing normal right condyle and left osteoarthritic condyle. The CBCT (Right) shows the same patient with a coronal view of each condyle

Figure 10: Right condyle and left condyle Orthodontic practice 41

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Pathophysiology of OA

CONTINUING EDUCATION Laboratory serology for RA A comprehensive rheumatoid panel for use in patients with suspected inflammatory or rheumatoid arthritis is in Figure 11. The orthodontist needs to be familiar with this complete panel.39 It is strongly recommended to have only a rheumatologist order this for your patients, since a general physician may not order the complete panel, and an incomplete diagnosis may be made. Rheumatoid serology should be considered with the following patients: • Patients with bilateral TMJ arthritis • Patients with a family history of RA or autoimmune disease • Patients who complain of general malaise and migratory joint and muscle pain • Patients with bilateral TMJ arthritis who are treatment-planned for extensive occlusal changes.

Synovial fluid testing Aspiration of synovial fluid during arthrocentesis has limited clinical application at this time. It can be helpful in diagnosis of psoriatic and gouty arthritis. It is usually not done as a primary procedure but as an adjunct to arthrocentesis. Evaluation of inflammatory mediators would help to identify acute versus chronic conditions and aid in treatment direction.40,41

Diagnosis of arthritis is made by necessary determinants Normal comprehensive TMD examination and history along with imaging will include necessary determinants for diagnosis of arthritis.44,45,46,47 Significant findings in arthritic patients include the following:* • Crepitation 49% detectable prevalence with stethoscopic findings • Pain focused more in joints than muscles • Changes in occlusion: posterior prematurities (unilateral or bilateral) anterior open bite, decreased overbite, increased overjet, and midline shift to the affected side • Increase in lower facial height and retrognathia • Facial asymmetry to affected joint (unilateral) • Canted occlusal plane towards the affected joint *

Complete Serology Testing Assay

Method

Clinical Use

Rheumatoid factor (RF)

Latex fixation with agglutination

Assists diagnosis and determination of lgM RF

Rheumatoid factor lgA

ELISA

Additional specificity in combination with other tests

Rheumatoid factor lgG

ELISA

May also provide information on disease course

Rheumatoid factor lgA, lgG, lgM

ELISA

Improves specificity of RF testing

Anti CCP

ELISA

More specific about progression of RF

RF panel with 14-3-3 eta protein

Latex fixation with agglutination

Increased specificity than RF alone

Erythrocye sedimentation rate

Modified Westgren

Assess disease activity

CRP (C-reative protein)

Nephalometry

Assess disease activity

Figure 11: Complete serology testing to be ordered for patients with suspected rheumatoid or inflammatory arthritis

and predictable.48,49 In most cases, this involves managing acute flares of a chronic disease. If mechanical stress can be reduced in these patients, flares will be greatly reduced. It may be helpful to coordinate this treatment with an orofacial pain dentist who is more familiar with medical and physical modalities.

Pain management • Rest (behavioral management), soft diet, splint, anti-inflammatories (e.g., Naprosyn 500 mg, EC BID for 2 weeks) Medrol dose pak x1 when severe pain and inflammation. • Topicals as indicated — e.g., Voltaren® Gel, compounded topicals. • If there is severe muscle pain, a muscle relaxer may be indicated — e.g., cyclobenzaprine 5 mg QHS. • Ice for 48-72 hours, and then moist heat. • PT as indicated — heat, strengthening, maintaining range of motion, ultrasound, TENS. • Arthritic patients should be counseled to avoid hard food on a permanent basis in an attempt to further reduce mechanical stress.

Occlusal management It is understood at this point that no specific malocclusion can be linked as a direct cause to TMJ arthritis. However, as has been shown, occlusions are modified by TMJ arthritis, and it is often necessary to initiate occlusal therapy for function, speech, and esthetics in these patients. Occlusal therapy has little validity in TMJ arthritic patients for pain management. This needs to be emphasized to the patient.50,51 Many arthritic patients function well with existing minor occlusal changes, and only conservative treatment is indicated. If the patient has sleep bruxism, continued wear of the stabilization splint at night is recommended. For mild bite changes, for example, anterior open bite, posterior interferences, or simple equilibration may be all that is needed. It is suggested that study casts be mounted prior to any permanent changes. Equilibration will not correct any midline shift or occlusal cants. For more severe malocclusions, prosthodontics, orthodontics, and orthognathic surgery or a combination of these may be indicated.

Limited range of motion is not necessarily associated with OA, but arthritic populations (rheumatoid) have an average limitation of 7 mm interincisal opening.

Management of patients with OA In most cases, pain management of patients with TMJ arthritis is straight-forward 42 Orthodontic practice

Figure 12: Synovial Tissue Biopsy. This is an arthroscopic view of the medial synovial drape of a left TMJ. A small forcep is used to biopsy the Figure 13: Mounted study models duplicating the patient recording the synovial tissue. Notice the inflammation in the occlusal changes in a patient with TMJ osteoarthritis. These models can synovium42,43 With permission of Dr. J. McCain be hand-articulated with normal occlusion Volume 5 Number 4

Prior to any major occlusal therapy, pain must be managed, ROM maximized, and reasonable occlusal stability (condylar stability) established. All patients must be informed that relapse can occur. In any patient who has TMJ arthritis, either gradual or sudden condylar changes can occur over the years, and no guarantees of permanent occlusal stability should be made to the patient. In OA patients, most condylar bony changes occur during the active disease phase (2-4 years). It has been shown in the literature that these joints can be stable up to 30 years assuming no further major insult.30 Gradual occlusal changes may result in occlusal plane changes and compensation, where the teeth remain in contact, but the occlusal plane inclines or cants up to the affected condyle. They can also result in the return of posterior second molar interferences and anterior open bite, as well as increasing midline shift to the affected side. These changes need to be monitored over time. 53,54,55 Protocol to determine condylar and occlusal stability • Archival set of mounted study models to compare future bite changes • CBCT (1:1 measurement). • Serial cephalometric films taken 1 year apart on the same machine. “B” point retrogression should be noted. • Splint markings followed periodically to assess bite changes. This can assess both bite opening and retrognathia. • MRI prior to major occlusal changes. • Serology, if bilateral arthritis.

It is necessary for orthodontists to understand the prevalence, pathophysiology, diagnosis, and management of arthritic patients of all ages. Simpler cases can be managed by the orthodontist alone. More complex cases will involve an interdisciplinary team, involving an orofacial pain dentist and physicians for further diagnosis and treatment as well as prognosis and timing of orthodontic treatment. Sodium hyaluronate Sodium hyaluronate has been investigated in use combined with arthrocentesis with mixed results. There is evidence that it has benefit in patients with disc displacements, but there is no evidence to show any effectiveness in OA patients. The concentration for use in TMJs has not been standardized, and it is not FDA labeled at this time but is approved by insurers. In long-term and short-term use in patients, sodium hyaluronate is equal to steroid in reducing pain, but has fewer side effects (chondromalacia) with repeated steroid injection).58,59,60,61,62,63,64

Alloplastic joint and autogenous joint replacement TMJ joints have been resected starting in Europe for over 150 years. Various materials including ivory, gold, gutta percha, tantalum were used with limited success. Although

autogenous joint replacements have success (rib graft and abdominal or buttocks fat), the most predicable treatment to establish joint stability in arthritic patients is with alloplastic joint replacement. In the case of rheumatoid patients, this may be the only choice. In cases of osteoarthritis, reasonable stability can be established and more conventional and conservative treatment chosen. In older patients with end-stage arthritis, or in younger patients who have failed other treatment, alloplastic joints may the only option. Studies have reported most inter-incisal openings after alloplastic surgery in the 30-35 mm range with an average of 33% improvement of opening, but this varies depending on the preoperative opening. The lateral pterygoid muscles are dissected off the joints during surgery; and therefore, there is limited lateral and protrusive movement. New prostheses are in development to correct this.36-41

Optional Nuclear imaging It is reasonable with 12-month stability as demonstrated by the previously mentioned protocol to proceed with treatment.

Surgical management Lysis and lavage or arthroscopic lysis and lavage with dissection of adhesions may be beneficial as a conservative surgical approach to patients with significant remaining pain and/or limited opening with OA. It is certainly more conservative and preferable to either autogenous or alloplastic joints as initial surgical management. Active physical therapy is required postoperatively to maintain opening, or limited opening may reoccur.56,57 Volume 5 Number 4

Figure 14: This demonstrates how splints can be used to follow occlusal changes in a patient with TMJ arthritis. The top maxillary splint was adjusted to maximum intercuspation to a patient’s adapted centric posture (Dawson 1994) (centric relation occlusion cannot exist in an arthritic patient). Notice that the patient has lost contact with the anterior of the splint and is marking heavier on the right posterior indicating mandibular retrogression and morphologic change (ramus shortening) in the right condyle

Figure 15: A-P considerations. A lower splint can be measured to follow mandibular retrogression over time by measuring increasing overbite

Figure 16: Total joint replacement. Before and after panorex showing placement of an alloplastic left joint in a patient with limited opening With permission of Dr. J. McCain Orthodontic practice 43

CONTINUING EDUCATION

Occlusal and condylar stability

CONTINUING EDUCATION In patients with alloplastic joint failure, autogenous abdominal fat over the remaining ramus has had some clinical success.

16. Hough AJ Jr. Pathology of osteoarthritis. In: Koopman WJ. Arthritis and Allied Conditions: A Textbook of Rheumatology, Volume 2. 14th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001.

Doxycycline and statins

18. Ogura N, Tobe M, Sakamaki H, Nagura H, Hosaka H, Akiba M, Abiko Y, Kondoh T. Interleukin-1beta increases RANTES gene expression and production in synovial fibroblasts from human temporomandibular joint. J Oral Pathol Med. 2004;33(1):629-633.

There have been recent articles advocating the use of doxycycline and statins in preventing the progression of osteoarthritis. Although doxycycline can be of benefit in certain forms of Lyme arthritis, there is no evidence to support its use in OA. There is no support for statins as antiinflammatory agents in OA.58,59

Conclusions It is necessary for orthodontists to understand the prevalence, pathophysiology, diagnosis, and management of arthritic patients of all ages. Simpler cases can be managed by the orthodontist alone. More complex cases will involve an interdisciplinary team, involving an orofacial pain dentist and physicians for further diagnosis and treatment as well as prognosis and timing of orthodontic treatment. The following articles will present specific patient histories to illustrate the information from this article. OP

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Management and treatment of temporomandibular disorders: a clinical perspective. J Man Manip Ther. 2009;17(4):247-254. 51. Abubaker AO., Temporomandibular disorders: an evidence-based approach to diagnosis and treatment, 2006 in TMJ Arthritis, D. M. Laskin, C. S. Greene, and W. L. Hylander, Eds., pp. 234–241, Quintessence Publishing, Hanover Park, Ill, USA. 52. Wolford LM. Idiopathic condylar resorption of the temporomandibular joint in teenage girls (cheerleaders syndrome). Proc (Bayl Univ Med Cent). 2001;14(3):246-252. 53. Mercuri LG. Osteoarthritis, osteoarthrosis, and idiopathic condylar resorption. Oral Maxillofac Surg Clin North Am. 2008;20(2):169-183. 54. Arnett GW, Milam SB, Gottesman L. Progressive mandibular retrusion — idiopathic condylar resorption. Part I. Am J Orthod Dentofacial Orthop. 1996;110(1):8-15. 55. Arnett GW, Milam SB, Gottesman L. Progressive mandibular retrusion—idiopathic condylar resorption. Part II. Am J Orthod Dentofacial Orthop. 1996;110(2):117-127. 56. Dimitroulis G. The prevalence of osteoarthrosis in cases of advanced internal derangement of the temporomandibular joint: a clinical, surgical and histological study. Int J Oral Maxillofac Surg. 2005;34(4):345–349. 57. Dolwick MF, Dimitroulis G. Is there a role for temporomandibular joint surgery? Br J Oral Maxillofac Surg. 1994;32(5):307–313. 58. Alpaslan GH, Alpaslan C. Efficacy of temporomandibular joint arthrocentesis with and without injection of sodium hyaluronate in treatment of internal derangements. J Oral Maxillofac Surg. 2001; 59(6): 613-618. 59. Bertolami, CN, Gay T, Clark G, Rendell J., Shetty V, Liu C., Swann DA. Use of sodium hyaluronate in treating temporomandibular joint disorders: a randomized, double-blind, placebo-controlled clinical trial. J Oral Maxillofac Surg. 1993;51(3):232-242. 60. Kopp S, Carlsson, GE, Haraldson T, Wenneberg B. Long-term effect of intra-articular injections of sodium hyaluronate and corticosteroid on temporomandibular joint arthritis. J Oral Maxillofac Surg. 1987;45(11):929-935. 61. Kopp S, Wenneberg B, Haraldson T, Carlsson GE. The shortterm effect of intra-articular injections of sodium hyaluronate and corticosteroid on temporomandibular joint pain and dysfunction. J Oral Maxillofac Surg. 1985;43(6):429-435. 62. Shi Z, Guo C, Awad M. Hyaluronate for temporomandibular joint disorders. Cochrane Database Syst Rev. 2003;1. 63. Sharma A, Rana AS, Jain G, Kalra P, Gupta D, Sharma S. Evaluation of efficacy of arthrocentesis (with normal saline) with or without sodium hyaluronate in treatment of internal derangement of TMJ – A prospective randomized study in 20 patients. Journal of Oral Biology and Craniofacial Research. 2013;3(3):112-119. 64. El-Hakim IE, Elyamani AO. Preliminary evaluation of histological changes found in a mechanical arthropatic temporomandibular joint (TMJ) exposed to an intra-articular Hyaluronic acid (HA) injection, in a rat model. J Craniomaxillofac Surg. 2011;39(8):610–614. 65. Giannakopoulos HE, Sinn DP, Quinn PD. Biomet Microfixation Temporomandibular Joint Replacement System: a 3-year followup study of patients treated during 1995 to 2005. J Oral Maxillofac Surg. 2012;70(4):787-794. 66. Driemel O, Ach T, Müller-Richter UD, Behr M, Reichert TE, Kunkel M, Reich R. Historical development of alloplastic temporomandibular joint replacement before 1945. Int J Oral Maxillofac Surg. 2009;38(4):301-307. 67. Kashi A, Saha S, Christensen RW. Temporomandibular joint disorders: artificial joint replacements and future research needs. J Long Term Eff Med Implants. 2006;16(6):459-474. 68. Wolford LM, Pitta MC, Reiche-Fischel O, Franco PF. TMJ Concepts/Techmedica custom-made TMJ total joint prosthesis: 5-year follow-up study. Int J Oral Maxillofac Surg. 2003;32(3):268-74. 69. Mercuri LG, Wolford LM, Sanders B, White RD, Giobbie-Hurder A. Long-term follow-up of the CAD/CAM patient fitted total temporomandibular joint reconstruction system. J Oral Maxillofac Surg. 2002;60(12):1440–1448. 70. Snijders GF, van den Ende CH, van Riel PL, van den Hoogen FH, den Broeder AA. Doxycycline has no symptom modifying effects in knee osteoarthritis: results from a randomized placebo controlled trial. Ann Rheum Dis. 2011;70(suppl 3):140.

43. Moses JJ, Hosaka, H. Arthroscopic punch for definitive diagnosis of synovial chondromatosis of the temporomandibular joint. Oral Surg Oral Med Oral Pathol. 1993;75(1):12-17

71. Da Costa BR, Nüesch E, Reichenbach S, Jüni P, Rutjes AW. Doxycycline for osteoarthritis of the knee or hip. Cochrane Database Syst Rev. 2012;11:1-30.

44. Tanaka E, Detamore MS, Mercuri LG. Degenerative disorders of the temporomandibular joint: etiology, diagnosis, and treatment. J. Dent Res. 2008;87(4):296–307.

72. Conaghan PG. The effects of statins on osteoarthritis structural progression: another glimpse of the holy grail? Ann Rheum Dis. 2012;71(5):633-634.

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Airway development and prevention of obstructive sleep apnea in children QUINTERO 1.

Obstructive sleep apnea (OSA) is a debilitating disease resulting in greater loss of life expectancy (LLE) and diminished quality of life (QOL), affecting anywhere from _____ of the U.S. population. a. 3% to 7% b. 10% to 14% c. 20% to 25% d. 46% to 50% The number of patients being diagnosed with OSA is increasing at an alarming rate of _____ per year likely due to increased patient and doctor awareness. a. 6% b. 15% c. 30% d. 50%

______ is critical in identifying pediatric patients at risk for OSA or for developing future OSA as adults. a. Immediate surgical intervention b. Early screening c. Understanding of growth and development d. Both b and c

Breathing is a function of craniofacial anatomy and the ______ caused by the collapse of the structures surrounding the upper airway, such as the tongue. a. esophageal flutter b. uvular interaction c. resultant airflow resistance d. constricted arch form

Recent studies have correlated facial dentofacial morphology with airway volume, and airway dimensions have ______ risk factors for OSA. a. been discounted as b. logically been correlated to c. shown no correlation to d. shown to be the only Furthermore, recent advances in imaging technology have made ultra-low dose cone beam computerized tomography (CBCT) such as the new i-CAT® FLX from Imaging Sciences International and everyday

Volume 5 Number 4

imaging of the airways possible with dose exposure less than a panorex and as low as _______. a. 3 μSv b. 8 μSv c. 15 μSv d. 25 μSv 7.

10.

The applications and implications of this technology in the ______ of OSA in the pediatric population are enormous. a. screening b. prevention c. diagnosis d. both a and b Orthognathic surgery in the form of maxillomandibular advancement has been shown to be the ___________ for patients suffering from obstructive sleep apnea. a. least expensive b. last resort c. most risky d. definitive treatment Several studies have demonstrated a ______ of OSA through MMA, when compared to CPAP or oral appliances, using AHI scores through polysomnograms as the measuring tool. a. 56% failure rate b. 20% success rate c. 46% success rate d. 100% success rate Proper screening using ultra-low-dose CBCT imaging and early management through interprofessional collaboration with _______ during the growing years of the face may prevent OSA in future generations, by promoting healthy growth of the craniofacial complex, and thus pharyngeal airway development, during childhood. a. ENTs b. pediatricians c. allergists d. all of the above

TMJ arthritis 2014: essentials for the orthodontic specialist MENCHEL 1.

There are over 100 different types of arthritis but most common is osteoarthritis, (OA) related to _______________. a. mechanical stress b. metabolic disease c. hormone imbalance d. blood breakdown products

Milam, et al., proposed a hypothesis for the etiology of TMJ OA relating it to mechanical stress. This stress could come from ______________. a. microtrauma (e.g., bruxism) b. macrotrauma (direct injury) c. antigen-antibody reaction d. both a and b Orthodontists should screen _______________ for joint changes. a. their youngest patients b. patients starting at 30 years old c. patients over 60 years old d. patients of all ages

It is understood at this point that no specific malocclusion can be linked as a direct cause to TMJ arthritis. However, as has been shown, occlusions are modified by TMJ arthritis, and it is often necessary to initiate occlusal therapy for __________ in these patients. a. function b. speech c. esthetics d. all of the above For mild bite changes, for example, ___________ may be all that is needed. a. anterior open bite b. posterior interferences c. simple equilibration d. all of the above

Equilibration ______________ any midline shift or occlusal cants. a. will correct b. will not correct c. is recommended for d. will cause

In OA patients, most condylar bony changes occur during _____________. a. the latent phase (6 months) b. the relapse phase (up to 30 years) c. the active disease phase (2-4 years) d. the generative stage (first year)

Lysis and lavage or arthroscopic lysis and lavage with dissection of adhesions may be beneficial as a ________ to patients with significant remaining pain and/or limited opening with OA. a. conservative surgical approach b. nontraditional approach c. radical approach d. short-term approach

Although autogenous joint replacements have success (rib graft and abdominal or buttocks fat), the most predicable treatment to establish joint stability in arthritic patients is with ____________ joint replacement. a. xenograft b. alloplastic c. hydroxyapatite d. strontium

10.

Studies have reported most inter-incisal openings after alloplastic surgery in the __________ range with an average of 33% improvement of opening, but this varies depending on the preoperative opening. a. 10-15 mm b. 20-25 mm c. 30-35 mm d. 40-45 mm

Orthodontic practice 45

CE CREDITS

ORTHODONTIC PRACTICE CE

RESEARCH

Objective: The purpose of this study was to investigate the efficacy of MI Paste™ compared to fluoride used in mitigating white spot lesions. Simultaneously, a survey was designed to investigate current trends of treatment alternatives for white spot lesions utilized by private orthodontic practitioners. Methods: A pilot study was conducted in a split-mouth trial comparing MI Paste versus fluoride gel. Subjects had baseline photographic records taken and were randomly assigned treatment options by arch, with each arch subdivided into quadrants of treatment and control. After 6 weeks of treatment, subjects were presented with a direct comparison of before-and-after photographs. Questionnaires were developed to evaluate each subject’s perception of change prior to and after seeing their photographs. A blinded panel of dental experts evaluated the appearances of the white spots before and after treatment using a 100-mm visual analog scale (VAS). In conjunction with this study, an email requesting participation in a seven-question online survey (Survey Monkey®) was sent to

Bethany R. Middleton, DMD, MS, graduated from Southern Illinois University School of Dental Medicine (DMD) in 2011 and Seton Hill University Center for Orthodontics (MS) in 2013, and is currently in orthodontic practice in Springfield, Illinois. She can be reached at mid0890@setonhill.edu. Donald J. Rinchuse, DMD, MS, MDS, PhD, is Professor and Graduate Orthodontic Program Director, Seton Hill University, Greensburg, Pennsylvania. He graduated from the University of Pittsburgh School of Dental Medicine in 1974 with degrees in Dentistry (DMD) and Pharmacology/Physiology (MS). He received his certificate and MDS degree in orthodontics in 1976 and a PhD in Higher Education in 1985 from the University of Pittsburgh. He is a Diplomate of the American Board of Orthodontics. In addition, Dr. Rinchuse is on the editorial review board of many professional journals, including the American Journal of Orthodontics and Dentofacial Orthopedics (AJO-DO). He has published over 100 articles, several book chapters, and a book, and has made many presentations. He can be reached at rinchuse@setonhill.edu. Thomas G. Zullo, PhD, is Adjunct Professor at Seton Hill University, Greensburg, Pennsylvania, and also Professor Emeritus of Dental Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania. He can be reached at zullo@pitt.edu.

46 Orthodontic practice

active and retired members of the AAO from the AAO Partners in Education, (n = 2300). Results: Subjects were generally pleased with changes in the appearance of their teeth. No statistically significant differences were discovered between MI Paste, fluoride gel, and the control. Although most quadrants reflected improvement, some did not. In the survey, 93% of practitioners observed white spot lesions in up to 25% of patients during treatment, which increased to 25%-50% after orthodontic treatment. 90% of orthodontists will at least inform patients of white spots. 71% offer a treatment protocol: 47% recommend normal home care, 35% recommend MI Paste, 38% recommend fluoride, and 30% will recommend MI Paste Plus™, a combination of fluoride and RecaldentTM. Nearly half of private practitioners will refer patients to a general dentist for treatment of white spot lesions. Conclusions: A number of products claim to reverse the appearance of white spot lesions; however, this pilot study demonstrated that, despite minor improvements, evidence is lacking whether any product, including normal home care, is superior. Subjects unanimously reported satisfaction with white spot treatments, despite varying outcomes. Orthodontists observing white spot lesions will recommend a variety of treatment alternatives for patients, which is reflective of the variety of recommendations seen in the literature.

Introduction White spot lesions can be described as porosities below the smooth surfaces of enamel that appear milky white due to altered light scatter.1-2 They have been a recurrent problem in orthodontic patients for decades, with little prevention being demonstrated in the recent past. These white spots have been reported to range in occurrence from 2%–96%3-6 of treated patients, presenting themselves as one of the most challenging drawbacks to orthodontics. As demonstrated by a survey, patients, parents, dentists, and orthodontists agree that such lesions not

only diminish appearances of teeth, but also are ultimately the responsibility of the patient when it comes to prevention.7 Identifying potential patients to target such prevention is a challenge in and of itself. However, determining what to do after these lesions have formed is an even greater dilemma. A number of studies recommend preventative treatments ranging from fluoride products (pastes, gels, varnishes, mouth rinses, etc.) to antimicrobials, xylitol gum, diet counseling, and casein derivatives.8-28 Two of the most popular treatment products currently being compared for effectiveness are fluoride products and the casein derivative known as casein phosphopeptide-amorphous calcium phosphate (CPPACP). In a recent study, fluoride varnish demonstrated itself to have slightly greater improvements than that of a CPP-ACP product known as MI Paste when subjects evaluated before and after photographs of treatments with said products.29 Often, fluoride is recommended more as a preventive measure in the inhibition of demineralization.9-12 CPP-ACP functions as a calcium and phosphate-binding agent which can adhere to both bacterial walls and the surfaces of teeth.24, 25 In acidic environments, these ions can be released to form a supersaturated ion concentration in the saliva, which releases the calcium-phosphate compound as a precipitate on the tooth surface.25 Recaldent™ (CPP-ACP) has made claims of remineralizing and reversing white spot lesions, decreasing tooth sensitivity, aiding in salivary flow for dry mouths, etc. White spot lesions developing during orthodontic treatment can be described as active or arrested, with active lesions having a better prognosis for recovery; this is due to the porosity of the enamel, which allows for uptake of the calcium-phosphate ions.8 Generally, patients who have completed orthodontic treatment have progressed to an arrested state, indicating a remineralization of the outer enamel layer, making the process for reversal or esthetic matching much more difficult.8 One study showed that subjects Volume 5 Number 4

Materials and methods This study was designed with two parts: a pilot study for a clinical trial to evaluate post-orthodontic white spot treatments, as well as a survey to discover current trends

of orthodontists in private practice. The study design was somewhat modeled after previous studies by Robertson, et al., at the Department of Orthodontics at the University of Texas Health Science Center at Houston; University of Alabama at Birmingham; and Ann Arbor, Michigan30; and also Huang, et al.,29 at Seattle and Bellevue, Washington, and Boise, Idaho. A flow chart was created for this trial (Figure 1). This research protocol was approved by the Seton Hill University Institutional Review Board. After conducting a power analysis for the trial, it was deemed too difficult to obtain a sample size large enough to create a statistically significant result from the patient pool currently available at the Center for Orthodontics. Instead, the trial design was modified to a pilot study which could potentially be expounded upon in future trials. Eight participants (with a total of 13 qualifying arches, or 26 quadrants) met the inclusion criteria and were willing to commit to 6 consecutive weeks of treatment, signed minor assent agreements, with guardians signing informed consent agreements. The participants had affected arches randomly assigned into one of two groups in an attempt to closely approximate the groups based on age and gender. Both groups were

Screening by Residents and Faculty for WSL’s

Screening

Assessment for Eligibility

Enrollment

Eligible for Randomization (n = 8; 13 arches)

Excluded: Did not meet inclusion criteria Declined to participate (n = 21; 37 potential arches)

MI Paste™/Control (n = 7 arches)

Randomized Group Assignment

PreviDent 5000/Control (n = 6 arches)

Dropouts (n = 0)

Follow-up

Dropouts (n = 0)

Analyzed (n = 7 arches)

Analysis

Analyzed (n = 6 arches)

Figure 1: Study participation flow chart Volume 5 Number 4

further divided into split-mouth experiment and control quadrants. These subjects were recruited over time, as qualifications were met, then scheduled to begin and end the experiment over the same 6-week period. Treatment was conducted from September 23, 2013, to November 7, 2013. Group A had MI Paste (GC America, Alsip, Illinois) for the experimental substance, while Group B was given Colgate® PreviDent® 5000 gel (Colgate-Palmolive, New York, New York). The control product was Tom’s of Maine non-fluoridated whitening toothpaste (Kennebunk, Maine). Subject randomization has a number of advantages, including selection bias reduction ensuring that certain study participants are not funneled into one group or another based on factors that could influence trial results. It allows for the incorporation of the probability theory to determine the likelihood that outcome differences are due to chance alone, and also serves as a means of investigator and subject blinding. In an attempt to account for and reduce selection bias, the principal investigator was not involved in the process of subject allocation to the two groups. After initial identification of subjects who fit the inclusion criteria, a staff member from Seton Hill University Center for Orthodontics randomly assigned the subjects using the flip of a coin. At the initial treatment appointment, a baseline level of the location of white spot lesions qualifying for the study was assessed and charted. Initial intraoral photographic records were taken. This was repeated after 6 weeks of treatment to evaluate progression or reversal of white spot lesions in both the Recaldent™ and fluoride groups.34-39 Three standard photographs were taken from the left buccal, right buccal, and centered anterior aspects to evaluate from first molar to first molar in both the maxilla and mandible. A single camera (Canon EOS 1000D Rebel XS) was used to take photos in a light-controlled environment to ensure consistency. Each subject was instructed to brush prior to the beginning of each treatment session. All qualifying tooth surfaces were pumice polished and rinsed. Lip retractors were then placed to reduce saliva contamination and allow adequate access to involved surfaces. These surfaces were etched with 37% phosphoric acid gel for 15 seconds, thoroughly rinsed, and dried. Each arch was then treated for with either MI Paste or PreviDent 5000 gel on one-half and a control of Tom’s of Maine on the other. Products were topically administered with a cotton-tipped applicator and left on for 4 minutes. The Orthodontic practice 47

RESEARCH

who were in active orthodontic treatment and used MI Paste Plus™ (MI Paste with 900 ppm sodium fluoride concentration) during treatment demonstrated improvement of existing white spot lesions and prevention of others, while the control subjects had increased incidence of WSLs and worsening of existing lesions.30 However, in another recent study, home care was found to be nearly as effective as either MI Paste Plus™ or PreviDent® 5000 (Colgate®) fluoride varnish.29 While this was performed within 2 months post-orthodontics, and for 8 weeks at home, it can be surmised that some remineralization may occur naturally. Several publications have recommended allowing this to occur for up to 6 months, and then applying bleaching for esthetic matching, or low concentrations of fluoride, or MI Paste’s Recaldent™.8,29,31 Other studies attributed a greater occurrence in WSLs to the type of bonding materials used on brackets, with glass ionomer cement showing less harm than acrylic bonding materials long-term.32,33

RESEARCH subjects expectorated and were instructed not to eat, drink, or rinse for 30 minutes. This protocol was conducted once a week for 6 weeks. Photographs were taken a week after the final treatment to prevent inaccurate appearances of desiccated teeth the day of the final treatment. After treatment two questionnaires were created to assess the perception of treatment outcomes and any changes in behavior due to the study, such as a Hawthorne effect.40 The questionnaires were presented to a group of residents not participating in the study to assess clarity of questions and modify wording in lay terms. Final versions of the questionnaires were adopted and disseminated to the subjects and guardians prior to viewing before/after comparison photographs. They were presented with a personalized slide show (PowerPoint, Microsoft) displaying two standardized orientation slides, which the principal investigator used to explain the evaluation process of white spots. These slides were taken from a previous study after permission was granted from the original author and the American Journal of Orthodontics and Dentofacial Orthopedics (AJO-DO) Rightslink.29 Once subjects were oriented with evaluation protocols, they were shown before and after photographs of

Figure 2: Right buccal photograph: used by a patient to evaluate and compare white spot lesions before and after treatment

their teeth (Figure 2), and assessed overall changes by demarcating a 100-mm visual analog scale and describing the degree and type of changes observed. All subjects were given the opportunity to continue treatment if desired at the end of the study. A panel of four dental experts were recruited to visually assess the differences in initial and final photographs of treated and control quadrants for all subjects. These evaluators were third-year orthodontic residents at Seton Hill University (two male, two female). All experts were presented with the same two orientation slides as the subjects and given oral instructions on how to evaluate changes using a 100-mm visual analog scale with a score of 0 indicating no improvement or worsening of a lesion and 100 indicating complete improvement or disappearance of the white spots. They were then presented with a 26-slide PowerPoint presentation, which displayed isolated photographs of each quadrant of treatment with side-by-side comparisons of initial and final photographs (Figure 3). Every assessor was blinded to the treatments rendered to each quadrant, and photos were not in sequential order of subjects so as to prevent evaluator fatigue. For the survey portion of the study, approval was granted from the Seton

Figure 3: Example of expert evaluation slides: lower right quadrant treated with MI Paste

Hill University Institutional Review Board, and a list of questions was compiled and reviewed by the investigator and faculty supervisor, as well as residents who were not participating in the study. It was then submitted for approval and review by American Association of Orthodontists Partners in Research. An email invitation was sent to active and retired members of the AAO (n = 2300) from the American Association of Orthodontists Partners in Education requesting participation in a seven-question online survey (Survey Monkey). These practitioners were asked to answer questions regarding their experience and in-office protocols for white spot lesions cause by orthodontics. The introductory letter informed members that the aim of the survey was to determine current trends in management and treatment of white spot lesions for private practitioners. The online survey was posted from October 24, 2013, to November 26, 2013. The survey link and cover letter were emailed to AAO members on two separate occasions. The survey questionnaire consisted of single-response, multi-response, and open-ended questions that gave members the opportunity to explain their answers. These questions were designed to discover the demographics and protocols of private practitioners. Questions were as follows: How long have you been practicing orthodontics? In approximately what percentage of your patients do you observe white spot lesions during treatment, after treatment? How do you manage patients with white spot lesions? If you offer a treatment protocol, what do you recommend? If you treat white spot lesions in-office, how long do you treat patients for improvement? If you treat white spot lesions in-office, how do you assess treatment success?

Patient No.

% Overall Improvement

% Increase in Self-esteem

Pleased with TX

Change in OH(Hawthorne Effect)

Paid attention to brushing

Varied/quadrant

Brushed more often

Brush longer/more

Desires Further Tx

Table 1: Patient posttreatment self-assessment results 48 Orthodontic practice

Volume 5 Number 4

A total of 29 subjects were initially identified as possible candidates for the pilot study. Of those subjects, 12 met the inclusion criteria, and 8 of those 12 consented to participate in the study (3 males, 5 females). All 8 subjects completed the entire 6-week treatment process, resulting in a dropout rate of 0%. The MI Paste group was composed of 7 quadrants on 6 subjects. The PreviDent 5000 group was composed of 6 quadrants on 5 subjects. Data collected from the subject selfassessments were compiled into a table format, utilizing qualitative and quantitative measurements (Table 1). Quantifiable data were measured using a 100 mm VAS, measuring the differences between selfesteem regarding the appearances of their teeth before and after the white spot treatment. After viewing the side-by-side comparisons of the initial and final photographs, subjects noted a range in improvement of the white spots from 30%–85%. Increased selfesteem in regards to tooth appearance was less significant, ranging from 0%–12% with an outlier increasing by 60%. All subjects and guardians were pleased with the outcome of treatment regardless of the products used, and 75% of the subjects desired no further treatment after the 6-week study. Of the two subjects (25%) who elected to continue treatment, only one subject returned for an additional in-office treatment. Three subjects (37.5%) reported a change in behavior during the study, stating an increase in frequency and duration of brushing. One subject and her parent both separately noted a worsening in the appearance of a quadrant of treatment related to an increase in the white spot appearance. This quadrant was treated with PreviDent 5000. Data were collected from the dental expert evaluators and all assessments were measured to the nearest millimeter, each millimeter correlating to a scale of 1% on the range from 0% (no improvement/ worsening) to 100% (complete disappearance of the lesion). This information was then analyzed using SPSS v.19, incorporating transformed variables that were the mean of the four judges in an attempt to best correlate the relationships of the different treatment groups. A Wilcoxon Signed Rank Test revealed no significant difference between Group A and the Control (p = 0.686), or Group B and the Control (p = 0.345). Overall, mild improvements were noted, yet some quadrants showed no improvement at all. Volume 5 Number 4

For the survey, of the 2300 emails sent to active and retired AAO members, 1500 actually opened the emails, and 133 participated in the survey (Table 2). Of those who participated in the survey, 63% had been practicing for over 20 years. Of the practitioners surveyed, 93% observed a presence of white spot lesions in 25% or less of their patient population. After orthodontic treatment, 14% claimed that the prevalence rose to between 25%–50%. Just over 90% of orthodontists said they inform their patients of these white spots, and 71% offer a treatment protocol; 47% will recommend normal home care to aid in the reversal. Those who offer treatments of Recaldent TM, fluoride, or a combination were relatively evenly disseminated. 35% recommend MI Paste, 38% recommend fluoride, and 30% will recommend MI Paste Plus, which is a combination of fluoride and RecaldentTM. Nearly half (48%) of private practitioners will refer patients to a general dentist if needed.

Discussion A number of prior studies have evaluated the efficacy of various topical agents and treatment techniques in the decrease of white spot lesions.2,8,12,14,17-35 However, the majority of these studies were conducted using protocols that allow for skewed results due to variability in patient compliance. This same lack of patient compliance is often blamed for the cause of these white spot lesions when considering poor

Topic

oral hygiene.8,14,15,36 This pilot study was an attempt to lay the foundation for evaluating the efficacy of the treatment agents in a controlled environment, eliminating one of the most difficult variables to monitor: whether or not the patient is actually using the product properly and consistently. By the orthodontist performing the treatment in a controlled environment, compliance was no longer an issue. This was a modest attempt to evaluate how the results compared to the current literature. In order to properly and effectively evaluate the products and procedures that claim to reverse white spots, it is imperative to minimize variables and control as many factors as possible. The design of this study was intended to do just that; however, a low power was obtained due to the small number of subjects. This could result in making a Type 2 error, or one that is a false negative. Perhaps there really are significant differences, but due to the small sample size, these differences were not picked up on a statistically significant level. There were also wide variations in assessing the data, due to the subjectivity of the measurements, i.e. individual evaluator interpretation of “improvement”. Quantifying results via a surface area percentage comparison as demonstrated by Huang, et al.,29 would prove to standardize data and increase reliability. In light of perceptions, although most of the subjects failed to note significant changes, they were still pleased with the

Results

1. Years Practicing Orthodontics

63% of participating orthodontists practiced 20 or more years

2. Patient Population with WSL During Treatment

50% reported white spots in 0%-10% of patients 43% reported white spots in 10%-25% of patients

3. Patient Population with WSL After treatment

42% still reported white spots in 0%-10% after treatment 44% reported white spots in 10%-25% after treatment 14% observed white spots in 25%-50% after treatment

4. Managment of WSL Patients

90% inform patients of WSL 71% offer some sort of treatment protocol 48% refer patients to a general dentist

5. Treatment Protocol Recommended

47% recommend normal homecare 35% recommend MI Paste 38% recommend fluoride 30% recommend MI Paste Plus (MI Paste + fluoride) 14% recommend resin infiltration (such as Icon)

6. Length of Treatment for WSL

7. Assessment of Treatment Success

18% treat WSL for 1-8 weeks 23% treat WSL for 2-4 months 19% treat WSL for 4-6 months 68% use visual assessment to determine success of treatment 33% base treatment success on patient satisfaction

Table 2: Survey results from orthodontists in private practice Orthodontic practice 49

RESEARCH

Results

RESEARCH results of treatment. It is plausible that patients will interpret a variety of treatments as having an influence or change due to the power of suggestion, as seen in a placebo effect. Perhaps it is simply the idea of “having a procedure performed” that aids patients in perception of a change. Without a single drop-out, it could be interpreted that patients and parents see the value of in-office treatments, and shifting the responsibility for compliance away from the patient. One subject reported that she knew she would not follow through with treatment if it was left up to her. The variability in dental expert interpretation of changes in white spots revealed that esthetics are subjective and open to interpretation, even when evaluating the severity of white spot lesions. Another weakness of the study was the variability in the appearance of the white spots in photographs. Although every photograph was taken in a light-controlled room, inconsistency exists from subject-tosubject, and also within the same subject, but different locations of the mouth. For example, assessing anterior teeth may have been more difficult due to a higher reflection of the flash, resulting in a “washed out” photograph when compared with a buccal view of posterior teeth. While each photograph was only compared directly with a photograph of the same section of the mouth, misinterpretation of severity could skew results. Despite shortcomings inherent in the design of this study, the lack of statistical significance could also be simply due to a true lack of difference between the three products utilized. Perhaps instead of the product itself having a significant effect on the white spots, the technique made more of an impact, albeit small, on the blending of the lesions, softening their appearances. In order to best assess these changes, histological samples could be analyzed. However, this would be impractical for an in vivo study where patient perception is paramount. Treatment alternatives vary greatly among practitioners. While some products claim to be the superior solution to white spots and other problems, evidence is lacking for all such claims. In fact, some studies imply that improving home care can be the most effective in reducing white spots29. Overall, most orthodontists acknowledge the presence of white spots in a significant percentage of their patients and are attempting to aid in treating them or referring to the general dentist as needed. 50 Orthodontic practice

They (white spot lesions) have been a recurrent problem in orthodontic patients for decades, with little prevention being demonstrated in the recent past. These white spots have been reported to range in occurrence from 2%–96% of treated patients, presenting themselves as one of the most challenging drawbacks to orthodontics.

This survey had a small return rate (5.8%), so universal application of these ideas may be questionable. Nonetheless, the variation in products currently on the market is somewhat a reflection of the findings in current literature. Some studies support the use of MI Paste, while others find fluoride or simply home care to be the best at reversing white spot lesions. As supported in this pilot study, all products can have some effects on white spot lesions; however, none appear to have superior results.

Conclusions Many products claim to reverse the appearance of white spot lesions. In congruence with the literature, this study lacked evidence to support that any product is superior to regular toothpaste and normal home care. Further studies are needed to determine a difference among white spot treatment alternatives, especially in regard to elimination of patient compliance. The survey of practitioners reflects this same disparity in treatment protocols as seen in the literature. • No statistically significant differences were discovered between any MI Paste, PreviDent 5000 fluoride gel, or the control (Tom’s of Maine non-fluoridated whitening toothpaste). • Subjects reported an improvement in their perceptions of dental appearances

due to treatment, and 100% were pleased with the outcome of their treatment. • Orthodontists in private practice observe a significant presence of white spot lesions among their current population (up to 25%), with some finding this number increases to 25%-50% after orthodontic treatment. • Currently, many products and technique alternatives are employed, with the majority of doctors offering some sort of treatment protocol: 47% recommend improved oral hygiene, 48% refer to general dentists if needed. Use of products, such as MI Paste, fluoride, and MI Paste Plus, is fairly equally distributed. OP

REFERENCES 1.

Summitt JB, Robbins JW, Schwartz RS. Fundamentals of Operative Dentistry: A Contemporary Approach. 3rd ed. Hanover Park, IL: Quintessence; 2006: 2-4.

2. Ogaard B. White spot lesions during orthodontic treatment: mechanisms and fluoride preventive aspects. Semin Orthod. 2008;14(3):183-193. 3.

Mizrahi E. Enamel demineralization following orthodontic treatment. Am Journal Orthod. 1982;82(1):62-67.

4. Gorelick L, Geiger AM, Gwinnett AJ. Incidence of white spot formation after bonding and banding. Am J Orthod. 1982;81(2):93-98. 5. Ogaard B, Rolla G, Arends J, ten Cate JM. Orthodontic appliances and enamel demineralization: Part 2. Prevention and treatment of lesions. Am J Orthod Dentofacial Orthop. 1988;94(2):123-128. 6. Mitchell L. Decalcification during orthodontic treatment with fixed appliances--an overview. Br J Orthod. 1992;19(3):199-205. 7. Maxfield BJ, Hamdan AM, Tüfekçi E, Shroff B, Best AM, Lindauer SJ. Development of white spot lesions during orthodontic treatment: perceptions of patients, parents, orthodontists, and general dentists. Am J Orthod Dentofacial Orthop. 2012;141(3):337-344.

Volume 5 Number 4

V. Final report on the effect of sucrose, fructose and xylitol diets on the caries incidence in man. Acta Odonto Scand. 1976;34(4):179-216.

9. Derks A, Katsaros C, Frencken JE, van’t Hof MA, KuijpersJagtman AM. Caries-inhibiting effect on preventive measures during orthodontic treatment with fixed appliances: A systematic review. Caries Res. 2004;38(5):413-420.

20. Mäkinen KK, Bennett CA, Hujoel PP, Isokangas PJ, Isotupa KP, Pape HR Jr, Mäkinen PL. Xylitol chewing gums and caries rates: a 40-month cohort study. J Dent Res. 1995;74(12):1904-1913.

10. Baysan A, Lynch E, Ellwood R, Davies R, Petersson L, Borsboom P. Reversal of primary root caries using dentifrices containing 5000 and 1100 ppm fluoride. Caries Res. 2001;35(1):41-46. 11. Schirrmeister JF, Gebrande JP, Altenburger MJ, Mönting JS, Hellwig E. Effect of dentifrice containing 5000 ppm fluoride on non-cavitated fissure carious lesions in vivo after 2 weeks. Am J Dent. 2007;20(4):212-216. 12. Alexander SA, Ripa LW. Effects of self-applied topical fluoride preparations in orthodontic patients. Angle Orthod. 2000;70(6):424-430. 13. American Dental Association Council of Scientific Affairs. Caries risk assessment. J Am Dent Assoc. 2006;137:1151-1159. 14. Benson PE, Parkin N, Millett DT, Dyer FE, Vine S, Shah A. Fluorides for the prevention of white spots on teeth during fixed brace treatment. The Cochrane Collaboration. Wellesley, UK: Wiley & Sons; 2007;3:1-35. 15. Marsh PD. Are dental diseases examples of ecological catastrophes? Microbiology. 2003;149(Pt 2):279-294. 16. Kimmel L, Tinanoff N. A modified mitis salivarius medium for a caries diagnosis test. Oral Microbiol Immunol. 1991;6(5):275-279. 17. Anderson MH. A review of the efficacy of chlorhexidine on dental caries and the caries infection. J Calif Dent Assoc. 2003;31(3):211-214. 18. Emilson CG, Linquist B, Wennerholm K. Recolonization of human tooth surfaces by streptococcus mutans after suppression by chlorhexidine treatment. J Dent Res. 1987;66(9):1503-1508. 19. Scheinin A, Mäkinen KK, Ylitalo K. Turku sugar studies:

Volume 5 Number 4

21. Zimmer S, Robke FJ, Roulet JF. Caries prevention with fluoride varnish in a socially deprived community. Community Dent Oral Epidemiol. 1999;27(2):103-108. 22. Isokangas P, Alanen P, Tiesko J, Mäkinen KK. Xylitol chewing gum in caries prevention: a field study in children. J Am Dent Assoc. 1988;117(2):315-320. 23. Dawes C, Macpherson LM. Effects of nine different chewing gums and lozenges on salivary flow rate and pH. Caries Res. 1992;26(3):176-182. 24. Aimutis WR. Bioactive properties of milk proteins with particular focus on anticariogenesis. J Nutr. 2004;134(4):989S-95S. 25. Tung MS, Eichmiller FC. Dental applications of amorphous calcium phosphates. J Clin Dent. 1999;10(1 Spec No):1-6. 26. Iijima Y, Cai F, Shen P, Walker G, Reynolds C, Reynolds EC. Acid resistance of enamel subsurface lesions remineralized by a sugar-free chewing gum containing casein phosphopeptide-amorphous calcium phosphate. Caries Res. 2004;38(6):551-556.

patients: A prospective randomized controlled trial. Am J Orthod Dentofaical Orthop. 2011;140(5):660-668. 31. Knösel M, Attin R, Becker K, Attin T. External bleaching effect on the color and luminosity of inactive white-spot lesions after fixed orthodontic appliances. Angle Orthod. 2007;77(4):646-652. 32. Shungin D, Olsson AI, Persson M. Orthodontic treatmentrelated white spot lesions: A 14-year prospective quantitative follow-up, including bonding material assessment. Am J Orthod Dentofaical Orthop. 2010;138(2):136 e1-8, 136-137. 33. Kohda N, Iijima M, Brantley W, Muguruma T, Yuasa T, Nakagaki S, Mizoguchi I. Effects of bonding materials on the mechanical properties of enamel around orthodontic brackets. Angle Orthod. 2012;82(2):187-195. 34 Murphy TC, Willmot DR, Rodd HD. Management of postorthodontic demineralized white lesions with microabrasion: a quantitative assessment. Am J Orthod Dentofaical Orthop. 2007;131(1):27-33. 35. Mitchell L. An investigation into the effect of a fluoride releasing adhesive on the prevalence of enamel surface changes associated with directly bonded orthodontic attachments. Br J Orthod. 1992;19(3):207-214. 36. Brenson PE, Pender N, Higham SM, Edgar WM. Morphometric assessment of enamel demineralisation from photographs. J Dent. 1998;26(8):669-677.

27. Azarpazhooh A, Limeback H. Clinical efficacy of casein derivatives: a systematic review of the literature. J Am Dent Assoc. 2008;139(7):915-924, 994-995.

37. Artun J, Thylstrup A. A 3-year clinical and SEM study of surface changes of carious enamel lesions after inactivation. Am J Orthod Dentofaical Orthop. 1989;95(4):327-333.

28. Tung MS, Eichmiller FC. Dental applications of amorphous calcium phosphates. J Clin Dent. 1999;10(1 Spec No):1-6.

38. Knosel M, Bojes M, Junk K, Ziebolz D. Increased susceptibility for white spot lesions by surplus orthodontic etching exceeding bracket base area. Am J Orthod Dentofaical Orthop. 2012;141(5):574-582.

29. Huang GJ, Roloff-Chiang B, Mills BE, Shalchi S, Spiekerman C, Korpak AM, Starrett JL, Greenlee GM, Drangsholt RJ, Matunas JC. Effectiveness of MI Paste Plus and PreviDent fluoride varnish for treatment of white spot lesions: a randomized controlled trial. Am J Orthod Dentofaical Orthop. 2013;143(1):31-41.

39. Ogaard B. Prevalence of white spot lesions in 19-year-olds: a study on untreated and orthodontically treated persons 5 years after treatment. Am J Orthod Dentofaical Orthop. 1989;96(5):423-427.

30. Robertson MA, Kau CH, English JD, Lee RP, Powers J, Nguyen JT. MI Paste Plus to prevent demineralization in orthodontic

40. Landsberger H. Hawthorne Revisited. Ithaca, NY: The New York State School of Industrial and Labor Relations; 1958: 132.

Orthodontic practice 51

RESEARCH

8. Guzmán-Armstrong S, Chalmers J, Warren J. White spot lesions: prevention and treatment. Am J Orthod Dentofacial Orthop. 2010;138(6):690-696.

TECHNOLOGY

eXceed™ — the “GPS approach” to orthodontic bracket placement Vladimir Lucenko, director of operations, IT, for Exact Invest OU, addresses precision bracket placement

he importance of precise bracket placement in fixed-appliance orthodontics cannot be overstated. Inaccurate positioning can lead to inadequate clinical results, additional re-bonding, as well as archwire adjustment appointments and prolonged treatment cycles. However, in the absence of any cost-effective alternative, most orthodontists continue to place braces in an artisan-like fashion, relaying primarily on their hand-to-eye coordination and clinical experience. To guarantee precision placement, two interrelated aspects must be covered: a) locating the most appropriate position for the bracket, taking into account the patient and treatment objectives, and b) once the desired position has been established, ensuring that the appliance is indeed placed in the correct spot. Outside of orthodontics, we routinely use this methodology with our car or mobile GPS devices. First, we let the unit find and present the most suitable route on the map, leading us to a specific address. Then, when the route has been accepted, the GPS guides us while driving, to make sure we reach the intended destination. Employing a similar approach, the eXceed™ system allows orthodontic care providers to accurately “drive” brackets to predefined targets on the labial crown surfaces. The process starts with the clinician submitting analog or digital impressions of the dentition to Great Lakes Orthodontics along with detailed bracket information. eXceed has an extensive library of virtual brackets and is compatible with essentially any straight-wire system. Depending on the type of service selected, patient images, panoramic X-rays, and a treatment plan may also be required. Upon submission, the orthodontist selects one of two alternatives to calculate ideal position. eXceed Rx provides a bracketing plan that is based on generally accepted placement guidelines such as MBT, Roth, or Damon. eXceed Tx, on the other hand, generates a plan where bracket positions are dictated by a posttreatment simulation, or a virtual treatment objective 52 Orthodontic practice

Adjusting bracket position in an eXceed Rx plan

Treatment simulation in an eXceed Tx plan

(VTO). Taken together, those two solutions represent the leading concepts in placement of fixed brackets. eXceed Rx focuses on the pretreatment malocclusion as the computational starting point, while eXceed Tx is all about optimizing the appliances to fit a virtual posttreatment setup. Next, eXceed generates a patient- and bracket-specific plan based on the data submitted and makes it available for review by the customer. All plans go through rigorous quality control and assurance checks, culminating in an inspection by a

certified staff orthodontist. The objective is to generate the best possible plan from the beginning and minimize the time the clinician has to spend on adjustments. In eXceed Tx, a dynamic treatment simulation is part of the bracketing plan. Occlusal harmony as well as eventual alignment can all be readily evaluated. The orthodontist utilizes the dedicated software to review, revise, or approve the plan. Software tools are available for fine-tuning bracket or tooth position on the screen. Should the necessary changes appear to be too time-consuming, revision Volume 5 Number 4

NEW Brackets. On Target

COMPUTERIZED PRECISION BRACKET PLACEMENT SOLUTION

eXceed Provides Unprecedented Accuracy Powerful software scientifically calculates the ideal position of the brackets on the teeth: • Outcomes are more predictable and consistent.

eXceed is Fast and Efficient • eXceed significantly reduces time spent placing brackets. • eXceed minimizes chair time and increases patient comfort.

eXceed Gives You Ultimate Control • Prior to tray fabrication, the file will be available for your review and approval. The user-friendly software will allow you to adjust the bracket placement giving you ultimate control. • We can use your brackets or you can select ours. eXceed is compatible with most popular bracket systems.

• Adjustment to brackets and archwires are minimized or eliminated. • Patient satisfaction is increased.

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GETTING STARTED WITH EXCEED IS EASY! Email: exceed@greatlakesortho.com Call: 1.800.828.7626

TECHNOLOGY

eXceed trays prior to shipping

notes can also be communicated, and a new plan will be posted. Once the virtual plan has been approved by the prescribing doctor, production of the delivery trays begins. To transfer the digital positioning coordinates, eXceed has developed a patented process for printing a working model with 3D silhouettes, accurately corresponding with the shape and location of the physical brackets. Next, a technician places the appliances from the officeâ&#x20AC;&#x2122;s inventory inside the printed silhouettes. Once positioned, double-layered bonding trays are then thermal-formed on a BiostarÂŽ and shipped to the doctor. Chairside, the trays can be delivered as a full arch or by quadrants. Proper isolation and saliva contamination are critical to successful tray delivery. Cheek retractors, absorbent pads, and an evacuator are highly recommended. Tooth surfaces are pumiced, rinsed, and dried with 37% phosphoric acid. A bonding agent is applied on each tooth, and the adhesive is distributed on the bracket pad. Since the bracket pads are completely devoid of any previous adhesive residue, there is no need to have them reconditioned. The trays are then seated and the brackets light-cured. Next, the trays are removed by peeling off the hard outer shell, followed by the soft inner tray. A scaler and then a 54 Orthodontic practice

Bonding the eXceed trays chairside

polishing bur are used to check bond strength and remove excess bonding material. Initial alignment wires can now be placed. The potential advantages offered by eXceed are considerable. From a clinical standpoint, computer-optimized bracket placement can provide gains in initial alignment, archwire sequencing, and expected occlusal outcome. As far as office management is concerned, bonding appointments can be made shorter and more work can be delegated to staff members, requiring minimal doctor time to review bracket positions. Treatments can become more predictable, with fewer emergency, re-bracketing, and wire-bending appointments necessary. Lastly, the ability to show the anticipated end result can be an extremely valuable tool for

patient education, case acceptance, and practice marketing. Overall, eXceed provides a muchneeded solution to one of the key issues in most orthodontic clinics. Utilizing state-ofthe-art hardware and software platforms, the system allows the orthodontist unprecedented control over the bonding process, while avoiding some of the pitfalls commonly associated with the conventional process. Computer-assisted procedures have long been seen as advantageous in other medical branches as well as in orthodontic aligner therapy. eXceed is extending this concept to the area of fixed appliances. For more information or to get started, visit www.exceed-ortho.com, or call Great Lakes Orthodontics at 1-800-828-7626. OP Volume 5 Number 4

Ali Oromchian examines some changes that can affect practices

s we welcome another new year, there are many changes and updates to employment laws across the United States that are important and relevant to your practice. 2013 saw a reduction of more than 30% in the number of labor and employment bills enacted as compared to 2012, but new legislation in 2014 provides for changes that are just as important as ever for both large and small employers. Changes to employment law this year run the gamut, spanning health care, Health Insurance Portability and Accountability Act (HIPAA), social media policy, minimum wage, and arbitration agreements.

The Patient Protection and Affordable Care Act The Patient Protection and Affordable Care Act (Affordable Care Act) includes measures meant specifically for small employers that help lower premium cost growth and increase access to affordable, high-quality health insurance. Currently, small Volume 5 Number 4

businesses (up to 50 full-time employees) pay on average 18% more than big businesses (more than 50 full-time employees) for health insurance because of administrative costs. The small business Health Care Tax Credit, offered as part of the Affordable Care Act, helps small employers afford the cost of health care coverage for their employees. The credit is designed to encourage small employers to offer health insurance coverage for the first time or maintain coverage they already have for employees. Beginning in 2014, there will be a tax credit of 50% to help offset the costs of insurance. It is available to qualified small employers of up to 50 employees that participate in the Small Business Health Options Program (SHOP). SHOP offers small employers increased purchasing power to obtain a better choice of high-quality coverage at a lower cost. To enroll, eligible employers must have an office within the service area of the SHOP and offer SHOP coverage to

all full-time employees. Enrollment for SHOP is open now. The Affordable Care Act creates incentives to promote employer wellness programs and encourage employers to promote and support healthier workplaces. Health-contingent wellness programs generally require employees to meet a specific standard related to their health to obtain a reward, such as programs rewarding employees who donâ&#x20AC;&#x2122;t use tobacco and programs rewarding employees who achieve lowered cholesterol Ali Oromchian, JD, LLM, is the founding attorney of the Dental & Medical Counsel, PC law firm and is renowned for his expertise in legal matters pertaining to dentists. Mr. Oromchian has served as a key opinion leader and legal authority in the dental industry with dental CPAs, consultants, banks, insurance brokers, and dental supplies and equipment companies. He serves as a legal consultant for numerous dental practice management firms that rely on his expertise for their clientsâ&#x20AC;&#x2122; businesses. He is also recognized as an exceptional speaker and educator who simplifies complex legal topics and has lectured extensively throughout the United States.

Orthodontic practice 55

LEGAL MATTERS

2014 employment law updates every dentist should know

LEGAL MATTERS levels. Under final rules effective January 1, 2014, the maximum reward to employers using a health-contingent wellness program will increase to 30 percent of the cost of health coverage. The maximum reward for programs designed to prevent or reduce tobacco use will be as high as 50 percent.

Health Insurance Portability and Accountability Act (HIPAA) Effective September 23, 2013, and through 2014 into the future, the new HIPAA rules are important for medical professionals to know and understand. They are part of sweeping changes made to the HIPAA Privacy and Security Rules through enactment of the Health Information Technology for Economic and Clinical Health (HITECH) Act. The new rules expand the obligations of physicians and other health care providers to protect patients’ protected health information (PHI), extend these obligations to a host of other individuals and companies who have access to PHI, and increase the penalties for violations of any of these obligations. There are several areas to focus on when implementing these changes: • Breach notification requirements — The obligation to notify patients if there is a breach of their protected health information (PHI) is expanded and clarified under the new rules. There is now a rebuttable presumption of a breach, and breaches must be reported unless, after completing a risk assessment using four factors, it is determined that there is a low probability of PHI compromise. • Disclosures to health plans — At the patient’s request, physicians and other health care providers may not disclose information about care the patient has paid for out-of-pocket to health plans, unless for treatment purposes or in the rare event the disclosure is required by law. • Marketing communications — The new rules further limit the circumstances when physicians and other health care providers may provide marketing communications to their patients in the absence of the patients’ written authorization. • Notice of Privacy Practices (NPP) — Physicians and other health care providers must amend their NPPs to reflect the changes set forth above, including those related to breach notification, disclosures to health plans, and marketing of PHI. 56 Orthodontic practice

2013 saw a reduction of more than 30% in the number of labor and employment bills enacted as compared to 2012, but new legislation in 2014 provides for changes that are just as important as ever for both large and small employers.

Social media privacy policy Legislation has been introduced or is pending in at least 36 states that governs social media and online privacy in the workplace. Ten states — Arkansas, Colorado, Illinois, Nevada, New Jersey, New Mexico, Oregon, Utah, Vermont, and Washington — enacted legislation in 2013. Fifteen states have 2014 legislation governing employee and applicant social media and online privacy — California, Florida, Georgia, Hawaii, Illinois, Iowa, Kansas, Massachusetts, Minnesota, New Hampshire, New York, North Carolina, Ohio, Rhode Island, and Wisconsin. Typical of the social media privacy legislation is new legislation in Florida, which prohibits an employer from requesting or requiring access to a social media account of an employee or prospective employee and prohibits an employer from taking retaliatory personnel action for an employee’s failure to provide access to his or her social media account. Further, it prohibits an employer from failing or refusing to hire a prospective employee who does not provide access to his or her social media account.

Arbitration agreements Several cases in the last year shed light on what rules will govern employer arbitration agreements going forward. The United States Supreme Court ruled in 2013 that arbitration agreements containing class action waivers are enforceable, even if individual arbitration is economically unfeasible, but employers must ensure the agreement contains an express waiver of class action arbitrations. The Ninth Circuit, applying California law, recently ruled that an employer cannot present an arbitration agreement on a “take it or leave it” basis when an employee submits an employment application. Recent California cases have held that an employer

must choose a reputable arbitration forum whose rules are accessible and balanced, the employer must give the arbitration terms to the employee when he signs the agreement, and the arbitration clause must be readily identifiable.

Minimum wage Laws have been enacted in many states that raise the minimum wage effective in 2014. These states include the following: • Arizona ($7.90/hour effective 1/1/2014) • California ($9.00/hour effective 7/1/2014) • Colorado ($8.00/hour effective 1/1/2014) • Connecticut ($8.70 effective 1/1/2014) • Florida ($7.93/hour effective 1/1/2014) • Missouri ($7.50/hour effective 1/1/2014) • Montana ($7.90/hour effective 1/1/2014) • New Jersey ($8.25/hour effective 1/1/2014) • New York ($8.75/hour effective 12/31/2014) • Ohio ($7.95/hour effective 1/1/2014) • Oregon ($9.10/hour effective 1/1/2014) • Rhode Island ($8.00/hour effective 1/1/2014) • Vermont ($8.73/hour effective 1/1/2014) • Washington ($9.32/hour effective 1/1/2014)

Employee handbooks With all of the changes to employment law in 2014, covering everything from health care to social media privacy and minimum wage, it is important that an employer’s employee handbook is updated to reflect these changes. To avoid mistakenly violating these and other important employment laws, we recommend using services such as HR for Health that ensure that you are compliant with all the necessary federal and state laws. OP Volume 5 Number 4

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