Orthodontic Practice US - September/October 2014 - Vol5.5. by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews

PROMOTING EXCELLENCE IN ORTHODONTICS Value of true horizontal in diagnosis and treatment planning Dr. Larry White

Are you getting the most out of your bracket Rx?

September/October 2014 – Vol 5 No 5

Orthodontics in the modern age Dr. Derek Mahony

Corporate profile Sirona

Company spotlight

Henry Schein® Orthodontics™

Practice profile Dr. David Kemp

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*Weber DJ 2nd, Koroluk LD, Phillips C, et al. Clinical effectiveness and efficiency of customized vs. conventional preadjusted bracket systems. J Clin Orthod. 2013

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 CHIEF OPERATING OFFICER | Andrea Hood Email: andreah@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

On digital orthodontics

t was the fall of 2007, and the Red Sox were making a run at their second World Series in four seasons. I was freshly graduated from my orthodontic residency at Harvard. I had left the vibrant streets of Boston for what I hoped were greener pastures, armed with my orthodontic degree and saddled with a gargantuan student loan. The rolling pastures of Lancaster, Pennsylvania, were in the literal sense greener than I had imagined. I joined a 90-year-old practice called Long Orthodontic Associates, a third-generation practice started by the grandfather of brothers Drs. Andy and Rusty Long. Dr. Eric Howard had purchased Rusty’s half of the practice, and Andy was contemplating retirement. The practice had a long and stellar reputation for sound delivery of care. Technology was standard for the day, with analog radiographs and paper charts shuttled to satellites by our devoted team. Even prior to my graduation, Eric and I envisioned a practice with 3D imaging and clinical protocols that broke away from the monotonous landscape of orthodontics in our geography; the practices were reputable, and no single practice really stood out clinically or otherwise. One day, Eric suggested suresmile®. I had seen the wire-bending robot at the AAO in Denver, and I repeated a version of the same erroneous sound bite I still sometimes hear: “It’s an expensive way to just bend wires.” About 1 year later, after much due diligence, an office remodel, digital charting, and a CBCT purchase, we took a leap of faith that a digital clinical management system would provide exactly the differentiating force we needed to grow our practice while enhancing patient care. When I look at the difference between our practice today and in 2009, I have to smile as they bear little resemblance to one another. Rather than four doctors working a total of 12 doctor days per week, we have three doctors working a total of 7 days with a 60% increase in revenue. Over the course of our experience as a digital practice, average treatment time has dropped by nearly 7 months with demonstrably better clinical results. Planning and communication on surgical and restorative cases have taken a giant step forward. With the use of CBCT and suresmile, we can visualize root position, model alveolar bone, and assess the TMJ and airway in ways we never imagined. Our in-house lab has transformed from a dusty den of plaster to a symphony of .stl files, 3D printed models, and robotically designed archwires. From our digital platform, we can adeptly handle labial and lingual treatment as well as aligners in any combination. Most notably, with each doctor on faculty at Penn, Harvard, and Pitt (Dr. Tim Snyder) respectively, our teaching materials are replete with images that tell poignant diagnostic and therapeutic stories to the residents. As with advances in any medical field, once we summon the courage to take a step forward, it becomes hard to imagine practicing any other way. I would encourage any practitioner to take a look at all of the digital clinical management systems on the marketplace and begin to transform your practices to keep in step with the inevitable marriage of technology and healthcare. It truly is better medicine. Dr. Manish Lamichane

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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 5

Manish Lamichane, DDS, MMSc, received his DDS from the University of Toronto with induction into Omicron Kappa Upsilon, completing his General Practice Residency at Harvard Medical School teaching affiliates Brigham and Women’s Hospital/Massachusetts General hospitals. After 5 years of private practice dentistry, Dr. Lamichane received his Masters in Medical Science in Orthodontics at the Harvard School of Dental Medicine where he is currently a lecturer. He co-owns two orthodontic practices in Pennsylvania and has spoken on the topic of 3D digital orthodontics nationally. Together with Dr. Eric Howard, they have over 400 suresmile finishes and over 300 suresmile cases in treatment.

Orthodontic practice 1

INTRODUCTION

September/October 2014 - Volume 5 Number 5

TABLE OF CONTENTS

Company spotlight

Henry Schein® Orthodontics™

Practice profile

Dr. David Kemp Kemp Orthodontics — creating beautiful smiles

Leading the orthodontic sleep apnea movement.......................................16

Clinical

A new table to guide bracket placement based on the concept of “smile arc protection” Drs. Tomás Castellanos and Thomas Pitts introduce a new table to guide vertical placement of brackets based on the effect upon the smile arc ....................................................... 19

Orthodontic concepts BioDigital Orthodontics Management of patients with Class 3 malocclusion: part 11

Drs. Rohit C.L. Sachdeva and Takao Kubota discuss the clinical management of class 3 malocclusion with SureSmile® ..............................28

Corporate profile Sirona

Sirona continues to develop innovative products shaping the future of dentistry ON THE COVER Cover photo courtesy of Planmeca. Article begins on page 64.

2 Orthodontic practice

Volume 5 Number 5

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 the latest techniques in Clinical Orthodontics. 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 Curtin Jon Acuff

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

We look forward to seeing you in California!

Visit www.mygcare.com/owc2015

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

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

TABLE OF CONTENTS Product spotlight

Ortho2’s Edge ...................................................... 49

Technology

Continuing education Value of true horizontal in diagnosis and treatment planning

Dr. Larry White evaluates malocclusions via the natural head postures of patients

3D CBCT imaging technology eliminates surprises, cultivates efficiency Wes Newsom, Director of Product Line Management for LED Dental, discusses the company’s launch into the dental imaging product category ...................................................... 50

Step-by-step

Accurate Bracket Positioner™ (ABP) Drs. Pablo Echarri, Martín Pedernera, and Claus Schendell, Eng, outline the steps to accurate bracket setup without setup models......................52 Ormco™ Custom: Scan, Design, Build, Bond A complete digital treatment solution .......................................................56

Product profile

CS 9300C This all-in-one system offers orthodontists multiple options for extraoral exams...............................58

Orthodontics in the modern age

Dr. Derek Mahony discusses the use of bracket modification in orthodontics for the 21st century

Sensation™ M An active self-ligating bracket offering the perfect mix of efficiency and control ...................................................... 60 iFinisher™ Aligner case finishing simplified By TP Orthodontics, Inc................. 62 Planmeca ProMax® 3D Ultra Low Dose™ protocol.............64

4 Orthodontic practice

Volume 5 Number 5

Not just different. Better. Introducing an innovative way to treat the most common misalignments. Not all anterior misalignment cases are alike. That’s why DENTSPLY developed MTM ® Clear•Aligner Service Center, a turnkey lab-based solution for treating the “Social Six”. With flat fee pricing and an unlimited number of aligners, MTM ® Clear•Aligner is the easy and affordable way to treat your adult patients. Using “force points” and a unique “open pathway” architecture, MTM ® Clear•Aligner moves teeth more easily into their desired positions, without the use of unsightly attachments. Whether you’re making cosmetic improvements, treating relapse or finishing/refining other orthodontic treatments, MTM ® Clear•Aligner can help you reach your goals in as little as three to six months.1 Call 1.888.898.4mtm(4686) to learn more about MTM ® Clear•Aligner.

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1. Data on file. 2. Initial treatment plan and first refinement, if needed.

PRACTICE PROFILE

Dr. David Kemp Kemp Orthodontics — creating beautiful smiles What can you tell us about your background? I grew up in a small town in Tennessee. After my parents divorced, we moved to an even smaller and more rural town in Tennessee where we lived for a couple of years with my grandparents. I attended a small, churchrelated college, Martin Methodist College, in Pulaski, Tennessee, where I met my wife, Rhonda. The summer before I started dental school, I worked for the Job Service Corp of Tennessee. This job was an excellent experience for me. My role was to connect rural farmers who needed labor with local workers to help them harvest their crops. I traveled all over Jackson County, Tennessee, to find willing laborers to work for these farmers. This process gave me a realistic look at many of life’s situations, and I am very thankful for this experience. I graduated college from the University of Tennessee at Martin, Tennessee, in 1980. I graduated dental school from the University of Tennessee Center for Health Sciences in Memphis in 1984. I then attended the University of Tennessee Orthodontic residency program and graduated in 1986. I opened my two orthodontic offices in Franklin and Brentwood, Tennessee, in July 1986. Rhonda and I have one son, Giorgio, who is in training at Vanderbilt to be a master yoga instructor. We live in a 200-year-old farmhouse on a 120-acre farm, growing hay and trees in Williamson County, Tennessee.

When did you become a specialist and why? I became an orthodontic specialist in 1986 after graduating from the University of Tennessee Center for Health Sciences at Memphis orthodontic residency program. I became a specialist because of a compassionate act to my family, which I will discuss in a later question. 6 Orthodontic practice

Kemp Orthodontics’ treatment area

Is your practice limited solely to orthodontics, or do you practice other types of dentistry? When I opened my practice in 1986, I limited my practice solely to orthodontics. We are in the job of creating beautiful smiles through esthetic orthodontic treatment.

Why did you decide to focus on orthodontics? Ironically, I am an orthodontist because of a compassionate action by another orthodontist. When I was in the seventh grade, I was able to get braces only because an orthodontist saw there was a financial need in our family and helped us. I am indebted to this orthodontist to this day for seeing a family in need and putting forth the effort to help our family. This act of kindness impressed me so much that my path was set — go to college, get in to dental school, and become an orthodontist. I am delighted to have the greatest job in the world. My job is much more than braces and creating beautiful smiles. It is all about relationships and how you develop those relationships through changing people’s lives.

Do your patients come through referrals? Our new patients come primarily from three top sources: 1. 49% are patient referrals. Our goal is to make Raving Fans of our patients through creating “Memorable Moments.” This process has helped our office dramatically increase our patient referrals. 2. 28% are Internet referrals. This source is definitely on the rise. A growing percentage of patients use the Internet to find their practitioners. We, as orthodontists, must strive to understand this medium in the future. These patients literally have interviewed you online before they even come into your office. These patients are ready to start treatment with you because they know who you are and what your reputation is. 3. 23% are dental referrals. We are so thankful for the excellent dental clinicians with whom we work to provide excellent care for their patients. I love our dental sources who understand and support what we are trying to do at Kemp Orthodontics. Volume 5 Number 5

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PRACTICE PROFILE

The pie chart above indicates our three top sources of new patients: We are very fortunate to be able to appeal to all three demographic areas as shown in the bottom chart

How long have you been practicing orthodontics, and what systems do you use? I opened my Franklin and Brentwood orthodontic practices in July 1986 and have been practicing as an orthodontist for 28 years. While in dental school, I had orthognathic surgery performed by the orthodontic and oral surgery residents. The orthodontic residency program placed bands on every tooth for this phase of treatment. This was now the second time I had orthodontics with full bands. My mind was set that I would strive to find an esthetic appliance system for my patients. This mindset would spill over into my next 28 years of practicing orthodontics. I have always chosen esthetic appliances for my patients. After the Great Recession of 2007, I continued to push toward the esthetic side of orthodontics for a number of reasons. In 2010, while many orthodontists were seeing their practices decline, I found my second youth. I made a decision to use 100% ceramic upper and lower Ultra Esthetic System appliances. After much research to find the ultimate esthetic bracket system, my quest led me to 3M’s Clarity™ ADVANCED brackets as the best esthetic bracket available. I have incorporated esthetic wires and auxiliaries that make our system of treating our patients exceptional. We are giving the market what it wants by embracing the esthetic mega trend. In 2012, $11 billion was spent on cosmetic procedures in the United States. As orthodontists, we must recognize the competitive market we are in. I want to continue to be the Esthetic Orthodontist in 8 Orthodontic practice

my region through what I call “esthetic differentiation.” As orthodontists, we are missing the esthetic mega trend considering 95% of brackets sold in the United States were metal in 2013. I especially am fond of using the esthetically efficient Forsus™ Class II Corrector – it’s an appliance that is easy to use, predictable, and is comfortable for the patient.

Kemp Orthodontics’ percentage of appliance usage

What training have you undertaken? I have always felt that continuing education is vital to learning better ways of doing your job. I strive to attend 100% more continuing education than required by the regulating board. It is vital to the success of your organization to empower your team through these educational courses as well. I have always enjoyed teaching and am very excited about being a 3M Unitek advocate. My lecture schedule involves traveling throughout the world and doing my in-office courses on: The New Game – Connecting the Dots Keys to A Healthy Practice

Building Your Practice On Marketing – Consultations – Efficiency I always enjoy learning new things and am always amazed at how much I learn when I am able to get to know these incredible orthodontists through teaching. I am very fortunate to have this opportunity.

Who has inspired you? Rhonda Kemp. My wife has inspired me and has helped give me the opportunity to become who I am — she is my greatest fan. Rhonda’s production management company works overtime to give me full access to my patients, colleagues, and community. She makes me look good. Winston Churchill. Winston Churchill was so much more than just a brilliant statesman who led England and the Allies to victory in World War II. Churchill was a man of words and a man of his word. Robert Draper. My grandfather was a man of his word as well. When my parents divorced, my grandparents took us into their tiny home, and my grandfather took on the role of raising me. He only had a sixth-grade education; however, he was a man of integrity, ethics, morals, and uncommon wisdom. I am forever grateful to him for instilling these values into my life. My team. I am inspired by my team through their dedication to do their job right consistently on the first time. They continue to challenge me to be better at what I do.

What is the most satisfying aspect of your practice? The most satisfying aspect of my practice by far happens on Thursday mornings when we throw a party with our patients to celebrate and unveil 15 to 20 beautiful smiles as we remove their braces. I most appreciate the time I spend with parents and patients going back in time to see where they started Volume 5 Number 5

PRACTICE PROFILE and what value we have created in their lives through orthodontics — many times there are happy tears. We always take photos together and post them on our website and Facebook page. This time is always special and at that moment, without exception, I rediscover how blessed I am to be doing what I do.

Professionally, what are you most proud of? There are endless milestones I am proud of throughout my career, but there is one story, however, I am most proud of. Tiffany was a sophomore in college, and because of the appearance of her teeth, she made a decision to go to a local dentist with money in hand to have all her teeth removed for denture placement. I am thankful her dentist recognized the situation Tiffany was in financially and reached out to our Philanthropic Seattle Study Club for help. I was able to treat Tiffany in 16 months in preparation for upper veneer restorative treatment. I was very honored to be able to help change a young lady’s life. Editors note: To read all of Tiffany’s story, please see the “Banding Together” column in the November/December 2014 issue of Orthodontic Practice US.

Kemp Orthodontics’ new patient consultation room

What do you think is unique about your practice? Our practice has always strived to be unique in a positive way. First of all, in order to appeal to the market, you have to understand the market. Our office has conducted patient surveys over the past 10 years. Our results provided us tremendous insight from our patients on how we can be unique in their minds. Our office survey found four top areas that our patients highly desire. The four areas are: 1. They highly desire esthetics. We incorporated into our brand in 2010 our goal to become the Esthetic Orthodontic Practice in our region. We have developed a very unique ultra esthetic bracket system. 3M Unitek Clarity ADVANCED bracket is at the core of our esthetic system. We also are stepping outside the box to help celebrities and others who have difficult scheduling requirements and often do not have the time to commit to traditional orthodontic treatment. We are doing what I call Hybrid Orthodontic Treatment in those cases and are able to give the market what it wants. 2. They want fast treatment. We are using many efficient techniques to make this 10 Orthodontic practice

Kemp Orthodontics’ reception desk

happen from what has been a “normal” treatment time. You must get the braces on accurately if you want to have any chance to have speedy treatment. Indirect bonding gives us this accuracy. We use progressive tandem wire sequencing to be able to deliver low forces continuously. This produces quicker unraveling and leveling so we can get to rectangular wires faster. We also use 3M Unitek Forsus Class II correctors so we can be predictable and promote faster Class II correction. We also are using Variable Prescription Orthodontics (VPO). This treatment technique is giving us an opportunity from the beginning of treatment to move teeth the right way faster. 3. They want great results. All the marketing in the world will not take the place of poor results. Orthodontics is an

Kemp Orthodontics’ infection control area

art and a science. We have to use our artistic abilities to create beautiful smiles. 4. They want to be wowed. We wow our patients through memorable moments we provide. Our office has become very unique by understanding what the market wants and in turn giving the market what it wants. Volume 5 Number 5

Expand

Your Possibilities Open and Trusted Connections The 3M True Definition Scanner gives you unparalleled accuracy, flexibility, ease of use and control. You choose how you want to practice digital dentistry. • Send scans to your existing lab. • Share open STL files with any system that accepts this industry-standard file format. • Expand your possibilities via Trusted Connections with leading chairside mills, digital implant workflows and orthodontic appliances. TM

3M and 3M ESPE are trademarks of 3M or 3M Deutschland GmbH. Incognito and Unitek are trademarks of 3M. Used under license in Canada. Other trademarks are property of their respective holders. ©3M 2014. All Rights Reserved.

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PRACTICE PROFILE What has been your biggest challenge? Time management. I sometimes overestimate what I can get done in a 24-hour period of time. That’s why I recognize I am blessed to have a fantastic team that keeps me on schedule.

What would you have become if you had not become a dentist? There was never, nor will there ever be, another option for me other than being an orthodontist.

What is the future of orthodontics and dentistry? The future of orthodontics and dentistry has been changing rapidly since the Great Recession of 2007. The business and the science have changed our game, and we all have to learn how to play this new game. I think the future of orthodontics and dentistry is extremely bright as long as we follow the advice of Jack Nicklaus: “Achievement is largely the product of steadily raising one’s levels of aspiration and expectations.”

market and then give the market what it wants. I would highly suggest you consider becoming the Esthetic Orthodontist in your community through esthetic differentiation. Be sure to read and apply the message in The Go-Giver by Bob Burg and John David Mann: “Your true worth is determined by how much more you give in value than you take in payment.” I would love for you to come see my practice at a future in-office course. Please email me at david@kemportho.com, or call my office at 615-790-7027. Be sure to check out our patient testimonial videos on our website: www.kemportho.com

Third hole of the Pacifico Jack Nicklaus golf course in Punta Mita, Mexico (The Tail of the Whale hole. The only natural island green in the world.)

What are your hobbies, and what do you do in your spare time? I am an avid golfer, and I love to play at new courses with incredible views — especially the golf courses in Mexico. My wife and I enjoy traveling to Whistler, Canada, to ski and snowboard. Rhonda and I love to travel and admire the nature in new destinations. One of our most favorite things to do is to stop and smell the roses while watching beautiful sunrises and sunsets. OP

In Whistler, Canada, at the top of Whistler Mountain

What are your top tips for maintaining a successful specialty practice? My top tip is to keep a hunger for knowledge, knowledge of clinical advances, technological improvements, time management skills, and leadership skills. For me, it was recognizing that to be leader, manager, and clinician of my practice is not at 33% each, but at 100% each and completely in balance. Then I have to lead my team through training and empower them to raise their standards with me. I continually strive to improve my systems to better my team and community. I have to provide a nurturing, positive environment to my team. My goal is to build an exceptional reputation in my community. My final tip is to enjoy quality of life. My goal is to achieve success, happiness, and balance.

What advice would you give to budding orthodontists? My advice would be first to determine and specify the goals you desire for yourself personally and professionally. Look at systems you have in place in both of these areas, and determine areas you need to make changes that are not achieving your goals. To be able to produce a healthy practice, the three areas you have to look at perfecting on a professional level are marketing, consultations, and efficiency. One of the most important decisions you may ever make is to understand the 12 Orthodontic practice

Top 10 Favorites 1. My adorable wife, Rhonda, who is my best friend and my awesome son, Giorgio. 2. I thoroughly enjoy creating enormous Esthetic Differentiation and branding myself as the region’s “Ultra Esthetic Orthodontist” by marketing my conventional, easy-to-use Clarity™ ADVANCED twin bracket and Forsus™ Correctors from 3M Unitek. 3. I also thoroughly enjoy creating enormous Esthetic Differentiation and branding myself as the region’s “Ultra Esthetic Orthodontist” without having to use the following: • Complex, expensive, or time-consuming technology, such as lingual braces (0% of starts) • Much clear aligner therapy (2% of starts) except in limited and strategic situations, such as Hybrid Orthodontic Therapy System (HOTS), to take advantage of the manufacturer’s investment in advertising and to capture patients who might not otherwise accept treatment. 4. I am very honored and delighted to be speaking as an advocate for 3M Unitek. Email me for a list of upcoming speaking events and locations: david@kemportho.com. I am thankful to be helping orthodontists achieve their goals by providing them with Three Keys to a Healthy Practice: Marketing, Consultations, and Efficiency. These three areas, if done well, can move us to a whole new level and help us achieve success through profitability. 5. Being able to wake up every day to know I will have an opportunity to change people’s lives in a positive way. 6. I just love our indirect bonding placement technique and our 0.5% bond failure rate. This system helps me to achieve my goals of creating beautiful smiles efficiently and in a shorter amount of time for my patients since the brackets are placed accurately, and ceramics stay on the teeth unbelievably well. 7. Dolphin Imaging & Management Solutions and Dolphin’s Aquarium™ software. 8. Instrumentarium dental digital panoramic and cephalometric units. 9. Traveling with my wife, playing awesome golf courses, and enjoying incredible sunrises and sunsets with her. 10. My incredible Kemp Orthodontics Team — they are “the bomb!” I am amazed to see my team excel after being empowered. If you would like to find out more about my in-office course and dates please go to this link: http://3MUnitek.cvent.com/KempOrtho

Volume 5 Number 5

CORPORATE PROFILE

Sirona Sirona continues to develop innovative products shaping the future of dentistry

or over 130 years, Sirona has consistently spearheaded technological developments in dentistry beginning with the invention of the first electrically powered dental drill in 1887. As the world’s largest manufacturer of dental technology, Sirona develops, manufactures, and markets a complete line of dental products that drive improved workflow, a better patient experience, and ultimately, increase the success of dentists who incorporate Sirona technology within their practices. Through Sirona’s robust product offering of CAD/CAM restoration systems (CEREC), digital intraoral, panoramic, and 3D imaging systems, dental treatment centers, handpieces and hygiene systems, the company provides innovative solutions for dental practices, clinics, and laboratories.

Sirona executive team (left to right): Walter Petersohn, Executive VP of sales; Rainer Berthan, Executive VP; Jeffrey T. Slovin, President and CEO; Ulrich Michel, Executive VP and CFO

Comprehensive 3D imaging In all dental disciplines, including implantology, endodontics, and orthodontics, there are numerous questions that can be answered far more easily using 3D CBCT X-ray. Sirona offers several 3D options that provide superior digital image quality at a low dose of radiation, making for an efficient workflow and more concise communication with patients.

Sirona production site in Bensheim, Germany

GALILEOS® As the first 3D imaging solution developed by Sirona, GALILEOS combines X-ray diagnostics, implant visualization, treatment planning, and patient communication in one tool. GALILEOS® Comfort Plus, the highend CBCT unit with HD mode, includes a large field-of-view and integrated FaceScan technology. ORTHOPHOS® XG 3D — a hybrid approach ORTHOPHOS XG 3D combines the advantages of 2D and 3D into one comprehensive unit. With an extensive selection of panoramic and cephalometric programs to choose from, the right 2D diagnostic images are now augmented with the ability to capture 3D X-ray. Volume 5 Number 5

Sirona Center of Innovation in Bensheim, Germany Orthodontic practice 13

CORPORATE PROFILE The history of Sirona Sirona, the dental technology and innovation leader, has served equipment dealers and dentists worldwide for more than 130 years. The company develops, manufactures, and markets a complete line of dental products, including CAD/CAM restoration systems (CEREC); digital intraoral, panoramic, and 3D imaging systems; dental treatment centers, and handpieces. Sirona employs a workforce of more than 3,200 at 28 locations worldwide, and markets its products in over 135 countries on all continents. The United States is Sirona’s largest single market, followed by Germany, Western Europe, and Asia. The company was spun-off from the Siemens Medical Technology Division in 1997, and since 2006, has been listed on the U.S. NASDAQ stock exchange (symbol: SIRO). In the last fiscal year (October 1, 2012, to September 30, 2013), Sirona reported revenues of $1.1 billion. Sirona develops and manufactures the majority of its products in Bensheim, Germany, the largest research, development, and production location in the dental industry. The company currently employs more than 290 scientists and, over the past seven years, has invested more than $350 million in R&D.

GALILEOS® Comfort Plus

Precise orthodontic procedures Through ORTHOPHOS XG 3D with ASTRA software, orthodontists will enjoy the ability to achieve a faster clinical workflow with ortho template and quick shot mode. The ASTRA software provides unprecedented image clarity for 2D images and automatic positioning for 2D pan. With Sirona’s technology, orthodontists can now have clarity on all elements that may affect orthodontic procedures, including displaced, impacted teeth; a cephalometric analysis; root resorptions; cleft lips; and full jaw and palate visualization.

Patented integrated technology The practice of implantology is quickly spreading throughout dentistry. Sirona 14 Orthodontic practice

GALILEOS provides true motion in cone beam with the SICAT Function software solution

pioneered guided implantology through the integration of 3D X-ray and CAD/CAM technology. GALILEOS CEREC INTEGRATION (GCI) gives the clinician complete control over the entire implant process, starting with the planning and ending with the manufacture of highly accurate abutments and crowns. For years, clinicians have benefited from the comprehensive 3D digital diagnostic and treatment solutions provided by GALILEOS CBCT. The single, 14-second scan transforms a traditional dental office into a center capable of fast, efficient, and accurate implant placements. The increased visualization changes the patient-clinician

conversation, proving better treatment acceptance, more informed diagnoses, and efficient treatment planning. With the integration of CEREC for the design and fabrication of the implant abutment and esthetic crown, you can be confident that your treatment plan workflow — as well as the entire process from patient presentation to final restoration placement — is completed smoothly and without complications. As the name suggests, GCI is all about the seamless collaboration and data sharing of systems and processes within the dental procedure. GCI allows simultaneous Volume 5 Number 5

GCI’s step-by-step workflow To envision the GCI workflow from start to finish, consider the following steps: 1. During the first patient visit, an optical impression of the bite is taken with CEREC, and the prosthetic restoration is planned using the CEREC software. 2. The GALILEOS 3D scan begins diagnoses of the bone structure and integration of the prosthetic recommendation into the X-ray volume. The implant is planned simultaneously according to the surgical and prosthetic conditions. 3. Next, the surgical guide is ordered in the software, and the planning data is transmitted to SICAT (in the case of the SICAT OPTIGUIDE process). 4. During the second patient visit, the implant is placed using the surgical guide. In the case of immediate loading, it is restored directly with a CEREC temporary prosthesis. If necessary, patient-specific, customized abutments with CEREC can be created and incorporated in this session. 5. With immediately loaded implants, the temporary prosthesis is replaced by the final prosthesis, and the case is completed. With traditionally placed implants — after completion of the healing phase — the implant is provided with a temporary or final prosthesis (with CEREC) in this session. The benefits of GCI include faster and more reliable treatment with fewer complications resulting in higher patient satisfaction with the final outcome. With GCI, the doctor is in complete control of all surgical and prosthetic parameters every step of the way.

Shaping the future through motion For the first time, GALILEOS provides true motion in cone beam with SICAT Function. SICAT Function is a revolutionary software solution with an integrated 3D workflow. With GALILEOS and SICAT Function, the doctor can use the patient’s 3D Cone Beam scan with his/her actual recorded jaw motion. This allows for the visualization and a movementoriented treatment plan. The recorded jaw movement can be visualized and reproduced at any location in the dentition or mandible. With SICAT Function, in-depth patient information is at your fingertips. You’re now provided with an understanding of the condyle-fossa relationship during jaw Volume 5 Number 5

Sirona means solutions for dental practices, clinics, and laboratories. It is all part of our goal of constantly striving to find new ways of making the best much better and providing customers with the ultimate in dental products and services.

The recorded jaw movement with SICAT Function can be visualized and reproduced at any location in the dentition or mandible

movement, anatomically correct trajectory, visualization of the specific positioning of the trajectory in 3D, as well as a comparison to conventionally used axial points and the ability to evaluate the occlusion based on the integrated optical surface scans. Continuing investment in research and development (R&D) ensures that Sirona remains the industry leader in dental innovation and quality applications. At Sirona, the focus is on continuous improvement, supported by one of the largest R&D organizations, and providing customers with the ultimate in dental products and services, now and well into the future.

The Sirona vision Sirona believes in providing dental practitioners with the tools they need to put and keep them ahead. From optimizing treatment workflow and patient communication, to creating modern practice management platforms, the company is constantly working to meet and exceed the expectations of its customers. Equally important is Sirona’s commitment in the field of innovation. In the future, digital networking will play a fundamental role in dental practices, clinics, and laboratories — influencing everything from treatment

to patient management. That is why great emphasis is placed on the research and development of digital, network-capable dental technology. It is just one more way in which Sirona is helping to build a stronger dental community prepared for all future challenges. Individuality is also a vital part of our company philosophy. Different markets have different needs, which is why Sirona products are manufactured with features and functions tailor-made to suit their requirements. In offering dental practices, clinics, and laboratories a wide spectrum of individual solutions, Sirona not only makes work more effective but boost earnings as well. Consulting is another essential component of this service, and Sirona works closely with dental dealers throughout the world, providing extensive support in marketing and sales promotions. To sum it all up — Sirona means solutions for dental practices, clinics, and laboratories. It is all part of our goal of constantly striving to find new ways of making the best much better and providing customers with the ultimate in dental products and services. For more information on Sirona, visit www.sirona.com, or call 800-659-5977. OP This information was provided by Sirona.

Orthodontic practice 15

CORPORATE PROFILE

assessment of both the prosthetic and surgical situation, as well as both processes to be fully controlled and accomplished in the dental practice.

COMPANY SPOTLIGHT

Henry Schein® Orthodontics™ Leading the orthodontic sleep apnea movement

How It All Began Nearly two years ago, Henry Schein® Orthodontics™ set out on a mission to understand a significant unmet healthcare need of Obstructive Sleep Apnea (OSA). We proposed the hypothesis that changes to the craniofacial structure surrounding the upper airway could have a positive and lasting impact on sleep apnea, and through our team efforts, we designed an orthodontic strategy that expands the scope of the orthodontic specialty practice (Figure 1). With proper screening, testing, diagnosis, and orthodontic treatment options, orthodontists are helping patients to breath, smile, and thrive again.

Understanding Obstructive Sleep Apnea (OSA) We discovered that OSA is emerging as one of the most widespread and costly health issues in the United States and is known to affect more than eighteen million Americans, including men, women, and children — 85% of whom are undiagnosed.1,2 The disease is characterized by upper airway obstruction, with repeated gaps in breathing and interrupted sleep. People with OSA are at serious risk of medical problems such as stroke,3 heart attack,4 obesity,5 diabetes,6 and motor vehicle accidents.7 Studies show that OSA can be hereditary2, that up to 10% of children have sleep apnea, and that children with sleep breathing disorders can suffer from behavioral problems and lower IQ scores.11 Standard OSA testing and treatment options can deter some patients from being diagnosed and then treated. For example, the continuous positive airway pressure (CPAP) unit is the gold standard for OSA treatment; however, up to 70% of patients are noncompliant or find the machine too uncomfortable to use. For these patients, an alternate OSA solution is needed.

OSA Advisory Team In alignment with one of Henry Schein’s core values, “Doing Well by Doing Good,” we gathered a small group of experienced orthodontists from various backgrounds related 16 Orthodontic practice

Figure 1

to sleep apnea. Together, we formed the very first Orthodontic Sleep Apnea Clinical Advisory Team, committed to making a totalhealth difference in the lives of patients. We know that orthodontists are uniquely trained to identify and treat craniofacial abnormalities and guide the growth of the craniofacial complex. So, as a team, we asked an important question — Are there potential orthodontic solutions to OSA and sleep breathing disorders that: 1. Enable orthodontists to screen for OSA and breathing problems? 2. Offer easier routes to diagnosis? 3. Provide less invasive and more durable results? It became clear early in this venture that an estimated 50% of sleep apnea cases involve the bony structure and/or soft tissues around the airway, and by modifying this structure by slow or rapid maxillary expansion (RME/SME),8,9,10 combined orthodontics with mandibular advancement (MA, Figure 2),12,13 or maxillomandibular advancement (MMA),14,15 the orthodontist may be able to address an underlying cause of the condition. With the right information and tools, the orthodontist is ideally positioned to identify, treat, and prevent OSA in

Figure 2

children and, perhaps, reverse the condition in adolescents and adults.

Together, we created the following mission statement:

To identify and develop the products and protocols that enable orthodontists to improve the lives of people who suffer from Obstructive Sleep Apnea. Our goal is to provide an easier, more efficient route to diagnosis, and treatment of symptoms that yield positive airway changes with more durable results. The Orthodontic Sleep Apnea approach will be a complete system, Volume 5 Number 5

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COMPANY SPOTLIGHT

Figure 3

(Figure 3) intended to establish a new standard of care and an expanded healthcare role for the orthodontist.

Why Orthodontists and Obstructive Sleep Apnea? Orthodontists already see a large number of people with airway problems and have been trained in facial growth, development, and airway. Screening patients of all ages provides a more holistic, total-health approach to patient examinations, and opens the door to treat patients and decrease or alleviate symptoms and co-morbidities related to sleep apnea. In addition, orthodontists are well-equipped and trained to provide a solution to many CPAP intolerant patients, who are left without options, when they are not wearing their breathing device. In 2012, the American Academy of Pediatrics stated that all children should be evaluated for snoring and sleep breathing disorders. OSA-trained orthodontists are singularly positioned to screen and treat children at a very early age, during their first orthodontic visit.

Orthodontic Strategies for Obstructive Sleep Apnea Henry Schein Orthodontics, in partnership with the Orthodontic Sleep Apnea Clinical Advisory Team, developed the first-of-its-kind program in the orthodontic industry, including a complete, evidencebased system. Drs. Lou Chmura and David Paquette are the program instructors; both have their own personal stories to share about sleep apnea. This program provides doctors with an understanding of sleep, sleep disordered breathing, and current diagnostic and treatment options, and a new orthodontic approach supported by protocols and products. The orthodontic approach is intended to provide patients with immediate relief from 18 Orthodontic practice

OSA, as well as changes to the airway that may address an underlying cause. We demonstrate innovative technologies and convenient, cost-effective processes to improve the diagnostic and treatment experience for patients of all ages. We also offer a robust practice integration program to help doctors get started. During the program, attendees learn: • The physiology of snoring and sleep disordered breathing • Clinical signs and screening methods for identifying Obstructive Sleep Apnea • Obstructive Sleep Apnea diagnostic and airway evaluation choices, including patient-friendly home sleep testing and cone beam technology • How the orthodontic strategy differs from conventional treatment options • The roles of mandibular positioning, maxillary arch development, and maxillomandibular advancement in airway management and patient treatment (Figure 4) • How to partner with healthcare professionals for diagnosis, comprehensive care, and new referral sources

• How to bill medical insurance for sleep apnea treatment • Effective patient awareness, education, and practice marketing resources We use training methods such as lecture, video, interactive group discussion, and hands-on exercises with FDA-cleared sleep apnea oral appliances and home sleep testing therapy.

Figure 4

This information was provided by Henry Schein® Orthodontics.™

Moving Forward To date, we have hosted nine Orthodontic Strategies for Sleep Apnea courses across the country and are honored to have received overwhelming positive reviews and encouragement from the specialist community. We are inspired by the industry’s enthusiastic response to making a difference in the well-being of sleep apnea patients, and will continue developing our program and support as we identify new trends, technologies, and products. Our goal is to help patients Breathe, Smile, and Thrive™ — our program motto! We believe that orthodontists should play a central role in the screening, testing, and treatment of sleep apnea patients. If we increase sleep apnea awareness, work with the medical community to ensure proper diagnosis, and provide patients with the highest standard of sleep apnea care, our mission will be accomplished. We encourage every orthodontist to join the orthodontic sleep apnea movement and make a profound difference in the lives of their patients and community. Come join the mission. OP

REFERENCES 1. National Sleep Foundation. 2002 “Sleep in America” Poll. http://sleepfoundation.org/sites/default/files/2002SleepInAmericaPoll. pdf. Accessed August 8, 2014. 2. Casale M, Pappacena M, Rinaldi V, Bressi F, Baptista P, Salvinelli F. Obstructive sleep apnea syndrome: from phenotype to genetic basis. Curr Genomics. 2009;10(2):119–126. 3. National Institutes of Health. Sleep Apnea Tied to Increased Risk of Stroke. NIH News. 2010. http://www.nih.gov/news/health/ apr2010/nhlbi-08.htm. Accessed August 8, 2014. 4. Shahrokh-Javaheri MD. Basics of Sleep Apnea and Heart Failure. Sleep Apnea and CV Disease, A CardioSource Clinical Community. 2013. http://apnea.cardiosource.org/Basics/2013/02/Basics-of-Sleep-Apnea-and-Heart-Failure.aspx. Accessed August 8, 2014. 5. Fritscher LG, Mottin CC, Canani S, Chatkin JM. Obesity and obstructive sleep apnea-hypopnea syndrome: the impact of bariatric surgery. Obes Surg. 2007;17(1):95-99. 6. Brooks B, Cistulli PA, Borkman M, Ross G, McGhee S, Grunstein RR, Sullivan CE, Yue DK. Obstructive sleep apnea in obese noninsulin-dependent diabetic patients: effect of continuous positive airway pressure treatment on insulin responsiveness. J Clin Endocrinol Metab. 1994;79(6):1681-1685. 7. Findley LJ, Unverzagt ME, Suratt PM. Automobile accidents involving patients with obstructive sleep apnea. Am Rev Respir Dis. 1988;138(2):337-340. 8. Pirelli P, Saponara M, Guilleminault C. Rapid maxillary expansion in children with obstructive sleep apnea syndrome. Sleep. 2004;27(4):761-766. 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. Cistulli PA, Palmisano RG, Poole MD. Treatment of obstructive sleep apnea syndrome by rapid maxillary expansion. Sleep. 1998;21(8):831-835. 11. Johns Hopkins Medicine. Childhood Sleep Apnea Linked to Brain Damage, Lower IQ. http://www.hopkinsmedicine.org/press_ releases/2006/08_21_06.html. Accessed August 8, 2014. 12. Kushida CA, Morgenthaler TI, Littner MR, Alessi CA, Bailey D, Coleman J Jr, Friedman L, Hirshkowitz M, Kapen S, Kramer M, Lee-Chiong T, Owens J, Pancer JP. Practice parameters for the treatment of snoring and Obstructive Sleep Apnea with oral appliances: an update for 2005. Sleep. 2006;9(2):240-243. 13. Ferguson KA1, Cartwright R, Rogers R, Schmidt-Nowara W. Oral appliances for snoring and obstructive sleep apnea: a review. Sleep. 2006;29(2):244-262. 14. Holty JE, Guilleminault C. Surgical options for the treatment of obstructive sleep apnea. Med Clin North Am. 2010;94(3):479-515. 15. Lye KW, Waite PD, Meara D, Wang D. Quality of life evaluation of maxillomandibular advancement surgery for treatment of obstructive sleep apnea. J Oral Maxillofac Surg. 2008;66(5):968-972.

Volume 5 Number 5

Drs. Tomás Castellanos and Thomas Pitts introduce a new table to guide vertical placement of brackets based on the effect upon the smile arc Summary

Background/objective: The correct placement of brackets is essential not only for functional but for esthetic smile success of the treatment. The objective of this paper is to introduce a new table to guide vertical placement of brackets, based on the effect upon the smile arc. Therefore, the table is named Guide Position Smile-Arc (GPS-A). Materials/methods: Two tables, one for upper dentition and one for lower dentition were designed to guide the bracket placement, in order to obtain or retain the best esthetic smile arc, based on the authors´ clinical experience. The limitations of other commonly used tables (Alexander and MBT™) are presented as antecedents of the new table. Results: Instructions to use the table are described in detail. Indications for previous dental morphology adjustment, use of positioners, and specifications for special situations are described. Conclusions/implications: The advantages of using this guide are summarized. The clinical table provides an easy and reliable guide for clinicians to place brackets for predictable pleasant smiles and functional occlusions.

Introduction Facial and smile esthetics are essentially inherent characteristics of the patient. Nonetheless, within morphologic-functional limits, Thomas Pitts, DDS, MScD, received a BA from the University of Nevada, Reno. He earned a DDS from University of the Pacific and was Valedictorian in 1965. He holds an MSD from the University of Washington and is in private practice in Killen, Texas. Dr. Pitts is Associate Clinical Professor in the Orthodontic Department of the University of the Pacific, Dugoni School of Dentistry in San Francisco, California. Tomás Castellanos, DDS, MSc, attended Pontificia Universidad Javeriana (Bogotá, Colombia). He has a MSc in Orthodontics and Maxillofacial Orthopedics and attended Nueva Granada Military University – CIEO. Dr. Castellanos is in exclusive private practice in orthodontics in Bogotá, Colombia.

Volume 5 Number 5

and thanks to the advances in today´s orthodontic technology, it is possible not only to obtain an excellent occlusion but to improve patient esthetics according to his/her expectations. Planning the treatment based on facial esthetics as a purpose to protect the smile arc is parallel to a strategy to achieve occlusal purposes. The functional aim of orthodontics is always to achieve a mutually protected occlusion; that is, anterior teeth protect posterior teeth from interference during lateral and protrusive movements, and posterior teeth protect anterior teeth as well, providing an adequate contact in closed-mouth position. The smile arc, in a frontal view, has been defined as the relationship of the curvature of the superior incisive and canine incisal edges with the curvature of the inferior lip in smiling position. In an ideal smile arc, the curvature of the superior incisal edge is parallel to the lowest smiling lip curvature. The term “consonant” describes this parallel relationship. In a non-consonant or flat smile, the maxillary incisal curvature is flatter than the inferior lip in smiling position. According to Frush and Fisher,3 a more sharp curvature of the upper incisal edges from canine to canine is more attractive/ youthful than a flatter curvature. Therefore, in individuals who don’t show curvature of the lower lip on smile, a smile arc is still the most desirable. The ideal smile arc as a guidance for anterior upper teeth indicates that the purpose should be an ideal position from canine to canine and a functional anterior bite. Accurate bracket positioning is essential to finish treatment with an excellent occlusion and beautiful smile. Additionally, the most common reason for unnecessary delay of treatment and the discovery of difficulties in the final stage is the incorrect bonding of the appliances. The need for excessive first order bends is not due to a failure in design of the orthodontic appliances, but due to incorrect bracket positioning. When some teeth are in extreme malposition, it is not always possible to place a bracket in an ideal position during the first visit, but it

is recommended to attempt to place the brackets in the best possible position to avoid further repositioning and compensatory bendings as treatment progresses. Previously established positions for bracket placements based on tooth dimensions, as frequently taught in orthodontic courses and programs, are inappropriate for optimum esthetics. For instance, if one assumes that all patients have the maxillary central incisors located 4.5 mm above the incisal edge, lateral incisors at 4 mm, and canines at 5 mm, and the orthodontist fails to account for the relationship of incisal edges with the lower lip, the position may not adjust for the esthetic criteria needed. Customized appliance placements have as much importance as customized treatment plans.4 Dr. Tom Pitts has developed a protocol for Smile Arc Protection (SAP) bracket positions that consistently produces beautiful Smile Arcs. Dr. Tomás Castellanos has quantified this esthetic positioning by measuring the length of the teeth. Hence, this is a “TomTom” production. The vertical positioning of brackets is a challenge for many orthodontists. This problem diminishes when positioning devices and customized tables are used to guide bracket placement, when using direct or indirect bonding. The Alexander technique5 uses the premolar height (X in the Vari-Simplex table for bracket heights) (Figure 1) for bracket positions in the entire arch. Bracket Height Maxillary Arch Centrals Laterals Cuspids Bicuspids 1st Molars 2nd Molars

X X - 0.5 mm X + 0.5 mm X X - 0.5 mm X - 1.0 mm

Mandibular Arch Centrals Laterals Cuspids Bicuspids 1st Molars

X - 0.5 mm X - 0.5 mm X + 0.5 mm X X - 0.5 mm

Figure 1: Table of Vari-Simplex bracket heights Orthodontic practice 19

CLINICAL

A new table to guide bracket placement based on the concept of “smile arc protection”

CLINICAL For example, if the normal slot height for a premolar bracket is 4.5 mm from the occlusal cusp, the other indicated heights demonstrated by this table should be 5.0 mm for canine, 4.0 mm for lateral, and 4.5 mm for centrals. The MBT™ table (Figure 2) offers another commonly used bracket positioning guide. It suggests average positions for brackets in the maxillary arch of 4.5 mm for the first premolar (X - 0.5 mm.), 5.0 mm for canine (X), 4.5 mm for lateral (X - 0.5 mm), and 5.0 mm for central (X).6 These and other techniques for bracket placement, based on popular tables and positioning devices, provide accuracy and high reproducibility. Unfortunately, bracket placements with these height discrepancies typically flatten the smile curve. Flattening of the smile arc during orthodontic treatment can occur by different mechanisms. The normal alignment of maxillary and mandibular dental arches may result in a reduction of curvature of the upper incisors with respect to the inferior lip curvature. Ackerman, et al.,4 evaluated smile arcs in treated and non-treated patients in their own practices. Almost 40% of the treated patients presented discernible changes in the smile arc with flattening of the smile arc occurring in 32%. In the control group (which was the treated group), 13% presented changes in the smile arcs, but flattening occurred in only 5% of this group. They reported no gender differences regarding smile features in treated or untreated groups. The present article introduces a new table to guide vertical placement of brackets,

Image 1: Smile curve flattened after orthodontic treatment. Brackets bonded with conventional heights. (Patient treated by Dr. Tomás Castellanos — MBT brackets) 20 Orthodontic practice

Figure 2: MBT™ Versatile+ Appliance Bracket placement guide

based on the smile arc effect — therefore, the table is named Guide Position Smile-Arc (GPS-A) (Images 1 and 2).

Table suggested for placement of brackets

vertical

Rationale The table presented (Figures 3 and 4) is based upon a great number of clinical studies and measurements taken on plaster casts and digital models from patients treated by the team of Drs. Tom Pitts and Tomás Castellanos. Its versatility and efficacy will be the subject of other articles presenting cases successfully treated applying this table.

Image 2: Consonant Smile-Arc, result of bonding brackets with GPS-A (Guide Position Smile-Arc) Tom-Tom (Patient treated by Dr. Tomás Castellanos — H4 brackets).

The table facilitates the vertical placement of brackets in positions that result in adequate smile curves, as well as mutually protected occlusions. It takes into account occlusal morphology, such as the angle of the articular eminence that is more vertical in dolichocephalic subjects than in mesocephalic or brachycephalic patients. In dolicocephalic patients as compared to brachycephalic, the molar cusps are higher, and fossae are deeper; anterior teeth clinical crowns are longer in a cervico-incisal direction. All these characteristics indicate that more overbite is necessary to disocclude posterior teeth in eccentric movements in dolicocephalic subjects. On the other hand, individuals with shorter faces, flatter TMJ eminences, and anterior teeth with shorter clinical crowns, less overbite is necessary to disocclude posterior teeth in eccentric movements.4 Also when considering the incisal–smile arc relationship, clinicians must extrude the upper incisors in flat smile cases or maintain the incisal smile arc when it is esthetically adequate. For a functionally adequate occlusion and esthetic smile curvature, a divergence must be kept between the occluso-gingival position of the slot with occlusal cusps or incisal edges, measured in mm, from the second molar tube all the way to the maxillary central incisor. This divergence is important as well, considering that the difference in mm between the slot height of the central incisor and the height in mm from the second molar tube gives an idea of the amount of overbite one will obtain at the end of treatment. It also affects the occlusal plane cant. Volume 5 Number 5

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CLINICAL The final overbite of any deep bite or open bite also depends on elastics, disarticulation buttons, mini-screws, and other auxiliary elements that potentiate the expression of the bracket’s torque. Of course, miniscrews can also help enhance the maxillary incisor position by intruding the mandibular incisors when needed. The transition point between the anterior and posterior dental segments additionally establishes the track of the smile arc, and therefore, the positioning for the whole dental arch should be planned taking this point as a clue. When the maxillary incisors are further extruded to enhance the smile curve and enamel display, a deeper bite can be produced by increasing the overbite. To avoid this effect, the table introduces a compensation in the position of the slot of mandibular canine-to-canine brackets.

Figures 3 and 4: Tables GPS-A lower and upper

Instructions to use the table (Figures 3 and 4) Previous to using the table, some patients require a recontouring to provide basic ideal morphology to each tooth. This ameloplastic procedure is based in the study of plaster models and removes only the necessary minimum dental enamel. The ameloplasty includes pronounced marginal ridges on the lingual surfaces, of incisors’ angles and incisal ridges, as well as irregular vestibular surfaces. Irregular vestibular surfaces prevent an optimum placement of brackets, which control rotations and torque.1 In most cases, canines require recontouring to improve their role in the smile arc. This process does not interfere with their functional role of canine disocclusion. Gingival margins are very important for anterior esthetics. Sometimes clinicians need to perform initial gingivoplasties with laser, electro-surgery, or any other similar technique. It is important to provide the right morphology, but clinicians should not recontour all hard and soft tissues, since leaving small discrepancies until the end of treatment allows for final detailing when the teeth have the best possible position. When teeth have fractures or abnormal wear, the teeth should be reconstructed prior to bracket bonding, in order to assure the ideal dental anatomy. Clinicians should communicate this to the patient, since future restorations may be necessary. If the maxillary molars present high and pronounced mesopalatal cusps, they should 22 Orthodontic practice

Figure 5: Accurate measurement for each tooth with digital gauge (Mitutoyo™ Super-Caliper Solar-Powered Series 500 — Digital Caliper at www.amazon.com)

Figure 6: The second step is to find the maxillary canine crown length and then the positions of the other maxillary teeth

receive recontouring to avoid interferences or early contacts. The same applies to the lingual cusps of the premolars. After obtaining the ideal dental morphology, the heights for bracket bonding in the maxillary arch are selected as follows: 1. Measure the length of the maxillary canine crown, from the cusp tip to the

gingival margin (after reconstruction, recontouring, or gingivoplasty). 2. Find this measurement in the columns of the table GPS-A (Guide Position Smile-Arc upper), and choose the adjacent number in the row. (Figure 6). The number in this file indicates the position for each bracket. Volume 5 Number 5

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CLINICAL 3. Select in a similar way the height to bond brackets for mandibular teeth: a) measure the length of the crown of the mandibular canine, from cusp tip to gingival margin (after reconstruction, recontouring, and gingivoplasty); b) find this number in the column of the table GPS-A (Guide Position Smile-Arc lower), and choose the number in the adjacent row. This number indicates the position for bonding each bracket in the mandibular area (Figure 7). Specific considerations The maxillary second molars must always be intruded. Its tubes are always positioned to slightly intrude these teeth to provide a negative coronal inclination and avoid functional interferences. The discrepancy between maxillary incisors and the maxillary lateral incisor must be kept between 0.5 mm and 1 mm to allow the movement of the mandibular canine during protrusive excursions and, additionally, to improve the smile arc. Longer incisors require a larger height difference. For those situations, the table includes two additional options. At the level of the mandibular molars, it is important to maintain an occlusal plane that grants correct coupling with the antagonist teeth. Individualization of the table for cases treated with premolar extraction Today’s effective mechanics, combining the use of mini-screws with passive selfligation appliances for en masse movement toward the place of molar extraction, has reduced the frequency of patients treated with premolar extractions. But when the orthodontist decides that it offers the best option, the table may be individualized. To do this, the anterior segment is managed as conventionally indicated in the GPS-A table, but the discrepancy between premolar and canine for every case will be 0.5 mm, and the discrepancy between premolar and molar will be 1.0 mm in every case, to avoid interferences and inadequate steps in these segments. Use of the positioner for vertical placement of each bracket The positioning gauge that measures the height to bond the brackets is placed in a slightly different way, depending on the segment of dental arch that is being considered.5 24 Orthodontic practice

Figure 7: The third step is to find the lower canine crown length measurement and the subsequent positions for the mandibular brackets

In general, this technique allows the orthodontist to obtain adequate occlusion and an esthetic smile We suggest for incisor, canine, and premolar regions to use the calibrator placed at 90º respect to the tangent of the middle zone. For the molar region, it is suggested to place it parallel to the occlusal surface of each molar (tracing an imaginary line between the buccal and the lingual cuspids of each molar). Advantages derived from the use of this table • A reduction of errors in positioning, which can be avoided, due to better precision, • Reproducibility, and predictability of the bracket bonding. • It allows a practical, standardized bonding procedure. • Avoids bracket repositioning and/or the introduction of excessive corrective wire bends. • Reduces chair time and unnecessary discomfort to the patient. • Saving months of treatment, it becomes an effective tool to motivate patients. • Allows better control of torque values.

Figure 8: Versatile high-precision positioner for proper location of each bracket from second molars to central incisors (GPS-A is a versatile high-precision positioner from Ortho Classic Inc. at www.orthoclassic.com)

REFERENCES 1. Pitts T. Begin with the end in mind: Bracket placement and early elastics protocol for smile arc protection. Clin Impres. 2009;17(1):1-11. 2. Sarver D, Ackerman MB. Dynamic smile visualization and quantification: Part 1. Evolution of the concept and dynamic records for smile capture. Am J Orthod Dentofacial Orthop. 2003;124(1):4-12. 3. Frush JP, Fisher RD. The dynesthetic interpretation of the dentogenic concept. J Prosthet Dent. 1958;8:558-581. 4. Ackerman JL, Ackerman MB, Brensinger CM, Landis JR. A morphometric analysis of the posed smile. Clin Orthod Res. 1998;1(1):2-11. 5. Alexander W. Build treatment into bracket placement. In: The 20 Principles of the Alexander Discipline. Chicago, IL: Quintessence; 2008:59. 6. McLaughlin R, Bennett J, Trevisi H. Systemized Orthodontic Treatment Mechanics. Philadelphia, PA: Mosby; 2001:60-65. 7. Echeverri E, Sencherman G. Neurofisiología de la oclusión. Columbia: Editorial Monserrate; 1991:175–189. 8. Sarver DM. The importance of incisor positioning in the esthetic smile: the smile arc. Am J Orthod Dentofacial Orthop. 2001;120(2):98-111.

In general, this technique allows the orthodontist to obtain adequate occlusion and an esthetic smile. OP Volume 5 Number 5

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ORTHODONTIC CONCEPTS

BioDigital Orthodontics Management of patients with Class 3 malocclusion: part 11 Drs Rohit C.L. Sachdeva and Takao Kubota discuss the clinical management of class 3 malocclusion with SureSmile® Introduction The Class 3 malocclusion is classified as a sagittal anomaly of the craniofacial skeleton. However, it is important to recognize that this malocclusion just as others not only manifests clinically in the sagittal plane but may have also transverse and vertical components adding to the complexity of its treatment.1,2 Furthermore, the correction of this malocclusion may be further complicated by temporal and dynamic elements such as maxilla-mandibular growth and functional pattern. Successful care of patients with Class 3 malocclusions requires consideration of many factors. For instance, an understanding of the structural and functional components of the condition, timing of care, psychosocial factors related to a patient’s ability to adhere to treatment measures, doctors’ skills, and choice and management of orthodontic appliances. Table 1 lists some of the common factors a clinician needs to consider in the nonsurgical management of the Class 3 patients. The aim of this paper is to discuss the management of patients presenting with a

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. 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 90 patents, is the recipient of the Japanese Society for Promotion of Science Award, and has over 180 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.

Class 3 malocclusion enabled by SureSmile® technology.3-15 The effective application of SureSmile requires that a clinician recognize when, where, and how the technology may benefit the patient during the care cycle. This requires a succinct understanding by a clinician in understanding the capabilities of the technology in designing personalized care, and delivering targeted therapeutics. Table 2 shows examples and uses of different design attributes that may be considered in the bending of the precision archwire to achieve controlled and predictable orthodontic tooth movement. An additional imperative in ensuring successful treatment outcomes requires subscription to clinical pathway guidelines (CPG). Figure 1 shows an example of a CPG designed by the first author in managing Class 3 patients. It should be noted that such guidelines provide a general road map in managing patient care, and deviations may and do occur at times to suit individual patient needs and or to deal with the unexpected. The following patient histories provide examples of management of the Class 3 malocclusion with SureSmile.

Table 1: Managing Class 3 Patients (Sachdeva) 1

Patient • • • • • • • • •

Treatment Strategies • • • •

Patient needs Age Sex Psychological characteristics Growth direction/Velocity Muscle type Habits Craniofacial morphology Arch length discrepancy

Functional correction Orthopedics Surgical Orthodontics - Eruption guidance - Compensatory/Decompensatory tooth movement

Force System/Appliance Selection • • • •

Orthopedic Orthopedic/Dental Dental Surgical

Risk Analysis

Patient Management • Timing of treatment • Scheduling of care

Retention Plan

Table 1: Considerations in the management of Class 3 patient treatment

Table 2: SureSmile Targeted Precision Therapeutics (Sachdeva)* Type 1

As a passive archwire to stabilize the respective dentoalveolar segments coupled with the use of active auxiliary mechanisms to correct the Class 3 problem, e.g., with Class 3 elastics.

Type 2

As a passive stabilizing mechanism to hold Class 3 dentoalveolar correction, e.g., if a lower molar is moved distally, and the clinician wishes to hold it in place.

Type 3

To actively override the discrepancies in bracket prescription or position that may act against the expedient correction of the Class 3.

Type 4

A hybrid version of a passive and an active archwire. An archwire may be designed to align the anteriors whie holding the posteriors stable, e.g., to maintain dentoalveolar compensations in the buccal segments.

Type 5

For sliding mechanisms to close space or where extraction space needs to be closed.

Type 6

Design of extremely complex archwire geometries; for instance, accentuating or maintaining the posterior Curve of Spee or Curve of Wilson or designing a prescription that builds dentoalveolar compensations to manage the treatment of a severe skeletal Class 3 patient non-surgically.

* Surgical archwires designed will be discussed in subsequent papers.

Table 2: Design Strategies for SureSmile targeted precision wires to manage the correction of a Class 3 condition in a patient 28 Orthodontic practice

Volume 5 Number 5

ORTHODONTIC CONCEPTS

Patient AI Patient AI, a 6-year-old female, presented with a Class 3 malocclusion in the early mixed dentition stage (Figure 1). Her malocclusion had a functional, skeletal, and a dentoalveolar component. A Virtual Diagnostic Simulation (VDS) was performed simulating the correction of all the three components of the malocclusion (Figure 2). There were three distinct Phases planned in the treatment of Patient AI: Phase I The initial treatment strategy involved restraining mandibular growth with a chin cup. Virtual Diagnostic Simulation was designed to plan this phase of treatment, which involved orthopedics, functional, and dentoalveolar movement (Figure 3). A functional forward shift that exacerbated the Class 3 malocclusion appeared to be related to the deflective contacts resulting from the rotated upper incisors as well as their thick marginal ridges (as shown in Figure 4). Therefore, the upper incisors were derotated with a sectional archwire and their thick marginal ridges selectively equilibrated. The dentoalveolar component of the Class 3 correction was achieved by advancing the upper incisors with the help of Class 1 elastics anchored against the chin cup. The line of action of these elastics was upward and forward through the estimated Center of Resistance of the incisors (Figure 5). This force system encouraged intrusion and forward translation of the incisors. Posterior bite turbos were also bonded to the lower molars to disocclude the anteriors to facilitate the forward movement of the incisors. Once positive overjet and overbite were achieved, the lateral incisors were aligned segmentally with a sectional archwire (Figure 5). Next, the patient was debonded. An active retention regiment was instituted by asking the patient to wear the chin cup nightly for a period of 12 months. Phase II The A-P correction 12 months post Phase I appeared relatively stable. However, the upper lateral incisors showed some relapse, and as a result, encroached upon the space of the upper canines and impeded their eruption. The primary objective of the second phase of treatment was to ensure that adequate space was gained to allow the eruption of the upper canines. This was accomplished by advancing the upper lateral incisors (Figure 6). This was accomplished in 3 months. Volume 5 Number 5

Figure 1: Flowchart of the two most common Clinical Pathway Guidelines (CPGs) to manage the treatment of patients with Class 3 malocclusions — Protocol A and Protocol B (Sachdeva)

Phase III The treatment was initiated 30 months after completion of Phase II when the second molars had erupted (Figure 7). Again, the patient appeared to be relatively stable in terms of her Class 3 correction. However, the upper laterals had shown some relapse towards the lingual. This phase of treatment was designed to achieve the optimal occlusion for the patient and involved full fixed appliance treatment. The Virtual Diagnostic Simulation (VDS) showing the planned orthodontic tooth movements is shown in Figure 8. It should be noted that significant movement of the upper lateral incisor is required as shown in Figure 9. Initial alignment in the upper and lower arch was achieved with a 0.016” CuNiTi AF 27°C. An upper utility arch was piggybacked on to the upper archwire (Figure 10).

It was activated such that the upper incisors remained slightly advanced. A Therapeutic scan for the patient was taken 8 weeks later (Figure 11). The Virtual Target Setup and SureSmile precision archwire design are shown in Figures 12B and 12C. Also, note special precautions were taken to design the archwire to minimize any tipping movement of the lateral incisors. SureSmile precision archwires .017 x .025 CuNiTi AF 35°C were installed 4 weeks post therapeutic scan (Figure 13). Patient progress was evaluated 8 weeks later (Figure 14), and debonded appointment was planned 2 weeks later (Figure 15). Note that the outcome (VFM) is similar to the plan (VDS) shown in Figure 16A. Also, one can see that the movement of the lateral incisors as planned was achieved (Figure 16B). Orthodontic practice 29

ORTHODONTIC CONCEPTS Although the total length of care for the patient was long (56.5 months), the active treatment time remained reasonably short (14.5 months) (Table 3). Furthermore, the treatment of patient AI clearly demonstrates how SureSmile technology can be blended with conventional treatment to provide efficient and effective care to a patient by the appropriate use of decision-making tools, targeted plans, and personalized precision archwires. Figure 2: Patient AI. Initial (pre-treatment) 6-year-old female presents with a Class 3 malocclusion in the early mixed dentition stage VDM

VDS-1 (Functional Shift)

VDS-2 (Dental Movements)

Figures 3A-3F: Patient AI. 3A. Virtual Diagnostic Model (early mixed dentition stage). 3B. The initial Virtual Diagnostic simulation â&#x20AC;&#x201D; 1 entailed simulating the functional shift. 3C. Shows the difference between the initial model and the simulated functional shift* VDS (white) vs. VDM (green). Also, in the inset table, one notes the amount of corrective displacement required to achieve the desired functional shift.* 3D. Virtual Diagnostic simulation â&#x20AC;&#x201D; 2 this entailed simulating dental movements. Note. The upper incisors were advanced. 3E. Shows the final result of the functional movement and dental correction. VDS (white) vs. VDM (green). 3F. Is a sagittal clipping plane view showing the nature of upper incisor displacement. The table shows the nature and magnitude of displacements of the dentition to correct the malocclusion *Mandibular growth simulations were not performed. By default, this demonstrated the restraint of mandibular growth.

Figures 4A-4C: Patient AI. VDS-2. Demonstrates the interferences at the level of the marginal ridges. 4A. The electronic articulating paper highlights in red the high spots on the marginal ridges. 4B. Shows it from an occlusal perspective. 4C. From a sagittal perspective 30 Orthodontic practice

Volume 5 Number 5

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ORTHODONTIC CONCEPTS

Figures 5A-5F: Patient AI. Phase I. The rotation on the upper incisors is corrected sectionally. 5A. Bite turbos to open the bite to facilitate advancement of upper incisors have been placed. 5B. 8 weeks later, central incisors have been derotated as the upper incisors are being proclined against the chin cup. 5C. 16 weeks later, the bite has been jumped. 5D. 20 weeks later, the upper lateral incisors are being aligned with a sectional archwire. 5E. 24 weeks later, note the alignment of the upper anterior segment and the overjet. The overbite is minimal, but remains positive. Loops were placed in the sectional wire to allow for more stable advancement of the incisors. Patient was debonded a month after and placed in active retention for 1 year. 5F. One year post debonding (The active retention period for Phase I ended at this time)

Figures 6A-6C: Patient AI. Phase II. 6A. Initiated 12 months post phase 1. 6B. 6 weeks. This was accomplished by advancing the upper lateral incisors. Finger springs were attached to a transpalatal arch. 6C. The upper laterals were tipped labially, and enough space for the canines was established to allow the eruption unimpeded. This was accomplished in 3 months. Note. The patient was not placed into retention after Phase II

32 Orthodontic practice

Volume 5 Number 5

ORTHODONTIC CONCEPTS

Figures 7A-7B: Patient AI. Phase III was initiated 30 months later. At this time, all the permanent teeth are erupted, except for the third molars. The second was designed to achieve the optimal occlusion for patient and involved full fixed appliance treatment. Also, note that the upper incisors have relapsed, and the Class 3 correction and overjet and overbite remains stable 7A. Initial intraoral photos. 7B. X-rays VDM (Phase III)

VDS

VDS (White) Vs. VDM (Green)

Figures 8A-8D: Patient AI. Phase III 8A. Virtual Diagnostic Model (VDM). 8B. Virtual Diagnostic Simulation (VDS) shows the planned orthodontic tooth movement. 8C. VDM (green) vs. VDS (white). 8D. Shows the nature and magnitude of displacements of the dentition

Figures 9A-9B: Patient AI. Phase III. Shows a clipping plane view for the planned movement for the lateral incisors. Note that the incisors need substantial translatory movements to enable desired correction Volume 5 Number 5

Figure 10: Patient AI. Phase III. Initial alignment was achieved with 0.016â&#x20AC;? CuNiTi AF 27Â°C. Upper utility arch was piggybacked on to the upper archwire and activated such that the upper incisors remained slightly advanced Orthodontic practice 33

ORTHODONTIC CONCEPTS

Figures 11A-11B: Patient AI. Phase III. 11A. Mid-treatment scan taken after 8 weeks. 11B. Mid-treatment X-rays

VTM

VTS

Figures 12A-12C: Patient AI. Phase III. 12A. Virtual Therapeutic Model (VTM). 12B. Virtual Target Setup (VTS) with SureSmile precision archwire designed. 12C. SureSmile precision archwire viewed against VTM

Figure 13: Patient AI. Phase III. 13A. SureSmile precision archwires .017x.025 CuNiTi AF 35째C were installed 4 weeks post therapeutic scan

Figure 14: Patient AI. Phase III. Patient progress monitored 8 weeks post SureSmile wire insertion. Check elastics were used anteriorly with a slight Class 3 vector

VFM

Figures 15A-15C: Patient AI. End of Phase III treatment. Patient was debonded 3.5 mos post therapeutic scan. 15A. Final intraoral photos. 15B. Final X-rays. 15C. Virtual Final Model (VFM) 34 Orthodontic practice

Volume 5 Number 5

Figures 16A-16B: Patient AI. Final outcome assessment. 16A. Note the VDS (white) was similar to the VFM (green). 16B. The movement of the upper lateral incisors was achieved as planned. This is shown in a single tooth clipping plane view

Major Objectives

Timing

Phase I

Orthopedic, functional, and dentoalveolar correction

6 months

Retention

Active

12 months

Phase II

Gaining arch length

3 months

Retention

Passive eruption

30 months

Phase III

Detailing occlusion

5.5 months

SureSmile Decision support, planning, and outcome evaluation

SureSmile Targeted/personalized therapeutics (Type 3 archwire)

Table 3: Patient AI. This table provides a summary of the treatment management of patient AI. The active treatment time was 12.5 months, and the total time of the care cycle was 30.5 months. The table also shows where SureSmile technology was used in providing patient care.

Patient MT Patient MT, an 18-year-old female patient presented with a skeletal Class 3 malocclusion with an open bite and severe crowding in both the upper and lower arches (Figure 17). To correct the crowding and manage the open bite and Class 3 malocclusion, it was decided to extract the upper second bicuspids, the lower left first bicuspid, and the lower right second bicuspid (since it had a root canal filling, and its long-term prognosis was considered poorer than the right first bicuspid). The Virtual Diagnostic Simulation (VDS) for patient MT is shown in (Figure 18). Figures 19A-19D shows the archwidth changes planned. Note the molar width was maintained while the upper first bicuspids were tipped buccally. In fact, their buccolingual inclinations were favorably disposed to allow for buccal tipping. The open bite was planned to be closed by extrusion of both the Volume 5 Number 5

lower and upper incisors. Also note that the lower incisors were tipped lingually to facilitate additional Class 3 correction (Figure 20). Initially extractions were planned in the lower arch and the canines sectionally retracted to prevent the flaring of the lower incisors. Concomitantly, upper expansion was initiated with a quadhelix appliance (Figures 21A-21F). After 3.5 months into treatment, the upper bicuspids were extracted, and separate canine retraction in the upper arch commenced. Anchorage and archwidth of both lower and upper molars were maintained with a lingual and transpalatal arch respectively. The spurs on the lower lingual arch were used to facilitate tongue reposturing. After preliminary upper canine retraction, the upper arch was fully bonded a month later. This was followed by full bonding of the lower arch (Figure 21C). Alignment of both the upper and lower segments was achieved

with an .016” CuNiTi Af 27°C archwire. Eight months into treatment both the upper and lower archwires were replaced with a .017” x .025” CuNiTii Af 35°C archwire to facilitate the correction of the tipping of the buccal segments during space closure. A Therapeutic scan was taken 10 months into treatment (Figure 22). A Virtual target setup and .017” x .025” CuNiTii Af 35°C SureSmile precision archwires were designed (Figures 23A-23C). The SureSmile archwires were installed 6 weeks later (Figure 24). The archwires were allowed to work out for 8 weeks (Figure 25). The patient was debonded 6 weeks later (Figure 26). The patient was in active treatment for 13.5 months. Superimposition of the Virtual Diagnostic Simulation against the Virtual Final Model shows that the treatment outcome matched the initial plan very closely (Figures 27 and 28A-28C). Orthodontic practice 35

ORTHODONTIC CONCEPTS

VDS (White) Vs. VDM (Green)

ORTHODONTIC CONCEPTS

Figures 17A-17B. Patient MT. 18 year old patient presents with skeletal Class 3 malocclusion, an open bite and severe crowding in both the upper and lower arches. 17A. Initial intraorals. 17B. Initial X-rays

VDM

VDS

VDS (White) Vs. VDM (Green)

Figures 18A-18D. Patient MT. 18A. Virtual Diagnostic Model (VDM). 18B. Virtual Diagnostic Simulation (VDS). Extractions of the upper second bicuspids, the lower left first bicuspid and the lower right second bicuspid was planned to correct the crowding, open bite and the Class 3 malocclusion. 18C. VDM (green) vs. VDS (white). 18D. Shows the nature and magnitude of displacements of the dentition

Figures 19A-19D. Patient MT. 19A-19B. Archwidth changes planned. Note. Molar width was maintained while the upper first bicuspids were tipped buccally. Bucco-lingual inclinations were favorably disposed to allow for buccal tipping. Note that the bucco-lingual inclinations of the upper bicuspids were favorably allowed for buccal tipping. 19C-19D. Shows an occlusal view of the archwidth changes both in the upper and lower arch and the AP change of the incisors 36 Orthodontic practice

Figures 20A-20B. Patient MT. 20A. Shows a sagittal clipping plane view of the incisors against the ceph and the initial VDM. 20B. VDS (White) vs. VDM (Green) Volume 5 Number 5

ORTHODONTIC CONCEPTS

Figures 21A-21D. Patient MT. 21A. Upper expansion was initiated with a quadhelix appliance. Lower extractions were performed, and sectional retraction of the teeth was initiated in the lower arch. Lower anchorage was reinforced with a lingual arch. Spurs were welded on the lingual arch to encourage reposturing of the tongue. 21B. After 3.5 months into treatment the upper bicuspids were extracted and separate canine retraction in the upper arch started. Anchorage and archwidth of both lower and upper molars was maintained with a lingual and transpalatal arch respectively. 21C. Next alignment of both the upper and lower segments was achieved with .016” CuNiTi Af 27°C archwire. 21D. Eight months into treatment both the upper and lower archwires were replaced with a .017” x .025” CuNiTii Af 35°C archwire to facilitate the correction of the tipping of the buccal segments during space closure

VTM

VTS

Figures 22A-22B. Patient MT. A. Mid-Treatment intraoral photos were taken 10 months from the beginning of active treatment. B. Mid-Treatment X-rays

Figure 24. Patient MT .017”x .025” CuNiTii Af 35°C SureSmile precision archwires were inserted 6 weeks post Mid-Treatment scan Volume 5 Number 5

Figures 23A-23C. Patient MT. 23A. Virtual Therapeutic Model (VTM). 23B. Virtual Target Setup (VTS) with SureSmile precision archwire designed. 23C. SureSmile precision archwire viewed against VTM

Figure 25. Patient MT. SureSmile precision archwires were allowed to work out for 8 weeks post insertion. Class 3 anterior diagonal elastics were used to correct the lower midline Orthodontic practice 37

ORTHODONTIC CONCEPTS

VFM

Figure 26. Patient MT. 26A. Final intraoral photos taken at debond 3.5 months post SureSmile wire insertion and 13.5 months from start of treatment. 26B. Final X-rays. 26C. Virtual Final Model

Figure 27. Patient MT. Superimposition of VFM (white) against the VDM (green) shows the plan matched closely to the final outcome

Figures 28A-28C. Patient MT. 28A-28B. Shows an incisal clipping plane view of the upper and lower arches. (VDS vs. VFM). Note. The final incisal position and the archwidths matched the plan. The sagittal plane clipping view of the incisors VDS Vs VFM is shown in 28C. Again, the vertical and the torque of these teeth were similar to the plan

Conclusions The patients presented in this paper demonstrate the versatility of using SureSmile technology in managing the care of a patient with a Class 3 malocclusion. As discussed previously, the application of the decision support system to plan care proactively allows the clinician to begin treatment with the “end in mind” and also plan mechanics consistent with the planned displacements of the dentofacial complex. Furthermore, strategic design and use of the precision archwire based upon the Virtual Target setup contributes significantly to gains in both effectiveness and efficiency significantly. An article in the future will discuss the surgical management of patients with Class 3 skeletal malocclusions. OP Acknowledgments The authors are most grateful to Dr. Sharan Aranha, BDS, MPA, and Arjun U.C. Sachdeva for their support and dedication in the preparation of this manuscript.

38 Orthodontic practice

REFERENCES 1. Ellis E 3rd, McNamara JA Jr. Components of adult Class III malocclusion. J Oral Maxillofac Surg. 1984;42(5):295-305. 2. Guyer EC, Ellis EE 3rd, McNamara JA Jr, Behrents RG. Components of class III malocclusion in juveniles and adolescents. Angle Orthod. 1986;56(1):7-30. 3. 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. 4. 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. 5. Sachdeva R, Kubota T, Moravec S. BioDigital orthodontics. Part 1-Management of Class 2 non–extraction patients: Part 8. Orthodontic Practice US. 2014;5(2):11-16. 6. 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. 7. Sachdeva R, Kubota T, Hayashi K. BioDigital orthodontics. Part 3- Management of patients with Class 2 malocclusion extraction: Part 10. Orthodontic Practice US. 2014;5(4):27-36. 8. Sachdeva R. BioDigital orthodontics: Planning care with SureSmile technology: Part 1. Orthodontic Practice US. 2013;4(1):18-23. 9. Sachdeva R. BioDigital orthodontics: Designing customized therapeutics and managing patient treatment with SureSmile technology: Part 2. Orthodontic Practice US. 2013;4(2):18-26. 10. Sachdeva R. BioDigital Orthodontics: Diagnopeutics with SureSmile technology (Part 3). Orthodontic Practice US. 2013;4(3):22-30. 11. Sachdeva R. BioDigital orthodontics: Outcome evaluation with SureSmile technology: Part 4. Orthodontic Practice US. 2013;4(4):28-33. 12. 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. 13. 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. 14. 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. 15. 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.

Volume 5 Number 5

AUTHOR GUIDELINES

Orthodontic Practice US is a peer-reviewed, bimonthly publication containing articles by leading authors from around the world. Orthodontic Practice US is designed to be read by specialists in Orthodontics, Periodontics, Oral Surgery, and Prosthodontics.

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Orthodontic practice 39

CONTINUING EDUCATION

Value of true horizontal in diagnosis and treatment planning Dr. Larry White evaluates malocclusions via the natural head postures of patients Abstract Dr. William Downs made the invaluable contribution of cephalometric analysis to orthodontics, and though his initial studies had a narrow application, it started the profession on a seemingly endless search for more relevance with this instrument. Researchers have since found that some of the reference points, angles, and planes he and Dr. Richard A. Riedel developed have serious handicaps, but their primacy accounts for their wide use, acceptance, and use with clinicians, schools, insurance companies, and accrediting agencies. Reliance on these esteemed standards to the neglect of these latter day developments in cephalometry can create misunderstandings regarding malocclusions with subsequent errors in therapy. This article offers an analysis based on true horizontal (TH), aka, natural head position. Additionally, it

In 1959, Dr. Larry White graduated from Baylor Dental College with a DDS degree and then served in the United States Air Force from 1959 to 1961. He then practiced general dentistry in Hobbs, New Mexico from 1961 to 1966 and subsequently returned to Baylor Dental College to receive a MSD degree in orthodontics in 1968. He returned to Hobbs to practice orthodontics exclusively. Dr. White had orthodontic offices in Hobbs, New Mexico; Roswell, New Mexico; and Denver City, Texas. Dr. White is a member of the American Dental Association, the Texas Dental Association, the Southwestern Society of Orthodontists, The American Association of Orthodontists, the Texas Orthodontic Study Club, and the Southwest Angle Orthodontic Society. Dr. White is a Diplomate of the American Board of Orthodontists and a fellow in the American College of Dentists. He has been a director and president of the Rocky Mountain Society of Orthodontists. He is a past president of the New Mexico Orthodontic Society and the Texas Orthodontic Study Club. He serves as manuscript reviewer for The Angle Orthodontist and was editor of the Journal of Clinical Orthodontics for 17 years. He was the first director of the University of Texas Health Science Center in San Antonio Orthodontic Residency Program. He now serves on the Advisory Editorial Board of Orthodontic Practice US and is also a contributing editor for the Orthodontic CYBERjournal. Dr. White has also served as Editor of the Dallas County Dental Society publication, Dateline. Dr. White has contributed more than 100 original articles to dental literature and has presented lectures to several orthodontic societies, universities, and study clubs. He has also lectured in over 35 countries throughout the world. He now practices orthodontics in Dallas, Texas and serves as an adjunct professor of orthodontics at Texas A&M University, Baylor Dental College in Dallas, Texas.

Educational aims and objectives

The aim of this article is to offer an analysis of malocclusions based on natural head position.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 48 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: â&#x20AC;˘ See some history of cephalometric analysis. â&#x20AC;˘ Identify features of the true horizontal cephalometric analysis. â&#x20AC;˘ Recognize the value of true horizontal in diagnosis and treatment planning.

relies on soft-tissue measurements that can assist orthodontic clinicians in positioning the teeth more realistically and presents several examples to validate its contention.

Introduction Dr. William Downs developed the first cephalometric analysis to interpret and give orthodontists an instrument to plan treatment based on developed norms.1,2 However, these norms came from a small number of adolescent Caucasians, and the developed norms had little relationship with other races. Subsequent studies have developed more age, race, and gender-specific cephalometric data for use in diagnosis and treatment planning. The most popular cephalometric analyses and treatment planning systems have been the Tweed Triangle,3,4 Steiner Analysis,5,6 Williams APo Line,7 and the Visualized Treatment Objectives developed by Ricketts8 and Holdaway.9,10 The basis for the cephalometric analysis presented in this paper resides in taking the cephalometric image with the patient in natural head posture and using true horizontal (TH) as the reference plane.11-15 Downs

used the Frankfort Horizontal Plane, which was a popular anthropological reference line, but he confessed a dislike for this horizontal reference because of its variability16 (Figure 1). By using true horizontal as a primary reference line, clinicians receive two advantages unavailable with other conventional intracranial reference planes: 1) the true horizontal plane better describes the dentoskeleton and profile as they appear in patients; and 2) the true horizontal reference plane displays less variance when the head is seen in a natural posture.

Features of the true horizontal cephalometric analysis Clinicians have used SNA, SNB, and ANB almost exclusively for assessing the sagittal difference between the maxilla and mandible since their introduction by Downs2,16,17 and Riedel,18 but they have more historical than practical use, since the angulation and/or length of the cranial base can cause serious misinterpretations of ANB measurements (Figure 2). Jenkins19 first attempted a solution to this conundrum of accurate sagittal discrepancy

Figure 1: Variability of the Frankfort horizontal plane 40 Orthodontic practice

Volume 5 Number 5

a) 2˚ ANB

can vary in so many ways as to make them susceptible to serious errors. Studies have shown that true horizontal reference plane has at least 6 times less variability than conventional intracranial reference planes.24-28 Cooke15 suggested using true horizontal plane rather than Frankfort horizontal because of its nonvariable nature and draws perpendicular lines from A and B points to that plane. The average space between A and B is 4 ± 2.5 mm, but that distance can vary widely (-1 to 10) in normal Class I occlusions (Figure 3). The average A-B difference for African-Americans is 7 ± 4 mm. Readers have a perfect right to ask if such a variance has clinical relevance, and the following patient history should satisfy that curiosity. A clinician presented this patient (Figure 4) to an audience and claimed that because of the 4° ANB angle, the patient had a Class II craniofacial skeleton when, in fact, measuring with A-B perpendiculars from true horizontal revealed -3 mm — a negative distance more often found with Class III malocclusions. This diagnosis encouraged the clinician to embark on a futile nonextraction therapy that required a reversal in treatment planning after 6-9 months. So, yes, a correct assessment of cephalometric features can mean the difference in clinical success or failure. Fortunately, with this

b) -2˚ ANB

patient, the missed diagnosis proved reversible, and nothing more than the waste of time occurred for the patient and doctor. But what of the patients whose missed diagnoses and treatment plans cannot find a simple remedy or any remedy? Reed Holdaway9,10 proposed two important diagnositic and treatment planning lines that use the true horizontal plane: 1) the subnasale depth measures the distance of subnasale to a perpendicular line drawn from true horizontal to the outer contour of the upper lip; ideally it is 3 mm but can range from 2-4 mm with Caucasians. Sulcus depth for African-American distances average 6 ± 2.5 mm29. When the Caucasian profile measures 2 mm or less, clinicians must carefully design their therapy so as not to retract the maxilla or maxillary incisors. 5 mm or more of sulcus depth for the Caucasian ordinarily indicates a need for reduction of the protrusion of the maxilla and/or maxillary incisors (Figure 5); and 2) the H line (Harmony line) (Figure 6) that measures the distance from subnasale to a line tangent to the soft-tissue chin and the vermillion border of the upper lip. In Caucasians this distance is ideally 5 mm but can vary between 3 and 7 mm. In well-balanced Caucasian faces the H line should just touch the outer contour of the

c) 5˚ ANB

Figures 2A-C: A. normal length cranial base, B. long cranial base, C. short cranial base

Figure 3: Measuring A-B sagittal discrepancy by using the true horizontal (TH) plane.

Figure 4: Patient with an ANB of 4° but an A-B measurement of -3 mm.

Figure 6: The H line

Volume 5 Number 5

Figure 5: Subnasale depth

Orthodontic practice 41

CONTINUING EDUCATION

by relating the points A-B to the occlusal plane, which he argued Dr. Edward H. Angle had also used for his classification of malocclusions. Harvold20 also used the occlusal plane as a reference for differentiating the sagittal discrepancy. The most popular technique for measuring A-B differences using the occlusal plane was developed by Jacobson21,22 while on faculty at Witwatersrand University in South Africa. The Witwatersrand, or Wits, appraisal sought to separate the A-B difference from reliance on the cranial base, and, while well justified, also chose the occlusal plane as the reference from which to make the measurements. Nevertheless, use of the occlusal plane introduces another highly variable foundation that compromises the improvement it promises. Chang23 suggested that since the occlusal plane was a dental parameter, clinicians should consider the Wits appraisal as a measurement of the sagittal relationship of the dentures and not the jaws. Consequently, he suggested an alternative by projecting perpendicular lines of the points A and B onto the Frankfort horizontal plane (which, strangely enough, in his article as well as many other publications have the FH plane adjusted to mimic true horizontal [TH]). Chang’s sagittal assessment eliminates nasion and the occlusal plane, which

CONTINUING EDUCATION

Figure 7: The A line

Figure 8: The NA line

Figure 9: Maxillary incisor angulation

Table 1: Harvold’s cephalometric measurements for Caucasians 6 yrs mm

7 yrs mm

8 yrs mm

9 yrs mm

10 yrs mm

11 yrs mm

12 yrs mm

13 yrs mm

14 yrs mm

15 yrs mm

16 yrs mm

17 yrs mm

Adult mm

Mnd. Length Co-Gn

100

103

105

108

111

113

115

117

118

119

120

Mx Length Co-Pt A

Mx-Mnd Difference

Figure 10: Maxillary and mandibular lengths and anterior face height

ANS-Menton

upper lip and the lower lip should be on the H line or within 1 mm of it. African-American H line measurements from subnasale to the H line average 13 ± 3 mm. Alvarez30 suggested using a perpendicular line from true horizontal (TH), i.e., the A line to establish a natural position for the maxillary central incisor. The A line is a perpendicular line drawn from true horizontal through a point ⅓ of the distance between soft-tissue A point and hard-tissue A point (Figure 7), and the maxillary incisor should touch or be within ± 1 mm of the A line for Caucasians. For AfricanAmericans the maxillary incisor will lie 2 mm ± 2 mm in front of the A line. Creekmore offered an additional measurement of ideal maxillary incisor position by relating the maxillary incisal edge to the NA line. The incisor should lie 4 ± 1 mm ahead of the NA line. This average measurement for African-Americans is 7 ± 2 mm. Furthermore, the NA line extended to the mandibular incisor should bisect the incisal edge of that tooth or be within ± 1 mm (Figure 8). For African-Americans, the mandibular incisor will lie 2 ± 3 mm in front of the NA line. Note the near ideal position of the maxillary incisor in the image at the top of the page and the retrusive position of the mandibular incisor, which suggests a need for mandibular advancement.

Mnd. Length Co-Gn

102

105

107

109

111

114

116

121

123

127

128

130

Mx Length Co-Pt A

100

Mx-Mnd Difference

ANS-Menton

Females

42 Orthodontic practice

Males

The maxillary incisor’s axial line should ideally pass through the distal of the orbit, and whose angle will ordinarily measure 107° ± 7° to true horizontal (Figure 9). However, this can vary from 93° to 120° and still offer ideal positions for the maxillary incisors depending on the A-B discrepancy, occlusal plane, and other features. Proper inclination of the maxillary incisors has unusual importance for upper lip support, and ultimately, the integrity of the soft-tissue profile. Other measurements that prove unusually helpful in a cephalometric diagnosis and treatment planning regimen are those offered by Harvold20 for determining the relative lengths of the maxilla and mandible measured from condylion, and the anterior face height measured from the anterior nasal spine to menton (Figure 10). The maxillary and mandibular lengths can help clinicians differentiate the etiologies of various

malocclusions by comparing their lengths to norms for that age. The maxillary length measures from condylion to A point, while the mandibular length measures from condylion to gnathion. The anterior face height (Figure 10) measured from anterior nasal spine to menton gives clinicians valuable information regarding the forward or backward rotation the mandible has had, and it provides more sensitivity and relevance than the mandibular plane angle while alerting doctors to the difficulty or ease they may have in opening or closing the overbite of a patient. Harvold’s measurements for males and females are found in Table I. Another measurement that has nothing to do with true horizontal but has great appeal for many clinicians is the A-Pogonion line in relation to the mandibular incisors. Williams7 introduced this diagnostic and treatment Volume 5 Number 5

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Figure 11: Williams’ ideal APo line related to the mandibular incisor

Figure 12: Untreated Class I occlusion

Maxillary 1 to A Line =+1mm Maxillary 1 to NA line = +4mm Maxillary 1 to TH = 115° ANB angle = 10° A-B / TH = 12mm IMPA = 114° Mandibular 1 to NB = 15mm Mandibular 1 to APo = 5mm Mandibular 1 to NA = -1mm Upper lip sulcus depth = 3mm H line to subnasale = 5mm H line to lower lip = -1mm

Figure 13: Cephalometric tracing of untreated Class I occlusion

Holdaway and Alvarez are probably correct when they direct us to the maxillary central incisor as the key to diagnosis and treatment planning rather than the mandibular incisor. The maxillary incisor routinely supports both upper and lower lips and determines the appearance of the soft-tissue profile. Others such as Bass36,37 and Eastham38 have come to similar conclusions using different measurements for the maxillary incisors, but the experience of these well-informed and highly experienced clinicians merits close attention. Finally, orthodontists must account for the occlusal plane, and this is best done by drawing a line that bisects the overlapping cusps of the first molars and the incisal overbite. In cases of greatly malpositioned incisors, draw the occlusal plane through the overlapping cusps of the first premolars and first molars (Figure 14). Ideally, the maxillary incisors will rest on the occlusal plane, and the mandibular incisors will extend 1 mm above the occlusal plane and occlude against the cingula of the maxillary incisors. Burstone39 and Bass36 have suggested good lip to maxillary incisor balance will find the occlusal plane about 3 mm below the lip embrasure. However, adolescents will benefit from positioning their maxillary incisors 5-6 mm below

Figure 14: Occlusal plane

the lip embrasure. As patients mature, the upper lip, as with other bodily features, will begin to sag, and maxillary incisors intruded during adolescence may completely disappear in adult smiles. Clinicians will need to keep these features in mind as they design treatment and exercise caution with any plan that advocates intrusion of the maxillary incisors with adolescents. Readers will find an ideal Caucasian adolescent tracing with salient features in the image on the next page (Figure 15) along with the measurements for this patient combined with the range of measurements for each of the described characteristics. Orthodontic practice 43

CONTINUING EDUCATION

planning recommendation in 1969. He suggested that in well-balanced faces and dentitions, the APo line would pass through the incisal edge of the mandibular incisor ±1m (Figure 11). However, subsequent and more extensive surveys of Class I occlusions associated with attractive faces have found acceptable mandibular incisor positions to the APo line to have a much wider range than what Williams advocated.31-33 Jacobson34 also cautions clinicians regarding the exclusive use of the mandibular incisor’s relation to APo for diagnosis and treatment planning because it does not consider the angulation of that tooth. As Casko31 and Creekmore31 have suggested, the wide acceptable variance of the mandibular incisor relates directly to the skeletal distance between the maxilla and mandible; e.g., the more advanced the maxilla is to the mandible, the more the mandibular incisors must protrude in order to contact the maxillary incisors. Even Tweed3 conceded that flared mandibular incisors were acceptable when there is no arch length discrepancy and the facial esthetics are good. Contrarily, the closer the maxilla is to the mandible, the more upright the mandibular incisors must be to occlude with the maxillary incisors. This feature of normal occlusion and skeletal compatibility in Class I patients proves the inadequacy of using the mandibular incisor as the primary diagnostic and treatment planning scheme. The following untreated woman with a Class I occlusion and ideal soft-tissue profile (Figure 12) illustrates how the mandibular incisors must protrude extensively when combined with a large A-B difference (Figures 12 and 13) and does so with no deleterious esthetic effects . Hardly anyone who looks at this face, profile, and occlusion would advocate treatment of any kind, much less extraction therapy. However, the cephalometric numbers related to the mandibular incisor are exactly those that more often than not compel clinicians to extract premolars and retract the anterior teeth to satisfy some previously agreed upon protocol . In an unpublished paper, Creekmore35 noted that all of the diagnostic and treatment planning regimens, e.g., Tweed, Steiner, Williams, Holdaway, Ricketts, Alvarez, etc., have validity for individuals with average A-B discrepancies. However, as the skeletal discrepancies between maxilla and mandible increase or decrease, these popular and venerable regimens have less relevance and in many cases lead to serious miscalculations.

CONTINUING EDUCATION Discussion Charles Tweed3,4 gave orthodontists their first cephalometrically derived treatment planning instrument — the Tweed Triangle — which favorably placed the mandibular central incisors within the confines of the anterior alveolar cortical plates. He then arranged the rest of the dentition to fit these mandibular incisors. Tweed felt that ideally positioned mandibular central incisors had a 90º angulation ± 3º to the mandibular plane. Practically all subsequent cephalometric treatment planning schemes drew from Tweed’s idea of first positioning the mandibular central incisors and then arranging the rest of the dentition to correspond to these teeth. The Steiner Analysis,5,6 Williams7 APo line, and Rickett’s8,40 Visualized Treatment Objective may have differed as to the position of the mandibular incisors, but all of them based their cephalometric treatment plans on the position of these teeth. Holdaway9,10 was the first to suggest the maxillary central incisors as the main determinant of lip posture, and that patients might receive better therapy if treatment planning started by determining where the lips should be at the conclusion of treatment. Rather than letting the relationship between mandibular central incisors and osseous tissues dictate the treatment plan and mechanics, Holdaway boldly suggested that clinicians should consider the effect such therapy will have on soft tissues. Ignoring this imperative can cause serious worsening of the profile and lip support as seen in Figure 16. Few clinicians would consider the results of this therapy as beneficial for the patient’s profile. Perhaps Holdaway’s most significant discovery was that, in Caucasians, the upper lip retracts exactly with the maxillary central incisors, with exceptions allowed for a few types of malocclusions and racial differences. Other authors41,42 have suggested differing

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Figure 15: An ideal Caucasian adolescent cephalometric tracing occlusion

clinical responses to maxillary incisor retraction, but the differences are attributable to the exceptional cases Holdaway mentioned and obvious racial differences in lip thickness. Despite whatever disagreement exists about the amount of movement treatment may produce on the maxillary incisors, hardly anyone now disputes the idea that lip posture and contour are, fundamentally, a function of maxillary central incisor position. So while there may not yet be a consensus about the amount of movement expected from therapy, simple acknowledgment of this incisor function warrants attention to the exclusion of hard-tissue determinants that have no direct relationship to lip contour. Without unanimous agreement about what to expect from treatment and subsequent positioning of the maxillary central incisors, clinicians might ask why they should rely on their placement in the face as a diagnostic and treatment planning instrument. Holdaway used this knowledge of maxillary central incisor effect on lip curl to design his visualized treatment objective (VTO), which subsequently gave him the targets for positioning the teeth. Describing the Holdaway VTO or any other is beyond the scope of this paper, but readers should familiarize themselves with his technique by reading

Figure 16: Cephalometric images of before and after treatment with premolar extractions dictated by osseous tissues 44 Orthodontic practice

True Horizontal H line from subnasale 5mm (3-7mm) Subnasale depth 3mm (2-4mm) A line 0mm (±1mm) Perpendicular to A point Perpendicular to B point [A-B difference 4mm (-3 to 12mm)] NA line to maxillary incisor 4mm± 1mm NA line to mandibular incisor 0mm± 1mm Condylion to A (age related-Harvold) Condylion to B (age related-Harvold) Occlusal plane 5-6mm below embrasure for adolescents; 3-4mm for adults. ANS to menton (age related-Harvold) Maxillary incisor to TH 115° (93°- 120°)

the original articles, since all other VTO techniques have proceeded from that one. The significant difference between Holdaway and other methods of diagnosis and treatment planning is that maxillary lip form has replaced the mandibular central incisor position as the focus of our treatment planning. By combining the Creekmore, Alvarez, and Holdaway analyses, clinicians will often find a consensus. When they differ substantially as in Figure 17, reliance on the Holdaway analysis offers the best alternative since it depends on the soft tissue exclusively, and that is what we ultimately consider when looking at someone. The patient in Figure 17 has an ideal lip sulcus of 3 mm, while the maxillary and mandibular incisors are substantially advanced of the NA line, and the maxillary incisor is 1.5 mm ahead of the Alvarez A line. By adhering to the Holdaway standard and not changing the maxillary incisor position, this patient runs less risk of profile deterioration. Perhaps the best clinical advice for clinicians who would use the maxillary incisor position for diagnosis and treatment planning is to evaluate their personal treatments and techniques to determine what they routinely accomplish with particular facial types and malocclusions. This type

Figure 17: Disagreement among the Creekmore, Alvarez, and Holdaway analyses Volume 5 Number 5

Conclusion The biggest problem with the acquisition and application of new ideas and techniques is not the actual learning of them, rather the forgetting and using of older and more habitual thoughts. This reluctance to unlearn old lessons is what economists, lawyers, and

social scientists call path dependence, which broadly means history matters. Path dependence explains how the set of decisions one faces for any given circumstance is limited by the decisions one has made in the past, even though past circumstances may no longer have relevance. A standard that is first-to-market can become entrenched (like the QWERTY layout in typewriters still used in computer keyboards). Such path dependence of inferior standards can persist simply because of the legacy they have built. QWERTY versus Dvorak as an example of this phenomenon has been re-asserted, questioned, and continues to be argued. Yet we continue to teach, use, and rely on QWERTY despite its proven inferiority. Path dependence has a close relationship to “imprinting,” which captures how initial environmental conditions leave a persistent mark or imprint on

organizations, industries, and communities, and thus continue to shape organizational behaviors and outcomes even as external environmental conditions change. Most orthodontic institutions, accrediting agencies, insurance companies, etc., may determine that the replacement of traditional cephalometry standards is not worth the distress an endorsement of clearly more relevant and accurate guidelines might cause, e.g., using true horizontal as a basis of diagnosis, treatment planning, and therapy. Nevertheless, the implementation by individual clinicians of measurements introduced in this article along with those of others cited herein could occur with hardly any anguish or difficulty. The benefits far outweigh the liabilities, and by evaluating malocclusions via the natural head postures of patients, orthodontists will discover more realistic diagnoses and treatment plans. OP

BIBLIOGRAPHY 1. Downs WB. Analysis of the dento-facial profile. Am J Orthod. 1952;38:162. 2. Downs WB. Variations in facial relationships: Their significance in treatment and prognosis. Am J Orthod. 1948;34(10):812-840. 3. Tweed CH. The Frankfort mandibular incisor angle (FMIA) in orthodontic diagnosis, treatment planning and prognosis. Angle Orthod. 1954;24(3):121-169. 4. Tweed CH. The diagnostic facial triangle in the control of treatment objectives. Am J Orthod. 1969;55(6):651-657. 5. Steiner CC. The use of cephalometrics as an aid to planning and assessing orthodontic treatment: Report of a case. Am J Orthod. 1960;46(10):721-735. 6. Steiner CC. Cephalometrics in clinical practice. Angle Orthod. 1959;29:8-29. 7. Williams R. The diagnostic line. Am J Orthod. 1969;55(5): 458-476. 8

Ricketts RM, Bench RW, Gugino CF, Hilgers JJ, Schulhof RJ. Bioprogressive Therapy. Denver, CO: Rocky Mountain Orthodontics; 1979.

9. Holdaway RA. A soft-tissue cephalometric analysis and its use in orthodontic treatment planning. Part I. Am J Orthod. 1983;84(1):1-28. 10. Holdaway RA. A soft tissue cephalometric analysis and its use in orthodontic treatment planning. Part II. Am J Orthod. 1984;85(4):279-293. 11. Moorees CFA, Kean, M.R. Natural head position, a basic consideration in the interpretation of cephalometric radiographs. Am J Phys Anthropol. 1958;16(2):213-234. 12. Michiels LY, Tourne LP. Nasion true vertical: a proposed method of testing the clinical validity of cephalometric measurements applied to a new cephalometric reference line. Int J Adult Orthodon Orthognath Surg. 1990;5(1):43-52. 13. Lundström F, Lundström A. Natural head position as a basis for cephalometric analysis. Am J Orthod. 1992;101(3):244-247. 14. Cooke MS, Wei SHY. Nasion true vertical: a proposed method for testing the clinical validity of cephalometric measurements applied to a new cephalometric line. Am J Orthod. 1988;93:280-288. 15. Cooke MS, Wei, SH. A summary five-factor cephalometric analysis based on natural head posture and the true horizontal. Am J Orthod Dentofacial Orthop. 1988;93(3):213-223. 16. Downs WB. Analysis of the dento-facial profile. Angle Orthod. 1956;26:191-212. 17. Cotton WN, Takano WS, Wong WM. The Downs analysis applied to the three other ethnic groups. Angle Orthod. 1951;21(4):213-220. 18. Riedel R. The relation of maxillary structures to cranium in malocclusion and normal occlusion. Angle Orthod. 1952;22(3):142-145. 19. Jenkins D. Analysis of orthodontic deformity employing lateral cephalostatic radiography. Am J Orthod. 1955;41(6):442-452. 20. Harvold E. Some biologic aspects of orthodontic treatment in the transitional dentition. Am J Orthod. 1963;49(1):1-14. 21. Jacobson A. The “Wits” appraisal of jaw disharmony. Am J Orthod. 1975;67(2):125-138. 22. Jacobson A. Application of the “Wits” appraisal. Am J Orthod. 1976;70(2):179-189. 23. Chang HP. Assessment of anteroposterior jaw relationship. Am J Orthod Dentofacial Orthop. 1987;92(2):117-122. 24. Cooke M. Cephalometric analyses based on natural head posture of Chinese children in Hong Kong [thesis]. Hong Kong: University of Hong Kong; 1986. 25. Moorrees CFA. Natural head position. In: Introduction to Radiographic Cephalometry. Philadelphia, PA: Lea & Febiger; 1985. 26. Moorrees CFA, Kean, M.R. Natural head posture, a basic consideration in the interpretation of cephalometric radiographs. Am J Phys Anthropol. 1958;16(2):213-234. 27. Solow B, Tallgren A. Natural head position in standing subjects. Acta Odontol Scand. 1971;29(5):591-607. 28. Foster TD, Howat AP, Naish PJ. Variation in cephalometric reference lines. Br J Orthod. 1981;8(4):183-187. 29. Alvarez A. The A line: a new guide for diagnosis and treatment planning. J Clin Orthod. 2001;35(9):556-569. 30. White LW. A cephalometric search for the ideal African-American soft-tissue profile. Orthodontic Practice US. 2012;3(2):18-24. 31. Casko JS, Shepherd WB. Dental and skeletal variation within the range of normal. Angle Orthod. 1984;54(1):5-17. 32. Creekmore TM. Where teeth belong and how to get them there. J Clin Orthod. 1997;31(9):586-608. 33. McNamara JA Jr, Ellis E III. Cephalometric analysis of untreated adults with ideal facial and occlusal relationships. Int J Adult Orthodon Orthognath Surg. 1988;3(4):221-231. 34. Jacobson A. Radiographic Cephalometry. Chicago, IL: Quintessence; 1995. 35. Creekmore TM, DDS. Personal correspondence, PowerPoint presentation. 2000. 36. Bass NM. The aesthetic analysis of the face. Eur J Orthod. 1991;13(5):343-350. 37. Bass NM. Measurement of the profile angle and the aesthetic analysis of the facial profile. J Orthod. 2003;30(1):3-9. 38. Eastham R. Relationship of the maxillary incisor to the soft tissue facial plane. Northwest Angle Society; 2002. 39. Burstone CJ. Lip posture and its significance in treatment planning. Am J Orthod. 1967;53(4):262-284. 40. Ricketts RM. Cephalometric analysis and synthesis. Angle Orthod. 1961;31:141-156. 41. Diels RM, Kalra V, DeLoach N Jr, Powers M, Nelson SS. Changes in soft tissue profile of African-Americans following extraction treatment. Angle Orthod. 1995;65(4):285-292. 42. Yogosawa F. Predicting soft tissue profile changes concurrent with orthodontic treatment. Angle Orthod. 1990;60(3):199-206.

Volume 5 Number 5

Orthodontic practice 45

CONTINUING EDUCATION

of private study will give clinicians a much more specific idea of what to expect with a particular treatment design and should permit orthodontists to achieve more accuracy in their treatment forecasts. Clinicians should not consider the Holdaway treatment-planning technique infallible or the only analysis necessary in deriving a diagnosis and treatment plan. However, it does place a diagnostic and therapeutic emphasis on the dental feature most responsible for lip contour and facial appearance, i.e., the maxillary central incisor.

CONTINUING EDUCATION

Orthodontics in the modern age Dr. Derek Mahony discusses the use of bracket modification in orthodontics for the 21st century

n the early 1970s, Dr. Lawrence Andrews introduced the Straight-Wire Appliance that permitted first, second, and third order movements for teeth without wire bends. The 1970s proved fertile in yet another significant way with the introduction of nickel titanium wires, as shown by Andreasen, et al., (1978). By the 1990s, development of new titanium wires (that responded to thermal changes) made the ligation of severe rotations easier, and the wires worked longer without requiring change, as several studies have shown (Kawashima, Ohno, Sachdeva, 1999; Kapila, Sachdeva, 1989; Sachdeva, 1994). Yet, for all of the sophistication that these new materials have brought to orthodontics, the mechanotherapy has not changed appreciably, nor has the treatment time for patients diminished. Invasive techniques requiring heavy archwire forces, multiple extractions, palatal expanders, and so on, remain favorite therapies for many orthodontists. These appliances, however, fail to mitigate the damaging effects of classical, routine orthodontic forces.

A new approach Dr. Dwight Damon has pursued the idea of “physiologically determined” tooth positioning using very light forces for many years. Advances in CT technology seem to confirm Dr. Damon’s belief that when “biologically sensible forces” are applied to the teeth, the alveolar bone can, and does, remodel itself, and a new physiological balance can be achieved. Patients treated with light forces, in passive tubes (with large arch forms that have small wire-to-lumen ratios), demonstrate movement of teeth with little tipping in all planes of space. Supporting alveolar bone also follows the teeth (Figure 1), according to Graber, Vanarsdall, and Vig (2005). Dr. Derek Mahony is a specialist orthodontist in Australia. He has spoken to thousands of general dental practitioners about the benefits of interceptive orthodontic treatment. Dr. Mahony completed his dental degree at the University of Sydney, Australia, before finishing his masters in orthodontics at the Eastman Dental Hospital, London. He has since completed a diploma in orthodontics at the Royal College of Surgeons, Edinburgh, and passed the Royal College of Dentists in Canada graduate examination in orthodontics.

46 Orthodontic practice

Educational aims and objectives

This article aims to present how the Damon System can present advantages to the dentist and patient.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 48 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Recognize that, when using the Damon® System, the treatment plan should consider the profile, arch width, and facial support of patients, instead of relying only on points and lines on osseous tissues in cephalometric tracings. • Identify the advantages and disadvantages of the Damon System.

A review of Retian’s (1951, 1974, 1971) and Rygh’s (1972, 1973) work regarding the effect of conventional forces on the periodontium and alveolar bone further convinced Dr. Damon that orthodontists needed to apply light forces to achieve less damaging and more natural physiological movements of teeth, particularly when trying to expand the arch form.

Damon® System development Several features of conventional orthodontic therapy, such as dependence on larger wires, a binding ligation system, a high wire-to-lumen ratio, and heavy reliance on extraction therapies, have prevented the application of light forces. The reduction of forces thus requires an entirely different system of brackets combined with a new system of force application. This requires nothing less than a quantum or qualitative change in orthodontic diagnosis, treatment planning, and therapy. In the cases I have treated with the Damon philosophy, my patients have noted more comfortable and faster tooth movement. By taking patient records at frequent intervals and analyzing these cases, I can now say that by minimizing the interruption of blood flow during tooth movement, with low-force wires, I have shortened the treatment time, lessened patient discomfort, and brought the treatment time of adults within the range of children.

Begin with the face

The Damon System begins with the face. Instead of relying only on points and lines on osseous tissues in cephalometric tracings,

Figure 1: The Damon tube — leveling, alignment, and arch adaptation depend upon a small wire-to-lumen ratio in a low friction environment

Dr. Damon suggests that we should also consider and treatment plan for the profile, arch width, and facial support of our patients. With the Damon System, we try to match our treatment mechanics with the natural lowforce systems of the body. Rather than a typical bracket that relies on conventional ligation, Dr. Damon felt a bracket that functioned as a tube with a static facial wall would obviate ligation altogether and allow the passive appliance needed to achieve physiological forces. He developed a bracket with a sliding facial wall that allows simple insertion, but closes to encapsulate the arch wire without tightly binding it. The first generation of the Damon selfligating bracket was introduced in 1995 (Figure 2A). Along with this new bracket concept, Dr. Damon fundamentally changed the types of arch wires and the sequence in which clinicians use them. Volume 5 Number 5

Figure 2B: Damon 2 bracket in closed position

His experience has shown that, with many patients, he can often eliminate retraction of molars, extractions (excluding those needed to reduce bimaxillary protrusions), and rapid palatal expansion. He offers compelling clinical evidence of doing such treatment with consistency (2005). The archwires Dr. Damon advocates as the initial wires are quite light in force (round .013 copper nickel titanium, Ormco Corporation) and with a wider arch form in comparison to those typically used by orthodontists. Dr. Damon persists in using these wires for longer intervals in order to fully exploit their developmental potential. This allows longer time periods between appointments, less discomfort, and fewer disruptions to patients’ lives.

Advantages and disadvantages No system of orthodontic therapy offers unalloyed blessings, and the Damon System has some distractions; for example, the bracket cost and its relatively large size. Nevertheless, its advantages more than outweigh these minor objections and offer the following substantial rewards for dentists and patients: • Shorter treatment time • Fewer appointments • Fewer extractions • The elimination of RPEs in most cases, and simplified mechanics in nearly all cases • Less reliance on patient compliance • A shorter learning curve for auxiliary personnel • A focus on tooth alignment and facial balance • Increased productivity and profitability. The most logical questions readers could propose would be why Dr. Damon has shown successfully sustained development of arches, whereas Dr. Edward H. Angle and others did not. The quantity of expansion probably differs little, but the quality of expansion offers a quantum change. Mollenhauer (1990; 2000) has suggested as much, with his appeal for light forces. Volume 5 Number 5

Figure 2C: Damon 3 bracket opened and closed

Even though Angle used a ribbon arch (which suggests a thin, delicate wire), the actual size of the wire had the dimension of .036 x .022 inches. Ligating to this wire would overwhelm the periodontium and prevent the development of a supporting dentoalveolar. Typical edgewise archwires also generate far more force than that compatible with physiological dentoalvelolar development. Rather than forming new bone, the supporting dentoalveolar simply bends and, upon completion of treatment, quickly returns. Astute clinicians often see this with molar retraction from headgear use and over-treat such cases in order to compensate for this regressive bone bending. Other researchers offer compelling evidence of bone bending as a feature of orthopedic appliance therapy (DeVincenzo, Moon, Lestrel, 2000), and they suggest the need of subsequent dentoalveolar development and modified posterior occlusion to maintain orthopedic corrections (Herbst, 1934). The most important caveat Dr. Damon offers clinicians is not to use their ordinary mechanics with this system, and I could not agree more. When I first began to use the system, I continued to use the regular sequence of arch wires and saw little advantage to these new, more expensive brackets. Nevertheless, as I began to use them according to Dr. Damon’s advice, I started seeing phenomenal changes.

Big changes Our profession is witnessing an interest in qualitatively different biomechanics, which offer the possibility of eliminating, or at least significantly reducing, the use of headgears, rapid palatal expanders, and serial extractions. Nevertheless, the bracket systems that make this possible should command the utmost respect and clinicians who wish to use these new methods should receive proper training. If a dentist thinks of this new technology only in terms of a brackets and continues to use conventional mechanics

and diagnosis, the true benefits of minimizing friction and binding will not become apparent. The big change comes when the clinician utilizes this low-force system to expand treatment planning options. This system should encourage dentists to challenge their own thought processes and take their patient care to a higher level. OP

REFERENCES 1. Andreasen GF, Morrow RE. Laboratory and clinical analyses of nitinol wire. Am J Orthod. 1978;73(2): 142-151. 2. Andreasen GF, Bigelow H, Andrews JG. 55 Nitinol wire: force developed as a function of “elastic memory. Aust Dent J. 1979;24(3): 146-149. 3. Andreasen GF. Treatment advantages using nitinol wire instead of 18-8 stainless wire with the edgewise bracket. Quintessence Int Dent Dig. 1980;11(12): 43-51. 4. Andrews LF. Straight wire, the concept and appliance. San Diego, CA: LA Wells Company; 1989. 5. Damon DH. Treatment of the face with biocompatible orthodontics. 4th ed. Orthodontics: current principles and techniques, ed. Tom Graber. St. Louis, MO: Elsevier Mosby; 2005. 6. DeVincenzo JP, Moon W, Lestrel PE. Mandibular shape changes with functional appliance therapy as assessed by Fourier descriptors. Unpublished article, 2000. 7. Graber T, Vanarsdall RL Jr, Vig KWL. Orthodontics: current principles and techniques.4th ed, St Louis: Elsevier Mosby; 2005. 8. Herbst E (1934) Thirty years experience with the retention joint. Zahnartzl Rundschau. 443: 1515-1524, 1563-1568, 1611-1616. 9. Kapila S, Sachdeva R. Mechanical properties and clinical applications of orthodontic wires. Am J Orthod Dentofacial Orthop. 1989;96(2): 100-109. 10. Kawashima I, Ohno H, Sachdeva R. Relationship between Af temperature and load changes in NiTi orthodontic wire under different thermo mechanical conditions. Dent Mater J. 1999;18(4): 403-412. 11. Mollenhauer B. An aligning auxiliary for ribbon arch brackets: rectangular boxes from ultrafine high tensile wires. Aust Orthod J. 1990;11(4): 219-226. 12. Mollenhauer B (2000) Ultralight forces for simultaneous orthodontics and orthopedics: part III. dentofacial orthopedics. International Journal of Oral and Maxillofacial Implants. 1(2): 195-201. 13. Reitan K. The initial tissue reaction incident to orthodontic tooth movement as related to influence of function; an experimental histologic study on animal and human material. Acta Odontol Scand Suppl. 1951; 6: 1-240. 14. Reitan K. Tissue behavior during orthodontic tooth movement. Am J Orthod. 1960;46(12): 881-900. 15. Reitan K, Kvam E. Comparative behavior of human and animal tissue during experimental tooth movement. Angle Orthod. 1971;41(1):1-14. 16. Reitan K. Initial tissue behavior during apical root resorption. Angle Orthod. 1974;44(1): 68-82. 17. Rygh P, Reitan K. Ultrastructural changes in periodontal ligament incident to orthodontic tooth movement. Trans Eur Orthod Soc. 1972;393-405. 18. Rygh P. Elimination of hyalinized periodontal tissues associated with orthodontic tooth movement. Scand J Dent Res. 1974;82(1): 57-73. 19. Sachdeva R. Variable transformation temperature orthodontics. Clinical Impressions. 1994;3(1): 2-17.

Orthodontic practice 47

CONTINUING EDUCATION

Figure 2A : Damon 1 (Damon SL)

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Value of true horizontal in diagnosis and treatment planning WHITE 1.

Jenkins first attempted a solution to this conundrum of accurate sagittal discrepancy by relating the points A-B to the ____________, which he argued Dr. Edward H. Angle had also used for his classification of malocclusions. a. occlusal plane b. cranial base c. true vertical reference plane d. upper lip Clinicians have used _________ almost exclusively for assessing the sagittal difference between the maxilla and mandible since their introduction by Downs and Riedel, but they have more historical than practical use, since the angulation and/or length of the cranial base can cause serious misinterpretations of ANB measurements a. SNA b. SNB c. ANB d. all of the above Studies have shown that true horizontal reference plane has at least ______ less variability than conventional intracranial reference planes. a. 2 times b. 4 times c. 6 times d. 8 times ________ offered an additional measurement of ideal maxillary incisor position by relating the maxillary incisal edge to the NA line. a. Angle b. Creekmore c. Frankfort d. Alvarez This feature of normal occlusion and skeletal compatibility in Class I patients proves the _____ of using the mandibular incisor as the primary diagnostic and treatment planning scheme. a. vital nature b. inadequacy

48 Orthodontic practice

c. natural proclination d. adequacy 6.

Finally, orthodontists must account for the _____, and this is best done by drawing a line that bisects the overlapping cusps of the first molars and the incisal overbite. a. occlusal plane b. A-Pogonion line c. Harvold measurements d. width of the gnathion Burstone and Bass have suggested good lip to maxillary incisor balance will find the occlusal plane about ____ below the lip embrasure. a. 1 mm b. 2 mm c. 3 mm d. 4 mm As patients mature, the upper lip, as with other bodily features, will begin to sag, and maxillary incisors intruded during adolescence may _____ in adult smiles. a. appear more prominent b. decay more quickly c. cause a diastema d. completely disappear

Tweed felt that ideally positioned mandibular central incisors had a _____ ± 3º to the mandibular plane. a. 45º angulation b. 65º angulation c. 75º angulation d. 90º angulation

10.

____ was the first to suggest the maxillary central incisors as the main determinant of lip posture, and that patients might receive better therapy if treatment planning started by determining where the lips should be at the conclusion of treatment. a. Bass b. Angle c. Burstone d. Holdaway

Orthodontics in the modern age MAHONY

In the early 1970s, _______ introduced the StraightWire Appliance that permitted first, second, and third order movements for teeth without wire bends. a. Dr. Lawrence Andrews b. Dr. Rohit Sachdeva c. Dr. Dwight Damon d. Dr. Emil Herbst

The 1970s proved fertile in yet another significant way with the introduction of __________ wires, as shown by Andreasen, et al., (1978). a. nickel-titanium b. polypropylene plastic c. stainless steel d. robotic

Dr. Dwight Damon has pursued the idea of “physiologically determined” tooth positioning using _________ for many years. a. very heavy forces b. very light forces c. neutral forces d. no force at all Several features of conventional orthodontic therapy, such as _______________ and heavy reliance on extraction therapies, have prevented the application of light forces. a. dependence on larger wires b. a binding ligation system c. a high wire-to-lumen ratio d. all of the above By taking patient records at frequent intervals and analyzing these cases, I (Dr. Mahony) can now say that by minimizing the interruption of blood flow during tooth movement, with low-force wires, I have ______________. a. shortened the treatment time b. lessened patient discomfort c. brought the treatment time of adults within the range of children d. all of the above

Rather than a typical bracket that relies on conventional ligation, Dr. Damon felt a bracket that functioned as a tube with a static facial wall would obviate ligation altogether, and allow the _____ needed to achieve physiological forces. a. rapid palatal expansion b. greater force c. passive appliance d. heavy archwire forces

His (Dr. Damon’s) experience has shown that, with many patients, he can _____ retraction of molars, extractions (excluding those needed to reduce bimaxillary protrusions), and rapid palatal expansion. a. often eliminate b. delay c. reduce d. speed up

No system of orthodontic therapy offers unalloyed blessings, and the Damon System has some distractions; for example, _____ . a. more appointments needed b. the bracket cost c. its relatively large size d. both b and c

Typical edgewise archwires also generate _____ than that compatible with physiological dentoalvelolar development. a. far more force b. far less force c. the same force d. less productivity

10.

The most important caveat Dr. Damon offers clinicians is _____ their ordinary mechanics with this system, and I could not agree more. a. to integrate b. to immediately implement c. not to use d. to train their staff to retrofit

Volume 5 Number 5

CE CREDITS

ORTHODONTIC PRACTICE CE

PRODUCT SPOTLIGHT

Ortho2’s Edge

rtho2’s Edge is a cloud-based practice management system designed for the orthodontist. Edge includes innovative features, such as a customizable dashboard, intuitive imaging, mobile apps, patient education animations, appointment reminders, and so much more. These core features are designed to keep your day on track and running smoothly. The Dynamic Dashboard allows all users to see what is important to them at a glance. A variety of widgets offer you real-time information about your office — from practice charts, to monitoring patients who are in your office waiting for their appointments, and viewing patients in your personalized Stacks — the dashboard can show you exactly what you want to see.

In addition, Edge offers several modules that take your practice from good to great. Edge Animations offers powerful surgical animations, and true 3D (stereoscopic) animations rendered with cutting-edge techniques make Animations one of the most powerful educational tools for orthodontists. Premier Imaging adds comprehensive image and timepoint morphing features to the Edge Imaging suite, in addition to ceph tracing and analysis. And Edge Reminders is a great way to stay in contact with your patients and minimize no-shows. This easyto-use system allows you to send reminders via phone, text, and/or e-mail. With the Edge Cloud, you don’t have to purchase, configure, and maintain complex network servers, nor do you have the cost, time, and worries of creating your own data backups. Your initial and ongoing hardware costs are significantly lower. All of your information is stored in an SAS-70 rated facility, which also manages data for large financial institutions and insurance companies. Storing your information in the cloud means that Edge goes where you go. Volume 5 Number 5

Edge Mobile, a free app for both Android and Apple devices, allows orthodontists to view vital information, including patient and professional information, their schedules and appointments, Stacks, and user-defined Edge Dashboard charts. Extend these features to your patients and responsible parties through the newly released Practice Connect, a completely customizable app made just for your office. It provides a variety of features that enhances patient experience and compliance, while at the same time offers valuable information to prospective patients and an area for referrals. Practice Connect allows patients to interact with their orthodontic experience in ways never before possible. Tailor the information your patients see, including but not limited to, upcoming appointments, images, animations, and even reward points. Additionally, responsible parties can view financial information, including any outstanding balances, and make payments. In addition, patients can set their own appointment reminders, check in from the app, and use another new feature in Edge — Patient Rewards. The patient reward system calculates points and tracks rewards you offer as incentive to motivate patient attendance, treatment cooperation, oral hygiene, and more. Patients can trade the points they earn by completing common treatment activities for prizes from your office. This use of positive

reinforcement helps motivate patients to be prompt to their appointments, schedule their next appointment while in the office, fill out online forms, and even keep their 6-month dental checkup. In addition to Practice Connect and Patient Rewards, the latest version of Edge includes the following: 1. ABO case submission in Premier Imaging. 2. Timepoint morphing, which allows you to take the images from throughout treatment and compile them into a sequence to show how treatment progressed. 3. The ability to schedule patient reminders for automatic submission based on a user-defined schedule. 4. Contracts can be designated as openended when creating them. 5. Many new widgets and reports.

About Ortho2 Ortho2 is the largest independently owned provider of comprehensive orthodontic practice management software and has been serving orthodontists exclusively for more than 30 years. Ortho2 is deeply committed to improving the efficiency and profitability of orthodontic practices through continuous research and innovation of practice management technologies. For more information about Ortho2, visit www.ortho2.com. OP This information has been provided by Ortho2.

Orthodontic practice 49

TECHNOLOGY

rthodontists rely on technology to improve the care they provide to their patients while ensuring their workflow is efficient. As a case in point, we’ve seen an upward trend over the past few years of orthodontic offices incorporating 3D cone beam computed tomography (CBCT) imaging into their practices. When used appropriately, CBCT imaging allows for a more comprehensive understanding of

the patient’s case and an improved diagnosis. This is largely due to the addition of accurate, patient-specific anatomical information that allows clinicians to more accurately diagnose and then plan treatment. This better

Bringing more than a decade of experience to LED Dental, Wes Newsom oversees the company’s product portfolio, including regulatory concerns, internal and external training and documentation, relations with corporate partners, regional development, and quality assurance processes. He also coordinates focus groups, market surveys, and competitive product research to ensure all products meet the needs of dental practitioners. Prior to joining LED Dental, Newsom worked at Carestream Dental in similar product line management roles in addition to serving as a lead field engineer and technical support analyst for the company’s digital imaging products. Newsom is based in Atlanta and holds a bachelor’s degree in management of information systems from the University of West Georgia. He is also certified in practical product management from Pragmatic Marketing Inc., the worldwide standard for successful product management.

50 Orthodontic practice

understanding leads to greater efficiency in scheduling and can help avoid clinical “surprises” that can create inefficiencies in case management. CBCT imaging moves radiographic imaging from the realm of pure diagnosis to a greater utility of facilitating image-guided treatments, and when combined with 3D optical scans, CBCT imaging can play a key role in 3D printing/medical modeling and 3D orthodontic treatment planning software systems, enabling practitioners to deliver the best possible care with the greatest efficiency.

CBCT imaging has been shown to benefit orthodontic workflow by providing additional information to clinicians before, during, and after the planned treatment. The main advantage of CBCT imaging is in providing accurate patient-specific information in all three planes of view. This allows practitioners to accurately quantify the envelope of alveolar bone, skeletal discrepancies, airway volumes, root angulation, and parallelism, and to precisely localize an impacted canine relative to the adjacent teeth. These are insights into a patient’s unique situation that 2D radiographic Volume 5 Number 5

Volume 5 Number 5

TECHNOLOGY

images and models alone cannot offer. CBCT imaging gives orthodontists a much more accurate view of root tip and torque and how the roots are being repositioned during treatment. This increased knowledge can assist in the prevention of periodontal issues posttreatment by ensuring that tooth movement isn’t happening too quickly and that roots are positioned within, and not beyond, the alveolus. With 2D images only, it can be difficult, if not impossible, to know where an impacted tooth is in relation to other anatomy. Practitioners can routinely eliminate unwanted surprises by using 3D imaging in the diagnostic and treatment planning phases. Field of view is critical with 3D imaging systems. Both orthodontists and patients are best served by having as much information as required, but ONLY that which is necessary to provide the appropriate diagnosis and treatment. Using the smallest field of view that does the job will reduce both the effective radiation dose to the patient and the liability for the practitioner. In addition, certain treatment tools, such as suresmile®(OraMetrix), utilize the increased accuracy and detail provided by CBCT to reduce treatment times for patients. Faster treatment times and fewer visits make orthodontic practices more efficient and result in more satisfied patients. The Samsung RAYSCAN Alpha from LED Dental (www.leddental.com), for example, has an optimal 9 cm x 9 cm CBCT field of view that captures both jaws, including third molars for orthodontic treatment planning, and offers digital 2D panoramic and cephalometric capabilities. Developed by Ray Co., Ltd., a subsidiary of Samsung Electronics, the RAYSCAN Alpha is fully upgradable from 2D to 3D in-office, allowing practitioners to transition from film to digital, and ultimately, CBCT at their own pace. The system’s CMOS and Direct Deposition CsI Detector ensures practitioners can quickly capture high-quality, 16-bit DICOM images at a low radiation dose. To minimize errors from positioning and movement (a common issue with younger patients), the system’s focal trough is stabilized and controlled through Adaptive Moving Focus technology. The Samsung RAYSCAN Alpha – Expert’s proprietary noise reduction technology enhances image quality by removing noise that would otherwise blur images. Due to its sleek design, the Samsung RAYSCAN Alpha – Expert can fit into nearly any practice’s floor plan. The system’s height adjustment component means patients of all

sizes, including adolescents and patients in wheelchairs, can fit comfortably in the unit. The RAYSCAN Alpha – Expert is also the world’s first imaging system to utilize a wireless remote control for patient positioning. Additionally, green, blue, yellow, and red LED lights indicate the status of the unit to practitioners at a glance: ready, standby, exposure, and emergency. In addition to the Samsung RAYSCAN Alpha – Expert’s advanced imaging capabilities and unique design, the system also features an intuitive user interface to streamline the capture process and simplify the manipulation of images. The unit also has a dedicated touch screen display for exposure parameter selection and image preview. The system utilizes LED Imaging Software for 2D images as well as Xelis 3D Imaging Software. With a 5-year warranty and the ability to integrate seamlessly with any practice management software, the Samsung RAYSCAN Alpha – Expert is a solid investment for any orthodontist.

While 3D digital imaging systems are a larger investment than 2D imaging products, the time savings and return on investment for those cases requiring advanced 3D imaging will greatly benefit orthodontic practices in the long run. Ultimately, the best purchase clinicians can make for their practices is a multi-function unit with a long-term warranty from a trusted company that will be there before, during, and after the point of sale. Since our launch in April, LED Dental has made a splash in the orthodontic market with 2D and 3D digital imaging products, highlighting our dedication to becoming one of the leading imaging providers in the industry. It’s our goal to provide practitioners with best-in-class imaging solutions ranging from extraoral imaging systems to intraoral cameras and beyond — so the next time you’re at a tradeshow, I invite you to come by our booth and explore the diverse product portfolio we have to offer! OP This information was provided by LED Dental.

Orthodontic practice 51

STEP-BY-STEP

Accurate Bracket Positioner™ (ABP) Drs. Pablo Echarri, Martín Pedernera, and Claus Schendell, Eng, outline the steps to accurate bracket setup without setup models Introduction The importance of the positioning of brackets has been demonstrated by many authors, in both labial and lingual orthodontics. Drs. Echarri and Schendell have developed the Accurate Bracket Positioner™ (ABP) to achieve precision mounting of labial or lingual brackets, with a working time of approximately 30 minutes for an arch wire with labial brackets and 45 minutes for an arch wire with lingual brackets. The objectives proposed for the development of the ABP were that it should: • be a precision instrument • be easy to operate • be usable with any type of labial or lingual bracket • allow independent customization of each bracket parameter • be capable of measuring each bracket parameter independently • provide information that allows the same bracket position to be reproduced if it is necessary to repeat a transfer tray • provide information that allows the creation of a transfer tray by precisely modifying any of the parameters with which the bracket was originally positioned • provide information that allows the ideal arch wire template to be created The ABP is based on using ABP positioners to three-dimensionally position the tooth from the initial patient model according to the prescription indicated by the specialist, and to position the bracket from the slot if using a “full size” ideal arch wire. Pablo Echarri, DDS, with over 25 years of orthodontic experience, operates a private practice in Barcelona, Spain. He obtained his DDS from the University of Montevideo, Uruguay. Dr. Echarri is a collaborating professor in Orthodontic Masters Studies at the Universities of Barcelona, Sevilla, and Alcalá de Henares. He has memberships in over 14 associations and societies in the orthodontic industry and is a founding member of the World Society of Lingual Orthodontics. Dr. Echarri has published seven books, including his most recent accomplishment, Microimplants and Orthodontics, and has written over 90 articles in orthodontic journals in eight countries.

52 Orthodontic practice

Figure 2: Model with the longitudinal axis

Figure 1: Accurate Bracket Positioner

Figure 3: Model with the rotation axis

The ABP (Figure 1) consists of a rotating base, which allows easy manipulation and visualization of the bracket positioning from any angle, and three towers: the anterior tower, the model tower, and the posterior tower. The model tower, in the center of the ABP, is used to position the model and allows the following movements: • antero-posterior (sagittal) movement • vertical movement • rotation • bucco-lingual inclination • mesio-distal inclination The anterior tower holds the torque and inclination indicator and the height styluses, as well as the torque scale. The height styluses allow tooth positioning in height, in-out, and rotation (first order), and the positioner allows positioning of mesiodistal inclination (second order) and torque (third order). The posterior tower holds the bracket holder and allows in-out, height, and rotation

movement of the brackets. The holder has two positions to allow labial or lingual positioning. The holder holds the Bracket Slot Holder, which holds the bracket to its slot. This accessory has three parts that can be adjusted to occupy the slot completely so that it always acts as a “full size” arch wire.

Lingual bracket procedure

positioning

The crown longitudinal axes, a horizontal line at the LA point (most prominent point of the crown [Figure 2]) and the rotation axes (incisal edges of the anterior teeth and labial cusps of the posterior teeth [Figure 3]) are drawn on the model. The model is painted with plaster separator and fixed on the model platform with silicone, in the closest possible position to the anterior tower. Positioning of lingual brackets should start with the canine, since it is the tooth with the greatest labial-lingual thickness and will be the one that determines the in-out and height of all the brackets of the six anterior teeth. Volume 5 Number 5

STEP-BY-STEP The following steps should be followed to position a tooth: 1. The model is fixed on the platform with silicone (Figure 4). 2. The model is placed so that the upper pin of the torque and inclination positioner matches the LA point, and the lower pin matches the longitudinal axis (Figure 4). To achieve this model position, the antero-posterior position of the base, the platform height, the bucco-lingual inclination of the platform, and the mesiodistal inclination of the platform should be adjusted. In this position, the torque gauge and inclination gauge should measure the indicated prescription. 3. The incisal edge of the tooth is leveled with the stylus, for which the platform height screw is adjusted (Figure 5). In Figure 5, the torque is observed on the left-hand scale, which is -1º, and the mesio-distal inclination (right-hand scale), which is 0º. 4. The tooth in-out, height, and rotation are adjusted, leveling the stylus with the incisal edge of the tooth and making the curvature of the stylus match the rotation axis by adjusting the rotating platform (Figure 6). 5. The bracket will be placed at 0º rotation or with the overcorrection indicated if necessary (Figure 7). This scale is in the upper part of the bracket holder in the posterior tower. Figure 7 shows 0º overcorrection of the rotation, but can be corrected to mesio or distal rotation at an indicated angle. 6. The bracket is placed in the Bracket Slot Holder and can be fixed with an elastic (Figures 8 and 9). 7. The bracket is centered on the mesiodistal center of the tooth, adjusting the lateral movement of the model tower (Figure 10). 8. The smallest possible in-out is selected (determined by the thickest tooth, which is the canine). This bracket position is measured on the in-out gauge of the posterior tower (Figure 11) and is

Figure 9: Placement of the JOY bracket on the tooth 54 Orthodontic practice

Figure 4: Positioning of the tooth, making the upper pin of the torque and inclination indicator match the LA point and the lower pin match the longitudinal axis

Figure 5: Torque measurement (-1º) on the scale of the interior tower and inclination measurement (0º) on the scale of the model tower.

Figure 6: Height and rotation positioning, making the curvature of the stylus match the rotation axis and leveling the stylus with the incisal edge of the tooth

Figure 7: Placement of the bracket with standard rotation

Figure 8: Placement of the JOY™ bracket on the tooth

Figure 10: Mesio-distal centering of the bracket on the tooth

Figure 11: Measurement of the in-out of the bracket Volume 5 Number 5

STEP-BY-STEP

Figure 12: Measurement of the height of the bracket

recorded so that it is possible to re-create an identical transfer tray if necessary. 9. The bracket is positioned at a height 1 mm from the gingival edge and 2 mm from the incisal edge. This bracket position is measured on the height gauge of the posterior tower (Figure 12) and is recorded so that it is possible to re-create an identical transfer tray if necessary. 10. A note is made of the bracket positioning in-out. 11. A note is made of the bracket positioning height. 12. A note is made of the height, in-out, and rotation position (first order) with which the tooth has been positioned. 13. A note is made of the mesio-distal inclination position (second order) with which the tooth has been positioned. 14. A note is made of the torque position (third order) with which the tooth has been positioned. 15. Light-cured composite is applied to the base of the bracket, and it is bonded to the tooth of the model tooth. After the removal of excess, it is light cured.

Figure 13: Brackets cemented from canine to canine

Figure 14: Premolar brackets cemented

The same is done for the six anterior teeth (Figure 13). The brackets of the first premolars are then positioned and bonded (Figure 14). The premolars are positioned with the same bracket height but with a different in-out. This in-out difference is recorded on the in-out gauge of the posterior tower and will be compensated for in the arch wire. This in-out difference will be the disto-canine in-set measurement of the arch wire. The brackets can be positioned with any prescription because each of the bracket parameters (in-out, height, rotation, mesiodistal inclination and torque) can be adjusted and measured independently. Thus, the ABP is an instrument that allows procedures to be completed using the very accurate bracket rebonding technique. For this procedure, the bracket is positioned on the model by modifying the indicated parameter. A new transfer tray is created that positions the bracket to achieve the final tooth position indicated by the case completion plan. Volume 5 Number 5

Summary The Accurate Bracket Positioner (ABP) allows the positioning of labial or lingual brackets on the model for any prescription without creating setup models, saving working time. Each parameter can be customized and measured independently,

making it possible to reproduce the position of the bracket to create an identical tray or a tray with a bracket position in which any of the parameters has been modified in a controlled manner. OP This article was provided by Adenta.

REFERENCES 1. Scholz RP, Swartz ML. Lingual orthodontics: A status report: Part 3. Indirect bonding – laboratory and clinical procedures. J Clin Orthod. 1982;16(2):812-820. 2. Echarri P. Técnica de posicionamiento de brackets linguales CLASS System. [CLASS System lingual brackets positioning technique]. Rev. Iberoamericana de Ortodoncia. 1997;16:1-17. 3. Echarri P. Ortodoncia Lingual. Técnica completa paso a paso. [Lingual Orthodontics. Complete step-by-step technique]. Barcelona (Spain): Nexus Ediciones S. L.;2003. 4. Echarri P, Schendell C. Kein Schleifen und Trimmen mehr. Kieferorthop Nachrichten. 2013;5:13-15. 5. Echarri P, Schendel C. Einfach und präzise. Kieferorthop Nachrichten. 2013;6:14-16. 6. Creekmore T. Lingual orthodontics — its renaissance. Am J Orthod Dentofacial Orthop. 1989;96(2):120-137. 7. Echarri P. Procedimiento para el posicionamiento de brackets en ortodoncia lingual II. [Procedure for bracket positioning in lingual orthodontics II]. Ortod Ling. 1998;1(3):107-117. 8. Echarri P. Lingual Orthodontics: An up-date of the bracket positioning and bonding procedures. J Orthod Society and Research of Thailand. 2003;3:1-14. 9. Echarri P. Lingual Orthodontics. Bracket set-up using Model Checker, Slot Machine, and CRC Ready Made Core Trays. Korean J Lingual Orthod. 2003; 2:58-71. 10. Echarri P, Pedernera M. Ortodoncia lingual simplificada. Técnica CLO3. [Simplified lingual orthodontics. CLO3 technique]. Tribuna Books Ripano Lingual Orthod J. 2014;(1):17-21. 11. Echarri P. Lingual technique indirect bonding: double transfer tray technique. World J Orthod. 2006; 7(2):154-158.

Orthodontic practice 55

STEP-BY-STEP

Ormco™ Custom: Scan, Design, Build, Bond A complete digital treatment solution

rmco™ is committed to accelerating orthodontists’ access to advanced clinical solutions. Ormco™ Custom is at the forefront of this pledge. Ormco Custom is a suite of products and services that offers an end-to-end digital workflow — from 3D digital scanning with precise, real-time data capture to state-of-the-art computerguided diagnostics and treatment planning to patient-specific appliance design and fabrication. Each of its components can operate independently, but seamless integration works synergistically for unparalleled convenience, efficiency, and predictable, high-quality outcomes. Ormco Custom’s four-step process — Scan, Design, Build, Bond — offers a high degree of systemization that helps optimize the patient experience, shorten treatment times, and improve treatment accuracy and predictability. In fact, the personalization Ormco Custom offers is proven to reduce treatment time by 37%, on average, with seven fewer office visits per case.* Additionally, with Ormco Custom, some doctors have grown their businesses by 50% or more.** To get you started, here is a look at how each element of Ormco Custom works.

3. Scan lower arch/8 short segments. 4. Scan upper arch/8 short segments. 5. Scan bite registration. 6. Upload impression. To learn about incorporating Lythos in your practice, please visit ichooselythos.com.

SCAN — Start right

DESIGN — Start with the end in sight

The Lythos™ Digital Impression System is the first step in the personalization process. Lythos is designed to integrate easily into any practice, harnessing the power of digital scanning to overcome the inherent challenges associated with taking accurate PVS impressions. The Lythos intraoral scanner captures and stitches together data in real-time, acquiring high-definition detail at all angulations of the tooth surface. Each scan can be manipulated on the Lythos touchscreen with rotation capabilities and several vantage points. With secure, cloudbased storage and easy file transfer, doctors have the convenience of working from any location. When using Lythos, the basic scanning steps are as follows: 1. Enter patient data. 2. Retract the teeth. 56 Orthodontic practice

Insignia™ Advanced Smile Design is a fully customized bracket system with an exact, calculated per-tooth prescription

based on unique dental anatomy, bracket placement, and final tooth position. The system allows you to incorporate artistic and clinical skills by manipulating tooth position on the screen to visualize your ideal finish. Once you approve the final outcome, each bracket, archwire, and clear precision placement guide (jig) is customized for bonding. Each aspect of the customized Insignia treatment is precisely calculated to optimize

Volume 5 Number 5

BOND — Protect your treatment plan Every Insignia case is accompanied by clear jigs manufactured to fit like a puzzle piece onto the patient’s unique occlusal anatomy. Clear jigs provide the ability to view exact bracket placement before light curing for a more comfortable bonding experience for both staff and patients. Additionally, every wire is custom designed for exact results and fewer finishing appointments.

The accuracy of Ormco Custom’s four-step process offers a high degree of systemization that helps optimize the patient experience, shorten treatment times, and improve treatment accuracy and predictability.

BUILD — Mass personalization Ormco Custom leads the way in manufacturing custom brackets, wires, and appliances that are unique to each patient and treatment plan. With the integration of AOA custom lab services, Ormco Custom delivers state-of-the-art digital technologies and unprecedented levels of customization. Offices looking for customized appliances simply send a completed Rx via email to AOA Lab. When using Lythos, placing “Lythos Scan” after the patient’s name will automatically trigger AOA to the Ormco cloud to retrieve the scan data. No file converting, no third-party FTP sites. From there, AOA uses cutting-edge SLA printers to create the personalized appliances. The SLA printers allow for superior detail and accuracy. Once the appliance(s) are fabricated, the practice will receive the product along with the printed model via UPS.

The jig segments are color coded with an ID dot to identify the appropriate quadrant

Simplified light curing allows you to cure from any direction

Getting started As you can see from the quick and easy steps, Ormco Custom is a unique digital platform that simplifies the treatment scanning, designing, building, and bonding process. To get started, Ormco Custom Starter Kits provide special introductory pricing that include free products or services of your choice.***

For more information, please contact your Ormco Sales Representative or visit www.ormcocustom.com. OP *

Weber DJ, 2nd, Koroluk LD, Phillips C, Nguyen T, Proffit WR. Clinical effectiveness and efficiency of customized vs. conventional preadjusted bracket systems. J Clin Orthod. 2013;47(4):261-266.

Study was a comparative study of personal practice. Data on file.

*** North American doctors only.

This information was provided by Ormco.

Volume 5 Number 5

Orthodontic practice 57

STEP-BY-STEP

tooth movement, ensuring the most efficient plan is at work. The five-step Insignia case submission process is as follows: 1. Log in to your account, select Add New Patient. 2. Enter the patient’s personal details. 3. Select the treatment type for the patient. 4. Upload patient photos. 5. Review and submit or save for a later submission. Find efficiency through personalization, from start to finish with Insignia. To learn more about the software, visit ai.ormco.com. Note: Lythos scans connect automatically to Insignia via the ormcodigital.com web portal, and with the Lythos rebate, every Insignia case submitted reduces the cost of Lythos by $100.

PRODUCT PROFILE

CS 9300C This all-in-one system offers orthodontists multiple options for extraoral exams

atient care and comfort is every doctor’s top priority. Orthodontists who deal with young patients have an even greater concern for keeping their patients stress-free, comfortable and — most important — safe during diagnosis and the treatment process. However, children have the tendency to fidget during extraoral exams, which often requires retakes and increased exposure to radiation. And, with office real estate at a premium, doctors may believe they have to choose between a system that can perform the all-important 2D cephalometric scan or cone beam computed tomography (CBCT) technology that offers faster scan times and less radiation. Now, the CS 9300C system with Low Dose mode from Carestream Dental provides orthodontists with a three-in-one unit that allows users to perform all extraoral exams by combining high-resolution 3D imaging, one-shot cephalometric technology, and high-quality panoramic imaging, plus the ability to create digital models. The system delivers outstanding images each time it’s used — giving doctors the precise visual evidence needed to diagnose more effectively. Plus, new Low Dose mode provides CBCT imaging using extremely low radiation for young patients. The CS 9300C captures vivid 3D images with up to seven selectable fields of view — from 5 cm x 5 cm to 17 cm x 13.5 cm — and image resolution up to 90 μm. Dental professionals can easily collimate field of view based on clinical needs to further reduce radiation exposure, adjust resolution, and change position according to exam specifications. Users can examine images slice-by-slice in stunning detail for enhanced diagnostic interpretation. This combination of speed, image quality, and precision placement dramatically reduces the need for retakes. The CS 9300C is built with an open design to accommodate patients in both standing and seated positions. This flexible design accommodates even the smallest patients as well as patients in wheelchairs. When 3D imaging is indicated, the CS 9300C is capable of performing CBCT scans using the new Low Dose mode. Low Dose 58 Orthodontic practice

combines extremely low radiation, fast scanning time, and excellent image detail. The newest technological advances in software algorithms and noise reduction processing allow the unit to capture effective low-dose 3D images. Low Dose delivers a significantly lower radiation dose than standard CBCT programs, adhering to the As Low As Reasonably Achievable (ALARA) principle. In fact, it allows for 3D imaging at a lower dose than panoramic imaging and reduces exposure time to as few as 3 seconds. Additionally, the ability to focus on a specific region of interest limits radiation to only the relevant anatomical structure(s) and reduces reading responsibilities of the clinician. High-quality 2D cephalometric and panoramic images still have an important place in today’s orthodontic practice, even given the capability of the CS 9300C to capture low-dose 3D images. Most digital cephalometric units take more than 10 seconds to scan a patient’s skull, which can lead to issues with patient movement that did not exist with film based cephalometric units. However, the unique one-shot technology of the CS 9300C captures digital cephalometric images in less than 1 second. This reduction in exposure time virtually eliminates the risk of patient movement, a common occurrence when dealing with fidgety young patients or perhaps even special needs patients, and optimizes image quality. The system also features a broad range of cephalometric image formats

to address a number of orthodontic diagnostic needs. Exclusive landmark recognition software even automates cephalometric tracing, saving significant practice time. The CS 9300C is unique in its ability to adapt to any practice’s workflow, rather than forcing doctors and staff to adapt their routine around it. The CS 9300C has preset programs and motorized movements with a streamlined user interface that make it remarkably easy to use. CS 3D Imaging software allows users to quickly access, review, and share images. The CS 9300C is also SureSmile® certified. In short, the CS 9300C gives orthodontists more options when it comes to treating their patients, no matter what the clinical need. New advancements such as Low Dose mode and one-shot cephalometric technology means young patients are exposed to less radiation than standard CBCT programs or traditional cephalometric scans, while achieving better image resolution. Not to mention, the CS 9300C comes with a minimal learning curve for doctors and their staff and fits seamlessly into a practice’s existing workflow. If you’re considering implementing a new imaging system, make sure it can address all of your imaging needs. For more information about CS 9300C with Low Dose mode, call 800-944-6365, or visit www.carestreamdental.com. OP This information was provided by Carestream Dental.

Volume 5 Number 5

LET’S REDEFINE ORTHODONTICS

The new CS 9300C with Fast Scan. Lowest-dose, all-in-one CBCT with one-shot ceph on the market. There’s no need to sacrifice quality or control to gain a low-dose advantage. The new CS 9300C does it all. One-shot ceph capability saves time. High-res 2D or 3D images are produced quickly for improved workflow. And all the while, Fast Scan mode minimizes exposure for patients young and old. Your need for speed has been sated.

PRODUCT PROFILE

Sensation™ M: an active self-ligating bracket offering the perfect mix of efficiency and control

ensation™ M Active Stainless Steel Self-Ligating Brackets provide ideal control in all stages of treatment. The passive stage of the clip during the initial treatment phase allows for more efficient leveling and aligning. Sliding mechanics are also enhanced during the passive and transitional phases. The active stage of the clip engages the archwire securely into the base of the archwire slot, fully expressing the in-out, angulation, and torque built-in to the bracket. Unlike traditional brackets, where forces can diminish when ligatures are stretched into place, the self-ligating clip design offers continuous force levels during wire deflection/ unloading. This allows practitioners to adjust time between office visits. The bracket’s versatility is in the clip design. This is the part that undergoes the most stress and manipulation throughout treatment. To ensure the clip remains “true” under these circumstances, it has been manufactured using a cobalt-nickel alloy to provide high resiliency and durability. Also designed as a fixed clip to prevent accidental removal, reliable clip operation is a key feature of Sensation™ M.

A versatile bracket The Sensation™ M Bracket is not only built with self-ligation in mind; it is also a classic twin-wing design, and it preserves the ligation abilities of a traditional bracket. There is ample under tie-wing area for application of elastomeric chains, and its low profile and smooth rounded facial contours optimize comfort for a better patient experience. Smooth rounded hooks also add to 60 Orthodontic practice

Passive Transitional Active

the patient experience and allow for easy and secure engagement of elastics.

Intuitive bracket placement

placement. Sensation™ M aims to make correct placement easy with visual IDs, and a bracket-to-tooth fit that feels right. Each bracket is uniquely color-coded with an ID dot in the upper corner, and each features a long axis scribe line. This acts as a clear visual cue for placement at the top and bottom of the boding base. Furthermore, each bracket has a uniquely shaped, compound contour base to provide an ideal bracket fit to the tooth’s surface. This, combined with the 80-gauge microetched mesh base, ensures maximum bond strength and predictable and safe debonding. With a passive-to-active design, high clip durability, and classic twin-wing elements, Sensation™ M is an intelligently designed bracket that delivers time savings for clinicians, and ensures practice productivity remains at its highest. To learn more about the Sensation™ M Bracket System, visit OrthoTechnology.com/SensationM, or call 1-800-999-3161. OP

Nothing is more important for simple and accurate finishing than ideal bracket

This information was provided by Ortho Technology.

Perfect bracket lineup in finishing There are self-ligating brackets in today’s market still designed with “torque in slot.” An undesirable effect arises as the treatment progresses with this bracket design. During the finishing stages when torquing teeth into their final position, the slots of the bracket align, but often the facial surfaces of the brackets do not. This can result in unwanted patient discomfort at the end of treatment, as opposed to the initial phases of treatment where this may be a more normal expectation. With Sensation™ M, however, the patient’s comfort progressively improves with treatment due to its torque-in-base design. In this case, when torque is applied, both the facial surfaces and slots align. The result is a far more comfortable and attractive “perfect bracket lineup.”

Volume 5 Number 5

THE PERFECT MIX

of efficiency & conTrol Torque in base Design Provides 3 key points of alignment by archwire slot, center of bracket base and center of clinical crown for more accurate placement

smaller overall brackeT Dimensions

CoMPaRE To

Increase inter-bracket distance to improve rotational control

EmpowEr® by American Orthodontics In-ovatIon® r by Dentsply GAC

lower Profile Design Enhances rotational leverage and lower anterior control

HigH qualiTy inTegral cliP Manufactured using a Cobalt-Nickel alloy built for resiliency and durability

Try One of Our Risk-Free, 100% Satisfaction

Guaranteed Introductory Offers Today!

BUY 5 CaSES GEt 2 INtRO CaSES FREE!*

1-800-999-3161 BUY 20 CaSES GEt 20 CaSES FREE!*

HURRY! OFFER EXPIRES 10/31/2014 © 2014 Ortho Technology, Inc. Sensation is a trademark of Ortho Technology. *Get 2 introductory patient cases (40 brackets) free when you purchase 5 cases (100 brackets) or get 20 cases (400 brackets) free when you buy 20 cases at retail price. Try Sensation M Brackets for the first time and if you are not completely satisfied then return the remaining cases and keep 2 introductory cases at no cost. We will even pay the cost of shipping. Offer expires 10/31/2014. Empower is a registered trademark of American Orthodontics and In-Ovation is a registered trademark of DENTSPLY GAC.

PRODUCT PROFILE

iFinisher™ — aligner case finishing simplified By TP Orthodontics, Inc.

t’s no secret that finishing aligner treatment cases is challenging at best and comes at a cost to both the patient and doctor. The new iFinisher™ is a single-appliance solution perfectly suited for improving aligner finishes, without the need for additional aligner trays. Based on the proven technology of the Original Tooth Positioner, the iFinisher was developed by orthodontist Dr. Daniel S. German specifically for aligner treatment as a simple, yet cost-effective solution for final finish improvement and bite correction. With one iFinisher, you may transition your patients to part-time wear, refine without the need to order more trays, and do something aligner trays alone cannot — promote an ideal occlusion in as little as 3 weeks. The iFinisher: • Corrects and relates teeth in both arches simultaneously • Corrects a posterior open bite • Closes slight spaces • Corrects minor rotations and buccolingual discrepancies • Replaces the need for additional aligner trays and allows for removal of bonded auxiliaries

Challenges in finishing aligner cases Most aligner cases require additional refinement to finish. Typically, this means more aligner trays for the patient, and more time and expense for the doctor. The challenges in attempting to finish with aligner trays alone are significant, including the cost associated with more aligners, the time lost during reorder, and the subsequent loss of active biology when teeth are primed for movement. As well, there is a significant loss of enthusiasm — and compliance — from patients who must pay for more trays and continue wearing their appliance full-time, long after

62 Orthodontic practice

they expected to be finished. Moreover, even esthetically pleasing results are commonly accompanied by a posterior open bite, resulting in a level of dissatisfaction with the outcome. The iFinisher effectively treats the occlusion where aligner trays alone cannot.

Case 1: Start iFinisher

A proven solution Based on the same finishing principles developed by Dr. H. D. Kesling over 70 years ago, the iFinisher relates teeth in both arches — providing a better quality, more efficient finish than aligner trays alone. Tooth positioners have long been recognized as a standard for achieving a great finish in orthodontic treatment. In fact, a recent study1 on finishing protocols indicated that using a tooth positioner will effectively close interproximal spaces and achieve “improvements in interocclusal contacts” (a recognized challenge with aligner treatment).

Patient-friendly Patients are excited to finish with the iFinisher. They appreciate a one-appliance approach to finishing, and that they only need to wear it part-time. Also, compliant patients see results in less time than if finishing with aligner trays. Because the iFinisher is small in size and made from a soft crystal-Flex® material with molded airways, the appliance is comfortable to wear. The iFinisher is also available in a variety of colors and custom designs to increase patient acceptance. As an added benefit, the iFinisher may also be used if relapse occurs.

Easy to implement The era of digital manufacturing provides a simple and efficient process for incorporating the iFinisher into treatment plans. The iFinisher can be produced from the final virtual setup or from a new intraoral scan. The prescription is easy and quick to complete: simply create an account through easyrx®, an online prescription management program accessible at TPOrtho.com/ labs. There, you can submit the iFinisher prescription, including additional customization options. Upload the STL file from the intraoral scan — there’s no need to ship impressions, unless the clinician prefers. Either way, doctors have access to review,

Case 1: iFinisher for 4 weeks

Case 2: Start iFinisher

Case 2: iFinisher for 8 weeks

verify, and give final approval of the files before appliance fabrication. Prescribing an iFinisher can provide impressive results and a level of efficiency not thought possible with aligner treatment. If you’re ready to improve your aligner case finishes while increasing patient satisfaction, the iFinisher just might be a great solution for your practice. To learn more about the iFinisher and other custom finishing solutions offered by TP Orthodontics, visit TPOrtho.com/labs, or call 1-800-348-8856. OP 1. Stock GJ, McNamara JA Jr, Baccetti T. Efficacy of 2 finishing protocols in the quality of orthodontic treatment outcome. Am J Orthod Dentofacial Orthop. 2011;140(5):688-695. The iFinisher trademark application is assigned to Daniel S. German, DDS, and is used with permission. Patents pending. This information was provided by TP Orthodontics, Inc.

Volume 5 Number 5

NEW

iFinisher™

This? or This? Now, you have a choice. Introducing the iFinisher – a simple, yet cost-effective solution for refinement and bite correction, without the need for additional aligner trays. The iFinisher corrects and relates teeth in both arches simultaneously, and closes posterior open bites in as little as three weeks – something that cannot be achieved with aligner trays alone. “I developed the iFinisher as a proven method of finishing my patients to a higher standard. Since implementing the iFinisher, I have been able to decrease the number of aligners needed while correcting the bite. I am astounded by the speed at which the occlusion improves.”

Maximum results. Minimal effort. iFinisher™.

Daniel S. German, D.D.S. Developer of the iFinisher

Nobody delivers as many proven finishing solutions as TPO® – guaranteed. From the Original Tooth Positioner to the Pre-Finisher®, Mini-Positioner™ and the NEW iFinisher, the world’s smallest custom finishing appliance, you’re sure to get the appliance that is just right for your patients. To learn more or to submit a case online, visit TPOrtho.com/labs or call 1-800-348-8856.

The iFinisher trademark application is assigned to Daniel S. German, D.D.S., and is used with permission. Patents pending. Mini-Positioner is a trademark of TP Orthodontics, Inc. TPO and Pre-Finisher are registered trademarks of TP Orthodontics, Inc. © 2014 TP Orthodontics Inc. All Rights Reserved.

PRODUCT PROFILE

Planmeca ProMax® 3D Ultra Low Dose™ protocol

lanmeca ProMax® 3D family units offer an Ultra Low Dose™ imaging protocol, where effective patient dose in CBCT image is even less than in a standard 2D panoramic image. The Planmeca ProMax® 3D is designed to obtain complete information on the patient’s anatomy in the minutest detail. This intelligent and multipurpose X-ray unit provides digital panoramic, cephalometric, and 3D imaging as well as 3D photos and 3D model scans. Ultra Low Dose imaging is based on intelligent 3D algorithms developed by Planmeca. Ultra Low Dose images are used, for example, in the following procedures: • Localization of unerupted and impacted teeth prior orthodontic treatment • Defining orthodontic landmarks for cephalometric analysis • Postoperative and follow-up images in maxillofacial surgery • Airways studies • Sinus studies • Implant planning The system always allows the clinician to choose the optimal balance based on the ALARA (As Low As Reasonably Achievable) principle.

Ultra Low Dose™ imaging is based on intelligent 3D algorithms developed by Planmeca

Planmeca ProMax 3D Mid in lime

Planmeca’s new Ultra Low Dose™ imaging protocol has changed the imaging practices at Tampere University Hospital in Finland. Dr Jorma Järnstedt, DDS, in Tampere University Hospital’s Oral and Maxillofacial Unit discussed his experience with the ProMax 3D. “We have been using the new Ultra Low Dose mode since last summer and have found it to be very useful in many imaging indications. These include postoperative follow-up, orthodontic cases requiring localization of uninterrupted teeth and their effects on the neighboring ones, sinus imaging in certain ENT cases where sinusitis needs to be excluded, pharyngeal airway measurements on sleep apnea patients, as well as all implant cases. “The new imaging mode has already changed the traditional imaging protocol: In many cases, 2D imaging can no longer be justified, since an Ultra Low Dose 3D image simply gives so much additional information with a similar radiation dose. Our patients are often concerned about radiation exposure, but once they hear that the dose is even lower than in traditional panoramic 2D imaging, they are always really relieved. Also, our surgeons often specifically ask us to use the Ultra Low Dose protocol. “We take around 2,000 CBCT images per year at the Oral and Maxillofacial Unit, and the number is constantly growing. We have been using the new Ultra Low Dose protocol for the imaging of both larger and smaller areas. It has proven to be a very beneficial method giving a vast amount of detailed anatomical information at a low radiation dose.” OP

Ultra Low Dose protocol using Planmeca ProMax 3D Max FOV Ø 8.5x5 cm / voxel size , 400µm 96kV / 1mA. DAP 34.4. Effective patient dose 4.0 µm – less than normal PA image!

Ultra Low Dose protocol using Planmeca ProMax 3D Classic FOV Ø 4x5 cm / voxel size , 200µm 90kV / 1mA. DAP 44.4. Effective patient dose 7.9µSv

Ultra Low Dose protocol using Planmeca ProMax 3D Max, FOV 23x16, 96kV / 1mA Effective patient dose 21 uSv This information was provided by Planmeca.

64 Orthodontic practice

Volume 5 Number 5

29.2 μSv

7 μSv

ø20 x 17cm

14.7 μSv

4 μSv

• Ultra Low-dose mode for optimal dose based on the ALARA radiation safety principle • Pediatric imaging mode lowers effective dose by 35%, with additional ultra low dose protocols for adults • Multi-bladed collimation focuses radiation to areas of clinical interest • Planmeca Romexis open-architecture software included • Optional SmartPan allows 2D and 3D images to be taken with the same sensor

For a free in-office consultation, please call

1-855-245-2908 or visit us on the web at www.planmecausa.com

• Mac OS and PC compatible

PLANMECA