Orthodontic Practice US - March/April 2015 - Vol6.2 by MedMark, LLC

March/April 2015 – Vol 6 No 2

PROMOTING EXCELLENCE IN ORTHODONTICS

Uprighting impacted mandibular second molars using NiTi wire

Drs. Daniel DiBagno, Lauren Sigler Busch, and Daniel J. Rinchuse

CBCT in the evaluation of airway — minimizing orthodontic relapse Dr. Steven Olmos

CMY

Practice profile

Dr. Mark Knoefel

BioDigital Orthodontics part 14

Drs. Rohit C.L. Sachdeva, Takao Kubota, and Kazuo Hayashi

Company spotlight Adenta

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INTRODUCTION

Ecstatic about esthetics: the new game in orthodontics

he year was 2007, and I had managed to build up a nice stack of chips. I had played the orthodontics game successfully in my first 21 years as a private practitioner, even though there were many skilled orthodontists at the table competing for those chips. But the Recession of 2007 caused a slowdown in the economy, and the landscape of dentistry, as we knew it, changed forever. According to the ADA, the gross domestic product (GDP) of the United States started an upswing in 2009, yet earnings in the field of dentistry did not follow suit for the first time in 33 years. Dr. Roger Levin asserted, “A large majority of orthodontists were seeing a decline in their earnings of 10% to 20% per year.” Yes, I was playing the game of orthodontics successfully, when suddenly, everything changed. I looked across the table and found new players in town, players doing aligners and traditional braces using Six Months Smiles®, 3 Month Braces, and Fastbraces® Technology. My next move was to get my chips back. I had to learn to play this new game really well. Our practice has always endeavored to be unique in a positive way. I understood that in order to appeal to the market, you have to understand the market. Our office conducted patient surveys over the past 10 years. The results provided us tremendous insight, revealing four key elements that our patients desire:

1. Patients desire esthetics. In 2010, while many orthodontists were watching their practices decline, I found my second youth. I made a decision to use 100% ceramic esthetic appliances. After much research, my quest led me to 3M Unitek’s Clarity™ ADVANCED Ceramic Brackets. I also incorporated esthetic wires and auxiliaries to make our system of treating patients the ultimate in esthetic orthodontic treatment. At Kemp Orthodontics, we are giving our market what it wants by embracing the esthetic megatrend. In 2012 alone, $11 billion was spent on cosmetic procedures in the U.S. Patients desire esthetics and are willing to pay for esthetics.

March/April 2015 - Volume 6 Number 2 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

2. Patients want fast treatment. At Kemp Orthodontics, we use many efficient techniques to reduce treatment time. Speedy treatment begins by placing the brackets on the teeth with consistent accuracy, and indirect bonding gives us this consistent accuracy. During treatment, we use progressive tandem wire sequencing to deliver low forces continuously. This practice produces quicker unraveling and leveling to progress to the use of rectangular wires faster. Additionally, we use 3M Unitek Forsus™ Class II Correctors and Variable Prescription Orthodontics (VPO) to move teeth the right way, faster.

3. Patients want great results. All the marketing in the world will not overcome the negativity of poor results.

4. Patients want to be wowed. We wow our patients through the memorable moments we create as we make every patient feel special at every visit. The future of orthodontics has changed rapidly since the Recession of 2007. Advances in science and technology offer us the opportunity to change the way we play our game, but we have to learn to play this new game. It is amazing to me that, in 2013, 95% of all brackets sold in the U.S. were metal brackets. Old game, old results. One of the most important decisions you may make is to consider differentiating yourself in your community by becoming “the esthetic orthodontist.” I think the future of orthodontics is extremely bright, as long as we follow the advice of pro-golfer, Jack Nicklaus, who said, “Achievement is largely the product of steadily raising one’s levels of aspiration and expectation.” David Kemp, DDS, earned his Bachelor of Science degree in Biology and Chemistry from the University of Tennessee at Martin. Dr. Kemp earned his Doctor of Dental Science degree from the University of Tennessee at Memphis. He also earned his postdoctoral Master of Science degree in Orthodontics from the University of Tennessee at Memphis. Dr. Kemp is honored to be speaking as an advocate for 3M Unitek. He is thankful to be helping orthodontists achieve their goals by delivering his message: “Ecstatic About Esthetics: The New Game In Orthodontics.” If you would like to find out more about Dr. Kemp’s in-office course and dates, please go to: http://3MUnitek.cvent.com/KempOrtho.

2 Orthodontic practice

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

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Volume 6 Number 2

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TABLE OF CONTENTS

Case study

Practice profile Mark Knoefel, DDS, MSc

Accelerate your practice with effective self-ligation techniques Dr. John Graham illustrates the benefits of accelerated tooth movement....................................... 16

Orthodontic opus

Orthodontic concepts BioDigital Orthodontics Management of patients with transverse (midline) discrepancies: part 14

Drs. Rohit C.L. Sachdeva, Takao Kubota, and Kazuo Hayashi discuss various factors involved in the treatment of a midline discrepancy .......................................................25

Propelling orthodontics Proactive treatment with Propel Dr. Thomas Shipley discusses how he has increased efficiency and productivity in his practice...............38

Company spotlight Being different â&#x20AC;Ś by design

Lorraine Porto, President of Adenta USA, discusses how Adenta is dedicated to serving the best interests of orthodontists

ON THE COVER Cover photo courtesy of Dr. John Graham Article begins on page 16.

4 Orthodontic practice

Volume 6 Number 2

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TABLE OF CONTENTS

Product profile

American Orthodontics Empower® Dual Activation™ System One system. Multiple applications. Zero compromise.............................50

Continuing education

Uprighting impacted mandibular second molars using NiTi wire Drs. Daniel DiBagno, Lauren Sigler Busch, and Daniel J. Rinchuse discuss uprighting impacted mandibular second molars

Product profile

New suresmile® Aligner Design The value of precision......................52

Product profile

GUARDIAN® Invisible Retainer System James Bonham explains the benefits of a long-term retention plan by Specialty Appliances........................ 54

Materials & equipment.........................55 Industry news...............56

Continuing education CBCT in the evaluation of airway — minimizing orthodontic relapse

Dr. Steven Olmos discusses the four points of breathing obstruction

6 Orthodontic practice

Volume 6 Number 2

PRACTICE PROFILE

Mark Knoefel, DDS, MSc Orthodontic opus What can you tell us about your background? The youngest of three children, I was born and raised in a small town outside of Montreal. My parents had recently immigrated to Canada from Germany. Thanks to them, I was raised speaking three languages (German, English, and French), a tremendous enrichment that I was able to pass on to my four children. My parents’ discipline, unconditional love, and devotion to friends and family were inspirational, to say the least, and created the ideal environment for us to thrive. Piano, organ, singing, theater, and public speaking essentially defined my formative years.

Why did you decide to focus on orthodontics? Science and art have characterized my identity, as well as a constant desire to communicate and interact with people. I couldn’t possibly pick a career in the arts, as I would have had to give up my passion for sciences. Similarly, picking a science career that suppressed my creativity would have been out of the question. Finally, having experienced treatment myself as a teenager, I immediately sensed that orthodontics would provide the balance between art, science, and human interaction that I was seeking.

How long have you been practicing, and what systems do you use? I began practicing in the spring of 1999. Oasis Orthodontics is patient-centered, meaning my goal is to personalize care based upon each patient’s individual needs. Shared decision-making with a patient, in combination with scientific evidence, drives my approach to care. Furthermore, my team is committed to continuous improvement initiatives, which promote learnings that are applied to ameliorate patient care.

What training have you undertaken? My training can be conveniently divided into two phases. First, my formal professional training (“fact-based knowledge”) began at the dental school at McGill University, and I graduated on the Dean’s Honor List in 1995. I completed a 1-year multidisciplinary 8 Orthodontic practice

Dr. Knoefel reviewing diagnostic images on an iPad with mother and patient at a consultation visit

hospital residency at the Montreal Children’s Hospital before moving to sunny Alberta. In the spring of 1999, I obtained my Master of Science in Orthodontics from the University of Alberta. Second, my “action-based” learning occurs every day in my practice. There is no doubt that our patients, parents, and team members teach us every day if we only take the time to listen and observe. My training, therefore, is continuous. I devote at least 1 full day each week to re-evaluating my patients’ treatment progress. By taking a full set of progress photos of my patients at least every 4 months and re-analyzing them on a daily basis away from the chairside, I have been literally humbled by the wealth of information they provide. Our practice culture at Oasis Orthodontics can be summarized as that of a learning organization. We have monthly in-practice training sessions where we discuss patient histories and use our findings to enhance our clinical skills, streamline care protocols and, most importantly, improve patient care throughout their journey at our practice.

day, his works are recognized not only as musical chefs d’oeuvres (masterpieces), but as scientific masterpieces as well. Ludwig van Beethoven’s symphonies, especially the Ninth, are not only beautiful, but they inspire passion in a manner that is unrivalled by any other composer. It is no accident that his Ode to Joy was selected as the anthem of the European Union. Although I am grateful to the plethora of teachers and mentors who have ignited my passion for knowledge, there is one who has impacted me the most professionally. Dr. Rohit Sachdeva embodies the essence of the 21st century Renaissance man. Yet, surprisingly, many of his contributions to the betterment of the profession and of patient care remain unrecognized. I can only give him tribute by sharing the lessons I have learned from him. In summary, these are to have the courage to demonstrate humility and servitude, the courage to be curious, and last, but not least, the courage to embrace and learn from failure.

Who has inspired you?

A common vision and a common set of values in an environment that allows open discussion. At Oasis Orthodontics, we thrive on divergent thinking. This applies to the doctors, the staff, and the patients alike. We are all working together to seek the truth.

Just as the arts and sciences have defined my identity, I have drawn inspiration from visionaries in both fields. The composer, Johann Sebastian Bach, laid the foundation for Western music. To this

What is the most satisfying aspect of your practice?

Volume 6 Number 2

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PRACTICE PROFILE Professionally, what are you most proud of? There exists no greater pride than to earn patient loyalty and to see them glow with a beautiful smile.

What do you think is unique about your practice? There are two primary aspects of Oasis Orthodontics that make us unique. The first is our multilingual, multi-ethnic team. Between the two doctors, we speak five languages. Croatian, Dutch, Vietnamese, Russian, Ukrainian, and French are spoken by the staff. We pride ourselves in interacting with our patients in as many languages as possible. Ultimately, the pleasant banter among patients and team members creates joy, which is a fundamental tenet of our patient care model. The other unique characteristic at Oasis Orthodontics is how we plan and deliver care. Our treatment planning does not simply occur at a high level — extraction versus non-extraction, surgery versus non-surgery, growth modification, etc. Every patient presents to us as a unique individual. Our patients are not put on an assembly line to address their needs. They are shown the respect of a “patient of one,” a concept to which Dr. Sachdeva introduced me. It begins with actively listening to patients, with a thorough diagnosis, including the patients’ physical and emotional health, their needs and expectations, and their lifestyle. Furthermore, the patient consultation appointment is not focused on selling care; it is about enhancing patient literacy. The design phase involves using 3D simulations to better understand the best and most creative ways to address the patient’s needs. This is followed by the planning phase, which incorporates all the processes and activities that will enable the care team to provide the most rewarding

A patient’s father reviews his treatment progress with Dr. Knoefel using FaceTime

care experience for the patient in an effective and efficient way. Also, a 3D virtual simulation is created for patients to illustrate the treatment objectives, educate them about potential risks and constraints, and help them monitor their own treatment progress. The same simulation is used for communication with referring dentists and other specialists. To ensure that treatment remains efficient, we rely on protocols and checklists at every visit. By following these systems, chairside team members are encouraged to act as nurse practitioners rather than passive “assistants.” On numerous occasions, their attention to detail has identified problems or potential issues with patient care that were missed by the doctors. Our goal is to have alignment completed within the first 4 months. At that time, a full set of records is obtained to perform a progress review. Any potential constraints or existing problems are successfully addressed before they are able to jeopardize treatment success. We measure ourselves with patient surveys; we encourage

patients to write to us and communicate with us. So, whether in the physical world or the virtual world, we are always in touch with them. There is no doubt that all of these things take time. But as modern orthodontic professionals, we realize that our work extends beyond the boundaries of the physical practice. Whether we are communicating with patients via webinars or treatment planning from a remote location, the physical and virtual worlds of orthodontics are playing equally important roles. They challenge the “traditional” private practice model, but we are compelled to do what is right for the patient.

What has been your biggest challenge? Balancing family and work life. With four children involved in sports, music, and art, as well as other community activities, it has been challenging to give as much attention to all aspects of my life as I would like. My wife is a saint!

What would you have become if you had not become an orthodontist? My career would have almost certainly been in music. When I was 17, I had the opportunity to study church music in Berlin, Germany. But the thought of moving to Europe at such a young age and giving up my

(Above) Dr. Bharwani performs a 4-month progress review on an iPad, with two adult female patients. (Left) The Oasis Team, with Drs. Mark Knoefel and Dolly Bharwani (back row, center, left to right)

10 Orthodontic practice

Volume 6 Number 2

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PRACTICE PROFILE passion for the sciences entirely, ultimately convinced me to pursue the direction I did.

What is the future of orthodontics and dentistry? We are at a crucial juncture in dentistry, in general, and in orthodontics, in particular. There exists a push-pull phenomenon in society between the patient as a consumer and the patient as a recipient of healthcare. Treatment will need to become more affordable, without sacrificing quality care. As a profession, and as a specialty, we can only succeed if patient care remains our priority. We will always need technology, and our staff will need to remain highly skilled. We will need to be more vigilant in how we assess technology, however. It must be a partner in providing care, but it can never replace us and must never be perceived as such. Investment in patient education, empathy, and communication must always supersede even the most sophisticated technology. If we are ever to sell anything, it is our skill set around diagnosis and planning care. The role of the therapeutic orthodontist will be increasingly challenged, since certain skill sets, such as wire bending, will likely become redundant in the future. The role of the virtual practice will become increasingly important, as more treatment decisions will be transferred from the chairside (where doctors tend to be attention-deficient) to the computer (where records can be analyzed thoroughly). If we are not agile and resilient, the future of orthodontics as a specialty itself will be at stake. Collaborative relationships between dental specialists in multi-doctor centers

(Above) Staff member leading one of the monthly in-practice training sessions (Left) Dr. Knoefel treatment planning in his home office

will become increasingly common, with the patient as the hub.

teach.” As such, it is our duty to educate our patients — not to act as “providers” for our “customers.”

What are your top tips for maintaining a successful practice?

What advice would you give to budding orthodontists?

One word: investment. Investing in planning, in patient care, and in the community. Quality care implies: 1. Treatment when and where it is needed 2. Personalized care 3. Immediate response to a patient’s needs 4. Patient safety One’s goal should never be a satisfied patient; it should be a loyal patient. The new patient consult is not a selling episode. It is an opportunity to actively listen and participate with patients in defining their care needs. The word “doctor” comes from the Latin “docere,” “to

Devote your energies to anticipating your patients’ needs. Success is a journey, not an outcome.

What are your hobbies, and what do you do in your spare time? Traveling with my wife and children is my favorite pastime. It not only is an opportunity to recharge, but also enhances our sensibility to different cultures and ethnicities. In my spare time, I am heavily involved in my children’s sporting and community activities, including coaching soccer for the last 3 years. I am looking forward to the day that I will be able to spend more time playing music again. OP

Top Favorites 1. My family — they give me purpose, and they give me strength. Watching my children grow has taught me more about life than anything I learned before they arrived. 2. My piano — in a world of high tech, nothing allows me to escape reality more than playing my favorite instrument. 3. Listening to classical music — nothing beats Bach’s organ music, Beethoven’s symphonies, and Chopin’s piano concertos. 4. Traveling with my family — what better way to recharge, to re-bond with the family, and to learn about the world at the same time? 5. My Canon EOS Rebel Xsi clinic camera — I have learned more through the lens of the clinic camera than through the piles of textbooks and articles I have accumulated over the years. 6. iPhone® — keeps me organized. It is unbelievable what a variety of tasks can be accomplished with one device. 7. Mac computers — I am saving between $24,000 and $30,000 a year in IT costs since I made the switch from PCs to iMacs at the office. 8. The SureSmile 3D decision support system for diagnostics and care planning, and professional and patient communication. 9. P90X® — the best exercise video series to keep oneself fit, especially in one’s 40s. 10. German beer — this is exactly why I need P90X®! 11. Dark chocolate — especially by the Swiss chocolatier, Lindt. 12 Orthodontic practice

Volume 6 Number 2

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COMPANY SPOTLIGHT

Being different … by design Lorraine Porto, President of Adenta USA, discusses how Adenta is dedicated to serving the best interests of orthodontists Lorraine Porto, President of Adenta USA

oday, the orthodontist has many bracket choices. When choosing a bracket manufacturer, the technology behind how and why a bracket is manufactured plays an important role, not only to the price, but to its overall performance. The most important goal of the manufacturer should be to serve the best interest for the daily needs of the orthodontist. When I first met the owner and chief engineer of Adenta GmbH, Claus Schendell, at our headquarters in Germany, I could see immediately that Adenta was different. We talked extensively for hours about his chosen manufacturing technique, CNC Milling, and the precision this technology offered to the orthodontist. Today, 98% of bracket manufacturers use MIM technology (Metal Injection Molding); however, Schendell pledged from the beginning never to sacrifice bracket mechanics over manufacturing costs.

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Microscopic Adenta CNC Milled bracket 14 Orthodontic practice

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Orthodontic practice 15

COMPANY SPOTLIGHT

Within the world of engineering, CNC Milling dominates high-tech products, highend watches, Formula 1, and aerospace. MIM was never introduced simply because it couldn’t offer the precision needed. As an orthodontist, you rely on this precision to transfer your chosen prescription. CNC Milling can produce bracket slots with tolerances within a thousandth of an inch. When you need a +17° torque, you get it; incorrect slot dimensions simply create more work for you. Many times difficulties with detailing stem directly from an imprecise slot that cannot deliver the bracket prescription that is required. CNC Milling also provided us with the freedom to advance and improve the function of brackets. We introduced into the industry for the first time a truly one-piece bracket and a sandblasted base, providing the low profile we had all been looking for and a bond strength that far exceeded that of the very popular mesh bases of the time. When self-ligating was first introduced, CNC milling allowed Schendell to take this self-ligating system into the world of lingual orthodontics, creating the first self-ligating lingual bracket. Why does 3D CAD/CAM CNC Milling matter to you, the orthodontist? • Highly precise slot dimensions for complete and accurate torque and finishing control • Smooth, flawless finish produces ultra-low frictional forces • Strong durable stainless steel that can easily withstand the rigors of orthodontic treatment • One-piece bracket with an ultra-small in-out for a purer translation of the prescription • Sandblasted mechanical undercuts for a strong and reliable bonding strength Being the first to introduce new features that eventually become standard has always made us different. Using a manufacturing technology that only 2% of the industry uses also makes us different. Many things have changed over the past 18 years that I have been with Adenta, and I will proudly stand at the top of any mountain to tell all who will listen. Yes, we are different ... manufacturing the most advanced, reliable, and precise orthodontic bracket in the industry. You see, sometimes it is good to be different! OP

CASE STUDY

Accelerate your practice with effective self-ligation techniques Dr. John Graham illustrates the benefits of accelerated tooth movement

hree years ago, I relocated to Salt Lake City, Utah, which is a highly competitive orthodontic market with a number of orthodontists as well as general practitioners who practice orthodontics. Looking for ways to clinically differentiate my new practice, I decided to focus on enhancing the patient experience by offering accelerated treatments and diminishing the pain associated with orthodontics. What I found as I researched and experimented with different techniques is that I needed to look beyond just patients’ perspectives and perceived benefits. As orthodontists, we know there are many health issues and financial burdens also associated with keeping patients in treatment longer than necessary. The clinical issues include increased risk of root resorption, decalcification, caries, gingivitis, and periodontal disease. In addition, emotional issues, such as loss of motivation to maintain treatment compliance and increased frustration on both the patients’ and orthodontists’ part, might occur as ultimately orthodontists begin to lose money on cases when treatment is prolonged.1 So what can we do to differentiate our practices, grow our businesses, and become more patient-centric in our treatment options? In a nutshell, we need better, shorter, and more comfortable treatment options. In my practices, this translates into doing fewer extractions, using passive self-ligation with the Damon™ System or Insignia™ (Ormco), and accelerating treatment with AcceleDent® (OrthoAccel® Technologies, Inc.). John Graham, DDS, MD, received his Bachelor of Science degree from Brigham Young University. He received his dental degree from Baylor College of Dentistry in Dallas, Texas, and then received his medical degree from the University of Texas Southwestern Medical School. After medical school, Dr. Graham completed an internship in general surgery at Parkland Memorial Hospital followed by training in oral and maxillofacial surgery. Following his surgical training, Dr. Graham received his certificate in orthodontics from the University of Rochester/Eastman Dental Center in Rochester, New York. Dr. Graham is an orthodontist who offers AcceleDent treatment in his practice, but he does not receive compensation from OrthoAccel® Technologies.

16 Orthodontic practice

Figure 1

According to the recent American Journal of Orthodontics and Dentofacial Orthopedics (AJO-DO) survey, orthodontic treatment on average takes approximately 2 years to complete. However, nearly 70% of the orthodontists who replied to the AJO-DO survey were interested in adopting additional clinical procedures to reduce treatment time, but many were not aware of such procedures. They deemed a 20%-40% reduction in treatment time to be appealing enough to use alternative techniques that accelerate orthodontic tooth movement.1 In my practice, I see 20%-40% reduction in treatment time and many times much greater than that by using AcceleDent and

self-ligating orthodontics. Before presenting those case studies, I want to review other accelerating treatment methods that I’ve experimented with over the years to demonstrate exactly why the AJO-DO report states that neither orthodontists nor patients favor invasive approaches to reducing orthodontic treatment time.1

Invasive techniques to accelerate tooth movement I opted to do Wilckodontics on a patient of mine named Alex. Alex was a swimmer, and he could not breathe through his nose at all because he had a constricted maxilla. Alex did not want to go through any kind of Volume 6 Number 2

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CASE STUDY orthognathic surgical procedure and wanted to have treatment completed as quickly as possible. Alex had significant maxillary constriction, and his breathing area was so constrained throughout his posterior upper oropharyngeal airway that he had less than 100 mm2 of area allocated for breathing (Figure 1). During the actual Wilckodontics procedure, a complete mucoperiosteal flap was reflected far into the buccal vestibule. The idea is to damage the bone as much as is reasonable, so vertical osteotomies are made with a reciprocating saw. Not only are vertical osteotomies made through the cortex, but divots were also made with a round bur. The point of this procedure is to elicit the regional acceleratory phenomenon (RAP) that H. M. Frost first identified in his research in 1983.2 RAP stimulates aggressive bone turnover. The next step in the process is to pack in freeze-dried bone to augment the accelerated bone physiology that occurs while the patient is being treated (Figure 2). Notice that the patient is already in braces. The braces were put on about a week before the procedure. After his third or fourth visit, Alex reported that he could actually breathe. For the first time as a swimmer, he snorted water down his nose and choked on it. It was the first time he ever had communication between his nose and his lungs, and he was elated! While the end result appeased the patient whose Class 3 corrected significantly, I was not happy as an orthodontist because of how long it took, the ultimate final results, and the invasiveness necessary to perform the procedure. Cortical perforations as a procedure have long been researched, and many orthodontists are familiar with the technique. According to research conducted by Teixeira, et al., in 2010, we know that orthodontic force in concert with cortical perforations produced twice the amount of tooth movement during the same period of time with the same delivery of force in the control.3 I’ve used this technique as well and have provided an example with a patient whom I bonded in October 2011. The patient had severe anterior rotations, and more than a year later in February 2013, tooth No. 9 still had not rotated. I was frustrated but wasn’t convinced that the tooth was ankylosed. Therefore, I performed multiple cortical perforations along the mesial and distal aspects of the root (Figure 3). One month later, the tooth started to move due to the cortical perforations, but one of the problems orthodontists face with this method is the limited time frame that 18 Orthodontic practice

such a procedure provides. Whether it’s done through cortical perforations, surgery or piezocision, patients only benefit from the procedure for about 6 months, at which time the procedure must be repeated if the accelerated benefits are to be enjoyed over a longer period of time. To summarize, the disadvantages of using cortical injury to accelerate orthodontic treatment include quick diminishment of RAP after the physiologic peak at 6 weeks, no diminution in the discomfort of orthodontic tooth movement, and no mechanical enhancement to my passive self-ligating treatment. Practically speaking, these issues are the complete converse of the advantages of using AcceleDent.

Passive self-ligation — light biological forces during treatment I believe in the effective integration of passive self-ligation using Damon and AcceleDent. At least 50% of my practice is comprised of adults, and 80% of those adults are being treated with AcceleDent. I also perform very few extractions — in my last 1,000 cases, my extraction rate was at 0.05%. I realized early on in my orthodontic training that forces conventionally used in orthodontics were far too heavy and actually slowed down tooth movement, which is why I’m much more in favor of light forces or what I call biological forces. It’s very similar movement to what orthopedic surgeons and physicians have employed

Figure 2

Figure 3 Volume 6 Number 2

CASE STUDY for years. Pointing to research published in Angle Orthodontist4: “All self-ligating designs performed with the efficiency and producibility associated with expectations. Specifically self-ligation out-performed the conventional brackets when coupled with up to 0.020 x 0.020 inch wires.” This article also reported that self-ligating brackets produced lower frictional values, better hygiene, and patient comfort, which is indeed true. Additionally, clinical studies have concluded that orthodontic treatment with self-ligated brackets reduced chair time and shortened treatment. Again, I’ve seen all of this in my practice for over a decade. My very first Damon case that I did in private practice was with a young girl named Brittany. She was severely crowded in the upper arch and had mild crowding on the lower. When we tried to get Brittany’s smiling photo, we were unable to because she had never smiled before. Brittany’s parents absolutely refused extractions. While I obviously would change a lot about this case today, the photos show the remarkable results that are possible with passive self-ligating brackets. Brittany has great gingival health as there’s no stripping or thinning, and her gingival levels are the exact same as they were when she started treatment. After treatment, she had great Class 1 occlusion on both sides, and her palate and physiological adaptation were remarkable (Figure 4). Two years after treatment, I did another round of CT scans and was very pleased with her stability. She relapsed about a millimeter in the maxillary arch only because she wasn’t wearing her nighttime retainer.

AcceleDent-preferred non-invasive option to accelerate tooth movement AcceleDent for accelerating orthodontic treatment is supported with much science and clinical evidence (Figure 5). Dr. Clinton Rubin at SUNY Stony Brook demonstrated in a sheep model that pulsatile forces delivered for 20 minutes a day, 30 hertz for a year had robust change in bone physiology compared to the controls. In another doubleblind, prospective, placebo-controlled clinical trial, Rubin demonstrated that the healing time of fresh fractures of the radius and tibia was reduced 40%. It has also been demonstrated in the clinical treatment of delayed unions and non-unions. We know that AcceleDent’s SoftPulse Technology™ works because it’s been used for over 2 decades in orthopedic surgery. AcceleDent employs pulsatile forces at 30 hertz, which is the same frequency used to increase the rate of fracture healing and 20 Orthodontic practice

Figure 4

Figure 5

Figure 6 Volume 6 Number 2

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CASE STUDY

Figure 7A: Alison 1/10/14

bone density by cellular signaling. With AcceleDent, I’m increasing the biologic response to pressure, thus moving teeth quicker and assisting the mechanics by the vibratory stimulus helping overcome the already decreased friction in the self-ligating brackets I use. Not to mention, we’re also greatly reducing patient discomfort — again, completely opposite of that which occurs with cortical perforation. There was a very interesting poster session presented at the American Association of Orthodontists 2014 Annual Session on the topic of “AcceleDent and the Efficiency of Fixed Appliances” (Figure 6). The poster shows that AcceleDent enhances efficiency of fixed mechanics by decreasing friction. It also shows that static and dynamic friction between orthodontic wire and brackets in a fixed appliance system is reduced by 8% and 22.3%, respectively.

AcceleDent case studies

Figure 7B: Alison 5/16/14

Figure 8: Jamie total treatment time 11 months 22 Orthodontic practice

For further demonstration, examine these real patient case studies from my practice. Allison is 33 years old and was a Class 2, Division 2 case that was bonded January 2014. Like most of my adult patients, she opted to use AcceleDent to accelerate her treatment. Allison’s reset appointment was 4 months later and in 18 x 25 wires. She started in 014 round wires, changed to 018 wire in February. In March, I changed her to a 14 x 25 rectangular copper NiTi wire, and in April, she was changed to an 18 x 25 copper NiTi. She was in light, 2-ounce elastics the entire time. For one visit, she went back down to 14 x 25s, and then in June, she was back to 18 x 25s preparing for the finishing phase in July. After 6 months of treatment, she was in her finishing wires followed by another 6 months of finishing bends. She got her braces off January 2015 and was only in treatment less than 11 months (Figure 7). Jamie is a 47-year-old AcceleDent patient of mine, and she completed treatment in 11 months. She was bonded in February 2014, changed to 14 round copper NiTi in March, 018 in April and 14 x 25 in May. By June, Jamie was in 18 x 25 copper NiTi, and in July, she went into her upper and lower finishing wires, a 19 x 25 TMA top and a 17 x 25 TMA below. Her finishing appointment was in October, and she got her braces off in January (Figure 8). In summary, I want to give a few takeaways from my AcceleDent case studies. 1. While these patients are moving quickly through their treatment, there is no compromise in the finishing. Volume 6 Number 2

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CASE STUDY 2. I see my AcceleDent patients every 4 weeks instead of every 6 or 8 weeks. This also means that reset appointments are pushed back to 4 months instead of the typical 6 to 8 months. 3. It’s important that you demarcate your AcceleDent patients on their charts because it’s going to affect how you schedule them. In my office, we do that by putting a small toolbox icon near their name. 4. My AcceleDent patients are in the round wire phase for generally 1, sometimes 2 months. Reset appointments are generally at either 4 or 6 months, giving me 6 months of finishing time and allowing me to complete treatment within a year or in less than a year (Figure 9). 5. You have to educate your patients about AcceleDent. Add the accelerated treatment option information to your website, share patient and staff testimonials via social media, alert patients about accelerated treatment via email, and distribute accelerated treatment marketing materials at events such as bridal expos, community health fairs, and back-to-school programs. Patients have made it clear that they’re no longer willing to tolerate 2 or more

24 Orthodontic practice

Figure 9

years of orthodontic treatment. We owe it to them to embrace, explore, and utilize technology that will not only enhance their patient experience, but also help us grow and differentiate our practices. I’m not shy to say that AcceleDent has been the single greatest asset in helping me achieve my goal of making sure the patient experience in braces is as brief and comfortable as possible. OP

REFERENCES 1. Uribe F, Padala S, Allareddy V, Nanda R. Patients’, parents’, and orthodontists’ perceptions of the need for and costs of additional procedures to reduce treatment time. Am J Orthod Dentofacial Orthop. 2014;145(4 Suppl):S65-73. 2. Frost, HM. The regional acceleratory phenomenon: a review. Henry Ford Hospital Medical Journal. Vol 31, No.1, pp 3-9, 1983. 3. Teixeira CC, Khoo E, Tran J, Chartres I, Liu Y, Thant LM, Khabensky I, Gart LP, Cisneros G, Alikhani M. Cytokine expression and accelerated tooth movement. J Dent Res. 2010;89(10):1135-1141. 4. Sandra P Henao, Robert P Kusy. Frictional evaluations of dental typodont models using four self-ligating designs and a conventional design. Angle Orthod. 2005;75(1):75-85.

Volume 6 Number 2

Drs. Rohit C.L. Sachdeva, Takao Kubota, and Kazuo Hayashi discuss various factors involved in the treatment of a midline discrepancy Introduction The versatility of using suresmile in the management of patients presenting with a range of malocclusions, including Class 1, Class 2, Class 3, and open bites and deep bites with or without extraction therapy, has been discussed at length in previous articles.1-16 The etiology of midline and transverse related malocclusions is multifactorial, and successful treatment of such patients requires a robust understanding of the factors contributing to the malocclusion (Table 1). Successful treatment outcome requires the design of a plan of care that includes a consistent therapeutic strategy. Generally speaking, midline and transverse problems commonly manifest concurrently in patients with malocclusions. The aim of this article is to discuss the application of suresmile in managing the total care of such patients.

Table 1: Factors associated with a midline shift

Patient SI Patient SI, a 15-year-old female, presented with a Class 1 malocclusion, moderate crowding in the upper and lower arches, and a dental midline discrepancy of 2.5 mm. There were two components to the midline discrepancy. The upper midline was about 1.0 to the left of the patient’s facial midline. This was the result of the skewed upper anterior arch. The lower was about 1.5 mm to the right of the facial midline as

Soft tissue Pathology, e.g., displacement associated with a cyst, unilateral masseteric hypertrophy Skeletal • Maxillary and mandibular spatial deviation as a result of asymmetric growth • Mandible — condylar pathology, e.g., unilateral condylar hyperplasia Dental • • • • • •

Unilateral tooth size discrepancies Asymmetric crowding or spacing, canted occlusal plane Skewed dental arch Unilateral ectopic eruption Retained primary teeth Shift associated with unilateral delayed eruption of a tooth

Step 1: Correction of the upper skewed arch The skewed upper anterior archform was first aligned through asymmetric dental movement of the incisors. This movement helped correct the midline partially by shifting it to the patient’s right. Also, it removed the potential prematurities that caused the mandibular shift and additionally opened up some space on the distal of the upper left canine to facilitate its alignment in the arch (Figure 2).

Functional • Asymmetric lip habits • Mandibular displacement provoked by occlusal prematurities or deviation as a result of a shift of the articular disc

Table 1: Some factors associated with a midline shift17-25

a result of a mandibular shift. Interferences resulting from the mesio-lingual rotation of the upper right central incisor appeared to be the trigger point for mandibular displacement (Figure 1). Before initiating treatment, a 3D care plan was designed (Figure 2). The upper facial midline was selected as the treatment midline. The dynamic arch length discrepancy was measured, and it was realized that the patient could be treated non-extraction to a Class 1 occlusion without overtly advancing the incisors or substantially expanding the

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 and Temple University, and the Hokkaido Health Sciences Center Japan. In the past, he held faculty positions at the University of Connecticut, Manitoba, and the Baylor College of Dentistry, Texas A&M. Dr. Sachdeva has over 80 patents, is the recipient of the Japanese Society for Promotion of Science Award, and has over 160 papers and abstracts to his credit. Visit Dr. Sachdeva’s blog on http://drsachdeva-conference.blogspot.com. All doctors are invited to join the “Improving Orthodontic Care” discussion blog. Please contact improveortho@gmail.com for access information.

Volume 6 Number 2

arches. The plan was formulated through a series of sequential steps. These are briefly described below:

Step 2: Correction of the upper archwidth The upper and lower archwidth were evaluated and the bucco-lingual axial inclinations of the buccal segments were evaluated. It was noted that the buccal segments were tipped lingually (Figure 3). The upper archwidth was corrected by a combination of translation and tipping movements (Figure 4). This resulted in the gain of additional space on the distal side of the upper canine, which would help in the alignment of the canine, (Figure 4A). Step 3: Correction of the mandibular shift and residual midline discrepancy Mandibular movement was simulated to correct its displacement by shifting it to the patient’s left. The virtual diagnostic simulation (VDS) is shown in Figure 5. Step 4: Alignment of the lower anteriors and lower archwidth The lower anterior teeth were aligned as well as the lower buccal segment uprighted (Figure 6). Step 5: Alignment of the upper canine, establishing the level of the esthetic occlusal plane and detailing the occlusion Orthodontic practice 25

ORTHODONTIC CONCEPTS

BioDigital Orthodontics Management of patients with transverse (midline) discrepancies: part 14

ORTHODONTIC CONCEPTS The VDS is shown in Figure 7A. The considerably reduced since the constraints aligned. Rectangular .017" x .025" CuNiTi limiting the extrusion of the canine into the upper left canine was extruded into the space AF 35ºC archwires were installed in both the created by the correction of the skewed arch were assessed to be minimal (Figure upper and lower arches and light box elastics anterior arch and expansion of the buccal 9A). Upper arch alignment was achieved applied in the buccal segment to help settle it down (Figure 9D). segment (Figures 7B and 7C). The maxillary in 8 weeks’ time. As predicted, an anterior A therapeutic scan was taken 6 weeks cant did not develop. Also, the upper archfunctional occlusal plane was selected as later (7.5 months from start of active treatwidth was substantially corrected. And, the the treatment occlusal plane. To this treatment) (Figure 10). upper midline was partially corrected as per ment plane, the upper anterior occlusal plane A virtual target setup and .017" x .025" was extruded (Figure 8). A comparison of plan. At this appointment, an upper utility the VDS versus VDM with the associated arch was placed to help jump the bite and CuNiTi suresmile precision archwires were displacement values of the dentition is shown lower arch expansion initiated (Figure 9B). designed (Figure 11). The suresmile preciin (Figure 8). Table 2 summarizes the main Four months into treatment, positive overjet sion archwires were placed 1.5 months post steps in designing the VDS for patient SI. and lower buccal segment archwidth were therapeutic scan (Figure 12). The patient As one may see, performing a VDS, established. The upper and lower buccal progress was evaluated 8 weeks later. The which is an integral part of the practice of archwidths were established. Note the patient was debonded 4 weeks later. The BioDigital Orthodontics, provides a host of mandible has shifted to the right, and the final records are shown in Figure 13. The benefits to both the doctor and the patient. upper and lower midlines are coincident. A total treatment time was 12 months. Also, These include the ability to plan and visualize .016" CuNiTi AF 35ºC was inserted to initiate the superimposition of the VDS with the VFM care in 3D, anticipate potential risks, design alignment in the lower arch. (Figure 9C). Two shows that the treatment objectives were mechanics (since the nature of planned tooth months later, the lower anterior segment was met (Figure 14). movement is visualized and can be measured), establish patient decision aids, and manage the care of a patient by defining care milestones based upon the anticipated response (Sachdeva). Once the treatment plan was designed, the upper arch was bonded (Tomy CLIPPY-C, aka, In-Ovation® C by Dentsply GAC International bracket with a slot width of .0180"). VDM Treatment was initiated in the upper arch to correct the skewed arch. A slightly expanded .016" CuNiTi AF 35ºC wire was installed. The upper left canine was engaged as it was recognized that alignment of the upper anterior arch and expansion of the buccal segments would create sufficient space for the alignment of the canine. The risk of a cant developing in the anterior occlusal plane was Figures 1A-1C: Patient SI. 1A. Initial intraoral photos, 1B. Virtual Diagnostic Model (VDM). 1C. Initial X-rays

Figures 2A-2E: Patient SI. VDS Step 1. Simulation of upper anterior arch alignment. 2A. Virtual diagnostic model. 2B. Correction of the upper skewed arch. Note space developing mesial to the canine, and the upper dental midline shifts to the right. 2C. VDS (white) vs. VDM (blue) shows the correction. 2D. Clipping plane view showing correction of midline. It is important to recognize that the midline is partially corrected at this point. 2E. Evaluation of VDS. Note the spacing developed as a result of alignment of the upper anterior teeth. The space is mesial to the upper right canine 26 Orthodontic practice

Volume 6 Number 2

Figures 4A-4B: Patient SI. VDS Step 2. 4A. VDS post-expansion of upper buccal segments. Note additional space developing mesial to the upper left canine. 4B. Shows superimposition of the VDS (white) vs. VDM (green) and the nature of expansion

VDS Step 3

Figures 5A-5H: Patient SI. VDS Step 3. The remaining midline discrepancy is treated by simulating the correction of the mandibular shift. 5A. Shows residual midline shift post alignment of the upper anteriors and uprighting of the upper buccal segments. 5B. Shows equal amount of expansion is planned in the upper segment. 5C. One can see there is an asymmetric buccal overjet; more on the left than on the right. This uncovers the mandibular shift displacement to the patientâ&#x20AC;&#x2122;s right. 5D. Shows the lower VDM. 5E. The direction of the simulated correction of the mandibular shift is shown. 5F. Shows the magnitude of displacement of the mandible. 5G. The corrected midline both from the buccal and lingual view. 5H. VDS showing upper midline post correction of the mandibular shift

VDS Step 4

Figures 6A-6B: Patient SI. VDS Step 4. 6A. Shows archwidth correction and anterior alignment in lower arch and lower buccal segment. 6B. This VDS (white) vs. VDM (blue) with the following movements: upper 2-2 incisor alignment, upper buccal expansion, mandibular shift correction, lower buccal segment expansion, lower alignment, and lower archwidth correction Volume 6 Number 2

Orthodontic practice 27

ORTHODONTIC CONCEPTS

Figure 3. Patient SI. Evaluation of the buccal segments and the archwidth on the virtual diagnostic model. Note both the upper and lower buccal segments are tipped lingually

ORTHODONTIC CONCEPTS VDS Step 5

Figures 7A-7C: Patient SI. VDS Step 5. 7A. Final VDS showing the level of the upper AOP is corrected by extrusion and final detailing of the occlusion. 7B and 7C. The upper canine is aligned into the mesial and distal space created before by the alignment of the upper incisors and expansion of the upper buccal segments. Also, note that there are no collisions on the mesial and distal contact points of the canine in its final aligned position, indicating that sufficient space was created by the alignment of the anteriors and buccal expansion

Figures 8A-8B: Patient SI. 8A. Final VDS (white) vs. VDM (blue). Note that the lower AOP is maintained, and the upper AOP is extruded. Also, the sagittal relationships of the buccal segments have been maintained. 8B. Shows the nature and magnitude of displacements of the dentition to correct the malocclusion Table 2 Step 1

Alignment of upper 2-2 skew

1. 2. 3. 4.

Step 2

Expansion of upper buccal segments

1. Correction of upper archwidth 2. Creation of space to align the upper left canine

Step 3

Mandibular shift

1. Residual midline correction

Step 4

Archwidth correction and anterior alignment in lower arch

1. Correction of lower crowding 2. Correction of lower archwidth

Step 5

Extrusion of upper incisors, alignment of the upper arch and finishing

1. Establishing the level of the upper AOP to the functional maxillary occlusal plane 2. Detailing of the occlusion

Partial midline correction Removal of dental prematurities Correction of 2-2 crowding Space created mesial to upper left canine

Table 2: Patient SI. Summary table of objective-driven simulations (Sachdeva)

Figures 9A-9D: Patient SI. 9A. Upper arch bonded, and a slightly expanded .016" CuNiTi AF 35ยบC initial wire inserted to correct the skewed arch and simultaneously expand the buccal segments and align the upper left canine. 9B. 2 months: Upper arch alignment was achieved. At this appointment, an upper utility arch was placed to help jump the bite and lower arch expansion initiated. 9C. 4 months: Positive overjet and lower buccal segment archwidth established. Note the mandible has shifted to the right, and the upper and lower midlines are coincident. A .016" CuNiTi AF 35ยบC lower alignment archwire inserted. 9D. 8 weeks later: Lower anterior segment aligned. Rectangular .017" x .025" CuNiTi AF 35ยบC archwires in upper and lower arches installed. Light box elastics were applied to the buccal segment to help settle the occlusion

28 Orthodontic practice

Volume 6 Number 2

ORTHODONTIC CONCEPTS

Figures 10A-10B: Patient SI. 7.5 months from start therapeutic scan taken at this point in treatment. 10A. Mid-treatment photos. 10B. Mid-treatment X-rays VTM

VTS

VTM (blue) vs. VTS (white)

Figures 11A-11D: Patient SI. 11A. Virtual Therapeutic Model (VTM). 11B. Virtual Target Setup (VTS) with suresmile precision archwire designed. 11C. VTM (blue) vs. VTS (white). 11D. suresmile precision archwire viewed against VTM. 11E. Shows the nature and magnitude of displacements of the dentition

Figure 12: Patient SI. .017" x .025" CuNiTi suresmile precision archwires inserted 6 weeks post therapeutic scan. Patient is at month nine in active treatment Volume 6 Number 2

Correction of a patientâ&#x20AC;&#x2122;s midline discrepancy requires a comprehensive understanding of the nature of the problem, an objective-driven plan, and the implementation of a therapeutic strategy that complements the plan. Orthodontic practice 29

ORTHODONTIC CONCEPTS

VFM

Figures 13A-13C: Patient SI. The patient was seen 8 weeks later (images not shown) and debonded 4 weeks after this visit. The total treatment time was 12 months. 13A. Final intraoral photos. 13B. Final X-rays. 13C. Virtual Final Model (VFM) VDS vs. VFM

Figure 14. Patient SI. Final outcome evaluation. VDS (green) vs. VFM (white) Note the treatment objectives were met

Patient TS Patient TS, a 20-year-old female, presented with a Class 2 subdivision right malocclusion. The upper arch demonstrated severe arch length deficiency with a completely blocked-out upper right lateral incisor. The upper midline was shifted to the right of the patient’s facial midline as a result of the tipping of the upper incisors toward the blocked tooth. The lower arch demonstrated moderate crowding (Figure 15). Based upon a dynamic arch length discrepancy analysis (Sachdeva), it was decided to treat the patient with a unilateral extraction of the upper right buccally erupted canine. The facial midline was selected as the treatment midline, and the treated occlusion would be 30 Orthodontic practice

Class 2 occlusion on the right and Class 1 on the left. The VDS is shown in Figure 16. The upper arch was bonded (Tomy CLIPPY-C, aka, In-Ovation C by Dentsply GAC International bracket with a slot width of .0180") and to achieve anterior alignment in the upper arch, a .016" x .022" CuNiTi AF 35°C archwire was installed. A slightly active open coil spring was placed between the upper right first bicuspid and upper right central incisor to help shift the upper midline to the left by tipping the incisors as well as to correct the skew in the upper arch. This also created some additional space to bring the upper right lateral into the arch (Figure 17A). The patient was next seen 6 weeks later, and at this time, the upper right lateral was bonded and engaged into the archwire. To facilitate the engagement of the lateral incisor, the upper rectangular archwire was replaced with a .016" CuNiTi AF 35°C archwire (Figure 17C). 1.5 months later, the lower arch was bonded, and a .016" CuNiTi AF 35°C alignment archwire engaged (Figure 17D). Six months from the start of treatment, the round upper archwire

was replaced with a .016" x .022" CuNiTi AF 35°C to provide additional stiffness to correct the upper anterior archform (Figure 17E). The next progress appointment was scheduled 6 weeks later. At this time, a therapeutic scan was taken. Note the upper arch form has improved in its symmetry. Furthermore, the upper lateral incisor has now been brought into the arch, and the lower arch is aligned. The therapeutic scan is shown in Figure 18. The virtual target setup and .017" x .025" CuNiTi suresmile precision archwires were designed (Figure 19). The precision archwires were inserted 6 weeks post therapeutic scan (Figure 20A). The patient was seen 8 weeks later (Figure 20B). At this stage of treatment, it was decided that the patient would be ready for debonding in 4 weeks’ time. Final records at debonding were taken (Figure 21). The superimposition of the virtual diagnostic simulation (VDS) on the virtual final model (VFM) shows that the treatment goals were met (Figure 22). The active treatment for the patient was 12 months. Volume 6 Number 2

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ORTHODONTIC CONCEPTS

Figures 15A-15B: Patient TS. 15A. Initial intraoral photos, 15B. Initial X-rays VDM

VDS

VDS (green) vs. VDM (blue)

Figures 16A-16D: Patient TS. Simulation with unilateral extraction was planned. 16A. Virtual Diagnostic Model (VDS). 16B. Virtual Diagnostic Simulation (VDS). 16C. VDM (green) vs. VDS (white).16D. Shows the nature and magnitude of displacements of the dentition to correct the malocclusion

Figures 17A-17E: Patient TS. 17A. Upper arch was bonded with Tomy CLIPPY-C with slot width .0180" and t.016" x .022" CuNiTi AF 35째C was installed to achieve anterior alignment. A slightly active open coil spring was placed between the upper right first bicuspid and upper right central incisor to help shift the upper midline to the left by tipping as well as to correct the skew in the upper arch. This also created some additional space to bring the upper right lateral into the arch. 17B. 1.5 months progress. 17C. Month 3: the upper right lateral is bonded and engaged into the archwire. To facilitate the engagement of the lateral incisor, the upper rectangular archwire was replaced by a .016" CuNiTi AF 35째C. 17D. Month 4.5: .016" CuNiTi AF 35째C alignment archwire engaged. 17E. Month 6: the upper archwire was replaced with a .016" x .022" CuNiTi AF 35째C. This archwire provided additional stiffness to correct the upper anterior archform 32 Orthodontic practice

Volume 6 Number 2

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ORTHODONTIC CONCEPTS

Figures 18A-18B: Patient TS. The mid-treatment therapeutic scan was taken 7.5 months from the beginning of treatment. 18A. Mid-treatment intraoral photos. 18B. Mid-treatment X-rays VTM

VTS

VTM (blue) vs. VTS (white)

Figures 19A-19E: Patient TS. 19A. Virtual Therapeutic Model (VTM). 19B. Virtual Target Setup (VTS) with suresmile precision archwire designed. 19C. VTM (blue) vs. VTS (white). 19D. suresmile precision archwire viewed against VTM. 19E. Shows the nature and magnitude of displacements of the dentition

Figures 20A-20B: Patient TS. 20A. 6 weeks post scan .017" x .025" CuNiTi suresmile precision archwires were installed. 20B. Progress 8 weeks post precision suresmile wire insertion 34 Orthodontic practice

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ORTHODONTIC CONCEPTS Discussion/Conclusions

VFM

Figures 21A-21C: Patient TS. The patient was debonded 4 weeks later. The total active treatment was 12 months from start of treatment. 21A. Final debond photos. 21B. Final X-rays. 21C. Virtual Final Model

Correction of a patient’s midline discrepancy requires a comprehensive understanding of the nature of the problem, an objective-driven plan, and the implementation of a therapeutic strategy that complements the plan. Breakdown in any of these elements may affect patient care adversely. Designing a plan of care with the aid of simulations requires expertise and is a skill that a clinician needs to develop. Simulations have little or no value if they do not encompass realistic expectations that are driven by a clinician’s understanding of the nature of tooth displacement in response to applied forces. 3D simulation-guided plans provide an invaluable resource to establish visual clarity of a treatment plan, helps the doctor measure personal performance, and are an excellent patient communication aid. OP

Acknowledgments

VDM (green) vs. VDS (white)

The authors express their sincerest thanks both to Sharan Aranha BDS, MPA, and Arjun Sachdeva for their tireless efforts in the preparation of this article.

Figure 22: Patient TS. Final evaluation showing the superimposition of the virtual diagnostic simulation (VDS) on the virtual final model (VFM) shows that the treatment goals were met

REFERENCES 1. 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. 2. 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. 3. 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.

Class 2 malocclusion non–extraction: Part 9. Orthodontic Practice US. 2014;5(3):29-41. 13. 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. 14. Sachdeva R, Kubota T, Hayashi K. BioDigital orthodontics. Management of patients with class 3 malocclusion: Part 11. Orthodontic Practice US. 2014;5(5):28-38. 15. Sachdeva RCL, Kubota T. BioDigital orthodontics. Part 1 - Management of patients with openbite: Part 12. Orthodontic Practice. 2014;5(6):22-31. 16. Sachdeva RCL, Kubota T,Lohse.J. BioDigital orthodontics. Part 2- Management of patients with openbite: Part 13. Orthodontic Practice 2015;6(1):13-23.

4. Sachdeva R. BioDigital orthodontics: Planning care with suresmile technology: Part 1. Orthodontic Practice US. 2013;4(1):18-23.

17. Proffit W, Turvey T. Dentofacial asymmetry. In: WR Proffit, RP White, DM Sarver, eds. Contemporary Treatment of Dentofacial Deformity. St. Louis, MO: Mosby; 2003.

5. Sachdeva R. BioDigital orthodontics: Designing customized therapeutics and managing patient treatment with suresmile technology: Part 2. Orthodontic Practice US. 2013;4(2):18-26.

18. Burstone CJ. Diagnosis and treatment planning ofpatients with asymmetries. Paper presented at: Seminars in Orthodontics; 1998.

6. Sachdeva R. BioDigital Orthodontics: Diagnopeutics with suresmile technology (Part 3). Orthodontic Practice US. 2013;4(3):22-30.

19. Chia MSY, Naini FB, Gill DS. The Aetiology, Diagnosis and Management of Mandibular Asymmetry. Ortho Update 2008;1:44-52.

7. Sachdeva R. BioDigital orthodontics: Outcome evaluation with suresmile technology: Part 4. Orthodontic Practice US. 2013;4(4):28-33.

20. Buranastidporn B, Hisano M, Soma K. Articular disc displacement in mandibular asymmetry patients. J Med Dent Sci. 2004;51(1):75-81.

8. 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.

21. Dong Y, Wang XM, Wang MQ, Widmalm SE. Asymmetric muscle function in patients with developmental mandibular asymmetry. J Oral Rehabil. 2008;35(1):27-36.

9. 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.

22. Kebede B, Megersa S. Idiopathic masseter muscle hypertrophy. Ethiop J Health Sci. 2011;21(3):209-212.

10. 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. 11. 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. 12. Sachdeva R, Kubota T, Hayashi K. BioDigital orthodontics. Part 2-Management of patient with

36 Orthodontic practice

23. Minich CM. An evaluation of skeletal and dental asymmetries in Class II subdivision malocclusions using cone-beam computed tomography. [abstract]. Saint Louis University: 2011. 24. Doyle WJ, Johnston O. On the meaning of increased fluctuating dental asymmetry: a cross populational study. Am J Phys Anthropol. 1977;46(1):127-134. 25. Pinho S, Ciriaco C, Faber J, Lenza MA. Impact of dental asymmetries on the perception of smile esthetics. Am J Orthod Dentofacial Orthop. 2007;132(6):748-753.

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PROPELLING ORTHODONTICS

Proactive treatment with Propel Dr. Thomas Shipley discusses how he has increased efficiency and productivity in his practice

t’s Wednesday afternoon, and I am at my desk. It’s time for the after-school rush, so I head out into the six-operatory orthodontic bay of my private practice. “Wait a moment,” I think. “Where is everyone?” There are only two patients in chairs, with four chairs empty. This concerns me, and I quickly return to my desk to run statistical reports. Then it dawns on me that I have time to run statistical reports on a Wednesday afternoon! Even better, I find that I am on track to have my best January in the history of my practice — this is all due to a simple technology I’ve added to my practice known as Propel. Since introducing Propel into my practice 2 years ago, I’ve noticed a trend — there are sporadic moments in the afternoons when I have more time to breathe and stretch. More so, I notice that I now have more time to converse with my patients. There are more giggles returning to the air, or at least I have more time to notice them. When I walk into the new patient exam room, I am more relaxed, and my patients notice it too. I started proactively using Propel in 2013, and last year I completed over 50 proactive Propel cases. Proactively means that I do the Propel procedure early on in an orthodontic case to speed up the overall time of treatment. For fixed appliance cases, that means that the patients will typically finish in less than a year. For Invisalign® patients, they will typically finish in half the time with fewer refinements.

If I have completed over 50 cases at least twice as fast, that means that I see 50 fewer patients every month — or that is about 12 fewer adjustments per week or three fewer every afternoon. That totals at least 1 hour of chair time every afternoon! Now, my toughest decision is what to do with the extra time. Given the new free time Propel has provided, I am able to keep the

practice running on time. I have reached my production goals, which has given me new opportunities to further market my practice. I have also decided I can wait a little longer to hire an associate. All of this was possible for an investment of about $6,000, which is enough devices for more than 50 patients. In my office, almost every patient whom I select as a candidate for Propel accepts

Figure 1: Case No. 1. Deep bite with generalized upper and lower spacing

Figure 2: Propel used to place micro-osteoperforations the same day appliances were bonded

Figure 3: Case completed in total of 9 1/2 weeks with deep bite resolution and space closure

Thomas S. Shipley, DMD, MS, received his Bachelor of Science degree in Business Management from Brigham Young University and went on to earn his doctorate from the University of Kentucky College of Dentistry. Dr. Shipley completed a Master’s program in Orthodontics at West Virginia University. Dr. Shipley maintains a full-time orthodontic practice in Peoria, Arizona. He is an Adjunct Professor of Orthodontics at The Arizona School of Dentistry Orthodontic Specialty Program. He is a member of the American Association of Orthodontics, the American Dental Association, the Pacific Coast Society of Orthodontics, and the Arizona Dental Association. He is board certified by the American Board of Orthodontics.

38 Orthodontic practice

Volume 6 Number 2

... I can offer Propel to release challenging movements, or I can offer Propel in my office for decreasing the overall treatment times of my patients, which has greatly increased efficiency and productivity

Figure 4: Case No. 2. Invisalign case with 90% deep bite and severe crowding

Figure 5: Propel used to place micro-osteoperforations four weeks into Invisalign treatment. The patient changed aligners every 3 days after Propel

Figure 6: Invisalign case completed in 4 months of total treatment time using Propel. 34 total aligners were used with no refinement

aligners at 2 weeks per aligner for a total of 68 weeks. In our office, one to two sets of refinement aligners would have been ordered to complete the case in a total of 18 to 24 months. In this case with Propel, no refinement was needed, and treatment was completed in exactly 18 weeks (about 4 months). The deep bite and crowding were fully resolved (Figure 6). In conclusion, I can offer Propel to release challenging movements, or I can offer Propel in my office for decreasing the overall treatment times of my patients, which has greatly increased efficiency and productivity. Propel can be implemented into the orthodontic office easily with little disruption to patient flow — other than creating more room for flow! OP This information is sponsored and provided by Propel Orthodontics.

Orthodontic practice 39

PROPELLING ORTHODONTICS

the treatment. Propel is a procedure where I use a surgical-grade stainless-steel driver to make “dimples” into the cortical plate directly through the gingiva or mucosa. This is typically done with very little discomfort or recovery for the patient. The result is a cellular cascade of events, which results in an increased rate of bone turnover and, therefore, an increased rate of tooth movement. I place a strong topical compound anesthetic over the soft tissue and leave it there for 4 minutes. If preferred, but usually not necessary, an injectable local anesthetic such as Septocaine® may be used. I rinse the topical off and wait 10 minutes. During this time, the patient rinses with chlorhexidine twice for 1 minute. As the topical begins to take full effect, the orthodontic technicians complete the scheduled orthodontic adjustment for the day. I then begin Propel, making 1 to 3 micro-osteoperforations (“dimples”) mesial and distal to each tooth I want to activate. The patients are instructed to take Tylenol®, if they experience any discomfort after treatment, but not ibuprofen as patients should avoid any NSAIDs as they can hinder orthodontic movement. Most patients report feeling some pressure for a few hours but complete resolution of any discomfort by the following day. Case No. 1 presents with a Class I dental deep bite with generalized upper and lower anterior spacing (Figure 1). Upper and lower fixed orthodontic appliances were placed. This case would typically be diagnosed as requiring 9 to 12 months in my office. We decided to speed the process, by using Propel. The day that the appliances were bonded, micro-osteoperforations were placed upper and lower anteriorly to create a cellular response, which speeds the rate of bone turnover in the area, thus speeding the rate of tooth movement (Figure 2). The deep bite was improved to 50%, and all spacing was closed in 9½ weeks (Figure 3). Case No. 2 presents with 90% deep bite, moderate upper crowding, and severe lower crowding (Figure 4). The patient was referred by a colleague who had received Propel at our office. Invisalign was chosen as the treatment choice, and Propel was initiated on the day attachments were placed for aligner No. 3 (Figure 5). The patient wore each of the remaining 32 aligners at just 3 days per aligner. Typically, without Propel, the patient would have switched the 34

CONTINUING EDUCATION

Uprighting impacted mandibular second molars using NiTi wire Drs. Daniel DiBagno, Lauren Sigler Busch, and Daniel J. Rinchuse discuss uprighting impacted mandibular second molars

he prevalence of ectopic eruption and/ or impaction of mandibular second molars has been reported to range from 0.3% to 2.3%.1,2,3,4,5,6 Recently, in a Caucasian sample, Cassetta, et al.,7 found an incidence of 1.36% of mandibular second molar impaction. There is ambiguity in the prevalence data reporting because second molar impaction rates may be grouped together, maxillary and mandibular, while other sources do not distinguish impactions from ectopic eruption. Moreover, the definition of impaction versus ectopic eruption varies in the orthodontic literature. According to the American Association of Orthodontists (AAO) Glossary of Orthodontic Terms, an impaction is “a condition that describes the total or partial lack of eruption of a tooth well after the normal age for eruption,” whereas ectopic is defined as “located away from normal position” or a “condition in which a tooth develops or erupts in an abnormal position.”8 Other researchers use the term ectopic to describe a tooth that could potentially erupt into the arch.9 Using this definition, a percentage of ectopically erupting teeth have the ability to self-correct over time into a normal position, whereas impacted teeth remain as such. The definition of ectopic eruption can be made only theoretically or in hindsight and, therefore, is an enigmatic orthodontic definition. Therefore, for the purposes of this paper, we will group the two terms together as impaction. Mandibular molar impaction is more likely to occur unilaterally than bilaterally. The impaction occurs more often on the right side than the left side. Impacted Daniel DiBagno, DMD, is Assistant Professor and Director of Clinical Training at Seton Hill University Graduate Program in Orthodontics, Greensburg, Pennsylvania. To contact Dr. DiBagno, email ddibagno@setonhill.edu. Lauren Sigler Busch, DDS, is a graduate orthodontic resident at Seton Hill University. Daniel J. Rinchuse, DMD, MS, MDS, PhD, is Professor and Program Director at Seton Hill University.

40 Orthodontic practice

Educational aims and objectives

This article aims to discuss uprighting impacted mandibular second molars using NiTi wire.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 45 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Realize the prevalence of ectopic eruption and/or impaction of mandibular second molars. • Identify some of the causes of eruption problems. • Identify some environmental factors associated with impaction. • Realize some of the challenges of treating mandibular second molars. • Read about the authors’ method for dealing with ectopic eruption and impaction of mandibular second molars in young patients.

second molars are most often inclined mesially.10 There appears to be no gender predisposition to mandibular second molar impaction11 although some studies report a male predisposition.4 Eruption problems can be due to genetic or environmental problems, specifically ectopic position or eruption path obstacles.12 Genetic causes of eruption disturbances remain elusive. While Parathyroid Hormone Receptor 1 PTH1R has been associated with Primary Failure of Eruption,13 specific genetic mutations that are associated with second molar impaction have not yet been identified. However, impaction of the mandibular second molar has been demonstrated to have an autosomal dominant inheritance pattern in Chinese Americans.6 Shapira, et al.,6 found that certain races have higher prevalence of impaction than others; for instance, 2.3% in Chinese American populations versus Israeli populations (1.4%).The same study also found reduced mesial root length of the mandibular second molar to be associated with its impaction. Environmental factors associated with impaction include crowding,7 supernumerary teeth, odontomas, cysts, or ectopic positions of the teeth in the deciduous dentition.5 Iatrogenic reasons for mandibular second molar impaction are use of appliances that maintain arch perimeter, such as the lower lingual holding arch and/or the Schwarz appliance,14 and incorrectly fitted bands.15

In a small sample, Evans showed an increase in second molar impaction prevalence from 1976 to 1986.16 The increased popularity of nonextraction treatment during the time period of the study translated into a decrease in extraction rates. It is postulated that the increase in nonextraction treatment during this time period also led to an increased prevalence of mandibular second molar impaction.7 Ectopic eruption of the second molars can cause multiple problems, such as resorption, pain, increased orthodontic treatment time, increased caries susceptibility, malocclusion, and periodontal disease.11 Mandibular second molars can oftentimes be frustrating for orthodontists. Not only is it difficult for the practitioner to work in the posterior of the mouth while maintaining a dry field to bond brackets, an impacted mandibular second molar may be only partially erupted, so placing a bracket is often problematic or impossible. Many methods and procedures have been reported in the orthodontic literature for uprighting mesioangular impacted mandibular second molars such as surgical methods involving extraction of third molars, extraction of the second molar, and autotransplantation.17 Other methods involved miniscrews/miniplates.18,19 Conservative approaches to correct mandibular second molar impaction include uprighting springs,15 tip-back cantilevers coupled with buccal exposure,15 pins,20 chain-activated auxiliaries,21 and separating Volume 6 Number 2

working field. Cut a 10-12 mm section of .016" x .016" nickel-titanium wire, and hold it at approximately the midpoint of the wire using either a Mathieu ligating plier or Weingart utility plier. Topical anesthesia and/or local infiltration of a dental anesthetic can be used when performing this procedure, but it is typically not necessary. The author (DD) has performed this procedure multiple times and has never used anesthetic. Gently pass the wire gingivally between the erupted first and impacted second molars, carefully following the distal contour of the first molar with the leading edge of the wire while sliding the wire in a gingival direction. In most instances, only 3-4 mm of wire will pass gingivally before resistance is felt. When resistance is felt, stop the gingival movement, and bend the occlusal portion of the wire mesially and downward, and hold it (with a ligature director) in the central groove of the first molar while your assistant places a couple small dabs of Band-Lok® (Reliance Orthodontic Products) over the wire, being careful not to get any Band-Lok on the ligature director. Light cure, release your hold with the ligature director, and take a periapical radiograph, if desired, to verify correct wire placement. If the radiograph reveals improper wire placement, remove the BandLok from the occlusal surface of the first molar, and repeat the procedure making the necessary directional adjustments. When the radiograph reveals proper wire placement, re-isolate and dry the occlusal surface of the first molar along with the occlusal third of its distal surface, and add sufficient Band-Lok to the occlusal surface to form a posterior bite turbo to disocclude the posterior teeth and protect the working sectional nickel-titanium wire. In addition, also apply a small amount of Band-Lok over the wire as it descends along the occlusal one-third of the distal surface of the first molar. This helps prevent buccal

or lingual movement and dislodgement of the working wire as the second molar is uprighting. When performing the procedure unilaterally, a bite turbo of equal size should be added to the first molar on the opposite side of the arch for patient comfort. The patient should be seen every 2-3 weeks to monitor the second molar uprighting progress. When allowed to go longer than 2-3 week intervals, the author (DD) has sometimes observed the leading edge of the working wire disengage from the second molar and the second molar “relapse” into its original position. At each follow-up appointment, a periapical radiograph should be taken to assess the position of the leading edge of the working wire and the position of the second molar. If the crown of the second molar is not sufficiently exposed in the oral cavity to permit bracket placement, the orthodontist must decide either to continue the uprighting process with the current wire or to replace it with a wire of longer length to prevent the disengagement of the leading edge of the working wire from the mesial surface of the uprighting molar. In the majority of cases, 2-4 appointments 2-3 weeks apart (4-12 weeks total) are sufficient to upright the second molar enough to place a bracket on the tooth.

In 2011 there were two published32,33 descriptions of a non-surgical technique for uprighting mesially impacted mandibular molars. Bach32 used an .014" x .025" Copper NiTi wire, whereas about the same time the author (DD), independently, developed a similar technique using .016" x .016" NiTi wire. The two previous descriptions of the technique did not include a literature review like this current paper and did not discuss a broader utility of the technique. To initiate uprighting, acid etch the first molar occlusal surface and the occlusal onethird of its distal surface for 30-60 seconds, rinse, dry, and isolate to maintain a dry

Figure 1: Panoramic radiograph revealing unerupted mesially angulated mandibular second molars

Case reports A 12-year 10-month-old male presented with a chief complaint of “I have crooked teeth and don’t like my smile.” Intraoral examination revealed an Angle’s Class I malocclusion with mild maxillary and mandibular anterior crowding, minimal overjet, and a severe (100%) impinging overbite with partially blocked out, but favorably positioned and unerupted, maxillary and mandibular canines. The panoramic radiograph (Figure 1) revealed unerupted and mesially angulated mandibular second molars seemingly

Appliance design and protocol

Volume 6 Number 2

Orthodontic practice 41

CONTINUING EDUCATION

wires.22 Many methods require the tooth to have one or more of the cusps exposed or present to place an uprighting appliance.23,24,25,26 Greater success is reported in younger patients, suggesting that the earlier the anomalous eruption is treated, the higher the success rate. The recommended age to treat the mandibular molar impaction is between age 11 and 14.27,28,29 More specifically, it is best to treat the impaction when mandibular second molar root formation is not yet complete.15 Conservative treatments of second mandibular molar impaction are successful in roughly 50% of cases.30 However, this data is skewed as it includes surgical combination treatment as well as maxillary impaction rates. In a retrospective follow-up study of impacted second molars (maxillary and mandibular) Magnusson and Kjellberg31 found the least successful treatment (11%) was extraction of the second molar to permit the third molar to replace it, while the most successful treatment (71%) was surgical exposure of the second molars. ValmasedaCastellon, et al.,30 found conservative treatments for first and second molar impaction, which included surgical exposure, orthodontic traction, surgical luxation and orthodontic traction, restoration, transplantation, or no treatment, resulted in a 50% success rate in 14- to 20-year-old patients. More studies are needed to evaluate the success rates of orthodontic treatment for mandibular second molar impaction. This paper demonstrates a simple, cost-effective, pain-free, and conservative method for dealing with ectopic eruption and impaction of mandibular second molars in young patients. This procedure is not appropriate for mandibular second molars that are afflicted with primary failure of eruption or secondary retention.

CONTINUING EDUCATION trapped in the distal crown-root concavity of the erupted first permanent molars on both sides. The developing crowns of both mandibular third molars appeared to overlap the distal surfaces of both unerupted permanent second molars. Both arches were bonded from first molar to first molar; and after leveling, alignment, and bite opening, space was made for the unerupted maxillary and mandibular canines. The canines were bonded upon eruption, and at that time, the mandibular right second molar was visibly erupting. However, the mandibular left second molar was not visible, and a panoramic radiograph (Figure 2) revealed it to continue to be mesio-angulated and impacted in the distal crown-root concavity of the permanent first molar with the developing crown of the third molar resting against its distal surface. At a subsequent appointment, a 10-12 mm section of .016" x .016" nickel-titanium wire was inserted between the impacted second molar and first molar and bonded to the first molar occlusal surface as described in the previous section (Figures 3 and 4). At the next appointment, 3 weeks later, the crown of the erupting mandibular left second molar was visible in the oral cavity (Figure 5). At this

Figure 2: Panoramic radiograph revealing meso-angulated and impacted left mandibular second molar

Figure 3: Periapical radiograph of .016 x .016 nickel-titanium wire inserted subgingivally to upright impacted second molar

Figure 5: Intraoral photograph revealing the crown of the previously impacted mandibular second molar. The second molar was uprighted using the NiTi wire technique described

Figure 8: Periapical radiograph at the end of treatment revealing upright mandibular left second molar 42 Orthodontic practice

Figure 4: Intraoral photograph of .016 x.016 nickel-titanium wire inserted distally and subgingivally to the mandibular first molar. The wire is bonded to occlusal surface of the mandibular left first molar

Figure 6: Periapical taken at time of separator placement following use of NiTi wire uprighting technique

Figure 7: Intraoral photograph of separator placement after crown eruption of mandibular left second molar. The separator has been placed to continue uprighting the mandibular left second molar

Figure 9: Posttreatment panoramic X-ray revealing upright mandibular left second molar Volume 6 Number 2

Figure 11: Panoramic radiograph revealing meso-angulated impacted mandibular left second molar

Figure 12: Periapical radiograph of NiTi wire engaged in mesial occlusal pit of impacted mandibular second molar

Figure 13: Periapical radiograph taken to monitor progress of impacted mandibular second molar. The angulation and position of the molar has improved

point in treatment, the NiTi was removed, and an elastic separator was placed between the mandibular left first and second molars for one visit (3 weeks) to complete the uprighting process (Figures 6 and 7). The mandibular left second molar was now in alignment (Figure 8), and the case was completed in the usual manner. Final radiographs and photos revealed an upright mandibular left second molar with the third molar still present and a total treatment time of 24 months (Figures 9 and 10). The second patient is a 13-year 1-month-old female who presented with a chief complaint of “My front teeth don’t overlap.” Intraoral examination revealed an Volume 6 Number 2

Figure 14: Intraoral photograph revealing the crown of the left mandibular second molar beginning has erupted into the oral cavity

Angle’s Class I malocclusion with a mild anterior open bite, mild maxillary and mandibular arch crowding, delayed development of the mandibular right second molar, and a mandibular left second molar with normal development and mesio-angulated impaction. (Figure 11). Prior to the bonding of fixed appliances, a 10-12 mm section of .016" x .016" nickeltitanium wire was inserted between the impacted second molar and the erupted first molar and bonded to the occlusal surface of the first molar as described in the appliance design and protocol section. However, due to the angulation of the impaction, it was not possible to follow the distal contour of the mandibular first molar with the leading edge of the nickel-titanium section of wire.

Therefore, the wire was engaged in the mesial occlusal pit of the impacted second molar (Figure 12). The patient was seen 17 days later to monitor her progress, and another periapical radiograph was taken to assess the uprighting progress (Figure 13). At this appointment a new, slightly longer, section of .016" x .016" nickel-titanium wire was inserted between the molars and secured to the occlusal surface of the first molar with Band-Lok. The patient was seen 25 days later, and the previously impacted second molar was visibly erupting into the oral cavity (Figure 14). Shortly afterward, comprehensive treatment was initiated, and the maxillary and mandibular arches were bonded from first molar to first molar. Four months later, a progress panoramic radiograph was taken Orthodontic practice 43

CONTINUING EDUCATION

Figure 10: Posttreatment intraoral photograph revealing upright mandibular left second molar

CONTINUING EDUCATION

Figure 16: Intraoral photograph demonstrating the crown of the previously impacted left mandibular second molar has nearly completely erupted into the oral cavity

Figure 15: Progress panoramic radiograph confirming the left mandibular second molar has fully erupted into the oral cavity

to assist in bracket repositioning (Figure 15). An occlusal photo taken on the same day shows the previously impacted mandibular left second molar erupting into the oral cavity (Figure 16). An elastic separator was then placed between the mandibular left first and second molars in an attempt to finalize the uprighting process. In the near future, it may also be necessary to bond a bracket to the mandibular left second molar to complete alignment. It may also be necessary to perform the same uprighting procedure on the patient’s slow-developing mandibular right second molar towards the end of active treatment and/or during retention.

Discussion With the decline in extractions in recent years,34 ,35 and a bias toward nonextraction treatment, impaction of second molars,

REFERENCES 1.

Bondemark L, Tsiopa J. Prevalence of ectopic eruption, impaction, retention and agenesis of the permanent second molar. Angle Orthod. 2007;77(5):773–778.

Johnsen DC. Prevalence of delayed emergence of permanent teeth as a result of local factors. J Am Dent Assoc. 1977;94(1):100-106.

Grover PS, Lorton L. The incidence of unerupted permanent teeth and related clinical cases. Oral Surg Oral Med Oral Pathol. 1985;59(4):420-425.

Varpio M, Wellfelt B. Disturbed eruption of the lower second molar: clinical appearance, prevalence, and etiology. ASDC J Dent Child. 1988;55(2):114-118.

Shapira Y, Finkelstein T, Shpack N, Lai YH, Kuftinec MM, Vardimon A. Mandibular second molar impaction. Part I: Genetic traits and characteristics. Am J Orthod Dentofacial Orthop. 2011;140(1):32-37.

Cassetta M, Altieri F, Di Mambro A, Galluccio G, Barbato E. Impaction of permanent mandibular second molar: a retrospective study. Med Oral Pathol Oral Cir Bucal. 2013;18(4):e564-e568.

American Association of Orthodontists. AAO Glossary, 2012

Baccetti T. A controlled study of dental anomalies. Angle Orthod. 1998;68(3):267-274.

10. Wellfelt B, Varpio M. Disturbed eruption of the permanent lower second molar: treatment and results. ASDC J Dent Child. 1988;55(3):183-189. 11. Fu PS, Wang JC, Wu YM, Huang TK, Chen WC, Tseng YC, Tseng CH, Hung CC. Impacted mandibular second molars: A retrospective study of prevalence and treatment outcome. Angle Orthod. 2012;82(4):670-675.

44 Orthodontic practice

particularly mandibular second molars may increase. E-space preservation (primary second molar space), as it is often called in the orthodontic literature, in a nonextraction protocol with a passive lingual arch is 10 to 20 times more likely to be associated with impaction of permanent mandibular second molars than in the general population.36 Likewise, Rubin, et al.,14 showed increased eruption disturbances of the mandibular second molars with orthodontic appliances that maintain arch perimeter in the mixed dentition. The advantages of the technique for uprighting second molars described in this paper are as follows: • Relatively painless • Inexpensive • Efficient • Effective

• Places little burden on the patient • Low-maintenance. With this technique, it is not necessary, as the case reports demonstrate, to extract the third molars prior to uprighting. A major advantage of this technique is that it can be performed on a bonded or unbonded mandibular arch. Instead of waiting many years and keeping orthodontic appliances on for an extended period of time until mandibular second molars erupt, impacted mandibular second molars can be uprighted before, during, or after active orthodontic treatment. The reciprocating effects on the mandibular first molar are minimal since the opposing occlusion of the maxillary arch prevents supra-eruption. When using this procedure on a bonded mandibular arch, uprighting can be initiated at the initial bonding appointment or at any time during the treatment sequence. OP

12. Andreasen JO, Petersen JK, Laskin DM. Textbook and Color Atlas of Tooth Impactions. Copenhagen, Denmark: Munksgaard; 1997: 199-208.

24. Shapira Y, Borell G, Nahlieli O, Kuftinec MM. Uprighting mesially impacted mandibular permanent second molars. Angle Orthod. 1998;68(2):173-178.

13. Frazier-Bowers SA, Simmons D, Wright JT, Proffit WR, Ackerman JL. Primary failure of eruption and PTH1R: the importance of a genetic diagnosis for orthodontic treatment planning. Am J Orthod Dentofacial Orthop. 2010;137(2): 160.e1-7, 160-161.

25. Lau CK, Whang CZ, Bister D. Orthodontic uprighting of severely impacted mandibular second molars. Am J Orthod Dentofacial Orthop. 2013;143(1):116-124.

14. Rubin RL, Baccetti T, McNamara JA Jr. Mandibular second molar eruption difficulties related to the maintenance of arch perimeter in the mixed dentition. Am J Orthod Dentofacial Orthop. 2012;141(2):146-152. 15. Sawicka M, Racka-Pilszak B, Rosnowska-Mazurkiewicz A. Uprighting partially impacted permanent second molars. Angle Orthod. 2007;77(1):148-154. 16. Evans R. Incidence of lower second permanent molar impaction. Br J Orthod. 1988;15(3):199-203. 17. Johnson JV, Quirk GP. Surgical repositioning of impacted mandibular second molar teeth. Am J Orthod Dentofacial Orthop. 1987;91(3):252-251. 18. Giancotti A, Muzzi F, Santini F, Arcuri C. Miniscrew treatment of ectopic mandibular molars. J Clin Orthod. 2003;37(7):380-383. 19. Lee KJ, Park YC, Hwang WS, Seong EH. Uprighting mandibular second molars with direct miniscrew anchorage. J Clin Orthod. 2007;41(10):627-635. 20. Buchner HJ. Correction of Impacted mandibular second molars. Angle Orthod. 1973;43(1):30-33. 21. Raghav S, Vinod P, Shashikala KV. The Neoslider appliance for uprighting mesially impacted mandibular second molars. J Clin Orthod. 2013;47(9):553-557. 22. Aksoy AU, Aras S. Use of nickel titanium coil springs for partially impacted second molars. J Clin Orthod. 1998;32(8):479-482. 23. Henns RJ. Uprighting impacted mandibular second molars. Angle Orthod. 1975;45:314-315.

26. Miao YQ, Zhong H. An uprighting appliance for impacted mandibular second and third molars. J Clin Orthod. 2006;40(2):110-116. 27. Peskin S, Graber TM. Surgical repositioning of teeth. J Am Dent Assoc. 1970;80:1320-1326. 28. Johnson E, Taylor RC. A surgical-orthodontic approach in uprighting mandibular second molars. Am J Orthod. 1972;61(5):508-514. 29. Davis WH, Patakas BM, Kaminishi RM, Parsch NE. Surgically uprighting and grafting mandibular second molars. Am J Orthod. 1976;69(5):555-561. 30. Valmaseda-Castellon E, De-la-Rosa-Gay C, Gay-Escoda C. Eruption disturbances of the first and second permanent molars: results of treatment in 43 cases. Am J Orthod Dentofacial Orthop. 1999;116(6):651-658. 31. Magnusson C, Kjellberg H. Impaction and retention of second molars: diagnosis, treatment and outcome. A retrospective follow-up study. Angle Orthod. 2009;79(3):422-427. 32. Bach RM. Non-surgical uprighting of mesially impacted lower molars. J Clin Orthod. 2011;45(12):679-681. 33. White LW. Orthodontic pearls: A clinical guide. Dallas:Taylor Publishing Co; 2011. 34. Proffit WR, Fields HW, Sarver DM. Contemporary Orthodontics. 5th ed. St. Louis, MO: Mosby; 2013. 35. Burrow SJ. The impact of extractions on facial and smile aesthetics. Semin Orthod. 2012;18(3):202-209. 36. Sonis A, Ackerman M. E-space preservation. Angle Orthod. 2011;81(6):1045-1049.

Volume 6 Number 2

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Uprighting impacted mandibular second molars using NiTi wire

CBCT in the evaluation of airway â&#x20AC;&#x201D; minimizing orthodontic relapse

The prevalence of ectopic eruption and/or impaction of mandibular second molars has been reported to range from _______. a. 0.3% to 2.3% b. 3% to 4.5% c. 5% to 6.2% d. 7.3% to 8.6%

The optimal result is one in which the ____ points of obstruction are best managed. a. two b. three c. four d. five

Eruption problems can be due to ________, specifically ectopic position or eruption path obstacles. a. genetic problems b. environmental problems c. buccal exposure d. both a and b

Triage of options is dependent on _______. a. a good clinical exam of the tongue and its posture b. cone beam computed tomography (CBCT) c. releasing the genioglossus tension d. both a and b

DIBAGNO/BUSCH/RINCHUSE

occlusal surface and the occlusal one-third of its distal surface for _____, rinse, dry, and isolate to maintain a dry working field. a. 10-20 seconds b. 30-60 seconds c. 90 seconds d. 2 minutes 7.

8. 3.

Iatrogenic reasons for mandibular second molar impaction are use of appliances that maintain arch perimeter, such as ______. a. the lower lingual holding arch b. the Schwarz appliance c. incorrectly fitted bands d. all of the above

The recommended age to treat the mandibular molar impaction is between _____. a. age 7 and 8.3 b. age 9.2 and 10 c. age 11 and 14 d. age 16 and 18

Conservative treatments of second mandibular molar impaction are successful in roughly ____ of cases. a. 10% b. 25% c. 50% d. 68%

To initiate uprighting, acid etch the first molar

Volume 6 Number 2

In most instances, only ______ of wire will pass gingivally before resistance is felt. a. 1 mm-2 mm b. 3 mm-4 mm c. 5 mm-6 mm d. 7 mm The patient should be seen every _____ to monitor the second molar uprighting progress. a. week b. 2-3 weeks c. month d. 6 months At each follow-up appointment, a ________ should be taken to assess the position of the leading edge of the working wire and the position of the second molar. a. digital photograph b. CBCT c. panoramic d. periapical radiograph

10. Instead of waiting many years and keeping orthodontic appliances on for an extended period of time until mandibular second molars erupt, impacted mandibular second molars can be uprighted ____ active orthodontic treatment. a. before b. during c. after d. all of the above

OLMOS

Scalloping of the tongue is _____ predictive of OSA. a. 40% b. 50% c. 60% d. 70% Nasal obstruction can be due to underdevelopment of the skeletal structures or excessive development such as _________, which can compress the uncinate process thus blocking maxillary sinus drainage. a. conchae bullosa b. hyper velopharynx c. increased genioglossus tension d. extended nares Lymphatic tissue obstruction such as ________ is a major airway obstruction in children and adults. a. conchae bullosa b. adenoids c. tonsils d. both b and c

A study published in the October 2014 edition of the AJO-DO demonstrated that _____ was as accurate as nasoendoscopy for adenoid and tonsil evaluation. a. intraoral photographs b. 2D radiographs c. CBCT d. visual examination

_______ may be related to the patient having bruxism secondary to OSA. a. Implant failures b. Nasal volume c. Open bite d. Ear infections

Recent research has shown that if the patient has OSA, nightguards can worsen the suffocating events by _____. a. 40% b. 50% c. 60% d. 70%

______ resulting in dry mouth increases the risk of caries and periodontal plaque. a. Nasal breathing b. Mouth breathing c. Sleeping with the mouth closed d. Bruxism

10. Whether the treatment is ______, or in the treatment and management of OSA, the use of CBCT imaging is a necessity. a. orthodontic b. prosthodontic c. periodontal d. all of the above

Orthodontic practice 45

CE CREDITS

ORTHODONTIC PRACTICE CE

CONTINUING EDUCATION

CBCT in the evaluation of airway — minimizing orthodontic relapse Dr. Steven Olmos discusses the four points of breathing obstruction

or those of us who treat obstructive sleep apnea (OSA) or those who have tried but run into problems that make you want to throw up your hands, think about the four points of breathing obstruction. Each patient has a different set of obstructions, so decisions on how to choose between the hundreds of appliances to treat breathing disorders are based upon multiple points of obstruction. The best treatment may be combination therapy (hybrid): oral appliance therapy, nasal positive pressure, and nasal surgery. The optimal result is one in which the four points of obstruction are best managed. Triage of options is dependent on a good clinical exam of the tongue and its posture and cone beam computed tomography (CBCT). So much of the literature and techniques to treat OSA for oral appliance therapy centers on moving the mandible forward for

Figure 1

Educational aims and objectives

This article aims to discuss the four points of breathing obstruction.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 45 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify the four points of breathing obstruction. • Realize various techniques to treat OSA for oral appliance therapy. • Recognize that CBCT may be an effective imaging modality for viewing OSA-related anatomy. • See how nasal obstruction influences OSA. • Realize that failure to evaluate all four points of obstruction and failure to establish a patent airway will affect the longevity of any dental treatment being rendered.

Figure 2

Steven Olmos, DDS, DABCP, DABCDSM, DABDSM, DAAPM, FAAOP, FAACP, FICCMO, FADI, FIAO, has been in private practice for more than 30 years with the last 20 years devoted to research and treatment of craniofacial pain, temporomandibular disorder (TMD), and sleep-disordered breathing. He obtained his DDS from the University of Southern California School of Dentistry and has continued his postgraduate education with over 4,000 hours and board certifications in the fields of mandibular orthopedic dysfunction and sleep-disordered breathing. Dr. Olmos is the founder of TMJ & Sleep Therapy Centres International with 28 licensed Centres in 5 countries dedicated exclusively to the diagnosis and treatment of these disorders. His protocols are an assimilation of his knowledge base, which is reflected by certifications in all philosophies of treatment both medical and dental. Dr. Olmos is an adjunct professor at the University of Tennessee School of Dentistry, where his system of diagnosis and treatment are utilized at the school’s Craniofacial Pain Center. This effort is focused to establish protocols between dentistry and medicine for optimal treatment outcomes.

46 Orthodontic practice

the beneficial effect of increasing the velopharynx and genioglossus tension to open the oropharynx. There is no one mandibular advancement device design that works for all patients with OSA.1 The percentages of the frequency of these obstructions2 are shown in Figure 2. A patient whose tongue retracts on opening will have limited success with an oral Volume 6 Number 2

appliance that does not address this condition. Tongue pillows designed to move the tongue forward are indicated, as mandibular forward titration alone will not address this condition. Scalloping of the tongue is 70% predictive of OSA as shown in Figure 3. Normal breathing is through the nose. Air drawn through the nose is filtered, moistened, heated, and combined with nitric oxide (a gas concentrated primarily in the maxillary sinuses that has antibiotic and antifungal properties). Proper nasal breathing helps prevent upper respiratory infections.4 Literature demonstrates that the two biggest factors in success with oral appliance therapy for OSA are body mass index (BMI) and nasal airway resistance.5 Diet and exercise are most often addressed, but the second biggest factor is often overlooked. Nasal obstruction can be as simple as narrow or collapsed nares. The Clinical consensus statement, published in the Journal of Otolaryngology-Head and Neck Surgery in 2010, established Nasal Valve Collapse as a diagnosable condition with specific treatment options for it.6 Obstructions of the flow of air through the internal nose can be as simple as soft tissue hypertrophy from food sensitivity or allergies. This is because the nasal structures are lined with erectile tissue and, therefore, are directly sensitized by irritants.7 Nasal obstruction can be due to underdevelopment of the skeletal structures or excessive development such as conchae bullosa, which can compress the uncinate process thus blocking maxillary sinus drainage (Figure 5). Nasal obstruction contributes to OSA and needs proper diagnosis for appropriate surgery.8 Lymphatic tissue obstruction such as adenoids and tonsils is a major airway obstruction in children and adults. A study published in the October 2014 edition of the American Journal of Orthodontics and Dentofacial Orthopedics (AJO-DO) demonstrated that CBCT was as accurate Volume 6 Number 2

Figure 4A

Figure 4B

Figure 4C

Figure 4D

CONTINUING EDUCATION

Figure 3: Tongue retracting on opening

Figure 5

Figure 6 Orthodontic practice 47

CONTINUING EDUCATION as nasoendoscopy for adenoid and tonsil evaluation.9 CBCT has the answers to identifying these problems and when we, as dentists, need to work with other specialists for optimal treatment success. The American Dental Association (ADA) recently published a recommendation that when CBCT is utilized, that the entire head be imaged to prevent missing incidental findings.10 The most frequent incidental findings are nasal and sinus related. This is extremely important as CBCT is used for TMD, implant, and orthodontic therapy without review of breathing disorders that likely affect the therapy and can be the origin. The Orofacial Pain Prospective Evaluation and Risk Assessment (OPPERA) study (NIH funded)

compared two large groups of TMD and OSA patients and determined that OSA symptoms preceded first-onset TMD.11 Research in addition to Dr. Harvold demonstrated in the orthodontic literature 30 years ago that blocking nasal breathing results in open bite as the tongue pushes forward to

maintain an airway.12, 13, 14 Current research demonstrates a continued need to understand why we see relapse even with our surgical patients.15 This is demonstrated in Figures 7-11 below in a 19-year-old male post-orthodontic therapy with retention.

Figure 7

Figure 8

Figure 9: Narrow oro-pharyngeal airway

Figure 10: Tx STUDIOâ&#x201E;˘ (i-CAT, Imaging Sciences International) software allows for quantifying nasal volume

Figure 11: Total nasal obstruction soft tissue hypertrophy of middle and inferior turbinates

Figure 12: Diastemas developed as the tongue pushed the retained anteriors

Figure 13: Notice fractured molar due to bruxism 48 Orthodontic practice

Figure 14: Elongated styloid processes (i-CAT image) demonstrating a long-standing motor activity of the mandible, likely the result of maintaining a patent airway16,17,18 Volume 6 Number 2

the efficacy of oral appliance design in the management of obstructive sleep apnoea. Eur J Orthod. 2011;33(3):318-324.

Morphologic response to changes in neuromuscular patterns experimentally induced by altered modes of respiration. Am J Orthod. 1984;85(2):115-124.

Vroegop AV, Vanderveken OM, Boudewyns AN, Scholman J, Saldien V, Wouters K, Braem MJ, Van de Heyning PH, Hamans E. Drug-induced sleep endoscopy in sleep-disordered breathing: report on 1249 cases. Laryngoscope. 2014;124(3):797-802.

14. Miller AJ, Vargervik K, Chierici G. Experimentally induced neuromuscular changes during and after nasal airway obstruction. Am J Orthod. 1984;85(5):385-392.

Weiss TM, Atanasov S, Calhoun KH. The association of tongue scalloping with obstructive sleep apnea and related sleep pathology. Otolaryngol Head Neck Surg. 2005;133(6):966-971.

Gupta N, Goel N, Kumar R. Correlation of exhaled nitric oxide, nasal nitric oxide and atopic status: A crosssectional study in bronchial asthma and allergic rhinitis. Lung India. 2014;31(4):342-347.

Zeng B, Ng AT, Qian J, Petocz P, Darendeliler MA, Cistulli PA. Influence of nasal resistance on oral appliance treatment outcome in obstructive sleep apnea. Sleep. 2008;31(4):543-547.

Rhee JS, Weaver EM, Park SS, Baker SR, Hilger PA, Kriet JD, Murakami C, Senior BA, Rosenfeld RM, DiVittorio D. Clinical consensus statement: Diagnosis and management of nasal valve compromise. Otolaryngol Head Neck Surg. 2010;143(1):48-59.

Eccles R. Sympathetic control of nasal erectile tissue. Eur J Respir Dis Suppl. 1983;128 (Pt 1):150-4.

Michels DS, Rodrigues AM, Nakanishi M, Sampaio AL, Venosa AR. Nasal involvement in obstructive sleep apnea syndrome. Int J Otolaryngol. 2014. 2014:717419. doi: 10.1155/2014/717419. Epub 2014 Nov 20.

Major MP, Witmans M, El-Hakim H, Major PW. Flores-Mir C. Agreement between cone-beam computed tomography and nasoendoscopy evaluations of adenoid hypertrophy. Am J Orthod Dentofacial Orthop. 2014:146(4):451-459.

10. Edwards R, Altalibi M, Flores-Mir C. The frequency and nature of incidental findings in cone-beam computed tomographic scans of the head and neck region: a systematic review. J Am Dent Assoc. 2013;144(2):161-170. 11. Sanders AE, Essick GK, Fillingim R, Knott C, Ohrbach R, Greenspan JD, Diatchenko L, Maixner W, Dubner R, Bair E, Miller VE, Slade GD. Sleep apnea symptoms and risk of temporomandibular disorder: OPPERA cohort. J Dent Res. 2013;92(7 suppl):70S-7S.

REFERENCES

12. Harvold E, Tomer BS, Vargervik K, Chierici G. Primate experiments on oral respiration. Am J Orthod. 1981;79(4):359-372.

13. Vargervik K, Miller AJ, ChiericiG, Harvold E, Tomer BS.

Ahrens A, McGrath C, Hägg U. A systematic review of

Volume 6 Number 2

15. Porciúncula GM, Koerich L, Eidson L, Gandini Junior LG, Gonçalves JR. Can cone-beam computed tomography superimposition help orthodontists better understand relapse in surgical patients? Am J Orthod Dentofacial Orthop. 2014;146(5):641-654. 16. Schames SE, Schames J, Schames M, Chagall-Gungur SS. Sleep bruxism, an autonomic self-regulating response by triggering the trigeminal cardiac reflex. J Calif Dent Assoc. 2012;40(8):670-671, 674-676. 17. Simmons JH. Neurology of sleep and sleep-related breathing disorders and their relationships to sleep bruxism. J Calif Dent Assoc. 2012;40(2):159-167. 18. Ohayon MM, Li KK, Guilleminault C. Risk factors for sleep bruxism in the general population. Chest. 2001;119(1):53-61. 19. Gagnon Y, Mayer P, Morisson F, Rompré PH, Lavigne GJ. Aggravation of respiratory disturbances by the use of an occlusal splint in apneic patients: a pilot study. Int J Prosthodont. 2004;17(4):447-453. 20. Nikolopoulou M, Ahlberg J, Visscher CM, Hamburger HL, Naeije M, Lobbezoo F. Effects of occlusal stabilization splints on obstructive sleep apnea: a randomized controlled trial. J Orofac Pain. 2013;27(3):199-205. 21. Gunaratnam K, Taylor B, Curtis B, Cistulli P. Obstructive sleep apnoea and periodontitis: a novel association? Sleep Breath. 2009;13(3):233-239. 22. Nizam N, Basoglu OK, Tasbakan MS, Nalbantsoy A, Buduneli N. Salivary Cytokines and the Association Between Obstructive Sleep Apnea Syndrome and Periodontal Disease. J Periodontol. 2014;85(7):e251-e258. 23. Seo WH, Cho ER, Thomas RJ, An SY, Ryu JJ, Kim H, Shin C. The association between periodontitis and obstructive sleep apnea: a preliminary study. J Periodontal Res. 2013;48(4):500-506. 24. Bakor SF, Pereira JC, Frascino S, Ladalardo TC, Pignatari SS, Weckx LL. Demineralization of teeth in mouth-breathing patients undergoing maxillary expansion. Braz J Otorhinolaryngol. 2010;76(6):709-712. 25. Ashley FP, Usiskin LA, Wilson RF, Wagaiyu E. The relationship between irregularity of the incisor teeth, plaque, and gingivitis: a study in a group of schoolchildren aged 11-14 years. Eur J Orthod. 1998;20(1):65-72.

Orthodontic practice 49

CONTINUING EDUCATION

This also explains diastemas that develop as we age with the development of OSA as demonstrated with a 45-year-old female with mild OSA (AHI 7.4), 20 years post-ortho with retention (Figures 12-14). Implant failures may be related to the patient having bruxism secondary to OSA. Nightguards are frequently produced after implant restoration. Recent research has shown that if the patient has OSA, nightguards can worsen the suffocating events by 50%.19,20 The latest research demonstrates the relationship between OSA and periodontal disease (PD).21,22,23 Mouth breathing resulting in dry mouth increases the risk of caries and periodontal plaque.24,25 Every aspect of dentistry is affected by a blocked airway. Dental and medical problems overlap so frequently and manifest as symptoms in the head and neck. It is imperative to evaluate breathing from the tip of the nose to the epiglottis. Failure to evaluate all four points of obstruction and failure to establish a patent airway will affect the longevity of any dental treatment being rendered. Whether the treatment is orthodontic, prosthodontic, periodontal, or in the treatment and management of OSA, the use of CBCT imaging is a necessity. OP

PRODUCT PROFILE

American Orthodontics Empower® Dual Activation™ System One system. Multiple applications. Zero compromise.

rthodontists looking for a self ligating solution that gives them both excellent anterior control and improved posterior sliding mechanics have a unique and smart choice in the Empower® Dual Activation™ System from American Orthodontics. This single, innovative system is designed to enhance a doctor’s treatment philosophy, delivering the benefits of both interactive and passive brackets in one unified system. “It really is the best of both worlds and allows me to efficiently give my patients the great finish they deserve,” says Dr. Troy Christensen, who practices in the Phoenix, Arizona area. ”The difference I have experienced after switching to Empower Dual Activation is very impressive.” American Orthodontics pioneered the Dual Activation System with the introduction of Empower Self Ligating Brackets, the most complete self ligating bracket system in the world.* Utilizing Empower and Dual Activation brings orthodontists the time-saving benefits and ease of self ligation, while allowing them to personalize the system to their specific needs using both interactive and passive techniques. Dual Activation delivers minimized ligation forces throughout the system, with interactive brackets on anterior teeth for full control and a precise finish, and passive brackets on posterior teeth for improved freedom play. Plus, matching in/outs between interactive and passive designs means no first order wire-bending compensations. “My decision to utilize Empower’s Dual Activation really comes down to two things — better control and improved efficiency,” says Dr. N.R. Krishnaswamy of Chennai, India. “Dual Activation allows me to schedule fewer arch wire changes and fewer visits compared to other systems.” 50 Orthodontic practice

To learn more about the Empower Dual Activation System, visit www.americanortho. com/DualActivation.

About American Orthodontics

“I was amazed from the start at the positive changes Dual Activation brought my practice and how much easier it is to finish cases,” says Dr. Dan Bills of Sicklerville, New Jersey. “I don’t have to detail and bend wire the way I used to, and that’s been a huge benefit.” The Dual Activation System allows orthodontists to make the system unique to their own treatment styles with Empower’s extensive options, including multiple prescriptions, wires, hooks, and pads. “The Dual Activation System just makes sense. It’s logical. I’ve found it to be a system I can really trust to get a great, efficient finish,” says Dr. Salvador Romero of Ciudad Juárez, Mexico. “And my patients trust Dual Activation because I trust it.”

American Orthodontics is the largest privately held orthodontic manufacturer in the world, proudly based in Sheboygan, Wisconsin. Since 1968, American Orthodontics has been manufacturing quality orthodontic products and peripherals for customers in more than 100 countries. More than 90% of American Orthodontics’ products are manufactured at its Sheboygan headquarters using highly automated production equipment and a skilled, dedicated workforce. With 11 wholly owned subsidiaries, a direct sales force in North America, and a global team of exclusive distributors, American Orthodontics is a true orthodontic industry leader, committed to providing customers quality products, personalized service, and dependable delivery. OP * Based on unique part number options This information was provided by American Orthodontics.

Volume 6 Number 2

CLASS II CORRECTION SIMPLIFIED Introducing PowerScope – an innovative appliance delivering easy Class II correction like you’ve never seen before. • Quick wire-to-wire installation • Fixed one-piece design requires no lab setup or patient compliance • Internal NiTi spring delivers 260 grams of force for continuous activation during treatment • Patient-friendly design maximizes comfort

To learn more, talk to your American Orthodontics sales representative or visit americanortho.com/PowerScope

PRODUCT PROFILE

New suresmile® Aligner Design The value of precision

My practice often uses aligner therapy at the beginning and finish of treatment. Not only does suresmile® Aligner Design put me in complete control, suresmile’s pricing program has already saved us thousands of dollars. Dr. J. Peter Kierl • Edmond, Oklahoma

Designed to your treatment plan Choosing suresmile as your Treatment Management System gives you options for incorporating aligner therapy into your practice. suresmile Aligner Design is ideal for the following case types requiring moderate tooth movement: 52 Orthodontic practice

• Aligner-only treatment • Aligner treatment in conjunction with braces, either to start or finish cases • Clear retainers at the end of treatment with braces — the scan can be performed before braces are removed, eliminating an office

visit, and it can be the start of a practice retention program. Designed to fit your plan, many patients are happy to finish their treatment in aligners rather than traditional appliances. For greater convenience, suresmile Aligner Designs may be printed out by a local laboratory of your choice. Volume 6 Number 2

This case was treated with braces for 8 weeks, followed by four sets of aligners. In finishing this case, we used a series of aligner designs printed by our local laboratory. We find that our patients are always happy to get August 2013 — Initial intraoral out of braces sooner, and we are pleased with the consistency of finish.

November 2013 — Planned result

January 2014 — Posttreatment

Case No. 2 This case was treated with 6 sets of aligners.

April 2014 — Initial intraoral

May 2014 — Planned result

August 2014 — Posttreatment

Case No. 3 This case was treated with 5 sets of aligners.

December 2013 — Initial intraoral

January 2014 — Planned result

April 2014 — Posttreatment

The suresmile Aligner Design Program

Also exclusively available is a Diagnostic digital model ($45/model) with the following features: • 3D Viewing Tools — 12 views • Automated Analytics — Bolton, arch width, quality grading • Simulations — alternative treatment plans • Communication — patients, referring doctors

Stay informed!

This program offers $350/month service access, support and maintenance fee (fee waived in any month during which caserelated purchases meet or exceed $350 or the amount equal to $350 minus caserelated purchases is charged as the fee for that month) + $300/case (including one therapeutic model and one setup).

Volume 6 Number 2

Sign up for the next suresmile webinar on aligners in 2015, and learn how your colleagues are successfully implementing suresmile Aligner Design into their practices. To register or for more information, call suresmile at 877-787-7645. OP

This information was provided by suresmile.

Orthodontic practice 53

PRODUCT PROFILE

Case No.1

PRODUCT PROFILE

GUARDIAN® Invisible Retainer System James Bonham explains the benefits of a long-term retention plan by Specialty Appliances

ooking for a better way to retain the beautiful smiles that you work so hard to create? The GUARDIAN® Invisible Retainer System is the most efficient way to protect your patients’ smiles for a lifetime. Specialty Appliances leverages advanced digital technology to produce precision fit clear retainers that incorporate many neverbefore-seen benefits. For example, GUARDIAN includes digital bracket removal. This enables retainer delivery at the patient’s debonding appointment, saving valuable time and money. Other benefits include integrated anterior refinement, coordinated fixed lingual retainers, and imbedded pontics. Improve your practice efficiency, increase profitability, and upgrade your long-term smile retention plan with GUARDIAN. Let’s face it; orthodontic patients will lose or break their retainers. The best way to prevent orthodontic relapse is to provide backup retainers. The GUARDIAN retention system includes multiple clear retainers and a 3D printed model. Many practices use the printed model to create additional retainers in their office, without the need for new impressions. As long as there has been no major dental change, you can produce a lifetime of retainers from the provided 3D printed model. You may also contact Specialty Appliances for new models or retainers. Driven by advanced technology, the GUARDIAN retention system offers many efficient features to save you time and money, eliminate appointments, reduce chair time, and help patients get out of braces sooner. Let’s review a few features and benefits.

James Bonham is a partner at Specialty Appliances and manages Sales and Marketing. He has spent the past 12 years in orthodontics with a strong focus on the integration of digital technology into orthodontic practices.

Digital bracket removal (no additional charge) One appointment prior to the debonding, take impressions or a digital scan while brackets are still in place. Specialty will digitize the models and virtually remove the brackets. The 3D models are then printed, and multiple GUARDIAN retainers are fabricated. Deliver the retainers immediately after removing braces, eliminating the standard retainer appointment.

Minor anterior refinement (only $20 per arch) Upon request, Specialty will integrate minor anterior refinement into your GUARDIAN retainers. Using sophisticated digital software, Specialty will add up to .25 mm of correction before printing the 3D model. If more anterior movement is required, Clear Image® Aligners are a great option prior to GUARDIAN retainers.

Guardian reset occlusal view

Other enhancements Specialty can also integrate tooth shade pontics and coordinated fixed lingual retainers (FLRs) into your retainers. FLRs are delivered with indirect bonding trays for efficiency and precision placement. The GUARDIAN invisible retainer then fits perfectly over the FLR. Specialty Appliances is forever committed to providing innovative and affordable orthodontic solutions to meet your practice needs. Contact us today for more information on the GUARDIAN Retention System. Patient education brochures are available upon request. Please visit our website at specialtyappliances.com for additional product information. OP This information was provided by Specialty Appliances.

54 Orthodontic practice

Digital bracket removal

Guardian retainers Volume 6 Number 2

M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT American Orthodontics launches new Luno™ instruments American Orthodontics has launched its new Luno™ orthodontic instrument line. Each Luno instrument is crafted from the highest quality American-forged steel to prevent corrosion, is hand-tested far beyond industry standards for quality, and delivers dependable performance and superior precision. The Luno design team developed each cutter, bender, and specialty plier with precision joints and high-density tool steel inserted blades to ensure a durable cutting surface. Luno instruments feature a signature, two-tone finish, making them instantly recognizable, and an ergonomic design provides optimum comfort. Each instrument is laser marked with applicable wire sizes, ensuring the right instrument for the right job. All Luno instruments also come with a 10-year warranty. American Orthodontics is the largest privately held orthodontic manufacturer in the world, proudly based in Sheboygan, Wisconsin. Since 1968, American Orthodontics has been manufacturing quality orthodontic products and peripherals for customers in more than 100 countries. More than 95% of American Orthodontics’ products are manufactured at its Sheboygan headquarters using highly automated production equipment and a skilled, dedicated workforce. Learn more about Luno by visiting americanortho.com/Luno.

TP Orthodontics sets a new standard for ceramic bracket design TP Orthodontics has introduced ClearVu® Cosmetic Brackets, the latest addition to their comprehensive line of esthetic solutions. With ClearVu Cosmetic Brackets, TPO® brings together a doctortrusted design and Personalized Color-Matching Technology® to deliver a ceramic bracket that will meet patient demand without compromising treatment plans. Personalized Color-Matching Technology, only available from TP Orthodontics, produces optical properties that allow ClearVu Cosmetic Brackets to blend with almost any tooth color — even being undetectable in photos. Non-staining ceramic material ensures an esthetically pleasing look throughout the course of treatment. The patented polymer base sets ClearVu Cosmetic Brackets apart from the others. The flexible polymer material provides a protective barrier between the ceramic bracket and the enamel, making debonding safe and comfortable for patients. Since the base flexes upon debonding, the bracket removes cleanly without the need to fracture the bracket or rely on special tools. The true-twin design of ClearVu Cosmetic Brackets offers multiple ligation options, while ball-end hooks allow for easy and secure placement of elastics. These brackets are also available with Readi-Base® eXact® Pre-Applied Adhesive. In addition to its manufacturing plant and headquarters in La Porte, Indiana, TPO, an ISO-certified manufacturer and provider of premier orthodontic services and products, maintains distribution centers throughout Mexico, Europe, Australia, South Africa, South America, Japan, and China. To learn more about ClearVu Cosmetic Brackets or other esthetic treatment solutions from TP Orthodontics, visit tportho.com, or call 800-348-8856.

Planmeca rolls out cloud service product

OrthoEssentials announces the addition of Bio-Chain to its product offering

Bio-Chain is more rubber-like and will outlast and outperform standard chain elastics. Bio-Chain remains active over a longer period of time and demonstrates superior rebound qualities. It is available in clear and gray and in all three filaments. For more details, email info@orthoessentials.net, or call 866-517-3247 or 215-396-3803.

Volume 6 Number 2

Dental equipment manufacturer Planmeca Oy developed Planmeca Romexis® software as an open architecture platform, making it compatible with most software operating systems and dental equipment. Now, Planmeca has taken this technology to a new level with Planmeca Romexis Cloud service, which works with Planmeca Romexis software so dentists can access and share diagnostic images from any imaging unit. This information is then accessible on most digital platforms, including mobile-, Mac-, and Windows-based operating systems, and can be stored for up to 14 days. Planmeca Romexis Cloud service lets dental professionals communicate with colleagues and transfer images and key case information securely, quickly, and seamlessly. This brings new possibilities to the dental practice, such as providing access to specialists from remote general practitioners, giving rural dentists the same referral base as any dentist in a large metropolitan area. Other features of the Planmeca Romexis Cloud service include: • All treatment plan elements are automatically added, including annotations and measurements. • Virtual patient cases include 2D X-ray images and photos, CBCT volumes, and 3D photos. • Images and reports are easily shared with patients. For more information, visit http://www.planmecausa.com.

Orthodontic practice 55

INDUSTRY NEWS ORTHOEVOLVE acquires OrthoUniversity.com ORTHOEVOLVE, conceived by Dr. Tom Pitts, is a series of comprehensive orthodontic education programs. These courses are held in a variety of different domestic and international cities year-round. In an effort to expand and further their educational services, ORTHOEVOLVE has acquired OrthoUniversity.com. OrthoUniversity.com or OrthoU.com is an online resource dedicated to providing orthodontic professionals a space to share orthodontic education and information among peers. OrthoUniversity.com has full social networking capabilities, classifieds, upcoming seminar and event info, and other education resources, including video and white papers. “We believe acquiring OrthoU.com creates a new set of opportunities for us to educate and communicate with our group members on a continued and personal one-on-one basis,” said ORTHOEVOLVE founder, Dr. Tom Pitts. “Participants will now have the ability to continue to ask questions and learn, long after the course is over.” To receive further information about ORTHOEVOLVE, its instructors, and upcoming courses, visit www.orthoevolve.com.

Henry Schein® Orthodontics announces 2015 course dates for the first-of-its-kind Soft Tissue Orthodontics™ course taught by Dr. Scott Frey BOTOX®, Xeomin®, and Dysport® (also known as neuromodulators) are emerging as therapeutic and cosmetic orthodontic treatment modalities. Designed specifically for orthodontists, this course will teach revolutionary techniques and tools to affect the soft tissues in orthodontic diagnosis and treatment using neuromodulators, allowing the doctor to take command of soft tissues and deliver exceptional treatment outcomes. Courses will be offered on the following dates: April 24-25, 2015 Warrendale, Pennsylvania September 11-12, 2015 Seattle, Washington October 23-24, 2015 Waltham, Massachusetts For more information, visit http://softtissueorthodontist.com.

The International 3D Congress on Dental Imaging — Go 3D: Your Story Starts Here The International 3D Congress on Dental Imaging is a unique 2-day experience filled with lectures and demonstrations of reallife applications of 3D imaging in dentistry. This event will take place on April 17-18 at the Dallas Marriott City Center in Dallas, Texas. Attendees will get perspectives from knowledgeable industry experts and network with colleagues. This program provides tips and best practices on how to be a 3D dentist and why this technology will help clinicians to be successful in today’s dental industry. The event provides 12 CE credits. Use promo code OP 2015 to save $150! For information, visit http://www.i-cat.com/events/congress.

56 Orthodontic practice

OrthoAccel® Technologies, Inc., secures $5 million equity financing to continue rapid growth OrthoAccel® Technologies, Inc., has closed on a $5 million equity financing. OrthoAccel Technologies, manufacturer of AcceleDent®, the first and only noninvasive FDA-cleared, Class II medical device that speeds up orthodontic treatment by as much as 50%, continues to raise capital to expand its sales force and support its rapid, dynamic growth. This financing announcement, which coincides with a public filing with the Securities and Exchange Commission, comes as AcceleDent is now available in more than 2,000 orthodontic locations in the United States. For more information, visit AcceleDent.com/orthodontists, or call 866-866-4919.

3M Unitek provides a grant to Pretend City Children’s Museum Together with the 3M Foundation, 3M Unitek has provided a grant to Pretend City Children’s Museum located in Irvine, California to revitalize and redesign their Dental Office Exhibit. The Dental Exhibit allows children to play with dental and orthodontic equipment in order to foster a curiosity and understanding about the importance of visiting the dentist and maintaining good habits between visits. Aimed at sparking excitement about the orthodontic journey, the exhibit also includes a 3M™ Paint Your Smile kiosk — which allows children to upload a photo of themselves and virtually try on Clarity™ ADVANCED Ceramic Brackets from 3M Unitek and experiment with different colored ligatures that really “pop.” Seeing first-hand what braces would look like helps with treatment acceptance and builds excitement for that first appointment. Orthodontists can access the tool with their own patients at www. paintyoursmile.com.

DEXIS™ and TeamSmile demonstrate teamwork in bringing dental care to underserved children Since the inception of the TeamSmile program in 2007, DEXIS has been a proud supporter through its donation and maintenance of its digital imaging systems, DEXIS™ Platinum sensors, CariVu™ caries detection, and DEXcam™ intraoral cameras, as well as financial contributions. TeamSmile partners with dental professionals and athletic organizations to bring together athletic role models and underserved children in communities across the country at events held year-round. These events allow children to obtain free screening and treatment and also learn about the importance of their overall health. DEXIS has rededicated efforts to assist TeamSmile with company volunteers, on-site systems, and funding. TeamSmile’s partnering with professional sports organizations develops bonds between children’s organizations, oral health professionals, surrounding communities, and the athletes that solidify this message: Oral health care is vitally important to longterm health. This experience teaches children that the mouth and body are linked for overall health. They also receive free oral health education, screening, and treatment. For more information about DEXIS, visit www.dexis.com.

Volume 6 Number 2

Can You See

Who’s Wearing Braces? (Your patients can’t see them either)

“I loved my Damon™ Clear braces…people didn’t even know that I had anything on my teeth. I now feel comfortable knowing my teeth look great.” — Christine, Damon Clear patient

Damon patients treated by Dr. Todd Bovenizer.

Introducing the 100% Clear SL bracket with 2x the rotational control* for meticulous finishing and efficient treatment. An aesthetic solution for image-conscious adults and teens, Damon Clear provides the performance and control needed to treat a wide variety of cases with exceptional results.

Order your Damon Clear2 brackets today! Visit www.ormco.com Visit Ormco Booth 1119 at the AAO Annual Session. *As compared to Damon Clear, data on file. Standard torque, upper 3-3 brackets.

CS 3500

NO impression material

NO trolley

NO focusing on the screen NO limitations

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

Enter the new reality at carestreamdental.com/cs3500ortho or call 800.944.6365 © Carestream Health, Inc. 2015. 12097 OR CS 3500 AD 0215