Orthodontic Practice US - November/December 2014 - Vol5.6 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews

An introduction to reviewing CBCT images Dr. Andrew Trosien

TMJ arthritis orthodontic dilemma, part 2: septic (suppurative) TMJ arthritis causing occlusal changes

forum.ormco.com

PROMOTING EXCELLENCE IN ORTHODONTICS

November/December 2014 – Vol 5 No 6

Henry Schein® Orthodontics™

Practice spotlight

BioDigital Orthodontics part 12 Drs. Rohit C.L. Sachdeva and Takao Kubota

Dr. Boyd Martin

Practice profile

Dr. Sonia Palleck

PAYING SUBSCRIBERS EARN 24 CONTINUING EDUCATION CREDITS PER YEAR!

JW MARRIOTT ORLANDO GRANDE LAKES

Corporate spotlight

FEB 18-21, 2015 | ORLANDO, FL

Dr. Harold F. Menchel

Can You See

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Damon patients treated by Dr. Todd Bovenizer.

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November/December 2014 - Volume 5 Number 6 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

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o have the luxury of practicing in the area where I grew up is perhaps why community outreach is so important to me. Giving back has always been a part of the culture of this practice — a tradition that dates back to its founding in 1958. I joined the practice in 1988 and became a partner shortly thereafter. I felt it was important to continue the custom of community philanthropy. We’ve participated in some of the usual things that small businesses in small towns do, supporting local little league teams and school bands. Our entire office team walks for fundraisers, holds special toy drives for the children in local hospitals, and collects food donations to help local soup kitchens and pet supplies for the Humane Society. Most people have heard how teachers use their own money to subsidize their students — for supplies and even for books — so we dedicate a portion of our marketing budget to school supplies. Some schools in Southeastern Connecticut don’t need help while others are quite disadvantaged. Because we’re dialed into the neighborhoods we serve, we understand where the need is greatest. One of our marketing activities even took a turn toward “paying it forward.” Making presentations on dental health and orthodontics in area classrooms prompted conversations with teachers and nurses about orthodontic emergencies, so we now deliver orthodontic emergency kits to all the local schools. School nurses visit our office to learn how to manage emergency care. Small things such as how to stabilize a bracket that has become loose or how to use wax to soothe an irritation keep kids in school and save parents an unscheduled visit to our office. Smile for a Lifetime Foundation (S4L) offers an incredible opportunity for us to give back to the community, and my practice partner, Dr. Gregory Hack, and I are quite involved in its endeavors. A bank president, a local lawyer, a pediatrician, pediatric dentists, an oral surgeon, and educators serve on the board of our local S4L chapter. We market directly to teachers, dentists, and school guidance counselors, looking for those children and adolescents who could most benefit from orthodontic care but whose family budgets could never cover the cost. The direst needs are disfiguring malocclusions. Through S4L, we are committed to offering six “orthodontic scholarships” to patients in need annually. From the applications received, the board grants these scholarships for treatment. The charter of the S4L Foundation was established to deliver complimentary orthodontic treatment, but our program covers the full gamut of dental care in those patients who require interdisciplinary care. We have partnered with general dentists and dental specialists in our community to provide pro bono dental care for our S4L patients whenever indicated. A network of clinicians offers a number of services such as extractions through an oral surgeon, periodontal surgery, and dental implant placement from a periodontist. One patient who recently required implant-supported crowns to replace both of his congenitally absent maxillary lateral incisors had dental implants placed by a periodontist and crowns placed by a prosthodontist with both dentists doing the work gratis. We do not receive any financial support from the national office of S4L. Seeing a young person‘s self-confidence blossom as a result of a natural smile and healthy bite is heartwarming, and the stories the kids tell about how different they feel about themselves and how differently they’re treated at school is what the effort is all about. Ormco™ has supported S4L with fundraisers at their annual Forum and through sizeable contributions. Being Damon™ System users, we appreciate their backing as they donate all our orthodontic clinical supplies to treat our S4L patients. We provide all of our patients with patient-centered, problem-oriented diagnosis and treatment planning. We utilize Damon™ System appliances, SureSmile®, and Invisalign® treatment solutions, which enable our practice to provide high-quality results predictably and consistently. Using orthodontic therapy that respects patients’ facial features, delicate soft tissues, and keeps them as comfortable as possible — there’s hardly a better way for an orthodontist to give to the community. Doctors interested in learning more about S4L and how to become a S4L provider in their community may visit www.s4l.org. Dr. Jim O’Leary

$99 $239

© 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 6

Dr. James M. O’Leary is a lifelong resident of Waterford, Connecticut. He is a partner in Orthodontic Associates of Southeastern Connecticut along with Dr. Gregory Hack. He received his B.S. degree from Ohio State University and his DMD degree, summa cum laude, from the Tufts University School of Dental Medicine in Boston. While at Tufts, he also completed his specialty training in orthodontics. Dr. O’Leary is a Diplomate of the American Board of Orthodontics. He has served as president of the Tufts University Orthodontic Alumni Association. He is founder and leader of the New England Damon Study Club.

Orthodontic practice 1

INTRODUCTION

On community

TABLE OF CONTENTS

Company spotlight

Henry ScheinÂŽ Orthodonticsâ&#x201E;˘ .......................................................14

Practice profile Dr. Sonia Palleck

Staying current and always learning

Case study

Non-extraction treatment for face-driven treatment planning Dr. Stuart L. Frost discusses nonextraction treatment mechanics and controlling torque.............................17

Orthodontic concepts BioDigital Orthodontics Management of patients with open bite (I): part 12

Drs. Rohit C.L. Sachdeva and Takao Kubota discuss successful treatment of open bite.....................................22

Practice spotlight 10 Boyd Martin, DMD, MS Architect of the smile

ON THE COVER Cover photo courtesy of Dr. Grummons. Article begins on page 46.

2 Orthodontic practice

Volume 5 Number 6

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

Continuing education

TMJ arthritis orthodontic dilemma, part 2: septic (suppurative) TMJ arthritis causing occlusal changes Dr. Harold F. Menchel discusses a disorder that can have significant effects on orthodontic treatment planning and treatment.....................37

Banding Together

Tiffany’s story Dr. David Kemp recounts a collaboration that changed a patient’s life.......................................40

Continuing education An introduction to reviewing CBCT images

Dr. Andrew Trosien discusses the benefits of a CBCT view

Technology

A more controlled approach to aligner therapy Dr. William Thomas discusses an aligner treatment alternative.............42 CBCT and 3D imaging goals for orthodontic patients Dr. Duane Grummons discusses how CBCT equips the orthodontist regarding unerupted teeth, facial asymmetry, craniofacial anomalies, temporomandibular (TMD) disorders, airway conditions, TAD planning, and true root information in the region of interest (ROI).....................................46

Practice development

A unique approach to ceramic brackets for organic practice growth Dr. Paul Tran explores the advantages of ceramic brackets..........................54 Generating more new case starts through topical search Diana P. Friedman explores how consumers search for online information.......................................56

Practice management Product profile Cloud computing in orthodontics Jake Gulick discusses how cloud computing can benefit an orthodontic practice........................................... 51

4 Orthodontic practice

Objet30 OrthoDesk 3D Printer by Stratasys Embrace digital dentistry, easily .......................................................58

Soft tissue incision, excision, ablation, coagulation with LightScalpel® No bleeding – No stitching – High productivity – Fast ROI....................60 Ormco™ Custom ........................................................62

Industry news ..............63 Materials & equipment.........................64

Volume 5 Number 6

Incognito™ Clear Precision Tray Less Deviation from Correct Bracket Position The precision of the Incognito™ Appliance System relies on the brackets being placed in the correct spot on the tooth. 3M Unitek has developed a proprietary way to build the indirect bonding tray using the same digital data created for designing the brackets. The result is more accurate placement of the brackets. Graphs illustrate the deviations of bracket positioning using the stated method as compared to the design data. The Incognito™ Clear Precision Tray method is significantly more accurate.

Incognito™ System Users Meeting 13-14 March 2015 Orlando, FL, USA

Source: 3M Unitek Lab. Measurement in mm.

Conventional Tray Method

Incognito™ Clear Precision Tray Method

Rebonding “Jig”: You can section this tray to use for accurately replacing brackets.

The new Incognito Clear Precision Tray – Precision taken to the next level. Call your sales representative or (800) 423-4588 for more information. 3MUnitek.com/Incognito 3M and Incognito are trademarks of 3M. Used under license in Canada. © 2014 3M. All rights reserved.

PRACTICE PROFILE

Dr. Sonia Palleck Staying current and always learning

erving the greater London and Woodstock, Ontario, areas, Dr. Palleck runs an esteemed practice that regards its patients as the number one priority day in and day out and recognizes that technology is the future of the craft.

What can you tell us about your background, and why you decided to become an orthodontist? I have four siblings, each of whom had orthodontic treatment as a child, just as I did. We were continually in and out of an orthodontic office, and I guess you could say that’s where I drew my inspiration to explore the profession. When I was 17 years old, I went to my orthodontist for my final retainer check, which happened to coincide with an aptitude test I had just taken in high school. I scored highest for being a dentist, and just like that, everything clicked! I went on to pursue dentistry at the University of Western Ontario and then completed 3 years of orthodontic specialty training at the same university. To come full circle, I now teach graduate orthodontic courses at the university, instructing graduate students about how to become orthodontists using Insignia™ (Ormco Corporation). 6 Orthodontic practice

How long have you been practicing, and what appliances do you use? I have not only had orthodontic treatment, I have experienced almost every procedure and appliance you could have in your mouth! I have been retreated twice to deal with problems that developed as a direct result of my earlier treatment, which included serial extractions, headgear, and jaw surgeries. This has impacted my philosophy greatly. My role as an orthodontist is to get the teeth to fit together — the nice side effect is that they are straight! I want to do this in as few visits as possible with as little pain as possible and make it as affordable as possible. I have been practicing for 15 years and use a variety of tools, most notably Ormco’s Insignia™ Advanced Smile Design™, which offers patients customized treatment planning and appliances tailored to their specific needs. In fact, my practice was an early adopter of Insignia, and we are currently the largest provider in Canada. We use the Lythos™ scanner to start designing the appliances online. No more impressions! We are Elite

providers of Invisalign® (Align Technology, Inc.), and we couple all of our treatment, whether it’s aligners or custom braces, with AcceleDent® (OrthoAccel Technologies, Inc.), a micropulse technology that soothes the teeth and speeds bone remodeling. I am definitely an early adopter when it comes to technology. If there’s a new, advanced product hitting the market, we either know what it is or have already placed our order for it.

What is the most satisfying aspect of your practice? The most satisfying aspect of my practice is having the opportunity to dramatically and positively impact people’s lives. It’s fulfilling to see a patient’s life change as a result of the work that my staff and I love doing so much. When treatment is finished, Volume 5 Number 6

CS 3500

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ALL YOU NEED TO ACQUIRE 3D DIGITAL MODELS, AND NOTHING YOU DON’T WELCOME TO THE NEW REALITY In the new reality, the CS 3500 intraoral scanner and CS Model software create highly accurate, true color 2D images and 3D digital models of teeth without conventional impressions. • • • • •

Obtain digital models in a fraction of the time of conventional models Virtually automatic bite registration Slim scanner head with two tip sizes for patient comfort Unique light guidance system for more patient-focused scanning Send digital files directly to lab for appliance fabrication

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PRACTICE PROFILE and the final smile is revealed, the look on each patient’s face is second to none. It gives my staff and me great joy that we’re able to inspire a new level of confidence in our patients. Every day I see retention patients who tell me about how much their new smile has changed their lives.

puzzle. If you keep the patient in mind with every decision you make and goal you set, you will build and maintain a successful practice. At Palleck Orthodontics, we aim to serve the patient as best as we possibly can.

What is unique about your practice?

There are three key pieces of advice that I would give to budding orthodontists. • Focus on your results. It’s important to remember that, ultimately, your patients’ results will determine your reputation in the marketplace. Giving your clients what they want — a beautiful, healthy smile — should be the primary focus. • Welcome technology with open arms. You never want to be behind the times. To remain relevant, you have to utilize the incredibly advanced orthodontic solutions that are continually made available to you. These tools have the capability to transform your practice and set you apart as a premium, patient-focused orthodontist.

My staff is exceptional! My colleagues often complain that they have to deal with staff issues. I am fortunate not to have those problems. We are like one big, happy, energetic family. I have 10 amazing women who collectively have 104 years of orthodontic experience! They are highly motivated and are continually updating and upgrading their skills to meet the challenges that evolving systems have on a busy practice. We are expanding into the adult market with more than 30% of our practice now over 20 years of age. I believe this is because we can treat most patients in 12 months or fewer with our approach.

What is the future of orthodontics?

What advice would you give to budding orthodontists?

• Never stop learning. Mastering orthodontics is a lifelong learning process. Dedicate yourself to staying up-to-date on the latest technologies, techniques, and developments. This is what will keep you ahead of the curve.

When you’re not behind the chair, where are you? I enjoy being active outside — I love biking, running, and swimming. In my leisure time, I also like to read or play golf with my husband. Of course, my young daughter keeps me busy as well! She signed us up for Zumba! Spending time with family and friends is very important to me.

If you hadn’t become an orthodontist, what would your career have been? I would probably be a writer or a professor. More specifically, I think I would really have enjoyed being an English professor. I love using my imagination. In a way, with orthodontics I get to flex my creative muscle every day. OP

I’m a strong believer that the future of orthodontics lies in technology. The profession as a whole is on the upswing, especially considering the influx of digital technologies. Practice tools such as Insignia are revolutionizing the market. Instead of taking a onesize-fits-all approach to patient care, with Insignia, practitioners are able to create exactly what they need — something that has never been available before. The best part about introducing new technologies into my practice is that patients respond, and they respond well.

What are your top tips for maintaining a successful practice? Always, always remember that the patient is the most important piece of the

Top Five Favorites • My husband, Jason, and daughter, Juka (It’s a tie!) • Timmy’s XL double-double every morning — usually with a cheese croissant • Insignia™ Advanced Smile Design™ • My staff: I look forward to seeing them every day • Our little dog, a Morkie, named Dasher Heart-Throb

8 Orthodontic practice

Volume 5 Number 6

PRACTICE SPOTLIGHT

Boyd Martin, DMD, MS Architect of the smile What can you tell us about your background? I grew up in Newport Beach, California, and received my undergraduate degree from University of California (UC) San Diego. I attended Tufts University School of Dental Medicine in Boston for my dental degree. Following an Advanced Education in General Dentistry (AEGD) at the University of Southern California School of Dentistry (USC), I returned to the East Coast for my orthodontic residency at Case Western Reserve University School of Dental Medicine in Cleveland, Ohio. At the time, Case Western was on the forefront of the development of the cephalogram, and each class contained only four people. The program was a 30-month certificate program combined with a Master’s degree. My Master’s thesis used cone beam (CBCT) technology to look at root morphology in three dimensions. I graduated residency in December 2007, returned to Southern California to get married, and have been at a practice supported by Pacific Dental Services® (PDS) since July 2008. In addition to clinical practice, I was fortunate to teach Phase I Orthodontics to USC Pediatric Dental Residents for 3 years at an offsite clinic in Garden Grove, California. In September 2015, I am entering an Executive Master’s Program in Public Health at the University of California, Los Angles (UCLA) Fielding School of Public Health.

When did you become a specialist and why? I started residency in July 2005 following my AEGD. I was always drawn to the closer patient interaction that orthodontics offered and was inspired by my own orthodontics at age 17-19 to become an orthodontist. I loved continuing the learning process and wanted to focus on a more specific aspect of dentistry. 10 Orthodontic practice

Is your practice limited solely to orthodontics, or do you practice other types of dentistry? My practice is solely limited to orthodontics, but I practice in a Dental Support Organization (DSO)-environment working for a PDSsupported owner-doctor and with other specialists, including an oral surgeon, pediatric dentist, endodontist, and periodontist. With the supported owner-doctor and their associate doctors on-site, I am able to discuss cases and referrals directly with the general dentist. I can also communicate directly to the other specialists when I need to refer my own patients.

Tell us more about your offices. I work for the owner-dentists at two practices: Hamner Dental Group and Orthodontics and Menifee Dental Group and Orthodontics. Hamner Dental Group and Orthodontics has a three-chair bay and two separate operatories for overflow and consults. They employ four assistants, a practice coordinator, manager, and two front desk staff members. I have been practicing at this office since July 2008. Menifee Dental Group and Orthodontics has a fourchair bay and three separate operatories for overflow and consults. They employ five

assistants, a practice coordinator, manager, and three front desk staff members. I have been practicing at this office since September 2009.

Why did you decide to focus on orthodontics? Orthodontics is more of a patientcentered specialty. I think that orthodontics is fun, and it is very gratifying to watch my patients grow up and become more confident in themselves. Orthodontics is a thinking specialty. It is the consistent challenge and thinking about each case that is really exciting.

Do your patients come through referrals? The majority of the patients are referred by the practice’s owner and associate doctors, but we are gaining more and more wordof-mouth referrals. As my practice grows, patients refer their friends and family to me for orthodontics, which I consider a great compliment. I have a reward/point system so patients can choose prizes, and I have monthly themes that the patients love. I even dressed up as Buzz Lightyear for Halloween.

How long have you been practicing orthodontics, and what systems do you use? I have been practicing orthodontics for 6 years. I use brackets from American Volume 5 Number 6

+ ORTHODONTISTS

+ SUPPORTED AUTONOMY

“PDS®-supported practices have provided me the wonderful opportunity to apply a team approach to treatment, meaning the general dentist and myself, as an orthodontic specialist, work ‘under the same roof’. The close proximity I have to the general dentist and other specialists has truly allowed for communication and collaboration between everyone involved in my patients’ care. Whether my orthodontically related opinion is sought, or if I am seeking a professional opinion myself, PDS-supported offices truly facilitate clinical collaboration and comprehensive care!”

Ryan Young, DMD, CAGS | Orthodontist

Discover your true potential as an orthodontist, as you collaborate with an owner dentist and associate dentists to provide comprehensive care.

Pacific Dental Services® can help you build a rewarding career: • Work with an owner dentist who’s committed to providing an excellent patient experience • Potential to earn high income

• Have the clinical autonomy to diagnose and plan your own treatments • Work with advanced technology and supplies • Treat patients in a modern and private work space

Join the team that’s transforming the dental industry. Visit: PacificDentalServices.com Email: specialtyopportunities@pacden.com

PRACTICE SPOTLIGHT Orthodontics in the MBT prescription as well as Invisalign®.

What training have you undertaken? I have earned CE credits at the annual Pacific Coast Society of Orthodontists (PSCO) and AAO meetings as well as during yearly seminars with Invisalign. I am a member of the Academy of Orthodontic Excellence (AOE) Study Club in Newport Beach, California, which is a group of orthodontists who meet quarterly and hear from speakers on a variety of subjects.

Who has inspired you? I am most inspired by Dr. Lysle Johnston, who was my instructor at Case Western Reserve University (CWRU). He taught seminars on Facial Growth at CWRU, as well as at the University of Michigan and St. Louis University. He really placed an emphasis on critical reading of the literature and thinking outside the box. He embodies the idea that orthodontics is really a “thinking” profession.

What is the most satisfying aspect of your practice? The excitement of the final deband. Everyone in the office is excited, but the patients most of all. I give the patient a goody bag, and the office sings and claps on the patient’s way out!

Professionally, what are you most proud of? I am very proud of the growth of the orthodontic programs in the offices in which I work and increasing the number of outside referrals. I am treating the general office staff and their children/friends/family, and they are my walking billboards. By striving for excellence in my clinical and professional interactions, my patients feel comfortable giving a referral.

What do you think is unique about where you practice? I think that having multiple specialists and general dentists under one roof is a unique aspect of the DSO-supported practice. The general team are always on hand to discuss orthodontics with their patients and show them the orthodontic bay. The excitement of orthodontics rolls over to non-orthodontic days. Patients like not having to go to multiple offices for dental treatment and are happy with the communication between all members of the offices. 12 Orthodontic practice

What has been your biggest challenge? My biggest challenge was getting accustomed to a large practice environment immediately following residency. I had to learn a new paperless software system and treat in a large open bay with multiple chairs. It was definitely eye-opening compared to the days of residency.

What would you have been if you didn’t become a dentist?

Top Ten Favorites 1. Practicing orthodontics 2. Spending time with family 3. Skiing in Utah 4. Spending time in Palm Springs, California 5. Reading novels (mystery and thrillers) 6. Sushi 7. Architecture and design 8. Yoga 9. Drinking a good wine with some friends 10. Books on CD during my commute

I had always dreamed of becoming an architect. There was something about the creativity, structure, and beauty of buildings and their design. These are aspects that I also recognize in orthodontics. In a way, I am the architect of the smile and the occlusion of the teeth. The harmony of aligned teeth is very pleasing, much like a beautiful building.

What is the future of orthodontics and dentistry? I think the future of orthodontics is going to include a larger emphasis on technology. Orthodontics will always be in demand due to esthetic concerns.

What are your top tips for maintaining a successful specialty practice? It is important to have excellent communication with your staff and with the referring dentists. Make all patient encounters an experience, and make them feel at home in your office. Talk to the patients to establish a rapport with them, as well as with the parents,

some of whom may become my future patients. Working in a DSO-environment, I have assistance on the administrative side, and I can focus my attention on my patients and on the clinical aspects of my practice.

What advice would you give to a budding orthodontist? Work is different from residency. Shadow another dentist to help transition into a practice environment. Find the practice environment that works for you, and work hard to be successful. Don’t forget the work/life balance. Try not to take work home, and really focus on the balance of life, including hobbies and interests.

What are your hobbies, and what do you do in your spare time? I love to spend time with my family and my two children, ages 2 and 4. I love to read, and I love architecture. As a family, we go skiing every year in Utah and love going out to Palm Springs for some sun. OP Volume 5 Number 6

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Crisp, clear, bright and FOG-FREE intra-oral photography made easy! Fogged up mirrors make intraoral photography time consuming and frustrating. The TRUEOPTICS™ handle, continuously blows a light steady flow of air across the mirror, eliminating the production of fog, and the built in LED lights create fast, easy and brilliant optics.

Picture quality is directly dependent on the quality of the dental mirror. To achieve high quality dental photos good enough for research, teaching, marketing or presentation of cases, the mirror should reflect with exceptional exposure optics. • Built in ventilation for a fog-free mirror • LED lights for clean bright visibility and easy camera focusing • Ideal long fluted handle provides optimal position and handling • Brilliant, high-quality image reproduction • Rhodium free mirrors - significantly improves resistance to scratches • 2 year warranty of complete handle against manufacturing defects Wide range of mirror sizes and shapes - double sided and double ended for that perfect fit. New videos now available on YouTube Keyword: Adenta USA

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CORPORATE SPOTLIGHT

Henry Schein® Orthodontics™

enry Schein Orthodontics is the NEW Orthodontic Specialty Division of Henry Schein. Henry Schein’s presence in the orthodontic market has expanded over the last several years, starting with the acquisition of Ortho Organizers® in 2008, ClassOne® in 2009, and Ortho Technology® in 2012. Placing Henry Schein’s orthodonticfocused operations under the Henry Schein umbrella will enhance the business prospects for the company and enable it to serve the orthodontic professional with innovative product offerings and practice solutions, which include forward-thinking educational offerings.

Changing the industry Proving our dedication to the orthodontic profession to help improve practice efficiency and patient results, Henry Schein Orthodontics, a U.S. manufacturer for over 35 years, has spent a substantial amount of time refining manufacturing procedures to ensure that top, high-quality products reach the clinician’s office. In addition, we have invested significant resources into engineering and new product development on key products orthodontists have been asking the industry to develop. Furthermore, we have collaborated with well-respected, globally known doctors to provide input and guidance to our product development team, as well as on educational topics missing from the industry. Proving Henry Schein Orthodontics strong commitment to partnering with orthodontists in the growth of their practice, we have come to market with the all-new Carriere® SLX™ Self-Ligating Bracket System. In just a few short months since its release, this passive system has established a new standard in performance within the industry. With 10 clinician-inspired enhancements, the SLX Appliance System has been completely redesigned while maintaining one of the lowest profiles on the market. The system offers an Optimized Damon® Rx and tooth-specific bracket sizes for more precise finishing with fewer rebonds and less wire bending. Multiple visual cues, including six horizontal and five vertical references, help ensure accurate bracket placement. Additionally, to help improve office efficiency and reduce gingival impingement, the doors 14 Orthodontic practice

SLX Self-Ligating Bracket

Carriere Motion Class II Appliance

of the brackets open toward the incisal edges/occlusal plane. Discover today the many innovative features that make the SLX Bracket System the only choice when using a self-ligating bracket. It is the new standard in performance and the new reality in value. Complementing the SLX Appliance System is one of the most popular Class II correction appliances on the market today, the Carriere Motion™ Class II Appliance. This appliance offers simplicity, ease of use, and patient compliance, all of which add up to fast, more predictable results. With its

sleek, aesthetic, and non-invasive design, the Motion Appliance shortens treatment time by up to 4 months. The Motion Appliance is used at the beginning of treatment, so whether you use traditional metal brackets or Invisalign® to treat your patients, it will be a game changer for your Class II corrections. Until a few years ago, there had not been a significant change in traditional brackets for many years; we knew there needed to be a change. While conducting “voice of customer,” we found that clinicians were also looking for something new when it Volume 5 Number 6

GAME CHANGER Now Availab le in the Op timized Damon Rx!

“SLX brackets include important design enhancements to improve tooth control and as such, will enable clinicians to take their SL cases to the next level.” David Paquette, D.D.S., M.S., M.S.D.

“The switch from Damon to SLX has been a big win in simplicity, cost, chair time, and treatment outcomes.” ®

John Stieber, D.D.S., P.S.

“The SLX Bracket System has the features to provide clinicians with greater efficiency, better finishes, and a lower price...I couldn’t be happier.” Michael Ragan, D.D.S.

INTRODUCING THE ALL-NEW CARRIERE SLX BRACKET SYSTEM ®

™

Our new passive self-ligating system incorporates more than ten clinician inspired enhancements – all designed to enable you to finish treatment more quickly and with the degree of quality that you expect. Try the SLX System today, and see why it’s a game changer for you, your patients, and your practice.

Learn more about the Carriere SLX Self-ligating Bracket System at 888.851.0533 or HenryScheinOrtho.com.

CORPORATE SPOTLIGHT came to traditional bracketing. This brought about the development of the NeoMaestro™ family of brackets. This system includes the Maestro® Premium Mini-Twin® Bracket, NeoLucent® Plus™ Ceramic Bracket, and NeoCrystal™ Sapphire Ceramic Bracket. Each bracket line was developed with the vision to offer clinicians the ultimate twin bracket system where the brackets are fully interchangeable between aesthetic and metal versions for convenient and costefficient bracketing. The three bracket lines offer uniform design features as it relates to bracket sizes, compatible in/out, same base compound contour, bond strength, and more. This unique family of brackets provides clinicians with optimal benefits and conveniences, while delivering successful treatment outcomes.

The new movement in orthodontics Our commitment to partnering with the orthodontist doesn’t stop at manufacturing. We are devoted to providing complete solutions, including groundbreaking educational courses that will make you stand out within your community. Almost 2 years ago, we introduced the overwhelmingly successful obstructive sleep apnea (OSA) courses to the orthodontic community. OSA is emerging as one of the most widespread and costly health issues in the United States. As you already know, orthodontic treatment offers more than just a beautiful smile and enhanced self-esteem; it also improves quality of life by providing overall health benefits. Our courses assist orthodontists in understanding how they can play a significant role in the diagnosis and treatment options of OSA by changing the airway. Henry Schein Orthodontics developed the curriculum for these courses through collaboration with key doctors in the industry, including Drs. Lou Chmura and Dave Paquette. Across the nation, there has been huge success with clinicians who have implemented the program. And Henry Schein Orthodontics wants to build upon this success and offer new methods for the orthodontic professional to offer total health solutions in their practice. So in 2015 we will offer courses on CBCT scanning, as well as on Soft Tissue Orthodontics. Henry Schein Orthodontics will also hold the first-of-itskind Total Health and Technology™ Symposium in July 2015. It will be a 2-day event, held at the famous Omni La Costa Resort in Carlsbad, California, with lectures from world-renowned clinicians. 16 Orthodontic practice

Twin Force Bite Corrector Devices

Building a future together Within the industry, Henry Schein is well liked for many core-company attributes, including that of offering exceptional value to their customers. Henry Schein Orthodontics is following in those footsteps and has recently launched a partnership program, the HSO Buying Club™. As a member, you will earn Award Points, which can be redeemed for FREE ancillary products! Additionally, you are eligible to receive deep discounts on all of your favorite products, as well as a majority of your peripheral products. Furthermore, you will be able to leverage both of your Henry Schein loyalty programs — in addition to earning Award

Our teams, in the field and in the office, are dedicated to the success of the clinician’s business by helping you provide your patients with a great smile, plus total health solutions. From clinician to staff member, know that you can “Rely on Us.” Points in the HSO Buying Club, your dollars will also count toward Henry Schein Practice Privilege Bonus Award Points. Our future is you! We work hard to earn our customers’ business. While we are growing and gaining market share, we are not resting on our laurels. The orthodontic community is a small community where relationships matter, and every customer is important. Our employees pride themselves in trying hard to develop successful relationships. Our teams, in the field and in the office, are dedicated to the success of the clinician’s business by helping you provide your patients with a great smile, plus total health solutions. From clinician to staff member, know that you can “Rely on Us.” OP This information was provided by Henry Schein Orthodontics.

Volume 5 Number 6

CASE STUDY

Non-extraction treatment for face-driven treatment planning Dr. Stuart L. Frost discusses non-extraction treatment mechanics and controlling torque

ne of the many buzzwords and phrases in orthodontics that are tossed around at meetings and events is “face-driven treatment planning.” Each of us may have a different take on what this means. In a similar vein, there is a great deal of discussion around treating cases with non-extraction methods. Before addressing how to do this, the first question should be “Why?” In my opinion, the reason to consider non-extraction therapy for patients who would be served by this method is to protect and enhance the upper lip and midface for optimal support as the patient ages. I teach courses on this topic throughout the world and have employed non-extraction therapy using effective, simple mechanics that minimize complicated treatment protocols and extractions and eliminate use of many painful auxiliaries, such as expanders and distalizers. Treating cases without removing teeth or using expanders requires a heightened focus on the timing and sequence of specific yet simple mechanics — mechanics that respect periodontal health and use light forces to create space and increase the transverse occlusion. The following case discusses non-extraction treatment mechanics while addressing the issue of controlling torque to prevent front teeth from flaring. Over-torqued front teeth are difficult to correct, but avoidable, using simple mechanics and a well-timed, methodical treatment approach.

Stuart L. Frost, DDS, is an Arizona native dedicated to the advancement of orthodontics. He is a Damon™ System mentor, worldwide lecturer, and part-time associate professor at the University of the Pacific School of Orthodontics where he educates and trains residents about passive mechanics. Dr. Frost graduated from the University of the Pacific School of Dentistry in 1992, and later completed a 1-year fellowship in temporomandibular joint dysfunction and a 2-year residency in orthodontics and dentofacial orthopedics at the University of Rochester. He maintains a private practice in Mesa, Arizona. See Dr. Frost at The Forum 2015 in February. For more information, visit forum.ormco.com.

Volume 5 Number 6

Figures 1A-1D: Pretreatment

Case presentation Diagnosis A 12-year-old male presented with severe crowding, a Class ll malocclusion, anterior crossbite, and both upper maxillary permanent cuspids and mandibular lateral incisors blocked out. One of our first steps in treating this patient was to assess his facial features. The patient was mesocephalic with

a slightly flat midface; he had an obtuse nasiolabial angle and little vermilion display. This combination of flat midface, limited lip projection, and deficient vermilion display helped me identify the fact that his facial features were not conducive to extractions. Removing teeth would have had a negative impact on his facial features long-term and would have created a concave profile as he aged. Orthodontic practice 17

CASE STUDY

Figures 2A-2E: Pretreatment

Treatment plan In addition to creating a non-extraction plan that would focus on opening space for the blocked-out upper cuspids and lower laterals, I wanted to make sure I was controlling the forward movement of anterior teeth with variable torque brackets. It would be a disservice to my patient if I opened space by flaring the front teeth forward. I use the Damon™ System appliances and take a low-friction, passive self-ligation approach to therapy, which is supported by coil springs to create space and develop the arches for maximum transverse adaptation. In a case such as this, the Damon™ System bracket technology is ideal because it provides rotational control with variable torque brackets to move teeth with minimal force. Due to the patient’s severe upper and lower crowding, we opted not to engage the .014" Copper NiTi wires in all the brackets at bonding. The lower lateral incisors were bonded from the beginning and wire tied to the half a bracket-width of coil spring (compressing the coil spring to the blocked out lateral). To ensure upright incisors, the correct bracket torque selection has to be made at the beginning of treatment. At all costs, we always want to avoid round tripping teeth and putting unnecessary force on them. To maintain good incisor position, we chose low-torque brackets for both the upper and lower arches 2-2. 18 Orthodontic practice

Along with choosing the right bracket torques, we disarticulated the arches in the posterior at bonding with bite turbos on the occlusal surfaces of the lower first molars.

Treatment progress 10 weeks into treatment/first visit after bonding We reactivated the coil springs half of a bracket width for the blocked-out cuspids and laterals. 5 months into treatment We engaged the lower laterals with a .014" Copper NiTi wire and activated the coil

spring half of a bracket width on the upper cuspids. 9 months into treatment Our goal was to open sufficient space for the cuspids to erupt so we could bond them. We took a two-pronged approach that included use of medium-light NiTi coil springs with half-of-a-bracket-width activation each 6 weeks — proceeding carefully so we would never overactivate the springs. By progressing slowly through the archwire sequence and activating the coil springs at each visit, we increased the transverse

Figure 3: Midtreatment cone beam image Volume 5 Number 6

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CASE STUDY occlusion and developed the arches. We were able to broaden the arch form and slowly advance the upper incisors without flaring them. By activating the coil springs and increasing the arch width slowly, we were able to keep the upper incisors upright. Also, I believe the lips and musculature of the face helped keep the incisors from flaring. This muscle-to-coil-spring relationship allows us to keep the front teeth from being pushed out, balancing the process by acting like a lip bumper. Essentially, with the use of arch wires, passive self-ligating brackets, and coil-spring mechanics, we can work with the muscles of the face to help change the force direction and increase arch width. At 17 months into treatment A cone beam image and Panorex were taken for root position and bracket placement evaluation. At this point, the patient had

Figure 4: At 17 months, note how upright the anterior teeth are

been in a .018" x .025" Cu NiTi wire on the upper arch for 10 weeks. Notice how upright the anterior teeth are. It is amazing to me how arch development, effective variabletorque bracket selection, and light-coil spring activation can prevent incisors from flaring.

Finishing In such cases, slowing the course of treatment is crucial to creating the space needed to eliminate crowding. In this 28-month-long case, we didn’t engage the upper cuspids until 9 months into treatment, using those 9 months to open the space slowly. Additionally, we didn’t put a wire through the lower incisors until 5 months into treatment. As a result, the patient has a beautiful finish with upright

incisor display where sufficient space was created to eliminate crowding using simple, non-extraction mechanics. The crowding and blocked-out teeth represented in this case are quite common patient conditions that roughly 50% of clinicians today would treat with extractions while others would integrate the use of rapid palatal expanders to create space. With simplified, passive self-ligating mechanics, there is an opportunity to slow treatment, not only to honor the patient’s facial features today, but also to enhance them for future maturation while creating space for a more natural correction. Furthermore, creating a timeline that allows for careful and planned movement, which is monitored, helps prevent flared front teeth and loss of torque control. OP

Figures 5A-5C: Posttreatment

Figures 6A-6E: Posttreatment 20 Orthodontic practice

Volume 5 Number 6

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ORTHODONTIC CONCEPTS

BioDigital Orthodontics Management of patients with open bite (I): part 12 Drs. Rohit C.L. Sachdeva and Takao Kubota discuss successful treatment of open bite Introduction The open bite malocclusion commonly has three components to it: namely, skeletal, dentoalveloar, and muscular.1,2 Successful treatment of the malocclusion requires correcting the structural deviations and dysfunction when present. In addition, the influence of temporal elements such as growth direction and velocity of the maxillamandibular complex need careful consideration in deciding the timing of care. From a perspective of structural planning, the major decision that drives the correction of an open bite is the choice and selection of the treatment occlusal plane cant (slope) and level. This is based upon a consideration of a host of factors such as the amount of upper incisor display, the height of the lower facial height, growth direction, patient cooperation, stability, etc. The purpose of this paper is not to discuss the decision matrix involved in the choice of the occlusal plane. However, with pertinent patient histories, we demonstrate the value of proactivity and personalized therapeutics enabled by technologies such

as SureSmile® in providing safe, effective, and efficient care to patients (the essence of the practice of BioDigital Orthodontics) presenting with open bites.

Patient AT Patient AT, a 26-year-old female, presented with a Class 3 skeletal malocclusion, bimaxillary dental protrusion, an anterior open bite with generalized spacing in the lower anterior segment, and a forward shift of the mandible that exaggerated her Class 3 malocclusion (Figure 1). There was no evidence of a hyperactive tongue. Initial examination of the malocclusion demonstrated deviation in the anterior occlusal plane in both the upper and lower arch (Figure 2). The maxillary functional occlusal plane was selected as the treatment occlusal plane. This means that both the upper and lower anterior occlusal plane would need to be extruded to the level of the maxillary functional occlusal plane. The virtual dental simulation (VDS) plan is shown in Figure 3. Treatment was initiated by installing a lower lingual arch to maintain lower

Rohit C.L. Sachdeva, BDS, M Dent Sc, is the co-founder 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.

22 Orthodontic practice

archwidth. The arch had spurs to encourage the tongue to re-accommodate (Figure 4A). Lower anterior alignment with .016" CuNiTi AF 27°C was begun simultaneously. Two weeks later, space consolidation using sliding mechanics on the same archwire was begun. Nine weeks into treatment, the lower archwire was replaced with a .016" x .022" CuNiTi AF 27°C archwire (Figure 4B) and space closure with sliding mechanics continued. In the third month of active treatment, the upper arch was bonded, and a .016" x .022" CuNiTi AF 27°C was used as an initial archwire to achieve preliminary bracket alignment (not shown). By the end of the fourth month of treatment, the lower space was consolidated, and positive overbite and overjet established. Also, unilateral Class 2 elastics were started on the right to help correct the mild Class 2 buccal occlusion (Figure 4C). Figure 4D shows the progress of treatment at 6 months into treatment. Eight months into treatment, a Therapeutic scan was taken (Figure 5). The Virtual

Figures 1A-1B: Patient AT. A 26-year-old female presented with a Class 3 skeletal malocclusion, bimaxillary dental protrusion, an anterior open bite with generalized spacing in the lower anterior segment, and a forward shift of the mandible that exaggerated her Class 3 malocclusion with no evidence of a hyperactive tongue. 1A. Initial intraoral photos. 1B. X-rays Volume 5 Number 6

VDS

ORTHODONTIC CONCEPTS

Target Setup (VTS) was planned from the Virtual Therapeutic Model (VTM) (Figures 6A-C). Upper and lower 017" x .025" CuNiTi AF 35°C SureSmile precision archwires were designed (Figure 6D). The SureSmile precision archwires were inserted 6 weeks post therapeutic scan, and the patient was asked to wear bilateral Class 2 elastics and diagonal anterior elastics to correct the midline (Figure 7). The patient was evaluated 8 weeks later. Class 2 correction and normal overbite were established (Figure 8). A month later, the patient was debonded (Figures 9 and 10). A comparison of the Virtual Diagnostic Simulation (VDS) to the Virtual Final Model (VFM) demonstrates that the treatment objectives were met (Figure 11A). Also, Figure 11B shows that the upper and lower anterior occlusal planes were successfully treated to the maxillary functional occlusal plane. Closer examination of the final occlusion shows a “rat hole” in the upper right lateral and lower canine area. This was anticipated in the Virtual Diagnostic Simulation and is a result of the anomalous morphology of the distal incisal line angle of the lateral incisor (Figure 11C).

VDM

Figures 2A-2C: Patient AT. 2A. Virtual Diagnostic Model (VDM). 2B. Virtual. 2C. Virtual observation of the deviation in the anterior occlusal plane in both the upper and lower arch. The maxillary functional occlusal plane was selected as the treatment occlusal plane VDS (white) vs. VDM (green)

Figures 3A-3D: Patient AT. 3A. Virtual Diagnostic Simulation (VDS). 3B. VDS (white) vs. VDM (green). 3C. Both upper and lower anterior occlusal plane were extruded to the level of the functional occlusal plane. 3D. Shows the nature and magnitude of the planned tooth movement

Figures 4A-4D: Patient AT. 4A. Lower lingual arch installed with spurs to maintain lower archwidth. The lower arch was bonded for anterior alignment with .016" CuNiTi AF 27°C. 4B. 9 weeks into treatment, the lower archwire was replaced with a .016" x .022" CuNiTi AF 27°C archwire. The upper arch was bonded in the third month (not shown), and a .016" x .022" CuNiTi AF 27°C was used as an initial archwire to achieve some preliminary bracket alignment. 4C. Month 4, all the lower space is consolidated. Also, note the reverse overjet has been corrected and positive overbite established by extrusion of the lower anterior segment. Unilateral Class 2 elastics were started on the right to help correct the mild Class 2 buccal occlusion. 4D. Progress intraoral photographs 6 months from start of treatment Volume 5 Number 6

Orthodontic practice 23

ORTHODONTIC CONCEPTS

Figures 5A-5B: Patient AT. Mid-treatment scan taken at 8 months. 5A. Intraoral photos at mid-treatment scan. 5B. Mid-treatment X-rays. VTM

VTS

VTS (white) vs. VTM (blue)

Figures 6A-6E: Patient AT. 6A. Virtual Therapeutic Model (VTM). 6B. Virtual Target Setup (VTS) with SureSmile precision archwire designed. 6C. VTS (white) vs. VTM (blue). 6D. Shows the nature and magnitude of displacements of the dentition. 6E. SureSmile precision archwire viewed against VTM

Figure 7: Patient AT. Upper and lower SureSmile precision archwires 017" x .025" CuNiTi AF 35째C were inserted 6 weeks post therapeutic scan. Patient was requested to wear bilateral Class 2 elastics

Figure 8: Patient AT. Patient progress 8 weeks post SureSmile wire insertion. Note Class 2 correction and normal overbite.

Figures 9A-9B: Patient AT. Patient was debonded 4.5 months post therapeutic scan and an active treatment of 12.5 months. 9A. Final intraoral photos. 9B. Final X-rays 24 Orthodontic practice

Volume 5 Number 6

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ORTHODONTIC CONCEPTS VFM

Figures 10A-10C: Patient AT. 10A. Virtual Final Model (VFM). 10B and 10C. Note both the upper and lower anterior occlusal plane been corrected to the level of the maxillary functional occlusal plane

VDS (white) vs. VFM (green)

Figures 11A-11C: Patient AT. 11A and 11B. VDS (white) vs. VFM (green) shows that the treatment objectives were met. 11C. Shows the anomalous shape of the right lateral incisor contributing to the “rat hole.” This is seen in the VDS (white) and in the VFM (green) models

Patient YM Patient YM, an 18-year-old female, presented with a Class 2 malocclusion and an anterior open bite with severe arch length discrepancy in the upper arch (Figures 12 and 13). Extraction of the upper first bicuspids was planned to treat the arch length discrepancy and correct the open bite. The maxillary functional occlusal plane was selected as the treatment occlusal plane. This meant that the upper incisors would need to be extruded. The lower arch would be treated non-extraction, and lower anterior interproximal reduction would be performed to alleviate lower crowding and minimize the flaring of the lower incisors. The Virtual Diagnostic Simulation plan demonstrates the planned tooth movement (Figures 14 and 15).

Treatment was initiated in the upper arch. A transpalatal arch was used to maintain archwidth and augment anchorage during space closure. Separate canine retraction was initiated with a .009" ligature wire rope tie (Figure 16A). By the third month, the canines were substantially retracted. At this time, the upper arch was bonded. In the upper arch, a .016" CuNiTi AF 35°C archwire was inserted to achieve anterior alignment. Second bicuspids were not bonded to further decrease the stiffness of canine molar archwire segment (Figure 16B). Four weeks later, the lower arch was bonded, and a similar archwire as for the upper was installed to achieve lower alignment. Minimal interproximal reduction was initiated amongst the lower anteriors at this time (Figure 16C). Five months

into treatment, the patient was requested to wear box elastics to counteract the reciprocal intrusive effect on the anteriors as the canines extruded (Figure 16D). Six weeks later, the initial upper and lower archwire wires were replaced with arch .016" x .022" CuNiTi AF archwires (Figure 16E). The patient’s progress is seen 7 months from the beginning of treatment (Figure 16F). Eight months into treatment, the mid-treatment scan of the patient was taken (Figure 17). Both the Virtual Target Setup and the .017" x .025" CuNiTi

Figures 12A-12B: Patient YM. 12A. Initial intraoral photographs. Patient has a Class 2 malocclusion with an anterior open bite with severe arch length discrepancy in the upper arch. 12B. Initial X-rays 26 Orthodontic practice

Volume 5 Number 6

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ORTHODONTIC CONCEPTS AF 35째C SureSmile precision archwires were designed (Figure 18). The precision archwires were inserted 6 weeks later. At this time, the patient was asked to continue wearing the anterior box elastics and also wear Class 2 elastics (Figure 19). The patient progress at 9.5 months in treatment and 8 weeks

post SureSmile archwire insertion is shown in Figure 20. The patient was debonded 1 month later (Figures 21 and 22). The superimposition of the Virtual Diagnostic Simulation to the Virtual Final Model shows that most of the objectives were met. However, the overbite was left a little shallow (Figure 23).

Polishing the marginal ridges of the upper incisors and some additional interproximal reduction of the lower anteriors would have created additional overjet into which both the upper incisors and lower incisors could be extruded to provide a better overbite relationship (Figure 24).

VDM

Figures 13A-13C: Patient YM. 13A. Virtual Diagnostic Model (VDM). 13B. and 13C. Patient has a mild lower Curve of Spee in the lower arch, not enough to create a positive overbite. The upper anterior occlusal plane has a slightly greater Curve of Spee, partially contributing to the edge-to-edge occlusion

VDS

VDS (white) vs. VDM (green)

Figures 14A-14E: Patient YM. 14A. Virtual Diagnostic Simulation (VDS). The upper first bicuspids have been extracted and lower IPR performed. 14B, 14C, and 14D. Note the lower Curve of Spee is maintained, and the upper incisors were extruded to establish overbite VDM. 14E. Planned orthodontic tooth movement displacements

Figure 15: Patient YM. The interproximal reduction planned in the lower arch. This is read as the overlap between the lower anteriors 28 Orthodontic practice

Volume 5 Number 6

ORTHODONTIC CONCEPTS Figures 16A-16F: Patient YM. 16A. Transpalatal arch used to maintain upper archwidth and augment anchorage during space closure. Separate canine retraction performed with an .009" ligature wire rope tie 16B. The canines are almost completely retracted 3 months later. At this time, the upper arch is bonded. An .016" CuNiTi AF 35째C wire was inserted in the upper arch to achieve anterior alignment. Second bicuspids were not bonded to decrease stiffness of canine molar archwire segment. 16C. Four weeks later, the lower arch is bonded installed and an .016" CuNiTi AF 35째C wire inserted to achieve alignment. Interproximal reduction was performed among the lower anteriors at this time. 16D. 5 months into treatment. The patient was requested to wear box elastics to counteract the reciprocal intrusive effect on the anteriors as the canines extruded. 16E. 4 weeks later, the initial upper and lower archwire wires are replaced with a .016" x .022" CuNiTi AF archwires. 16F. Treatment Progress 7 months from start of treatment

Figures 17A-17B: Patient YM. Intraoral images at 8 months. Mid-treatment scan taken at this stage in treatment. 17A. Intraoral photos at the mid-treatment scan. 17B. Mid-treatment X-rays Volume 5 Number 6

Orthodontic practice 29

ORTHODONTIC CONCEPTS VTS

VTM

Figures 18A-18E: Patient YM. 18A. Virtual Therapeutic Model (VTM). 18B. Virtual Target Setup (VTS) with SureSmile precision archwire designed. 18C. VTS (white) vs. VTM (blue). 18D. Shows the nature and magnitude of displacements of the dentition. 18E. SureSmile precision archwire viewed against VTM

Figure 19: Patient YM. Six weeks later, the upper and lower 017" x .025" CuNiTi AF 35째C SureSmile precision archwires were installed. Anterior box elastic wear continues

Figure 20: Patient YM. Treatment progress at 9.5 months from the start of treatment and 8 weeks post SureSmile archwire insertion. Note positive overbite established

Figures 21A-21B: Patient YM. Patient was debonded 4.5 months post therapeutic scan and an active treatment of 12.5 months. 21A. Final intraoral photos. 21B. Final X-rays 30 Orthodontic practice

Volume 5 Number 6

Figures 22A-22C: Patient YM. 22A. Virtual Final Model (VFM). 22B and 22C. Note anterior occlusal plane objectives not entirely met. The upper anterior occlusal plane appears a little lower than the functional because the posterior cusp tips are worn out. Additional extrusion of both the lower arch and the upper would have helped provide better overbite

VDS (white) vs. VFM (green)

Figures 23A-23B: Patient YM. 23A. VDS (white) vs. VFM (green) superimposition shows most of the objectives were achieved; however, a little more extrusion of both the upper and lower anteriors would have helped provide a better overbite. 23B. Note the lateral view with the clipping plane shows the overbite was left a little shallow

Conclusions Effective and efficient treatment of patients with open bites requires proper diagnosis, planning, and careful management. Patient participation is of vital importance, especially if elastic wear is required. With SureSmile, it is necessary for the clinician to carefully plan and orchestrate orthodontic tooth movement during the pre-SureSmile therapeutic phase of treatment as well.3-16 This implies that the conventional and SureSmile therapeutic phase of treatment should be driven by consistent objectives based upon a formal plan of care designed at the beginning of treatment. In patient YM, it would have been judicious not to have used a continuous archwire alignment of the maxillary dentition. The reciprocal intrusive force generated on the anterior teeth as the upper canines extruded put the patient at risk in terms of exaggerating the anterior open bite. It would have been preferable to extrude the canines to the occlusal plane using segmental mechanics. Long-term stability in the correction of an open bite is dependent upon Volume 5 Number 6

Figure 24: Patient YM. Polishing the marginal ridges of the upper incisors and some additional interproximal reduction of the lower anteriors would have created additional overjet into which both the upper incisors and lower incisors could be extruded to provide a better overbite relationship

the etiology of the condition and growth pattern of the patient. With regard to the patients discussed in this paper, tongue retraining exercises were recommended for patient AT as adjunctive therapy. For patient YM, posterior bite blocks were incorporated in a Hawley retainer to maintain the correction. OP Acknowledgments

The authors are grateful to Dr. Sharan Aranha, BDS, MPA, and Arjun UC Sachdeva for their enthusiastic support in the preparation of this manuscript. REFERENCES 1. Ngan P, Fields HW. Open bite: a review of etiology and management. Pediatr Dent. 1997;19(2):91-98. 2. Subtelny JD, Sakuda M. Open-bite: diagnosis and treatment. Am J Orthod. 1964;50(5):337-358. 3. 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. 4. 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. 5. 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.

6. 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. 7. 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. 8. 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. 9. 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. 10. 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. 11. Sachdeva R, Kubota T. BioDigital orthodontics. Management of patients with class 3 malocclusion: Part 11. Orthodontic Practice US. 2014;5(5)28-38. 12. Sachdeva R. BioDigital orthodontics: Planning care with SureSmile technology: Part 1. Orthodontic Practice US. 2013;4(1):18-23. 13. Sachdeva R. BioDigital orthodontics: Designing customized therapeutics and managing patient treatment with SureSmile technology: Part 2. Orthodontic Practice US. 2013;4(2):18-26. 14. Sachdeva R. BioDigital Orthodontics: Diagnopeutics with SureSmile technology (Part 3). Orthodontic Practice US. 2013;4(3):22-30. 15. Sachdeva R. BioDigital orthodontics: Outcome evaluation with SureSmile technology: Part 4. Orthodontic Practice US. 2013;4(4):28-33. 16. 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.

Orthodontic practice 31

ORTHODONTIC CONCEPTS

VFM

CONTINUING EDUCATION

An introduction to reviewing CBCT images Dr. Andrew Trosien discusses the benefits of a CBCT view

one beam computed tomography (CBCT) is becoming much more common in dentistry. A few years ago, it was unusual to get images from a colleague’s CBCT machine, whereas today it is not unusual for a few doctors in a given town to have a CBCT machine. But unless you recently graduated from orthodontic residency, you haven’t had access to much training in the interpretation of CBCTs. Further compounding the issue is the fact that much research on and with CBCTs has occurred within the last few years. So forward-looking practitioners would be wise to learn about how to approach a CT scan, and what to look for, what to measure, and what it means. Some debate remains as to whether CBCT should be used only for select patients or as a complete replacement for traditional orthodontic X-rays. Much of this dispute revolves around the radiation doses of CBCT and the fear that patients are subjected to excessive levels of CT radiation. However, these fears are unfounded. While a traditional, hospital-based spiral CT of the head give a dose of 860 microsieverts (the equivalent of more than 45 panoramic X-rays), the cone beam CT gives much less.1 The difference is related to the design of the machine, and the difference between the cone and spiral beams. For reference, the extended field of view (full head) on an i-CAT, with the traditional .3 mm3 voxel size at 8.9 seconds, results in a dose of 74 microsieverts, which

Andrew Trosien, DDS, MS, graduated first in his class from the University of Michigan School of Dentistry. He was Chief Resident of the orthodontic residency program at the University of California, San Francisco, where he received his orthodontic certificate and Masters in Oral Biology. He is currently on faculty at UCSF and teaches the residents Phase I removable orthodontics at La Clinica de la Raza of Oakland, California. Dr. Trosien maintains a private practice in Tracy, California, where he has been voted Number 1 orthodontist for 11 consecutive years. Dr. Trosien worked for and consulted with Align Technology Research and Development on the Invisalign® appliance and holds a patent in conjunction with them on virtual articulation. He is a published author in TMJ research, Invisalign treatment, and orthodontic technology. He has lectured in the United States and Europe and is a Diplomate of the American Board of Orthodontics. He can be contacted at www.trosienorthodontics.com.

32 Orthodontic practice

Educational aims and objectives

This article aims to discuss the advantages of CBCT view for orthodontic diagnosis.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 36 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Realize the radiation differences between CBCT scans and panoramic radiographs. • Identify anatomy that can be distinguished on slices and volume CBCT views. • Recognize some usual and unusual anatomical discoveries on CBCT scans. • Read about some details that can be viewed on CBCT regarding degenerative joint disease. • Identify when it may be necessary to outsource the scan for a reading.

Figure 1: Coronal, axial, and sagittal CBCT slices (with an additional image of the volume)

is less than four panoramic radiographs.1 And for a low dose “progress” scan, with a 0.3 mm3 voxel and 4.8 seconds, the dose is lower than 1.5 panoramic radiographs.1 The amount of radiation in a full-mouth series with F-speed film is the equivalent of nine panos,1 while the CBCT gives an amazing amount of information with minimal radiation dose. Fundamentally, a CBCT can be viewed in two different ways: As slices or as a volume. It’s not a matter of which you prefer — both are important. Certain features are best viewed in slices, while others are best viewed in the volume. Initially, when viewing a CBCT as part of a formal work up, most doctors will start with the slice data (Figure 1). The idea is to scroll through the volume, “slice by slice,” and look for anything out of the ordinary. It takes a while to identify what

Figure 2: A coronal slice

is considered normal, and what is actually abnormal. When starting with the coronal slice (Figure 2), we can scroll through and see the maxillary sinuses, the nasal septum, the nasal turbinates, the ethmoid sinuses, and Volume 5 Number 6

Figure 4: Mucoceles in the maxillary sinuses

Figure 5: Giant cell tumor in the maxillary sinus. Note the irregular contour

Figure 6: Wax in the right ear canal

the ear canals. (Of course, most anatomy can be seen with this view, but anatomy like the teeth, the maxilla and mandible, condyles, etc., are more easily seen in other CBCT views.) The maxillary sinuses can be completely occluded if the patient has a cold (Figure 3) or can have a thick lining, showing inflammation. There may also be what appears to be a small “balloon” in the sinus, which is a harmless mucous retention cyst (Figure 4). It is the balloon-like appearance that is indicative of a mucous retention cyst. In contrast, if it does not have that smooth, “inflated” round appearance, it may be a tumor (Figure 5) and should be reviewed by a radiologist. Surprisingly, it is not unusual to see a really small maxillary sinus, which is just an aplasia, and typically needs no intervention. The ear canals should be generally open, though it is not atypical to see an

accumulation of wax (Figure 6). However, if anything is seen in any of these areas that looks particularly radiopaque, it’s probably something that should not be there, and should be checked out — like this piece of metal from the tip of forceps used to remove an ear tube (Figure 7). The coronal view also shows the tongue. While not diagnostic of a problem, it is worth noting if there is a space between the top of the tongue and the palate in this view (Figure 8). It has been shown that expanding the maxilla creates a larger volume for the tongue to occupy, allowing it to migrate away from the back of the throat, opening the airway.2 A low tongue posture with the subsequent narrow maxilla may lead to a treatment plan involving maxillary expansion. Next, viewing the volume from the axial view, we can scroll through the frontal sinuses, the ethmoid sinuses, the nasal

Volume 5 Number 6

CONTINUING EDUCATION

Figure 3: An occluded sinus due to infection

Figure 7: Exceptionally radiopaque object in ear canal. After extraction it was determined to be part of the forceps used to remove the patient’s ear tubes over a decade earlier Orthodontic practice 33

CONTINUING EDUCATION

Figure 8: Space between the top of the tongue and palate

septum, and the maxillary sinuses. Sometimes an ordinary-looking structure in the coronal view of the maxillary sinuses can be viewed in the axial view for more information. The axial view offers the best view of the nasal septum. A deviated septum is not atypical and requires nothing more than informing the patient or the parent (Figure 9). The sagittal view gives the best view of the airway. The adenoids, soft palate, and base of the tongue are all structures that can occlude the airway. While we cannot do any sort of volume measurements on this sagittal view, it does give an indication of what structures are responsible for the airway occlusion. The volume view gives an overall assessment of the symmetry and structure of the skull and jaws. This view allows us to check the maxilla and mandible for supernumerary teeth, ectopic teeth, missing teeth, etc. We can toggle the view setting to show just osseous tissue to see the level of the bone around the teeth, as well as its thickness facially and lingually to them. Switching to an airway view allows measurement of the pharyngeal airway volume (Figure 10). The CBCT provides a reliable and accurate airway volume measurement.3 If the minimal crosssectional area of the pharyngeal airway is below 50 mm,2 then the patient is at high risk for obstructive sleep apnea. Between 50 and 100 mm2 indicates moderate risk, and greater than 100 mm2 is low risk.4,5 The CBCT offers a superior way of assessing the condyles. Prior to CBCT, a tomographic series was routinely used to view the joints, and the quality of the images was much lower than what we now receive from a CBCT. As research continues with CBCT, we should gain more knowledge about the temporomandibular joints (TMJs). The condyles are best viewed in their own dedicated slice window. 34 Orthodontic practice

Figure 9: Deviated nasal septum

Figure 10: Airway measurement. The smallest cross-sectional area here is the important measurement

Figure 11: Incomplete cortical outline of the condyle diagnostic of active degenerative joint disease. It can be seen in both the coronal and sagittal sections

Figure 12: A normal condyle in sagittal view. Note the smooth cortical outline and anterior curvature of the head of the condyle

The principal abnormality that one looks for in TMJs is degenerative joint disease (DJD). DJD destroys the articular tissues and occurs when the remodeling capacity of the articular tissues is exceeded by functional demands. The primary diagnostic feature is a lack of cortical outline along the superior aspect of the condyle. A cessation of the cortical outline, or cortical fuzziness, indicates active degeneration (Figure 11). Because CBCT screening includes an

analysis of the TMJs, it is worth reviewing the continuum of temporomandibular dysfunction. A normal joint presents a smooth, rounded cortical outline with an anterior cant (Figure 12). Once a disc displacement develops, some sclerosis and flattening along the superior anterior aspect of the condyle can be seen. Next, the condyle develops further flattening, and finally results in a nonreducing disc. At this point, erosions that characterize active DJD often develop. As Volume 5 Number 6

patient). Resolution of the disease can take months and needs follow-up with periodic CBCT scans. Clinicians should note that the shape of the condyle is not the issue as much as the presence or absence of cortical outline. A bifid condyle (Figure 14), while having a divot in its center, is a normal variation, has a continual cortical outline, and does not indicate DJD. Given the nature of degenerative joint disease and the difficulty for novice CT readers to confidently diagnose it, there are a number of services for outsourcing the reading. BeamReaders, started by Dr. David Hatcher, is the most well-known of these.

Some doctors choose to upload every CBCT taken for a BeamReaders report. Others choose to upload those images that have areas of suspicion. These services have a staff of doctors with a significant amount of experience and provide an abundance of knowledge. The most difficult thing to learn when interpreting CBCT scans is the variations of “normal.” After viewing a few dozen scans, doctors will develop a familiarity with the different variations of normal. As with any new technology, orthodontists should avail themselves of literature, courses, and hands-on experiences to enhance their knowledge and interpretive skills with CBCT. Practice makes perfect only when the practice is perfect. OP

REFERENCES 1. Ludlow JB, Ivanovic M. Comparative dosimetry of dental CBCT devices and 64-slice CT for oral and maxillofacial radiology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;106(1):106-114. 2. Iwasaki T, Saitoh I, Takemoto Y, Inada E, Kakuno E, Kanomi R, Hayasaki H, Yamasaki Y. Tongue posture improvement and pharyngeal airway enlargement as secondary effects of rapid maxillary expansion: a cone-beam computed tomography study. Am J Orthod Dentofacial Orthop. 2013;143(2):235-245. 3. Ghoneima A, Kula K. Accuracy and reliability of cone-beam computed tomography for airway volume analysis. Eur J Orthod. 2013;35(2):256-261. 4. Avrahami E, Englender M. Relation between CT axial cross-sectional area of the oropharynx and obstructive sleep apnea syndrome in adults. AJNR Am J Neuroradiol. 1995;16(1):135–140. 5. Ogawa T, Enciso R, Shintaku WH, Clark GT. Evaluation of cross-section airway configuration of obstructive sleep apnea. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;103(1):102–108.

Figure 13: After healing of DJD, osteophyte formation may be seen, giving the characteristic “beaking” appearance

Volume 5 Number 6

Figure 14: A bifid condyle. Note that the presence of a continuous cortical outline rules out DJD

6. McNeil C, ed. Science and Practice of Occlusion. Chicago, IL: Quintessence; 1997.

Orthodontic practice 35

CONTINUING EDUCATION

the joint attempts to heal, bone will accumulate on the margin of the condyle, giving the characteristic “beaking” appearance of osteophyte formation (Figure 13). At this point it is not unusual to see subchondral bone cysts, which are characterized by a radiolucency below the cortex of the joint.6 From an orthodontic perspective, a patient with a history of DJD is less troublesome than a patient with active DJD. In other words, finding beaking and reduced condylar height should not be as alarming as seeing an incomplete cortical outline, which as the hallmark of DJD, contraindicates orthodontic treatment. Orthodontic therapy in the presence of DJD will exacerbate condylar resorption much like orthodontic treatment in the presence of active periodontal disease will exacerbate alveolar bone loss. If a patient has active DJD, the orthodontist may choose to wait (in the absence of symptoms) or to make a centric relation bite splint (for the symptomatic

Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 12/1/2012 to 11/30/2016 Provider ID# 325231

REF: OP V5.6 TROSIEN REF: OP V5.6 MENCHEL

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An introduction to reviewing CBCT images TROSIEN

While a traditional, hospital-based spiral CT of the head gives a dose of 860 microsieverts (the equivalent of more than 45 panoramic X-rays), the cone beam CT _____________. a. gives much less b. gives considerably more c. gives the exact same amount d. has no radiation at all

When starting with the _______, we can scroll through and see the maxillary sinuses, the nasal septum, the nasal turbinates, the ethmoid sinuses, and the ear canals. a. axial slice b. coronal slice c. saggital slice d. the condylar slice

Next, viewing the volume from the _______, we can scroll through the frontal sinuses, the ethmoid sinuses, the nasal septum, and the maxillary sinuses. a. axial view b. coronal view c. saggital view d. occlusal view The ______ are all structures that can occlude the airway. a. adenoids b. soft palate c. base of the tongue d. all of the above The CBCT provides a __________ airway volume measurement. a. partial b. reliable c. accurate d. both b and c

36 Orthodontic practice

TMJ arthritis orthodontic dilemma, part 2: septic (suppurative) TMJ arthritis causing occlusal changes MENCHEL

If the minimal cross-sectional area of the pharyngeal airway is ______, then the patient is at high risk for obstructive sleep apnea. a. above 50 mm b. 60 mm c. below 50 mm d. 70 mm

Septic bacterial joint arthritis affects populations of older patients (greater than 55 years) and infants. The most common joints affected are the _________ in children. a. hip and knee b. wrist and ankle c. wrist and knee d. ankle and hip

Prior to CBCT, a _____ was routinely used to view the joints, and the quality of the images was much lower than what we now receive from a CBCT. a. 2D digital X-ray b. occlusal X-ray c. intraoral photograph d. tomographic series

Over a third of the incidence (septic bacterial joint arthritis) is in ____________. a. infants below the age of 2 b. toddlers above the age of 3 c. adults greater than 55 years d. seniors above 70 years old

The most common isolated organisms are Staph aureus and H. influenzae. This is a focal infection and needs to be distinguished from ________, which is more systemic and caused by the spirochete Borrelia burgdorferi. a. ankylosing spondylitis b. Reflex Sympathetic Dystrophy Syndrome c. Lyme arthritis d. Psoriatic arthritis

The principal abnormality that one looks for in TMJs is ___________. a. pharyngeal tightening b. degenerative joint disease (DJD c. ectopic teeth d. supernumerary teeth

DJD destroys ______ and occurs when the remodeling capacity of the articular tissues is exceeded by functional demands. a. the articular tissues b. sinus retention c. the ethmoid sinuses d. the septum

10. In other words, finding beaking and reduced condylar height should not be as alarming as seeing an incomplete cortical outline, which, as the hallmark of DJD, ___ orthodontic treatment. a. indicates b. contraindicates c. mandates d. determines the outline for

It is essential that in infants with perforation of the tympanic membrane (TM), either with PE tubes or from TM rupture, that these patients be treated _________ than for routine cases of otitis media to prevent septic arthritis. a. less aggressively with NSAIDS b. more gently with acetaminophen c. more aggressively with antibiotics d. more aggressively with steroids This disorder can be screened at a young age and long-term treatment planning coordinated with the __________. a. dentist b. orofacial pain dentist c. oral surgeon d. all of the above

In JRA, the lesions are almost always bilateral, and the patient will have a general feeling of _________. a. malaise b. migratory joint pain c. aggression d. both a and b

Rheumatology evaluation is _____________ in these cases, and any long-term medical management should be under the care of this physician. a. not necessary b. always mandatory c. optional d. not recommended

If there is no systemic component to the arthritis, and it is a form of osteoarthritis, secondary to bacterial infection, medications _____ to alter the disease progression. a. are still recommended b. are not indicated c. can be used experimentally d. in the NSAID family can be used

The responsibility falls on the __________to diagnose and manage occlusal changes in these patients. a. endodontist b. orthodontist c. pediatric dentist d. both b and c

10. Controlling mechanical stress is also vital in these patients, and if the patient __________, a hard acrylic night splint is recommended even without signs and symptoms of TMJ pain or dysfunction. a. is a thumb sucker b. has attention deficit disorder c. has ear tubes d. is a bruxer

Volume 5 Number 6

CE CREDITS

ORTHODONTIC PRACTICE CE

Dr. Harold F. Menchel discusses a disorder that can have significant effects on orthodontic treatment planning and treatment Abstract A past article has discussed the orthodontic implications of TMJ arthritis.1 In this article, the author proposes a mechanism of infectious TMJ arthritis in infants related to otitis media. This infection causes condylar lysis and altered growth causing occlusal changes.2 This disorder will have significant effects on orthodontic treatment planning and treatment. A case history is presented to support this hypothesis.

Introduction Septic bacterial joint arthritis affects populations of older patients (greater than 55 years) and infants. The most common joints affected are the hip and knee in children. Over a third of the incidence is in infants below the age of 2. The incidence is estimated at 6/100,000.3 The most common isolated organisms are Staph aureus and H. influenzae. This is a focal infection and needs to be distinguished from Lyme arthritis, which is more systemic and caused by the spirochete Borrelia burgdorferi.4,5 There are previous reports of septic TMJ arthritis related to middle ear infections in the literature.6,7,8,9 There are also reports of spread of bacteria to the joints from bacterial pharyngitis caused by streptococcal infections. It is controversial, however, if this is from direct infection or is a reactive arthritis.10

Educational aims and objectives

This article aims to discuss TMJ arthritis and its occlusal changes.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 36 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Realize that TMJ arthritis is a possible mechanism for degenerative joint disease in infants and children. • Identify some of the symptoms of TMJ arthritis. • Recognize the differentiation between juvenile rheumatoid arthritis (JRA) and TMJ arthritis. • See the importance of controlling mechanical stress is also vital in these patients.

severe left ear pain, preauricular swelling, and limited opening. She reported occasional mild pain on the left only over the past few years, which had increased over the past month. She was unable to chew or open her mouth without pain. She was unaware of bruxism. There was no temporal pattern to her pain. The patient reported occasional moderate temporal headache on the left side only.

Medical history Positive for numerous episodes of otitis media as infant with pressure equalization (PE) tubes placed to drain infection. The medical history was otherwise unremarkable.

Dental history The patient had been treated orthodontically with a palatal expander to correct a

unilateral crossbite at age 8. The records were supplied and indicated that the crossbite was reduced with centered midline. The patient had reported bite changes and was scheduled for definitive orthodontic treatment when she was referred for TMD pain and dysfunction.

Objective findings The patient had severe pain to palpation of the left TMJ with mild pain on the right. She also had severe pain in the muscles of mastication more on the left. There was evident hyperalgesia in the left preauricular area, but no swelling was noticed during examination. She had no cervical pain. Occlusal evaluation revealed a Angle Class III canine relationship on the right and a Angle Class I relationship on the left with the canine in crossbite.

Case history Subjective A 13-year old patient was referred to an orofacial pain dentist with symptoms of Harold F. Menchel, DMD, is a worldwide educator on the topic of orofacial pain. He is adjunct faculty at Nova Southeastern Dental School in Fort Lauderdale, Florida, educating both undergraduates and graduate residents. He is also director of Orofacial Pain Education at Larkin Teaching Hospital in Coral Gables Florida. Dr. Menchel is a Diplomate of the American Board of Orofacial Pain and a Fellow of the Academy of Orofacial Pain. He is in private practice in Coral Springs, Florida, limiting his practice to orofacial pain and sleep-disordered breathing.

Figure 1: Patient — age 13 years, 2 months — presenting with facial asymmetry to the left (dotted lines) Volume 5 Number 6

Orthodontic practice 37

CONTINUING EDUCATION

TMJ arthritis orthodontic dilemma, part 2: septic (suppurative) TMJ arthritis causing occlusal changes

CONTINUING EDUCATION Maximum intercuspation = centric relation, and there was no evident slide or shift on closing. She deviated to the left on opening and protrusion. Her maximum intercisal opening was 35 mm with a “soft” end feel. After ice and gentle manipulation, the patient opened to 45 mm. There was a midline shift to the left of 3 mm, decreased posterior overjet on the left, increased posterior overjet on the right. Vertical overlap was 15%, and horizontal overlap 1.5 mm on the right and 2.5 mm on the left with an evident open bite in the right anterior. The patient has a facial asymmetry to the left (Figure 1).

continues to wear the splint at night. The splint is checked at 3-month intervals. Notice the changes in Figure 7.

Figure 6: CBCT showing atrophy and flattening of left condyle in both sagittal and frontal view11

Diagnosis • Septic arthritis left TMJ • Myalgia • Protective co-contraction

Plan

Figures 2 and 3: Initial presenting occlusion. Notice midline shift to the left and the cuspid crossbite. The lateral view is presented in Figure 1.

Imaging Imaging for the patient is below. MRI imaging was initially planned, but due to patient’s progress, this was deferred. No initial TMJ surgery was anticipated.

Figure 4: Presenting Panorex. Notice the flattened left condyle (white arrow) and the bilateral calcified mastoid processes, which can be indicative of resolved mastoiditis

TMD Pain management involved standard TMD conservative therapy,12 resting the mandible with soft diet and behavioral modification (no gum chewing, no resting chin on hand, etc.), and home care (ice for 72 hours followed by moist heat). The patient was prescribed NSAID (Naprosyn 220 mg BID [Aleve®]), acetaminophen/diphenhydramine (Tylenol® PM), and QHS to aid sleep and for pain. She was referred to physical therapy for further evaluation, TMJ mobilization, and modalities as necessary for reduction of inflammation and range of motion improvement. A lower flat plane orthotic was placed with mandatory nightwear and day wear as necessary for pain. The occlusion was very unstable, and splint adjustments were made once a week for the first month. The patient responded very well and in 6 weeks had minimal pain to loading, an opening of 50 mm with no deviation, or limitation in range of motion (ROM). She

Splint adjustment change over 3 months

Figure 5: Lateral cephalometric film with lower border of mandible demonstrating asymmetry 38 Orthodontic practice

Figure 7: The splint was adjusted to equal bilateral contact. Notice the changes over a 3-month interval where the patient has lost contact with the incisors, and she is hitting more heavily on the posterior, particularly on the left. This is good indication of joint erosion or remodeling from the arthritis

Occlusal — orthodontic This patient has an unstable occlusion due to continuing condylar erosion and limited growth in the left condyle. Final orthodontic correction is contraindicated at this time and will not be done until full growth (in females 16-18 years). There is certainly indication in this case for possible orthognathic correction. Records are being taken annually to chart the progression of the disease. Although this is a unilateral lesion, further imaging and diagnosis will be necessary before the final treatment. Inflammatory arthritis needs to be ruled out. This will involve the protocols mentioned in a previous article in this series.1 This patient is now 15 and not yet at full growth. Her progress will be documented in further articles.

Discussion This case history is proposed as a possible mechanism for degenerative joint disease in infants and children. This mechanism is shown in the following figure.

Figure 8: This is an axial CT through the external ear of an 8-month old infant. Labeled are the external ear canal (EAC), the condyle, foramen of Huschke,13 (HF) a communication between the EAC and the infratemporal, which closes at age 3. Drainage of the middle ear with perforation of the tympanic membrane (TM) with pressure equalization tubes (PE tubes) can afford a communication where pus can go from the middle ear and infect the TMJ (white arrow)

Although the incidence of TMJ septic arthritis is unknown and certainly uncommon, this author has seen a number of cases with similar presentation and history over the past 20 years. Injury, of course, cannot be ruled out as a cause, but in this case, and similar cases, there are no reports of injury. TMJ injury is rare in children.14 Notice that the joint changes were evident on a previous Panorex Volume 5 Number 6

Figure 11: Facial asymmetry increase Figure 9: TMJ injury is rare is children. Notice that the joint changes were evident on a previous Panorex taken 5 years before when the patient was 8 years old 14

Also notice how the facial asymmetry and malocclusion is increasing in the next figures that follow.

Clinical implications and conclusions The author is proposing a mechanism for TMJ arthritic degeneration in children, which could be overlooked.15,16 It is essential that in infants with perforation of the tympanic membrane (TM), either with PE tubes or from TM rupture, that these patients be treated more aggressively with antibiotics than for routine cases of otitis media to prevent septic arthritis. Pediatricians need to be aware of the possibility of this disease. This disorder can be screened at a young age and long-term treatment planning coordinated with the dentist, orofacial pain dentist, and oral surgeon. It needs to be differentiated from juvenile rheumatoid arthritis (JRA).17 In JRA, the lesions are almost always bilateral, and the patient will have a general feeling of malaise and migratory joint pain.

Rheumatology evaluation is always mandatory in these cases, and any long-term medical management should be under the care of this physician. If there is no systemic component to the arthritis, and it is a form of osteoarthritis, secondary to bacterial infection, medications are not indicated to alter the disease progression. The responsibility falls on the orthodontist and pediatric dentist to diagnose and manage occlusal changes in these patients.18 Controlling mechanical stress is also vital in these patients, and if the patient is a bruxer, a hard acrylic night splint is recommended even without signs and symptoms of TMJ pain or dysfunction. OP This article was presented at the American Academy of Orofacial Pain (AAOP) International Conference on Orofacial Pain and Temporomandibular Disorders (ICOT) in Las Vegas in May 2014.

Figure 10: Occlusal changes

REFERENCES 1. Menchel HF. TMJ arthritis 2014: Essentials for the orthodontist, Part 1. Orthodontic Practice US. 2014;5(4):40-44. 2. Yamada K, Satou Y, Hanada K, Hayashi T, Ito J. A case of anterior open bite developing during adolescence. J Orthod. 2001;28(1):19-24. 3. Mathews CJ, Coakley G. Septic arthritis: current diagnostic and therapeutic algorithm. Curr Opin Rheumatol. 2008;20(4):457-462. 4. Welkon CJ, Long SS, Fisher MC, Alburger PD. Pyogenic arthritis in infants and children: a review of 95 cases. Pediatr Infect Dis. 1986;5(6):669-676. 5. Morrey, BF, Bianco AJ Jr, Rhodes KH. Septic arthritis in children. Orthop Clin North Am. 1975;6(4):923-934. 6. Yamada K, Saito I, Hanada K, Hayashi T. Observation of three cases of temporomandibular joint osteoarthritis and mandibular morphology during adolescence using helical CT. J Oral Rehabil. 2004;31(4):298-305. 7. Regev E, Koplewitz BZ, Nitzan DW, Bar-Ziv J. Ankylosis of the temporomandibular joint as a sequelae of septic arthritis and neonatal sepsis. Pediatr Infect Dis J. 2003;22(1):99-101. 8. Hammoudi K, Manceau A, Cazeneuve N, Poulain D, Buis J, Soin C. Childhood septic temporomandibular arthritis [in French]. Ann Otolaryngol Chir Cervicofac. 2009;126(1):18-21. 9. GĂźven O. A clinical study on temporomandibular joint ankylosis in children. J Craniofac. Surg. 2008;19(5):1263-1269. 10. Nelson JD. The bacterial etiology and antibiotic management of septic arthritis in infants and children. Pediatrics. 1972;50(3):437-440. 11. Honey OB, Scarfe WC, Hilgers MJ, Klueber K, Silveira AM, Haskell BS, Farman AG. Accuracy of cone-beam computed tomography imaging of the temporomandibular joint: comparisons with panoramic radiology and linear tomography. Am J Orthod Dentofacial Orthop. 2007;132(4):429-438. 12. Menchel HF. What is conservative care for TMD? TMJ and Facial Pain Institute Web site. http://www.tmjtherapy.com/splintherapyfortmj.html. Accessed August 6, 2014. 13. Lacout A, Marsot-Dupuch K, Smokerb WR, Lasjaunias P. Foramen tympanicum, or foramen of Huschke: pathologic cases and anatomic CT study. AJNR Am J Neuroadiol. 2005;26(6):1317-1323. 14. Fischer DJ, Mueller BA, Critchlow CW, LeResche L. The association of temporomandibular disorder pain with history of head and neck injury in adolescents. J Orofac Pain. 2006;20(3):191-198. 15. Saslaw MM, Mishra S, Green M, Yellon R, Michaels MG. Suppurative arthritis complicating otitis media. Pediatr Infect Dis J. 1999;18(5):475-476. 16. Mandel EM, Casselbrant ML, Kurs-Lasky M. Acute otorrhea: bacteriology of a common complication of tympanostomy tubes. Ann Otol Rhinol Laryngol. 1994;103(9):713-718. 17. Weiss JE, Ilowite NT. Juvenile idiopathic arthritis. Rheum Dis Clin North Am. 2007;33(3):441â&#x20AC;&#x201C;470 18. American Academy of Pediatric Dentistry. Guidelines on Acquired Temporomandibular Disorders in Infants, Children, and Adolescents. American Academy of Pediatric Dentistry, Clinical Affairs Committee, Temporomandibular Joint Problems in Children Subcommittee. 2010;35(6):262-267.

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Orthodontic practice 39

CONTINUING EDUCATION

taken 5 years before when the patient was 8 years old.

BANDING TOGETHER

Tiffany’s story Dr. David Kemp recounts a collaboration that changed a patient’s life

here are endless mountaintop milestones I am proud of throughout my 28 years of orthodontic practice. 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 her upper teeth removed for denture placement. The local Affordable Dentures® of Nashville refused Tiffany’s wishes and mentioned there was a better solution. I am very thankful for the dentist who recognized that Tiffany needed something special to happen to help her with her situation. He referred her to the show “Extreme Makeover,” and she applied for a spot on the show. After a short while, the lead producer of the show called Tiffany to tell her that, while her situation with her 40 Orthodontic practice

smile was really bad, he could not produce a full episode for her. However, he referred her to Dr. Dennis Wells of Nashville Center for Aesthetic Dentistry. Dr. Wells introduced Tiffany to the philanthropic Pinnacle Seattle Study Club of Nashville, which chose without hesitation to take on Tiffany’s case. We were delighted to have the opportunity to change a most wonderful young lady’s life through our professional abilities. I want to thank Dr. Michael Skinner for his periodontal treatment for Tiffany and Dr. Dennis Wells of Nashville Center for Aesthetic Dentistry for his restorative veneer treatment for Tiffany. The following is how Tiffany tells her story. “Every time I would smile or laugh I would cover my mouth. When I was 18 years old, I was starting college, and I decided I wanted to have a fresh start meeting new people at

college. I was so embarrassed for anyone to see my teeth, and that made me revert inward. I made a decision I would change this, so I decided to get my upper teeth pulled and a have dentures placed. I was thinking this would give me a better appearance in the community.” Tiffany’s desires were, “I just want a normal, straight smile, for my teeth to be the same color and not splotchy. I would really like not to show as much of my upper gum, and I would love to have a beautiful smile.” Tiffany’s interests and logistical issues due to traveling back and forth for care from college were considered when developing a treatment plan. She lived almost 2 hours away at college. The treatment goals focused on correcting her excessive gingival display, asymmetry, occlusal plane, short clinical Volume 5 Number 6

Volume 5 Number 6

BANDING TOGETHER

crowns, and mottled enamel after eliminating generalized gingivitis and achieving oral health. The orthodontic strategy was to treat the patient without extractions. The focus for final position of Tiffany’s upper anterior teeth was to establish gingival marginal heights with symmetry for esthetic veneer placement. Clarity™ (3M Unitek) brackets were positioned at different heights on the left and right upper anterior teeth to ensure the leveling of the anterior occlusal plane. Variable Prescription Orthodontics (VPO) was used by inverting the brackets on the upper anterior teeth to provide the best possible torque mechanics throughout orthodontic treatment. We wanted to retract her anteriors as much as possible, making way to provide ideal veneer placement. An indirect orthodontic bonding technique was used to provide accurate progressive placement of the brackets. The gummy smile was also substantially improved by the simultaneous intrusion and retraction of the upper anterior and posterior teeth. Cosmetic crown lengthening was performed to establish more ideal proportions of the anterior teeth as well as to continue to reduce the gingiva display. Ten years later, Tiffany says, “My goal was to become a lawyer, and I know if you are in the courtroom, you are in front of people, meeting with clients all the time, you have to have a nice smile to be presentable. My transformation journey that Dr. Kemp, Dr. Skinner, and Dr. Wells provided gave me my life back and truly gave me the confidence to become a lawyer. I finished law school with honors in Memphis and have practiced family and personal injury law for the past 2 years. I have now moved back to middle Tennessee, and I am interviewing law firms for a job in real estate law in the Franklin and Brentwood, Tennessee area. “This was a life-changer event for me. I now have the confidence to go up to people and be able to talk to them with ease. I do not have to cover my mouth when I smile anymore. I am so much more outgoing. I love to put myself out there. I am not trying to hide, and I am not as timid. This has given me the ability to let my personality shine. I am not embarrassed any more. I still get compliments on my smile all the time, and I never would have dreamed that I would ever have that experience. “This journey has improved my quality of life in an unbelievable way. I used to keep to myself and was really quiet. Now that I have a great smile, I can put myself out there, and

Tiffany, initial 10/17/2005

Tiffany, follow-up 8/6/2014

Photos produced electronically using the Dolphin DIGITAL Imaging System

Tiffany, follow-up 8/6/2014

I am not afraid to talk to people. I now can smile freely, and I have so much more selfconfidence. This experience has given me the freedom to truly be who I want to be.” Treating Tiffany and watching her life story unfold has been one of my greatest professional and personal experiences. To see her reach her full potential and hear her tell her story is more rewarding to me than words can really address. This story and

the stories of all my patients capture what my idea of being a successful orthodontist is really about — changing people’s lives in a positive way by creating their beautiful smiles. Tiffany’s video story can be viewed on our website at www.kemportho.com. Click on the YouTube Channel tab on the upper right corner of our website, and click on Tiffany’s Story. OP Orthodontic practice 41

TECHNOLOGY

A more controlled approach to aligner therapy Dr. William Thomas discusses an aligner treatment alternative

ou have a new prospective patient waiting in your consult room; your treatment coordinator (TC) has provided the patient with the various alternatives to treatment and has informed you that the patient is set on being treated with aligners. The patient records indicate a need for fixed Class II Treatment Mechanics, and the patient’s mandible is somewhat retrognathic. Your training and experience tell you that the patient needs fixed therapy and does not qualify for pure aligner therapy. Your TC then drops the bomb. She also mentions that they have already seen one of your largest referring dentists and have been quoted a fee for aligner treatment that is 20% less than your fixed appliance fee. So now what? This scenario is happening in orthodontic offices across the country. Patients today demand appliances that may or may not be optimal for their specific needs. Trying to convince patients and sometimes their parents that certain treatment modalities may not be best for their case is often like trying to sell ice to an Eskimo. Many orthodontists are caught in a variable quandary: “Do I treat the patient with the appliances they desire and make them work, or do I recommend the appliance therapy I feel best meets their dental needs, putting me in an uncomfortable position with my referring dentist?” The resolution most often falls somewhere in between standing firm or losing the case. Clear aligners and positioners have long been used to straighten and retain teeth. Clear thermoformed plastic with varying degrees of elasticity, formed over models of gradually aligned teeth, have been around the orthodontic world for decades. William Thomas, DDS, MS, has been an orthodontic specialist in the field of dentistry for over 25 years. He earned both his dental and orthodontic degrees from Georgetown Dental School in Washington, D.C. Upon graduation from dental school, he was selected by the prestigious National Dental Honor Society OKU, received awards for outstanding graduating senior in prosthodontic (dentures) and pediatric treatment, and graduated in the top 5% of his class. Dr. Thomas is in private practice in Poway, California. He has presented at a various orthodontic meetings and study clubs, and his work has been published in a variety of orthodontic trade magazines.

42 Orthodontic practice

My history in orthodontic software used for diagnostics and treatment planning dates back to the mid-1990s when I worked on developing a software program with Dr. Larry Andrews. I helped develop software that prescribed variations in bracket prescriptions based on Dr. Andrews’ Six Keys to Normal (Optimal) Occlusion™ and his Six Elements (6E) Orthodontic Philosophy™. This was developed long before CAD-CAM dentistry made any significant impact in our specialty and was well ahead of its time. Later, as I developed my practice, I joined the Ormco™ Dr. Thomas showcases a set of Orchestrate 3D™ printed models that will training team lecturing on the be used to fabricate aligners. Damon® System and enjoyed lecturing throughout the world. During the last decade, there have been many of my cases were not progressing the way I thought they should. Repeated case numerous advances in digital dentistry. Most of my referring dentists in the San Diego corrections were often required. In some market now offer CEREC customized crowns cases, appliances I received did not seem to using the Sirona™ System. In orthodontics, track dental movement to a desired optimal digitally made appliance systems are now a clinical level. I worked with various attachstandard alternative for many offices. More ment options to make the appliances work recently, intraoral scanning has fast taken better, especially for my Class II patients. Still, hold in orthodontic offices, and I feel we are I felt limited in what I could accomplish with the appliance systems available. now reaching the next level of digital orthodontic care. Additionally, I found that many of my local As I strive to develop improved treatment general dental colleagues continue to offer alternatives, my patients have become more aligners in their practices, often at a lower educated and more demanding regarding the fee than mine. It appears to me in my area that approximately 60%-80% of the general appliances they want — esthetics, comfort, and speed being their priorities. In my pracdentists are actively providing clear aligner tice, new patient consults for clear aligners treatment. It seemed like I was caught in a have increased dramatically; however, some Catch-22, having to re-differentiate my pracof these patients, from my education and tice and specialty, yet still offer an aligner training, did not “qualify” for the appliance service to my patients. Last year, I learned about a new system they desired. Still, these patients demanded called Orchestrate 3D™. Orchestrate 3D™ more esthetic options without using fixed appliances. was founded by a group of orthodontists lead by Dr. Todd Ehrler, who developed After several years of treating with the software that allowed orthodontists to available aligners on the market, it began to create a financial nightmare in my practice, completely control their digital set ups and driving my overhead up, severely taxing my dental movements. cash flow, and creating a gradual loss of Using any open STL file, Orchestrate control in my treatment. Chasing the “volume 3D™ Software enables the doctor and staff to have complete control of determining the discount” seemed to me like being on a wheel that kept the reward just slightly out of reach velocity of dental movements, allowing a varifor my “average” size practice. To top that off, ation of treatment planning that can be more Volume 5 Number 6

Orchestrate 3D™ gyroscope tool Treatment planning in Orchestrate 3D™ is much more intuitive from an orthodontist’s perspective than other systems where I do not have control. It takes me limited time to work up a case in the software and, more importantly during treatment, fewer headaches when I find appliances not moving teeth in my practice. With Orchestrate 3D™,

TECHNOLOGY

customized to the patients’ needs. So far, I have started over 150 patients with Orchestrate 3D™. Orchestrate 3D™ allows me an ability to provide aligner therapy combining thermoformed materials with variations in thicknesses allowing for a varied modulus of elasticity. Orchestrate 3D™ also allows me to design customized attachments in a variety of geometries, which allow us to better intrude and extrude teeth. With Orchestrate 3D™, I am treating cases that I would have never treated with any other outsourced system. I feel like I am in much better control with the Orchestrate 3D™ design software and now have the ability to do practice-designed setups that, in my hands, is better aligned to the biomechanical needs of a specific case. Analogous to multiple arch wire progressions we have all followed with our fixed therapy, I have developed a systematic multi-thickness progression using varying thicknesses of thermoformed retainer material. In my hands, this has greatly improved tooth movement and what is commonly called “tooth tracking,” along with the ability to completely customize more optimally designed attachments using the Orchestrate 3D™ Smile Design Software. Using Orchestrate 3D™, the orthodontist determines the velocity of tooth movements he/she feels comfortable with given the case to be treated. Coupled with these doctordetermined movements, clinicians can customize their own attachments using the Orchestrate gyroscope tool. This has allowed me to better control my dental movements in all three dimensions.

Dr. Thomas designs a treatment plan utilizing attachments in the Orchestrate 3D™ software

I continue to be impressed with the speed and efficiency of treatment. In an effort to maximize tooth movement and tracking, I prescribe two to three vacuumformed aligners made on each 3D printed model. Initially, I used Dentsply Essix™ in three thicknesses: .030, .035, and .040. I am now starting to use the Forestadent® Track® material fabricated on its Track machine. I am also collaborating with Specialty Appliances lab in Atlanta, Georgia, on expanding scopes of hybrid aligner therapy using fixed Class II appliances along with its manufacturing aligners using my variable thickness aligner sequences. During early stages of treatment, I desire low initial force systems; therefore, the first two 3D printed upper and lower models are made with vacuum formed aligners using .030- and .035-inch thickness. This enables the dentition and periodontal ligament apparatus the ability to initiate tooth movement and help transition the patient past the initial soreness phase. Occasionally, I use an initial .020 for my initial “adjustment” aligner. My standard treatment protocol is to use .030 and .035 for the majority of the treatment. When the case has progressed

to the final two models, I incorporate a final stage protocol of .030 and .040. If I am really concerned about extrusion and tooth tracking, I’ll include three aligners per 3D model — .030, .035, and .040. In my practice, this regiment has greatly improved the speed of dental movement through dramatically improved “tracking” and also has seemed to improve my patients’ compliance. In the cases where teeth do not seem to be tracking as fast as I would like, I can go back and adjust the digital setup and get new printed models in a few days. Although I am still finishing many of my Orchestrate cases, I feel as if I use fewer aligners than I used to while achieving the same, if not better, tooth movement. With Orchestrate, I keep all of my printed models in-house and can fabricate a replacement appliance often on the same day. Once I fully incorporate an in-office 3D model printer, storage of these models will become obsolete. If a specific model is required, it will simply be printed on an as needed basis. In my practice, the biggest benefits with the Orchestrate 3D™ system are that I see improved control in treatment progression

Easy-to-use gyroscope tool designs both custom attachments as well as tooth movement and position Volume 5 Number 6

Orthodontic practice 43

TECHNOLOGY and am able to continually refine tooth movements anytime during treatment with limited additional cost. Typically, I have four to six “setups” or 3D printed models made at a time, on which two to three aligners are vacuum formed on each as previously described. This treatment strategy produces 10-18 aligners per arch and enables changes quickly and efficiently if needed during treatment progression. Prior to using Orchestrate 3D™, I was locked into a treatment plan and appliances that were predetermined before the patient ever started treatment. With this new technology, I can now make additive clinical decisions and modifications regarding tooth movement and force applications during the course of orthodontic treatment, which has given me much better control of my treatment and a new outlook on using aligners in my practice. Further, through my previous experience with aligners, I had limited ability to monitor or manipulate dental tracking easily and efficiently during treatment; therefore, some cases fell behind or had to be retreatment planned. This meant new impressions, lost revenue, lost patient goodwill, and lost profitability. By treatment planning with Orchestrate 3D™, I focus on maintaining facial-lingual and mesial-distal movements to approximately 0.3 mm per stage, and I keep extrusion and intrusion movements down around 0.1 mm per stage. By adding the option for variable force levels delivered by multiple material thicknesses, I have seen dramatic improvement in how fast teeth are moving, and I feel like I am using fewer appliances to gain my desired dental movements due to dramatically improved tracking. An alternative strategy to enhancing more difficult movements — i.e., extrusion — is to combine simultaneous lingual attachments. The 3D printed models provided by Orchestrate 3D™ resist tooth fracture better than stone models. Using Pam® as a nonstick material on the printed models enables aligners to be removed easily and efficiently, allowing my lab technician to fabricate multiple aligners on each model easily without excessive breakage. In some cases, seating attachments are critical to achieve specific tooth movements with clear aligners. Typically these are bonded onto teeth with a high strength composite resin. With the Orchestrate 3D™ software system, precise and completely custom precision attachments are designed by the doctor enhancing treatment efficiency. Initial attachment bonding trays are typically 44 Orthodontic practice

Doctor-designed attachments for either labial or lingual enhance treatment efficiency and tracking

made using .020 thickness Essix™ material. When attachments are used with the Orchestrate 3D™ software, an additional “setup” or 3D printed model is printed along with the aligner models. I term this Stage 0. With Orchestrate 3D™ software, I have been able to design more optimal attachment geometries that have greatly enhanced the speed of treatment and, in my practice, reduced the number of aligners needed compared to an outsourced lab service. Combined with variable modulus of elasticity retainers we can fabricate in my lab, Orchestrate 3D™ opens up a much broader range of patients whom I now feel comfortable treating with clear aligners. Orchestrate 3D™ also allows me an option to treat patients initially with fixed labial or lingual brackets to achieve difficult leveling and aligning, and then switch finishing with Orchestrate planned finishing appliances. In short, Orchestrate 3D™ has given me an in-sourced system of which I am in full control, both from a treatment aspect and from a practice overhead and cash flow standpoint. Prior to using Orchestrate 3D™, we found ourselves trying to convince perspective patients that my clinical training and specialized education was worth a premium fee and large down payment to cover all startup costs. However, for those patients who desired a second opinion and who wanted clear aligner therapy, they often choose to get treatment from a general dentist who offered the same system and a reduced fee. In the past, I had a choice: Should I

reduce my fee, or should I lose the patient start? With Orchestrate 3D™, I feel I can now offer a premium treatment with improved clinical advantages at a cost that allows me to treat patients with the same fee as my fixed appliance therapy. When given the choice of braces or clear aligners — at the same cost — the choice has been a resounding 90% clear aligners. Now when my TC comes to me with prospective patients who desire therapy with customized aligners, I cannot wait to tell them about this new technology, which allows us improved clinical options and still gives them the clear aligner appliance they desire. As we learn more about how we can utilize Orchestrate 3D™, I feel my practice continues to embrace new opportunities that we never had before. My career has been an interesting journey, and I now, once again, look at my cases in a totally new way — through a new paradigm in which clear aligners can finally be highly effective clinically while also financially palatable and cash flow friendly. By using Orchestrate 3D™, my creative treatment planning has only now just begun! I am now working with Orchestrate 3D™ to help educate clinicians and their staff to realize the same benefits we have enjoyed in my practice. If you are interested in learning more about in-office courses or wish to comment, please email me at Drt@powaybraces.com; visit the Orchestrate 3D website at www.Orchestrate3D.com; or visit the AlignerPlus™ website at www. AlignerPlus.com for additional information, times, and dates about upcoming courses. OP Volume 5 Number 6

Your treatment, your terms...

Comprehensive Training Course: January 9-10, 2015 Upland, CA

•

Diagnosis

•

Appliance Fabrication & Delivery

•

Treatment Planning

•

In-Office 3D Printing

•

Tooth Movement

Contact Lauren Oates to Register: lauren@orchestrate3d.com Available From:

1747 N Riverside Avenue, Rialto CA 92376 | www.orchestrate3d.com | (855) 284-6900

TECHNOLOGY

CBCT and 3D imaging goals for orthodontic patients Dr. Duane Grummons discusses how CBCT equips the orthodontist regarding unerupted teeth, facial asymmetry, craniofacial anomalies, temporomandibular (TMD) disorders, airway conditions, TAD planning, and true root information in the region of interest (ROI).

he AAO recommends orthodontic screening by age 7. To get adequate diagnostic jaw and bite information, the use of low-dose CBCT imaging is often indicated and preferred. We know enough about its application to consider it the imaging of choice for comprehensive orthodontic treatment.1 This reveals eruption guidance and jaw imbalance decisions and airway/TMJ problems that influence facial growth and development. Patient age is less important since imaging relates to the individual needs and timing. Clinicians establish imaging goals and select the optimal imaging modality to answer clinical questions. The imaging goals and prescribed need for a low dose, limited field of view (FOV) CBCT scan should be determined after a careful clinical examination. The doctor first evaluates to determine any cone beam imaging need, rather than all patients getting a scan. CBCT is the preferred imaging modality considering patient risks (radiation dose) while also recognizing the implications of not utilizing CBCT and having incomplete diagnostic information.

New thinking and imaging perspectives Perhaps we as a profession, should change the pretreatment records as a result of technological changes in our profession with CBCT. The standard of care has been elevated such that 3D imaging should be an essential part of certain imaging decisions.2 We should image wisely and always adhere to the ALARA principle. We can obtain a Duane Grummons, DDS, MSD, is a board-certified orthodontist with a specialty practice in Spokane, Washington. He has published orthodontic articles and chapters, and has lectured for most U.S. and worldwide orthodontic organizations. Dr. Grummons is internationally recognized for his clinical approaches to facial orthopedics, facial asymmetry, TMD management, and non-extraction orthodontic treatments. Dr. Grummons is Associate Professor of Orthodontics at the Loma Linda University Medical Center Orthodontic Department. He has appeared before many dental, surgical, and medical conferences, and has made radio/TV appearances. He can be contacted at grummons1@comcast.net.

46 Orthodontic practice

CBCT scan for patients in the range of 27 µSV-80 µSV; less with i-CAT FLX. Infrequently, do we prescribe a full field of view (FOV) scan at any high resolution or with a long scan time. Such low-dose scans are typically less than full mouth dental X-rays.3 The i-CAT data set equips the clinician to focus on the patient’s individual needs and identify the appropriate imaging parameters, such as whether to capture a limited field of view (FOV) 8 x 8 or 16 x 8, or a single arch or region, versus a full-volume scan. 3D panorals are undistorted4 and make a significant difference, so 81% less errors occur compared to 2D panorals.5 We can focus on an impacted tooth with less radiation. If we are evaluating the airway and/or obstructive conditions, this requires moderate FOV pharyngeal anatomic information with certain specific volumetrics utilizing i-CAT, Anatomage, and/or Dolphin 3D software for computations and assessment, which 2D X-rays do not provide.

Figure 1: Coronal slice showing hypertrophic tonsils causing airway obstruction, snoring, and mouth breathing

Low-dose 3D images Primary advantages of low dose, limited FOV CBCT are accuracy of image geometry, reliability of measurements, localization of ectopic teeth, and assessment of root resorption. While achieving quality 3D images is important, capturing scans responsibly with the lowest radiation dose possible is a priority. Clinicians must make prudent decisions about their imaging options for the best diagnostic information for their patients and practices. Practitioners can make evidencebased decisions to prescribe cone beam imaging technologies for acquiring vivid diagnostic images. Low-dose volumes are useful for tasks such as midtreatment assessment of orthodontic patients for root position and angulation within the arch. Our main diagnostic focus includes jaws, alveolar bone around teeth, TMJ, and airway. 3D renderings are the “steak,” not just the “sizzle.” Daily ambient radiation equals 8 microsieverts (4-7 days in the sun).3 Dental fullmouth X-rays are about 150 µSv and more

Figure 2: Traumatic bone cyst, left mandible

Figure 3: CBCT 9 sec/.3 voxel scan — abnormal soft tissue tumor interruption obliterated sinus and orbital walls. Sinonasal sarcoma Volume 5 Number 6

Second opinions We welcome other opinions, so patients can compare our 3D technology and knowledge base to colleagues. Being “smart” is believing half of what you hear; “brilliant” is knowing which half to believe. Patients become inspired and enthusiastic about treatment with us as they perceive our 3D strengths, which set our practice apart from the competition.

Figure 4: CBCT 5 sec/.3 voxel scan. Anatomic visualization and measurements of mandibular asymmetry. 3D coronal slice at first molars

Patients immediately discover and experience the difference between our depth of analysis and information, compared to the quick screening cursory orthodontic exam that occurs in many offices. Often, we treat the outliers — the patients with abnormal conditions. After patients have gone to other doctors seeking an opinion, we regularly find undiagnosed problems in our 3D scan after thorough new patient evaluation. Patients value this. Once we discover the complete situation and analyze diagnostics, we can explain and visualize findings with the patient, report back to colleagues, and co-manage these conditions. We outline a course of effective and efficient orthodontic therapy for each challenging case and make it clinically navigate/flow well.

asymmetric craniofacial structural etiology. Treatment progress and therapeutic changes can be measured and viewed by visualizing, evaluating, and comparing maxillo-mandibular structures. CBCT in orthodontics equips clinicians regarding problems with erupting teeth, facial asymmetry, craniofacial anomalies, temporomandibular joint (TMJ) disorders, airway obstruction, TAD strategies, and root resorption.

Game changer

CBCT data and anatomic cranial base superimposition areas make it possible to visualize and specify Class II and Class III

Cone beam DICOM imaging data and 3D renderings provide exceptional information and exquisite 3D images revealing the craniofacial structures and the malocclusions we treat. Treatment changes and comparatives can be truly captured, created, viewed, measured, analyzed, and convincingly visualized. If a treatment challenge is not going according to plan, we can scan to identify and specify why, and then modify our clinical approach.

Figure 5: Anatomic visualization and measurements of mandibular asymmetry. CBCT coronal slice at the first molars reveals 6-mm width discrepancy between convexity of lingual crown and mid-sagittal plane

Figure 6: CBCT 5 sec/.4 voxel scan. Dynamic visualization of skeletal malocclusion (maxillary transverse hypoplasia) with bilateral posterior crossbites

Structural analysis

Figure 8: 3D leaves no doubt. Dentist missed supernumerary Nos. 8 and 9 on 2D pano. Dolphin 3D axial view reveals true dentoalveolar relationships

Figure 7: Grummons 3D Frontal Asymmetry Analysis - Anatomage Volume 5 Number 6

Figures 9A and 9B: Subcondylar fractures — missed by hospital ER probably due to inadequate CBCT 3D imaging Orthodontic practice 47

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radiation than a low-dose CBCT scan.3,6 I recommend to keep a 2D ceph and panoral unit for routine orthodontic situations. For our new patients, 2D digital screening images are prescribed for 25%, and 3D CBCT scan for 75%. Of our scans captured, 90% are 5-second scans, and 10% are 9-second or other scans.

TECHNOLOGY Discovery and visualization i-CAT imaging allows us to see true clinical anatomy that would not be visible with 2D imaging. In the TMJ region, this includes pathosis, undiscovered fractures, and degenerative conditions. We have found lesions or tumors in the airway and sinuses that extend into the cranial base of the skull and put life at risk. Some frustrated patients have visited multiple doctors with a problem. From the cone beam scan, we have discovered the issues that allowed the specialist to understand the etiology of an abnormal condition. We can help identify and co-manage these conditions. Tumors in jaws and cysts around teeth must be treated first, before orthodontics can begin. 3D imaging helps me outline a course of orthodontics for the challenging case, and so therapy navigates well.

of our practice, and teaching about radiation exposure is a priority. We don’t wait for patients to ask. We educate them before an image is taken. We explain and demonstrate the FOV and scan resolution we select as best and safe for individual needs. We explain by comparing the radiation from a scan to the everyday environment, like an extended airplane flight or weekly ambient radiation, which typically is more than one low-dose limited FOV scan. 3D users must be ready to inform our peers about radiation comparisons as well. If another colleague says that the panoramic image is good enough, we must know deeply about 3D imaging to explain the difference between radiation and distortion from a 2D

X-ray versus a 3D scan, and compare the benefits of 3D cone beam images for diagnosis and treatment planning. This technology keeps getting better. The 3D CBCT from i-CAT™ (the i-CAT™ FLX) offers a QuickScan+ feature that captures a fulldentition 3D scan without distortion.

Figure 10: Colorize/number dentition/supernumeraries

Figure 11: Superimposition of T1-T3 of 3D data

Figure 12: TMJ views showing advanced DJD

Figures 13A and 13B: Supernumerary third molar

Anywhere Dolphin, ScreenFlow, and Dropbox communications We improve communications with such tools as colorization and different translucencies to depict the 3D anatomy and its influence upon the course of treatment. Digital communications: email by AnywhereDolphin. com is HIPAA compliant; Dropbox.com or Box.com (DICOM and image file sharing),

Airway issues Regarding 3D airway and sleep-disordered breathing or obstructive pharyngeal conditions, clinicians can do harm by doing nothing. “Nobody ever died from crooked teeth” — say that to the man who fell asleep at the wheel. Some ENT and sleep doctors tell patients that what we identify on our i-CAT CBCT scans is what they primarily trust and rely upon. This has helped immensely to improve our clinical effectiveness, best patient care, and referral relationships. Nasal breathers have greater airway volumes.7 RME maxillary orthopedic growth modification is effective for increasing nasal airflow.8 The oropharynx and nasopharynx volumes of Class II subjects are significantly lower than other groups.9

Education and communication Patient education is an important part

Figure 14: Submerged primary molar tooth #a 48 Orthodontic practice

Figures 15A-15D. Four renderings to view tooth No. 5 impaction: 15A. Segmented grayscale with white background. 15B. Segmented solid volume with black background. 15C. Coronal CBCT slice. 15D. Sagittal CBCT slice Volume 5 Number 6

3D imaging for lower dose than a 2D panoramic* is not magic… …it’s The i-CAT FLX is a reality! This latest advancement of our award-winning technology offers a range of innovative features that deliver increased clarity, ease-of-use, and control. Now with Visual iQuity™ and QuickScan+ technologies, the power of capturing diagnostic 3D images at a lower dose than a 2D panoramic x-ray is in your hands.

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*Utilizing the i-CAT FLX QuickScan+ exposure protocol. Use of lower dosage imaging may only be suitable for certain diagnostic tasks. i-CAT FLX offers a variety of exposure protocols allowing clinicians to adjust dosage to specific diagnostic needs.

TECHNOLOGY

Figure 17: Cone beam volumetric tomography (CBVT) low dose scan provides face/airway friendly orthodontics. View jaws, teeth, airway, TMJs, vertebral region, and soft tissue from one scan

Figures 16A-16E: Transposed canines and first premolars

CDs, flash drives, GoToMeeting, Skype, MAC ScreenFlow, video messaging, and live video chat are used. 3D imaging photo overlays accurately depict the smile dynamics and facial anatomy. Video clips are better for soft tissue smile animation and dynamics of the smile. Relax the smile to repose; animate the smile fully; and return to neutral. This displays the teeth and muscular function during speech and smiling.

Concluding remarks When considering the safety zone of X-ray exposure, it helps to compare to our ambient exposure of 8µSv per day. The radiation exposure for a round-trip flight from San Francisco to New York is approximately 72µSv, about equal to one CBCT scan.10 We do not disregard any risk of dental X-rays. However, when we discuss the move in orthodontic imaging from traditional pan/ceph to CBCT cone beam volumetric tomography (CBVT), there should not be disagreement about exposure risk. The risks of medical imaging at effective doses below 50,000 microsieverts for single procedures are too low to be detectable and maybe nonexistent.11 50 Orthodontic practice

Figure 18: Pesky canines

i-CAT is known for its low-dose radiation, a fact appreciated by patients. The diagnostic benefits of CBCT have been clearly substantiated by research and clinical circumstances. A primary benefit of CBCT is in seeing the anatomic truth. You don’t know what you can’t see. How else can you visualize airway, TMJs, transverse relationships, buccal-lingual widths of bone, and teeth/root positions all in one simple low-dose scan? There is no comparison.12 The transformation of my clinical practice with i-CAT CBCT 3D is extraordinary. Imaging goals and CBCT protocol seek answers to specific clinical questions utilizing a precise and exquisite display of relevant anatomical representation. Individualized patient findings are closely analyzed by the clinician. Each of us has huge capacity to continuously learn and achieve to become brighter and better. One is not a successful clinician until fullest efforts have been made to become the best one can be in providing the finest individualized patient care. The future is now. Together, we lead the way with i-CAT cone beam and related technologies in modern orthodontic practice. Stay out in front — the lead dog has the best view in the race. See you at the top! OP

REFERENCES 1. Larsen BE. Cone-beam computed tomography is the imaging technique of choice for comprehensive orthodontic assessment. Am J Orthod Dentofacial Orthop. 2012;141(4):402, 404, 406. 2. Curley A, Hatcher DC. Cone beam CT — anatomic assessment and legal issues: the new standards of care. J Calif Dent Assoc. 2009;37(9):653-662. 3. Unites States Nuclear Regulatory Commission. Radiation Dosage. http://www.nrc.gov/. 4. Haney E, Gansky SA, Lee JS, Johnson E, Maki K, Miller AJ, Huang JC. Comparative analysis of traditional radiographs and cone-beam computed tomography volumetric images in the diagnosis and treatment planning of maxillary impacted canines. Am J Orthod Dentofacial Orthop. 2010;137(5):590-597. 5. Granlund CM, Lith A, Molander B, Gröndahl K, Hansen K, Ekestubbe A. Frequency of errors and pathology in panoramic images of young orthodontic patients. Eur J Orthod. 2012;34(4):452-457. 6. Ludlow JB, Walker C. Assessment of phantom dosimetry and image quality of i-CAT FLX cone-beam computed tomography. Am J Orthod Dentofacial Orthop. 2013;144(6):802-817. 7. Alves M Jr, Baratieri C, Nojima LI, Nojima MC, Ruellas AC. Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children. Int J Pediatr Otorhinolaryngol. 2011;75(9):1195-1199. 8. Pirelli P, Saponara M, Guilleminault C. Rapid maxillary expansion in children with obstructive sleep apnea syndrome. Sleep. 2004;15;27(4):761-766. 9. El H, Palomo JM, Airway volume for different dentofacial skeletal patterns. Am J Orthod Dentofacial Orthop. 2011;139(6):e511-e521. 10. Carlson S, Graham J, Harrell WE Jr, Lin EY, Molen A, Womack WR. The truth about CBCT radiation. Orthotown. 2011;Sept:62-68. 11. American Association of Physics in Medicine, December 13, 2011. 12. Grummons D. Innovations for CBCT with 3D Diagnosis and Orthodontic Planning and Treatment. Orthotown. September 2012;50-53.

Volume 5 Number 6

PRACTICE MANAGEMENT

Cloud computing in orthodontics Jake Gulick discusses how cloud computing can benefit an orthodontic practice

What is cloud computing? If you visit any technology-related website section these days, you are bound to see articles about â&#x20AC;&#x153;the cloud.â&#x20AC;? The cloud is a very fast-growing technology, and many people do not realize they have been using the cloud

Jake Gulick has been with Cloud9Ortho for 3 years and has worked in the orthodontic technology sector for over 7 years. He started as a trainer for Cloud9Ortho and has seen firsthand how cloud computing can change an orthodontic practice. He graduated from The University of Iowa with a BBA in Marketing.

Volume 5 Number 6

in their daily lives and office for years. Email clients, such as Gmail and Yahoo, are cloudbased. The easiest way to explain the cloud is that the data is available 24/7/365, and the information is not stored on your device. Instead, the data is stored in a data center, sometimes thousands of miles away. Cloud computing is not a new concept even in the orthodontic world. Companies such as TeleVox and Sesame have been providing cloud services to offices for many years. They make the phone calls and send emails from a data center, not from your office. They also allow patients to access

information about their appointments and financial balance from any computer. The patient is logging into the cloud when using one of these systems.

Why is the cloud growing so fast? A big reason is the number of companies investing in the cloud. For example, Dell Computers, whose core business had been selling computer hardware, has invested over $1 billion in data centers. IBM has also been aggressively investing in the cloud by spending over $3 billion acquiring cloudbased companies. Orthodontic practice 51

PRACTICE MANAGEMENT Over the last 5 years, we have seen a huge shift in the services being offered by companies such as Microsoft, Amazon, and Apple. Microsoft 365 is the office suite built on the cloud. Amazon has many cloud applications, including Amazon Cloud to store music and files. Apple has expanded iCloud to allow sharing across all of your iOS devices and Apple computers. Cloud computing is making our lives simpler by allowing us to access our data anytime, anywhere, from any device. With the explosion of smartphones and tablets, the demand for cloud services has erupted.

How does cloud computing fit into your practice? As mentioned previously, you are probably already using it for email or patient communication, but over the last several years, we have seen cloud practice management software enter the orthodontic world. Not all clouds are created equal, so make sure you research each option and understand the different platforms.

How can it help your practice? By moving your practice to the cloud, you will have much more freedom with your practice. If it is a web-based application built from the ground up, you will be able to run your practice from any computer, PC or Mac, in its native mode and without installing any software. You will no longer need a server in the office as all data is stored in real time in the cloud. Your IT cost would be reduced since there is no longer an expensive server to buy or maintain, and your connection costs should be reduced significantly. You will not have “satellite” offices any more since every office will run exactly like your main office. Images will be lighting fast in all offices as well. The use of remote desktop, Terminal Services, LogMeIn, or other old technology will be eliminated. You also will no longer need to worry about backups of your data or imaging as those would all be taken care of for you! Imagine having a laptop fail in your clinic and being able to go to Best Buy or connect to Amazon.com, order a new laptop, plug it in, and be using your software without calling your IT company or even your software company. That is the power of the cloud!

What are the concerns regarding cloud computing? The biggest worry about the cloud is 52 Orthodontic practice

Cloud computing is making our lives simpler by allowing us to access our data anytime, anywhere, from any device.

about the security of your data. Think of this way — do you keep your money in your house under your couch or in a bank where it is secure? Think of your patient data the same way. Is it safer in your office where someone could break in and steal your server, or a data center with armed security? If you were using a cloud system and someone broke into your office, there is no server or data to steal since it is all stored offsite. “Cloud computing is often far more secure than traditional computing, because companies like Google and Amazon can attract and retain cyber-security personnel of a higher quality than many governmental agencies,” said Vivek Kundra, former federal CIO of the United States.

What if the Internet connection goes down? The Internet is only getting better and more stable by the day. I do not remember the last time my Internet was down. The broadband Internet connections from mobile carriers like Verizon and AT&T are getting huge boosts in speed. If you are concerned with losing your local Internet connection, you can pay $50 per month for a backup HotSpot for your practice or have a backup DSL connection. Chances are you will never use it, but for peace of mind, some may find it comforting.

What should you ask a cloud provider? As much as cloud computing can help your practice, if you are not careful, you can also be misled by “cloud washing,” which is “the purposeful and sometimes deceptive attempt by a vendor to rebrand an old product or service by associating the buzzword ‘cloud’ with it.” This is not just happening in orthodontics but across all industries. When looking into a cloud practice management software, be sure to ask if it was built as a web-based application. Many times, companies will just move your server offsite, host your data for you, and call it “cloud.” David Linthicum, a cloud computing expert with InfoWorld, says, “Truth be told, most of those presentations are given by salespeople who don’t know a cloud from a hole in the ground; they actually believe what they’re selling is a cloud.”

Bottom line A cloud-based practice management software can be a great addition to your practice and allow you the freedom you have only dreamed about before, but before you jump in with both feet, make sure you ask the right questions and move to an application that was designed from scratch to operate in the cloud. Only then will you achieve the full benefits of a cloud application. OP

REFERENCES 1. Kan M. Dell to invest $1 billion to boost data storage products. CIO. http://www.cio.com/article/679181/Dell_to_Invest_1_Billion_ to_Boost_Data_Storage_Products. Accessed August 7, 2014. 2. Reuters. IBM to spend $1.2 billion to expand cloud services. http://www.reuters.com/article/2014/01/17/us-ibm-datacentersidUSBREA0G05P20140117. Accessed August 7, 2014. 3. McMahon B. Explore the cloud. Club Managers Association of America. http://www.cmaa.org/template.aspx?id=40823. Accessed August 7, 2014. 4. Linthicum D. It’s hosting, dammit: Fed up with fake cloud providers. InfoWorld. http://www.infoworld.com/d/cloud-computing/ its-hosting-dammit-fed-fake-cloud-providers-206384. Accessed August 7, 2014.

Volume 5 Number 6

Switch to the Most Cutting Edge Practice Management Software You can be just like our Cloud9 customers below. . . I am happier with Cloud9 than I have ever been with any practice management software Dr. Clarence Red, Joliet, IL We love the program, the support and our whole experience with customer service has been great! Susan, Dr. Doug Hiser, Cumming, GA Buy it today! You'll love it especially if you have multiple oﬃces. It has been easy to use and very adaptable. Dr. Keith Harvey, Mobile, AL The entire Cloud9Ortho team is more knowledgeable, friendly and trustworthy than any other software system provider that I have ever worked with Dr. Ron Maddox, San Dimas, CA

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PRACTICE DEVELOPMENT

A unique approach to ceramic brackets for organic practice growth Dr. Paul Tran explores the advantages of ceramic brackets

s orthodontists, we often think of esthetics as a final result — a patient comes in with malaligned teeth, and we give them a beautiful smile at the end of treatment. However, I will be the first to admit that as orthodontists, we don’t always pay close enough attention to the treatment process in its entirety. In order to achieve a successful esthetic result, we must focus on esthetics during the complete treatment journey, from the tools and materials we utilize to the brackets themselves. While my practice still offers metal brackets, we have successfully adopted esthetic brackets and are quickly moving toward becoming a practice that exclusively offers esthetic options to our patients. We have developed a unique concept for approaching the choice between metal and ceramic, and from a practice growth standpoint, it has proven to be one of the best moves we’ve ever made. I’d like to share with you how we accomplished this and provide tips on how to effectively make this transition with both your adult and teen patients.

In the beginning When I began practicing in the orthodontic field 20 years ago, I primarily used metal brackets and treated only a select few adult patients with ceramic brackets. At the time, ceramic brackets were not as efficient — they were harder to debond, bulky, and shattered frequently. Like many of my colleagues, I tried to talk my patients out of ceramic brackets because I didn’t feel that they offered an effective solution. Paul Tran, DDS, MSD, was born in Hong Kong, China, and grew up in Brazil. While residing in those countries, Dr. Tran learned to speak Chinese and Portuguese fluently. Dr. Tran attended the University of Houston for his undergraduate degree, his DDS degree in 1990 from the Baylor College of Dentistry, and his Orthodontic Certificate and MSD in 1994 from the University of Kentucky. He started Tran Orthodontics in 1995 and now practices in Middletown and Prospect, Kentucky. He has served in many capacities in organized dentistry such as president of the Kentucky Association of Orthodontists and a delegate to the American Association of Orthodontists. Over the past 20 years, Dr. Tran has spent countless hours learning from the very best in dentistry and orthodontics and is also an alumnus of the prestigious McLaughlin Program.

54 Orthodontic practice

Figures 1 and 2: Ceramic bracket systems such as Clarity™ ADVANCED Ceramic Brackets from 3M Unitek (top) offer a more discreet and esthetic treatment option compared to metal brackets (right)

When clear aligners came into the market about 15 years ago, they were heavily promoted throughout the orthodontic world. We saw the market respond to the promotions, and patients began to ask for clear aligners. While we initially treated patients with clear aligners to meet this growing demand, we recognized that traditional braces were more effective, easier to maintain, and achieved the best final result. As demand grew for clear aligners, it became obvious that there was a fervent need for esthetic solutions. When we were introduced to ceramic systems such as Clarity™ Metal-Reinforced Ceramic Brackets from 3M Unitek, it was clear that this was a completely advanced product. The quality, ease of debonding, strength, and durability of these ceramic brackets were so impressive that we decided to use 3M Clarity brackets with the majority of our patients. Ceramic brackets became our solution to meet the growing demand for esthetic products and gave our patients the superior smiles we both desired. To be clear — clinically, ceramic brackets are no different than traditional metal brackets. There is no learning curve when making the transition, and in my experience,

debonding is considerably easier. I now work with Clarity™ ADVANCED Ceramic Brackets from 3M Unitek and have had excellent results. If you can use a metal bracket on a patient, you can also use a ceramic bracket.

A unique perspective on pricing When we began the transition toward an almost exclusive ceramic practice, we made a major decision that has set us apart from other practices: We decided that whether a patient wanted metal or ceramic, we would charge the same fee. How is this possible? Even though ceramic brackets have a higher initial cost compared to metal brackets, our office overhead never changed significantly. However, the benefits we saw were an increase in new patients seeking esthetic solutions, and that itself more than made up for the cost difference, especially when spread over a number of patients every month. For our patients, removing cost concerns from the equation eliminated the difficult part Volume 5 Number 6

metal bracket on a patient’s upper arch (not including molar brackets). Since transitioning to ceramic brackets and offering a level playing field in terms of associated costs to our patients, we have seen incredible growth in our practice. We believe that this is attributable directly to the superior esthetics we’re offering, and the fact that our patients aren’t afraid to talk about it. Referrals and word of mouth are indispensable in creating a solid reputation and a steady patient stream.

Esthetic solutions for the younger crowd

Figure 3: Colored ties can easily be removed from ceramic brackets for younger patients’ important life moments such as their first day of school or family pictures

Figure 4: For younger patients, the Paint Your Smile tool from 3M Unitek at paintyoursmile.com allows them to see firsthand how the colored elastic ties will “pop” with ceramic brackets

When the fee scale is equal, adults don’t generally need any additional encouragement to opt for ceramic brackets. Younger patients, however, have different priorities, and sometimes require us to take extra time to explain why we recommend clear brackets, since most of their friends are still wearing traditional metal braces and they want to “fit in.” I begin conversations with my younger patients and their parents by discussing major life moments. Transitioning into high school is a big step for the majority of them (Figure 3). We want them to be able to laugh and smile without being self-conscious about their braces on the first day of school. We discuss color options, and they’re usually amazed when they see how much the colored elastic ties “pop” on a ceramic bracket (Figure 4). We always tell their parents that the beauty of ceramic brackets is that the colored bands can always be replaced with clear for important milestones or pictures. A great resource we have used for younger patients is the Paint Your Smile tool from 3M Unitek at paintyoursmile.com. This website allows us to upload a “selfie” of the patient and show them what their ceramic braces will look like compared to

Figure 5: From the initial consultation to the final office visit, it’s important to give first-class service and treatment to every patient who walks through the door Volume 5 Number 6

traditional metal braces. The website lets them test-drive different colored bands on their braces before committing to a treatment option. Giving younger patients this type of platform to create their own smile gives them some independence when coming in with their parents.

The take-aways If you see the advantage in transitioning to ceramic brackets in your practice, it’s important to be prepared to position this esthetic solution as a value-add to your patients and clearly communicate the benefits. While it’s not always as easy as a patient walking in and asking, “Can I have ceramic brackets?”— when the patients understand what they will gain from a truly esthetic treatment plan, their experience is instantly elevated (Figure 5). For me, there are three things that have been most important in making this a successful transition: 1. Thinking creatively — By implementing an equal pay scale for traditional metal and ceramic brackets, we help our patients enjoy outstanding results and, at the same time, grow the practice and establish a positive reputation in our community. 2. Training staff — In order to get buy-in from your patients, your staff has to be educated about the benefits and fully committed to furthering the goal. 3. Utilizing resources — You are not alone in wanting to make a positive change in your practice. I rely heavily on my 3M Unitek sales representatives to field my questions, help brainstorm new ideas for marketing, and collaborate on how to best communicate product benefits. As orthodontists, it’s our duty to offer the best possible solutions for our patients, and in my opinion, ceramic brackets help me to accomplish this every day (Figure 6). OP

Figure 6: Dr. Paul Tran (left) and Dr. Kristen George (right) serve both the Middletown and Prospect, Kentucky, communities at Tran Orthodontics Orthodontic practice 55

PRACTICE DEVELOPMENT

of their decision process, and now they overwhelmingly choose ceramic brackets for their treatment. For our practice, we receive a greater benefit from being perceived as a top-notch esthetic practice with happy patients than we would from pinching a few pennies. In the last 5 years, our practice has not purchased a single traditional

PRACTICE DEVELOPMENT

Generating more new case starts through topical search Diana P. Friedman explores how consumers search for online information

hen consumers, including prospective orthodontic patients, head to the Internet, 93% start by initiating a search.1 Healthcare continues to be a topic of great interest, as 72% of Internet users look online for health information.2 However, where consumers conduct their searches is undergoing a dramatic shift. Welcome to the world of topical search — websites or portals that cater to a specific topic or area of interest. Though the term topical search may be new, websites that cater to highly targeted search results have been around for a long time and are gaining significant traction. A recent study found that topical search sites experienced an 8% increase in search traffic while major search engine traffic decreased by 3% over the same period.3 Some great examples of successful consumer topical websites include WebMD, Amazon, and eBay. Healthgrades.com is the best example of a dental and orthodontic topical search site and is the most influential when it comes to searching and evaluating healthcare providers. More than 225 million visitors use the Healthgrades.com website each year to connect with healthcare providers that best meet their treatment needs. An amazing 20-plus million of these prospective patients search Healthgrades.com for a new dental care provider in their local area (including searches for an orthodontist). More compelling is the demographics of Healthgrades. com visitors — overwhelmingly female (72%), highly educated (84% have some postsecondary education), and affluent (52% have annual household incomes greater than $75,000). Not only are these demographics ideal for orthodontics, the behavior of prospective patients using Healthgrades.com goes far beyond just looking for health information

Diana P. Friedman, MA, MBA, is president and chief executive officer of Sesame Communications. She has a 20-year success track record in leading dental innovation and marketing. Throughout her career, Friedman served as a recognized practice management consultant, author, and speaker. She holds an MA in Sociology and an MBA from Arizona State University.

56 Orthodontic practice

Establishing a predictable stream of new case starts remains a key driver of practice growth and profitability. — research shows more than half of visitors (54%) will schedule an appointment with a provider. Of this large group of prospective patients, an astounding 38% of them schedule the same day they visit, and 95% make an appointment within a week. It’s clear that Healthgrades visitors conducting topical searches are an ideal target audience for growth-minded orthodontists. Topical search sites such as Healthgrades are changing the way prospective patients find your practice. So how can you take advantage of this to drive more new case starts? Let’s examine the construct of the Healthgrades topical search site to find the answer.

Healthgrades: two profile types Basic A Basic Profile is already available and practitioners can “claim” it for free. It includes limited information about your orthodontic practice such as name and address. These profiles include third-party and competitive practice advertisements and do not provide visitors with a way to schedule an appointment with your practice. Any Healthgrades visitor can submit a review of your practice, but they are not verified as your patients. So while you do want to claim your Basic Profile to ensure your provider information is accurate, the ability to gain case starts through the visibility afforded in having a top ranking for your location, or convert visitors into patients, is severely limited. Enhanced Late last year, Healthgrades Enhanced Profiles were introduced to the dental

industry through a new partnership between Healthgrades and Sesame Communications. The Enhanced Profile provides your practice with a multitude of benefits over the Basic Profile and is the best way to turn your share of the 20 million prospective patients searching for a dentist or orthodontist into new patient appointments. The major benefits of an Enhanced Profile on the Healthgrades.com topical search site include the following: Automatic publishing of verified patient reviews — With a Healthgrades Enhanced Profile, verified, and high-quality postappointment surveys from Ortho Sesame are automatically published to your Healthgrades Enhanced Profile. This ensures that the vast majority of patient reviews are verified and represent the true value your practice delivers. It also helps prospective orthodontic patients have confidence that the review ratings are accurate and credible. Priority positioning in local search results on Healthgrades.com — An Enhanced Profile gives your practice higher placement in search results and greater visibility to patients searching for an orthodontist in your area. It provides premium postings in their “Featured Provider” section in addition to your inclusion in organic search results. On average, a visitor to Healthgrades.com will view 1.9 profiles during their visit, so it is imperative that your practice be featured prominently in the search results. Only Enhanced Profiles can show up in both featured and organic search results. Front page calls to action — Enhanced Profiles allow patients to easily schedule an appointment with your practice by providing front page access to your practice phone number, a “Request an Appointment” link, and a link to your practice website. With one click on your Healthgrades Profile, a prospective patient can easily schedule that first appointment. This easy access helps facilitate more appointment requests for your practice. Comprehensive doctor and practice information — When a prospective patient sees a large quantity of high-quality reviews, Volume 5 Number 6

Volume 5 Number 6

practice’s Healthgrades Enhanced Profile. The analysis showed that practices generated, on average, more than 11 calls during a 4-week period after the initial launch of their Enhanced Profile. The study analyzed the volume of incoming calls received by 98 dental and orthodontic practices with Healthgrades Enhanced Profiles from Sesame during the time period between December 9, 2013, and January 25, 2014, and in addition to the average of 11.1 calls received, also found that: • Practices, on average, had 21.33 postappointment reviews automatically published from Dental Sesame or Ortho Sesame. • Of practices with Dental Sesame or Ortho Sesame and a Healthgrades Enhanced Profile, 94.12% showed up on page 1 of local organic search results on Healthgrades.com, in addition to their Featured Provider listing.

highly targeted, and qualified set of prospective patients looking to make an appointment with a provider in your local area. Establishing a predictable stream of new case starts remains a key driver of practice growth and profitability. While many practices have rightfully embraced other digital marketing strategies to attract these new patients, they have yet to adopt a systematic method of success where reviews are concerned. With increased traffic on topical sites and performance percentages like this, it’s time to utilize this new channel as a primary source of new patients. OP

Final thoughts

3. comScore. ComScore Releases the “2013 U.S. Digital Future in Focus” Report [press release]. www.comscore. com/Insights/Press_Releases/2013/2/comScore_Releases_ the_2013_U.S._Digital_Future_in_Focus_Report. Published February 14, 2013. Accessed August 8, 2014.

Topical search sites, such as Healthgrades, help you get in front of a focused,

REFERENCES 1. Bianchini D. 10 Stats to Justify SEO. Search Engine Journal Web site. http://www.searchenginejournal.com/10-statsto-justify-seo/36762/. Published November 21, 2011. Accessed August 8, 2014. 2. Fox S, Duggan M. Health Online 2013. Pew Research Internet Project Web site. http://www.pewinternet.org/ Reports/2013/Health-online/Summary-of-Findings.aspx. Published January 15, 2013. Accessed August 8, 2014.

Orthodontic practice 57

PRACTICE DEVELOPMENT

they naturally want to find out more about the practice. The Healthgrades Enhanced Profile includes significantly more information about your practice than a Basic Profile, including full biographies, practitioner photos and videos, testimonials, and procedures. An Enhanced Profile gives prospective patients a fuller picture of the unique benefits of your practice and makes it simple for them to contact your office. Tracked ROI of your Healthgrades responses— Activating an Enhanced Profile allows your practice to track every new patient call and online appointment request received through Healthgrades.com. This important data lets you easily see how effective your Healthgrades Enhanced Profile is at bringing in new patients. Sesame Communications conducted a recent study to measure the call volume for dental and orthodontic providers who have Healthgrades Enhanced Profiles. The evaluation tracked the number of prospective patient appointment request calls that were generated from a unique local phone number placed on the front page of a

PRODUCT PROFILE

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ased on PolyJet 3D Printing technology, the Objet30 OrthoDesk is your entry point into the world of digital dentistry. With it, you can: • Digitize your workflow from CAD file to model • Accelerate production times • Increase capacity • Eliminate manual modeling • Enjoy a clean, safe, efficient process • Store models digitally • Lead the market with cutting-edge technology Digital orthodontics is rapidly becoming the industry standard. With the power to slash delivery times, increase capacity, and eliminate bulky model storage, the advantages are clear. But due to size and cost considerations, 3D printers have only been suitable for larger labs. Until now. Objet30 OrthoDesk is specially designed for small- to medium-sized labs and clinics. It is compact, affordable, and easy to use. With

industry-leading inkjet-based 3D printing technology, it offers all of the advantages of a 3D printer, in a package that is just right for you.

The future of orthodontics fits on your desktop Objet30 OrthoDesk is the first system of its kind, combining state-of-the art 3D printing technology with a small footprint. It is easy to use and includes specialized dental printing materials in convenient sealed cartridges. Now, you can fabricate stone models, orthodontic appliances, delivery and positioning trays, clear aligners, and retainers — right on your desktop.

Digitize your workflow, today With the Objet30 OrthoDesk 3D Printer automating your model work, you can dramatically reduce fabrication times and increase output per technician. By transitioning to a fully digital process, you also eliminate the discomfort and inconvenience of physical impressions and build customer satisfaction.

Fast ROI for labs and clinics of any size The Objet30 OrthoDesk is specially designed to meet the needs of smaller labs and clinics. It combines speed and accuracy, ease of use, compact size, and specialized dental materials — at a price that ensures rapid return on investment.

An end to physical model storage With a fully digital process, there is no need to store bulky, physical models. Store all of your cases digitally, for as long as you need.

Materials The Objet30 OrthoDesk offers three PolyJet Dental Materials, specially engineered for dentistry, in convenient sealed cartridges: • VeroDentPlus (MED690), a dark beige material that prints layers as fine as 16 microns to create amazingly fine features and finish, and offers excellent strength, accuracy, and durability • Clear Bio-compatible (MED610), a transparent material medically approved for temporary in-mouth placement • VeroGlaze (MED620), an acrylic material for realistic veneer models and diagnostic wax-ups that require A2-Shade color match To learn more, visit www.stratasys.com/ industries/dental. OP This information was provided by Stratasys.

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Volume 5 Number 6

Objet30 OrthoDesk The Future of Orthodontics Fits on Your Desktop

Exclusively designed for smaller labs and clinics, the new Objet30 OrthoDesk is office-friendly, affordable and easy to use. It is the first solution that puts cutting-edge, 3D printing technology on your desktop. Now you can digitally manufacture stone models, orthodontic appliances, delivery and positioning trays, clear aligners and retainers faster than ever. Transition to a digital workflow and do away with bulky physical model storage. Take the leap to digital orthodontics today, and:

• • • • •

Increase your production capacity and accuracy Accelerate production times Eliminate traditional stone model storage Stay ahead of the competition Eliminate the inconvenience of physical impressions

Find out how Objet 3D printers from Stratasys can make digital orthodontics a reality for your lab.

stratasysdental.com | dental@stratasys.com

PRODUCT PROFILE

Soft tissue incision, excision, ablation, coagulation with www.LightScalpel.com / 1-866-589-2722

No bleeding – No stitching – High productivity – Fast ROI Easy and quick to learn LightScalpel frenectomy took under 30 seconds to perform, required no local anesthetic — $425 billing fee per 2014 CDT billing code D7960 (varies by region).

LightScalpel hyperplastic tissue removal took under 3 minutes per tooth to remedy the gingival overgrowth — billing included in the restorative fee.

Photos courtesy Martin Kaplan, DMD, Stoughton, Massachusetts

LightScalpel fibroma removal took under 1 minute to perform — $365 billing fee per 2014 CDT billing code D7410 (varies by region).

Photo courtesy Robert Levine, DDS, Scottsdale, Arizona

LightScalpel handpieces are autoclavable, durable, and ergonomic, with straight and angled nozzles. They are designed for high-speed soft tissue incision/excision/ ablation with simultaneous coagulation of wound margins.

Flexible Laser Fiber provides the clinician with the most natural “scalpel-like” feel. The fiber is durable, light, maneuverable, and offers high precision.

Ceramic tip for intra-sulcular ablation/coagulation Angled tipless handpiece for incision/excision/ ablation/coagulation

Incision/excision/ablation with focused laser beam

Nozzle-to-tissue distance 1-3 mm maintains 250 µm focal spot on the tissue

Coagulation depth of the margins < 100 µm Width of incision < 250 µm Depth of incision is proportional to irradiance [Joules/cm2]

Coagulation with defocused laser beam

Nozzle-to-tissue distance 6-9 mm maintains 500-800 µm focal spot on the tissue

Coagulation depth is 100-300 µm, depending on exposure time

This information was provided by LightScalpel.

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Volume 5 Number 6

PRODUCT PROFILE

Ormco™ Custom

ith digital technology taking center stage in the orthodontic profession, Ormco™ Corporation continues to introduce computer-designed appliances and 3D software that aid in practice profitability and treatment personalization. A leader in the field of digital orthodontics, Ormco unveiled Ormco™ Custom earlier this year. Ormco Custom is an end-to-end digital workflow solution that includes Insignia™ Advanced Smile Design™, Lythos™ Digital Impression System and AOA Lab. Together, this suite of products has become the core driver behind innovative 3D diagnostics, treatment planning, and customized appliance fabrication that has revolutionized practices across the country.

Insignia Advanced Smile Design Insignia Advanced Smile Design — which is proven to reduce treatment time by 37% with seven fewer patient visits*— is a fully customized appliance system that allows doctors to show patients a 3D virtual movie of their projected final result prior to starting treatment. Insignia’s fully customized bracket system provides an exact calculated pertooth prescription based on each patient’s unique dental anatomy, and the clinician’s desired bracket placement and final tooth position. This advanced technology enables orthodontists to deliver on a treatment plan — designed specifically for each patient — with unprecedented accuracy. In doing so, Insignia fosters more predictable treatment in less overall time with fewer adjustments and reduced chair time. Insignia’s latest software enhancements make the platform even more intuitive with integrated support elements for greater ease of use. To learn more about Insignia Ai, visit http://ai.ormco.com/.

Insignia Advanced Smile Design

Lythos Digital Impression System Making PVS impression a thing of the past, the Lythos Digital Impression System is specifically designed to integrate easily into any practice. It allows users to own, store, and send treatment scans — at no cost — to orthodontic labs and appliance manufacturers that accept .stl files for the creation of a variety of custom appliances and/or study models. Utilizing AFI laser video technology, Lythos captures and pieces together data in real-time, acquiring high-definition detail

Together, this suite of products has become the core driver behind innovative 3D diagnostics, treatment

at all angulations of the tooth surface. Unique to orthodontic impression systems, Lythos can provide up to 2.5 million 3D data points per second, resulting in an exact, distortion-free, high-resolution scan. The system has been praised for its portability and features an ergonomically designed wand for comfortable scanning throughout the day. To receive hands-on training and a Lythos demonstration, doctors are encouraged to contact their local Ormco Sales Representative. To hear why orthodontists choose Lythos as their scanner of choice, please visit www.ichooselythos.com.

AOA Lab Completing Ormco Custom is AOA Lab, a full-service, digital orthodontic laboratory serving orthodontic professionals worldwide. AOA Lab fabricates customized appliances, including Class II correctors, aligners, splints, and retainers. To streamline practice workflow, doctors simply need to place the key words “Lythos Scan” after their patients’ names, which will automatically trigger a notification to AOA to retrieve the scanned data from the Ormco cloud. No file converting. No third-party FTP sites involved. Learn more about Ormco Custom at www.ormcocustom.com. OP

planning, and customized appliance fabrication that has revolutionized practices across the country.

* 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.

This information was provided by Ormco Corporation.

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Volume 5 Number 6

AcceleDent® Aura wins American Business Award in “Best New Product” category

The high precision of the CS 3500 has earned it the coveted distinction of an OraMetrix Inc. certification for use with its suresmile® technology. suresmile combines 3D diagnostic imaging with computerized treatment planning and robotic archwire customization. The suresmile system enables doctors to pro-actively plan tooth movement on digital models and customize prescriptive archwires for precise and efficient treatment. The integration of CS 3500 scans with the suresmile software means orthodontists will have improved treatment planning and unprecedented control over treatment. The CS 3500 acquires true color, 2D and 3D images that can be used with CS Model software to create digital models. Requiring no external heater, powder or trolley system, the CS 3500 features high-angulation scanning of up to 45 degrees and to a depth from -2 to +13 mm. It also features autoclavable tips available in two sizes — a smaller tip for children or adults with small mouths and a larger tip for adults. Carestream Dental is now the only company to have both a CBCT unit and intraoral scanner certified by suresmile. For more information call 800-944-6365 or visit www.carestreamdental.com. For more about suresmile, visit www.suresmile.com.

OrthoAccel® Technologies, Inc., has announced that AcceleDent® Aura won a Silver Stevie® Award in the 12th Annual American Business Awards (ABA) Competition in the category of New Product of the Year — Health and Pharmaceuticals. AcceleDent Aura is the first and only FDA-cleared, noninvasive medical device that speeds up orthodontic treatment by as much as 50% with just 20 minutes of daily use. Patients, orthodontists, or staff members interested in learning more about AcceleDent’s groundbreaking technology can visit http://acceledent.com.

Donald Tuttle joins Henry Schein® Orthodontics™ Henry Schein® Orthodontics™ announced that Donald (“Don”) Tuttle joined them as General Manager/Vice President, responsible for all aspects of the orthodontic portfolio that resides within the Henry Schein Dental Specialty Group Division, which includes both Ortho Organizers®, Inc., and Ortho Technology®, Inc., companies. Tuttle joins Henry Schein with more than 32 years of distinguished leadership experience in the dental industry, with an emphasis in the orthodontic and specialty areas.

Info on Ortho2 Users Group Meeting Ortho2 customers aren’t the only ones who can benefit from an Ortho2 Users Group Meeting. Every year between 300 and 500 people gather to boost staff motivation, discover new features and techniques, and implement positive change in the office. Here are 10 good reasons to consider attending: 1. Classes 2. Exhibit hall 3. Computer room 4. Direct access to Ortho2 developers 5. Networking with doctors and staff 6. Mingling with industry-leading consultants and doctors 7. Exclusive discounts 8. Location 9. The famous Ortho2 Welcome Party 10. The knowledge and benefits you and your practice receive So please consider joining us in sunny Scottsdale, Arizona, on February 19-21, 2015. You won’t regret it! For more information, visit http://www.ortho2.com/Meetings AndWebinars/UGM/Default.aspx.

Henry Schein® Orthodontics™ announces Andrews’ Six Elements Orthodontic Philosophy™ Courses The Six Elements (6E) Orthodontic Philosophy™ elevates orthodontic treatment goals from being subjective to being scientific. In this course you will learn the 6E Orthodontic Philosophy, which encompasses the new and improved Andrews2™ StraightWire Appliance System, scientific treatment goals, a positionally correct classification system, and “rules” for treating, which have been proven to be efficient and effective. For more information on dates for future courses visit http:// www.henryscheinortho.com.

Volume 5 Number 6

Orthodontic practice 63

INDUSTRY NEWS

CS 3500 Intraoral Scanner receives certification for use with suresmile® orthodontic technology

INDUSTRY NEWS 2-day seminar from TP Orthodontics TP Orthodontics is hosting a 2-day event that offers the opportunity to learn from five industry leaders. The event will be held in Scottsdale, Arizona, at the Four Seasons Resort from December 3-5, 2014. The following topics will be covered: • James A. Jasper, DDS — “Intermaxillary Edgewise (And a Look at Overjet Appliances through the Eyes of Physics)” • Daniel J. Rinchuse — “Efficiency and Effectiveness in Clinical Orthodontic Practice” • Donald J. Rinchuse — “An Evidence-Based View on Occlusion and TMD” • Daniel S. German — “Difficulty Finishing Aligner Patients Is Not a Myth: 20 Principles to Achieve Excellent Outcomes” • Messias Rodrigues — “The Simplified Straight-Wire Technique” For more information or to register, visit www.tportho.com, or call 1-800-348-8856.

M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT 3M Unitek Announces Release of Unitek™ Treatment Management Portal 4.2 Available now, the next generation of the Unitek™ Treatment Management Portal (TMP) 4.2 offers new products to accompany the 100% customizable Incognito™ Appliance System, including new Incognito™ Clear Precision Trays. The trays consist of a hard outer shell with a soft inlay manufactured directly from digital data. Incognito™ Brackets are inserted directly into the tray, enabling increased visual control and more accurate placement during the bonding process. Additionally, the trays can be cut and used as a rebonding “jig” for accurately replacing brackets. Unitek TMP is an orthodontic case management platform for digital model management, treatment planning, and ordering of the Incognito Appliance System. This platform allows for the virtual display and archive of digital study models, and reduces onsite storage while allowing patient data to be managed more efficiently. The TMP 4.2 has been released as an automatic update for all users. To learn more about Unitek TMP 4.2, visit www.3MUnitek. com/tmp.

64 Orthodontic practice

VALO awarded the Pride Institute’s “Best of Class” Technology Award for third consecutive year Opal Orthodontics, along with Ultradent Products, Inc., a global manufacturer and distributor of orthodontic materials and equipment, received The Pride Institute’s “Best of Class” Technology Award for VALO, Opal Orthodontics’ and Ultradent’s curing light, for the third consecutive year. The award is the highest honor for innovation in curing lights. Each product honored as “Best of Class” features unique characteristics that differentiate it from the competition in a compelling way and, more importantly, creates value for the orthodontist and dentist. To learn more about VALO by Opal Orthodontics, call 888-863-5883, or visit www.opalorthodontics.com.

LED Dental’s LED IC200 intraoral camera features advanced touch-capture functionality LED Dental, a wholly owned subsidiary of LED Medical Diagnostics, Inc., has launched its LED IC200, designed to acquire high-resolution intraoral and extraoral images with auto-focus and a large depth of field. The LED IC200 offers the following: • High-resolution imaging with an image resolution of 768 x 494 pixels. • Diagnostic flexibility, featuring eight LED lights for uniform illumination and an increased 105-degree angle of view for improved observation of distal areas. The aspheric lens prevents image distortion and works together with the intraoral camera’s auto-focus technology to provide sharper images. The intraoral camera also offers a large depth of field for capturing a wide range of images from single tooth to portrait. • Touch-capture acquisition helps prevent camera movement during acquisition, allowing the camera to stay completely focused for crystal clear images. • Direct USB plug-in. • Ergonomic design, including slim head, rounded contours, and lightweight body. • Open-architecture workflow for smooth integration with third party software and imaging solutions. For more information, call 844-952-7327, or visit www.leddental.com.

Volume 5 Number 6

Image Softly With Planmeca HOW HIGH IS YOUR DOSE? Ultra Low-Dose Protocol • Pediatric imaging mode lowers effective dose by 35%, with additional ultra-low dose protocols for adults • Pediatric volume sizes to further reduce radiation Dosage • Based on intelligent 3D algorithms developed by Planmeca • Adjustable kV and mA values allow you to choose the optimal dose based on the ALARA radiation safety principle • Multi-bladed collimation focuses radiation to areas of clinical interest • Low-dose images can be used for airway studies, orthodontic planning, sinus cases, and more • Doses as low as 4 µSv

For a free in-office consultation, please call

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

Come and See PLANMECA at Greater New York Dental Meeting Booth #4028

PLANMECA