Orthodontic Practice US - May/June 2015 - Vol6.3 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews May/June 2015 – Vol 6 No 3

Improving alignment by modulating archwire force Drs. George F. Schudy and Larry White

BioDigital Orthodontics part 15 Drs. Rohit C.L. Sachdeva, Takao Kubota, and Kazuo Hayashi

Corporate profile OrthoAccel® Technologies, Inc.

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Drs. Moshood B. Martins, Daniel Rinchuse, Lauren S. Busch, Anthony L. Farrow, and Thomas Zullo

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Current perception of optimal lip protrusion among African American laypersons

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PROPELLING ORTHODONTICS

The impact of integrating Acceleration Technology into your practice Dr. Lou Shuman discusses the benefits of Ortho Acceleration

rthodontic Acceleration is on the threshold of forever changing how orthodontics is provided. The benefits of acceleration far outweigh any perceived barriers, and soon the consumer population will demand it as part of standard orthodontic care, as was the case with Invisalign®. The clinical literature demonstrating the efficacy of micro-osteoperforation abounds (for Propel clinical articles and case studies go to www.propelorthodontics.com), as well as studies that show patients are interested in accelerated treatment and willing to pay extra for reduced treatment time.1 This month’s column moves in a different direction — first, a personal opinion on Propel technology and then practice management tools that can accelerate practice growth in addition to clinical acceleration. To start, what sets Propel apart as the most viable Accelerated Orthodontic option? • It is doctor controlled and NOT patient controlled. • That means you have a significantly better chance of more predictable results and promised time outcomes. • It has the ability to target difficult movements and treat just one arch, which is critical for those with adult patients. • As an orthodontist specializing in adults for many years, lower adult onset crowding was the single most common case I treated. After reviewing other orthodontic acceleration systems, I have difficulty accepting

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•

technologies that impact the entire dentition when the treatment plan calls for treating only one arch. Many times, it only takes one visit or application to provide 3-6 months of acceleration. This is far more efficient than relying on patients to be compliant on a daily basis and, in many cases, while also attempting to be compliant with aligner wear simultaneously.

•

It is by far the most cost-effective treatment available today2 with pricing as low as $100 per patient. Similar to all Acceleration Technologies, your gross production per hour can easily double. Your annual production is significantly increased as you have more open chair time for new patients by finishing cases so much faster.

Lou Shuman, DMD, CAGS, is the President of Pride Institute, a renowned practice management institute, and is personally known for his expertise in Internet strategy, emerging technologies, e-learning applications, and digital marketing methods. Highly respected in the dental corporate and education community, he is an executive consultant for KavoKerr Group (KKG), Propel Orthodontics, WEO Media, Zquiet, DEXIS, i-CAT, Pelton Crane, HR for Health, and Implant Direct. He is the Chairman of the Technology Advisory Board for WEO Media and is also on the Clinical Advisory and Editorial Boards at Orthodontic Practice US, Dentistry Today, Dental Products Report, Dental Practice Report, The Progressive Dentist, and Seattle Sleep Education LLC. He is the managing editor of Dental Sleep Practice journal and the only dentist who has been selected both as a “Top CE Leader in Dentistry” and a “Leader in Dental Consulting” by Dentistry Today magazine. Dr. Gordon Christensen cited him as “one of the most influential dentists in the country today.” Prior to becoming President of Pride Institute, Dr. Shuman served as Vice President of Clinical Education and Strategic Relations at Align Technology for 7 years. During that time, he was responsible for the clinical creation of Orthodontic and GP clinical programs, was the professional and clinical lead on multiple concept development projects, including the creation of Vivera retainers, and integrated the Invisalign technique into orthodontic and dental school curriculums throughout North America. He is the past owner of a 10-doctor private group practice where he specialized in Adult Orthodontics. He received his Certificate in Advanced Graduate Studies in Orthodontics from Dr. Anthony Gianelly at the Henry M. Goldman Boston University School of Dental Medicine.

38 Orthodontic practice

Volume 6 Number 3

Learn about practice management tools that can accelerate practice growth in our featured article “The impact of integrating Acceleration Technology into your practice” written by Dr. Lou Shuman on page 46 of this issue.

Propel Orthodontics ——

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Connect with Propel at AAO Booth #3007 Learn from leading practitioners about the latest, most innovative technique in orthodontics during a complimentary lecture series. Accelerated Tooth Movement with Braces or Aligners Saturday, May 16 at 11 am | Thomas Shipley, DMD

The Impact of Integrating Acceleration into Your Practice Sunday, May 17 at 11 am | Lou Shuman, DMD, CAGS

Gaining Confidence in Micro-Osteoperforation Monday, May 18 at 11 am | John Pobanz, DMD

Enter to win an Apple Watch AAO attendees can enter the giveaway to win 1 of 3 Apple Watches by stopping by the Propel booth on Saturday, Sunday or Monday.

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INTRODUCTION

Seeking the high-fidelity occlusion

he armamentarium of the orthodontist has changed dramatically in the past several decades — from pre-formed stainless steel arches to nickel titanium and its many variations and from banded to direct-bonded to self-ligating appliances. I’m sure you can think of many other transitions. Today, our society is in the midst of what can be called nothing less than the digital revolution. From newspapers to cooking utensils, everything is available digitally. Digital orthodontics is very much a part of this change in the way we do things. Dr. J. Peter Kierl This has been observed often in the pages of this journal and put into practice every day in virtually (the next generation of orthodontics?) every office, whether acknowledged or not. Almost certainly, your scheduling is maintained on your office’s computer. And, in most practices, X-rays are digital, as is patient photography. This comes as no great revelation. Still, the day-to-day practice of orthodontics is generally a hand-eye proposition. It is also true that, with every passing day, digital orthodontics is very much here and producing superior results in practices globally, in spite of the fact that many of us have been hesitant to adopt it across our entire practice. Why? Because, in a word, it is change at a level never before experienced since the possibility of improving an individual’s occlusion was first considered. Straightening teeth is now as much a matter of pixels and the cloud as it is of mechanics and force. Digital treatment of patients — from case planning to wire staging to communications — is here today and even more so tomorrow, as technologies become, at once, more sophisticated and affordable. Perhaps the greatest shift in the practice of orthodontics brought on by the digital revolution is proactive rather than reactive treatment. In the pre-digital practice modality, we bonded (or banded) the patient; placed a low-force, leveling archwire; waited, watched, and reacted; and kept reacting until we reached a satisfactory result. In the digital practice, the role of treatment planning takes preeminence, providing us with the opportunity to plan the final occlusion using specific tooth-by-tooth movement. In the old model, we basically knew where we wanted to go with each patient and worked to get there. In the digital model, we can analyze the patient’s malocclusion, specifically design its treatment, and achieve it. As an orthodontist, this not only gives us a new level of diagnostic sophistication, but also empowers us to see the future and contour it to our ideal goal. When high fidelity (hi-fi) came to record players, it just sounded better. Listening expectations only grew as we learned to hear recorded (now mostly digital) music differently. The same shift in how we approach the occlusion is happening for us today. There is nothing more gratifying than being able to show patients my plan for their occlusion, knowing that I possess the clinical skills and tools to achieve that specific occlusion, not to mention with greater efficiency than ever before. The high-fidelity occlusion means happier smiles all around. That’s what the digital revolution makes possible, achieving the optimal result for each and every patient. Dr. J. Peter Kierl

May/June 2015 - Volume 6 Number 3 EDITORIAL ADVISORS Lisa Alvetro, DDS, MSD Daniel Bills, DMD, MS Robert E. Binder, DMD S. Jay Bowman, DMD, MSD Stanley Braun, DDS, MME, FACD Gary P. Brigham, DDS, MSD George J. Cisneros, DMD, MMSc Jason B. Cope, DDS, PhD Neil Counihan, BDS, CERT Orth Eric R. Gheewalla, DMD, BS Dan Grauer, DDS, Morth, MS Mark G. Hans, DDS, MSD William (Bill) Harrell, Jr, DMD John L. Hayes, DMD, MBA Paul Humber, BDS, LDS RCS, DipMCS Laurence Jerrold, DDS, JD, ABO Chung H. Kau, BDS, MScD, MBA, PhD, MOrth, FDS, FFD, FAMS Marc S. Lemchen, DDS Edward Y. Lin, DDS, MS Thomas J. Marcel, DDS Andrew McCance, BDS, PhD, MSc, FDSRCPS, MOrth RCS, DOrth RCS Mark W. McDonough, DMD Randall C. Moles, DDS, MS Elliott M. Moskowitz, DDS, MSd, CDE Atif Qureshi, BDS Rohit C.L. Sachdeva, BDS, M.dentSc Gerald S. Samson, DDS Margherita Santoro, DDS Shalin R. Shah, DMD (Abstract Editor) Lou Shuman, DMD, CAGS Scott A. Soderquist, DDS, MS Robert L. Vanarsdall, Jr, DDS John Voudouris (Hon) DDS, DOrth, MScD Neil M. Warshawsky, DDS, MS, PC John White, DDS, MSD Larry W. White, DDS, MSD, FACD CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day BDS, VT Julian English BA (Hons), editorial director FMC Dr. Paul Langmaid CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-in-chief Private Dentistry Dr. Chris Potts BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon

PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com 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 CREATIVE DIRECTOR/PRODUCTION MANAGER | Amanda Culver Email: amanda@medmarkaz.com FRONT OFFICE MANAGER | Theresa Jones Email: tjones@medmarkaz.com

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J. Peter Kierl, DDS, MS, graduated from the University of Oklahoma College of Dentistry, completed his orthodontic residency at the University of Iowa, and received his master’s degree in Orthodontic Sciences. He has been in private practice for more than 33 years in Edmond, Oklahoma. He has been a clinical professor in the Graduate Clinic in the Department of Orthodontics at the University of Oklahoma College of Dentistry since 1982. He achieved his certification with the American Board of Orthodontics in 1993. Dr. Kierl has been a 100% suresmile® practice since July 2006. He has completed more than 3,000 suresmile cases and more than 250 lingual cases using the suresmile system.

2 Orthodontic practice

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© FMC 2015. All rights reserved. FMC is part of the specialist publishing group Springer Science+Business Media. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Orthodontic Practice US or the publisher.

Volume 6 Number 3

Differentiate your practice, Educateandyour patients Grow! “Damon™ Clear2 has helped to differentiate my practice. My patients could not be happier with the brackets’ transparency and their results. Now with My Smile Consult™, I have a powerful education tool to make my consultations even more effective.” — Dr. Todd Bovenizer

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Introducing Ormco’s interactive consultation tool, designed to educate patients and increase case starts! • 25+ videos and numerous photos • For use before, during and/or after the consultation • Customizable with your practice branding, patient photos and patient testimonials • Free service for orthodontists treating with the Damon™ System

TABLE OF CONTENTS

Corporate profile OrthoAccel Technologies, Inc. ®

Orthodontist’s viewpoint Take only CBCTs on these types of orthodontic cases Dr. Jack Fisher discusses 10 reasons to use 3D imaging........................... 20

Eyeing significant market growth opportunities

Orthodontic concepts BioDigital Orthodontics Management of patients with transverse (midline) discrepancies (2): part 15 Drs. Rohit C.L. Sachdeva, Takao Kubota, and Kazuo Hayashi discuss how to plan care based upon an in-depth diagnosis and design therapeutics....................................28

Propelling orthodontics The impact of integrating Acceleration Technology into your practice Dr. Lou Shuman discusses the benefits of Ortho Acceleration..........46

Case study

The Baxmann Mini Telescope™ (BMT) in practical testing

Dr. Martin Baxmann discusses an apparatus for Class II treatment

ON THE COVER Cover photo courtesy of Dr. Jack Fisher. Article begins on page 20.

4 Orthodontic practice

Volume 6 Number 3

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TABLE OF CONTENTS

Continuing education Improving alignment by modulating archwire force Drs. George F. Schudy and Larry White explore acceleration of tooth movement.......................................53

Continuing education AAO preview................59

Current perception of optimal lip protrusion among African American laypersons

Drs. Moshood B. Martins, Daniel Rinchuse, Lauren S. Busch, Anthony L. Farrow, and Thomas Zullo discuss the subtle differences in people’s esthetic preferences

Laboratory link Digital impression scanning — improving workflow and the orthodontic experience James Bonham discusses how the modern laboratory can benefit the patient and the practice................... 68

In focus Focus Ortho — Software that adapts to you................................ 72

Technology Clear Collection instruments for clear aligner treatments In part 1 of a series, Dr. S. Jay Bowman explores instruments that help increase the utility of aligners and expand the scope of appropriate applications.....................................74

6 Orthodontic practice

Security guards

Product profile

Your data: (Relatively) convenient ways to keep it safe and secure Dr. Mark S. Sanchez offers practical steps to keeping your private and professional information from the ne’er-do-wells..................................79

Objet30 OrthoDesk: digital orthodontics from your desktop..........................................84

Product profile American Orthodontics PowerScope™ Class II Corrector Innovative, effective Class II correction ....................................................... 82

Industry news...............86 Materials & equipment.........................86

Volume 6 Number 3

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CORPORATE PROFILE

OrthoAccel® Technologies, Inc. Eyeing significant market growth opportunities

aster orthodontic treatment has always been patients’ number one request. According to a recent American Journal of Orthodontics and Dentofacial Orthopedics survey, orthodontists acknowledge that if they can reduce treatment time by 20% to 40%, then alternative techniques to accelerate tooth movement are attractive to them as well.1 The results are an evergrowing population of patients who want faster treatment and forward-thinking orthodontists who enthusiastically want to offer an accelerated option. It’s no coincidence that in the orthodontic industry, OrthoAccel® Technologies, Inc., is gaining rapid market share with AcceleDent®, an FDA-cleared, prescription-only Class II medical device that has proven to shorten orthodontic treatment by as much as 50%. With this safe and gentle treatment option, orthodontic patients simply use AcceleDent for 20 minutes a day while SoftPulse Technology® accelerates their tooth movement. AcceleDent, the Leader in Accelerated Orthodontics™, is the first and only noninvasive technique that speeds orthodontic treatment. Since the company’s introduction to the U.S. market in 2012, AcceleDent is now offered in more than 2,300 provider locations throughout North America — and that number is growing daily. A recent Journal of Clinical Orthodontics’ survey underscores the company’s dynamic growth, stating that AcceleDent is the most common accelerated treatment technique used by orthodontists. In the survey, 62% of practices that use accelerated treatment reported that they occasionally or routinely use AcceleDent.2 Parallel to these reports and trends is OrthoAccel Technologies’ own story as a young startup company with an innovative new product — one many consider to be the first major orthodontic innovation in more than 15 years. OrthoAccel has experienced extreme growth each of the past 3 years, reporting an 80% increase in sales in 2014. The company’s progress has continued to impress investors, and in January 2015, OrthoAccel continued its recent transition to a blended debt and 10 Orthodontic practice

AcceleDent is fast, safe, and gentle, and clinically proven to accelerate tooth movement up to 50%

President and CEO Mike Lowe displays OrthoAccel Technologies’ Silver Stevie for American Business Awards best new health and pharmaceutical product of the year

equity capitalization, consistent with its maturing operations. “Our stockholders and equity partners remain enthusiastic about our rapid market growth and what we’ve been able to accomplish in the U.S. and Canada in 3 short years,” said Mike Lowe, OrthoAccel’s president and CEO. “AcceleDent is the first to market in the category of non-invasive accelerated

orthodontic treatment techniques, so it’s up to us to continue educating orthodontists and consumers about the value of accelerated treatment while also continuing to push the envelope in the area of innovation.” A simple-to-use, hands-free device, AcceleDent has received numerous accolades and awards in the category of best new consumer products. The device was Volume 6 Number 3

Growth milestones — industry and consumer

OrthoAccel Technologies’ President and CEO Mike Lowe is honored as one of Houston’s best and brightest young professionals at Houston Business Journal’s 40 Under 40 Awards.

Volume 6 Number 3

Lowe, who was named a Houston Business Journal “40 Under 40” honoree for his impressive contributions to the orthodontic industry and to Houston’s medical technology sector, attributes OrthoAccel’s business success to two factors: industry acceptance and consumer awareness. “Our goal as a company is to improve patients’ journeys to healthy, beautiful smiles, and we believe that is a goal we share with every orthodontist,” said Lowe. “That’s why AcceleDent was integrated into more than 500 additional practices in 2014 alone.” Lowe adds that industry acceptance is steadily increasing in part because leading orthodontists continue to share compelling AcceleDent patient case studies with their peers. Many of these orthodontists have adopted AcceleDent as standard of care in their practices. For example, Dr. Sonia Palleck of Woodstock, Ontario, was an early adopter and has already accelerated the treatment of more than 250 patients using AcceleDent. Salt Lake City, Utah-based Dr. John Graham, one of the first AcceleDent providers in the U.S., has successfully enhanced practice economics and efficiency through the adoption of non-invasive, accelerated orthodontic treatment. “In more than a decade of practicing orthodontics, I’ve used several types of accelerated treatment options, but none compare to AcceleDent’s ability to provide faster treatment without compromising results,” said Graham. “By offering AcceleDent, I’m able to make my patients’ orthodontic experience faster and more pleasant, with many of my patients reporting less discomfort when using AcceleDent.” In a recent independent study, 100% of patients surveyed reported that AcceleDent is easy to use and that they were satisfied with their experience using the technology. The overwhelming majority of patients also said they would recommend AcceleDent to a family member or friend. “More patients are asking their orthodontists about accelerated treatment with Orthodontic practice 11

CORPORATE PROFILE

recently recognized by the American Business Awards, Good Design Awards, and Best in Biz Awards. The distinct nature of AcceleDent’s technology, as touted by these prestigious award programs, has also been solidified with the issuance of two new patents for the device’s proprietary SoftPulse Technology® by the United States Patent and Trademark Office.

CORPORATE PROFILE

“In more than a decade of practicing orthodontics, I’ve used several types of accelerated treatment options, but none compare to AcceleDent’s ability to provide faster treatment without compromising results.” – Dr. John Graham, Salt Lake City, Utah AcceleDent, and more orthodontists are eager to offer AcceleDent because of widespread, positive patient results,” said Lowe. “The momentum continues to build.” AcceleDent use has been common among adolescents and adults and is particularly appealing to adults who once avoided orthodontic treatment because of length of treatment time. Research from the American Association of Orthodontists (AAO) revealed that adults report improved lifestyles after orthodontic treatment, with 83% stating they experienced an increase in interpersonal relationships and 58% stating an improved career success.3 OrthoAccel’s marketing and sales team has found that accelerated treatment with AcceleDent is particularly appealing to 12 Orthodontic practice

patients striving toward specific milestones such as weddings, graduations, proms, vacations, and career promotions.

More growth opportunities OrthoAccel’s dynamic growth in 2014 has attracted some of the orthodontic industry’s most experienced and recognizable names, helping Lowe double his sales team and round out his senior leadership team. Lowe’s executive management team includes Kathleen Malaspina, chief innovation officer and vice president of marketing; Kelly Enos, chief financial officer and vice president of finance and administration; Doug Bukaty, vice president of sales; and Jeff Layton, chief operations officer. Additionally, Lowe anticipates that the company’s continued growth

in 2015 will spur job creation in the areas of engineering, marketing, accounting, and administration. With American Association of Orthodontists reporting an increasing number of orthodontic patients across all demographic segments, Lowe predicts steady growth in sales targets as well. In 2012, the U.S. had a 22% increase in adolescent orthodontic patients as compared to 2010, representing the largest number of non-adult orthodontic patients since the beginning of data collection recording. There was a 29% increase in adult patients during that same timeframe, another record high. And reflecting the trend of men becoming more esthetically conscious, there was a 44% increase in male orthodontic patients.4 “The market research clearly shows that AcceleDent is the premier choice for accelerating orthodontic treatment, and as this market continues to expand, integration of AcceleDent into orthodontic practices is primed to grow rapidly,” says Lowe. In addition, “brand awareness becomes more widespread daily as pleased patients share their AcceleDent testimonials with friends and family virally via social media.” OrthoAccel is enthusiastic about the significant growth in provider numbers and the future for AcceleDent. “OrthoAccel’s mission is to deliver innovative and clinically impactful solutions to orthodontic specialists, and we are pleased to build on the success of the AcceleDent brand,” said Malaspina. “Our entire team is eagerly anticipating the upcoming 2015 AAO in San Francisco, and we’re excited to again present a premier educational lecture schedule at Booth No. 615 with some of the industry’s top national and international practitioners. In addition, we have planned several creative and unique activities for conference guests to share their positive experiences with AcceleDent.” To learn more about AcceleDent or how to offer the technology in your practice, please visit AcceleDent’s sales representative locator at acceledent.com/orthodontists, or call 866-866-4919. 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 Ortho. 2014;145(4 Suppl):S65-73. 2. Keim RG, Gottlieb EL, Vogels DS 3rd, Vogels PB. 2014 JCO study of orthodontic diagnosis and treatment procedures, Part 1: results and trends. J Clin Orthod. 2014; 48(10):607-30. 3. The Bulletin (a bimonthly publication of the American Association of Orthodontists). 31(6):13. 4. AAO Economics of Orthodontics Survey (formerly the Annual Economic Survey and the Biennial Patient Census Survey) 2012.

Volume 6 Number 3

CASE STUDY

The Baxmann Mini Telescope™ (BMT) in practical testing Dr. Martin Baxmann discusses an apparatus for Class II treatment

he lack of dependence on patient cooperation is one of the key issues for the long-term development of fixed Class II type equipment. This type of equipment is distinguished by a high level of efficiency, ease of use, high comfort in wear, and patient acceptance, all the while maintaining the lowest possible manufacturing costs. Despite extensive development and the introduction of new concepts, this is yet to be fully achieved, and only limited progress has been achieved. Nevertheless, we can observe a continuous process of improvement in the existing equipment and constant development of new technologies. One of these promising new developments is the Baxmann Mini Telescope™ (BMT, Figure 1), produced and distributed by Adenta. The specific purpose behind the development of the BMT was to create an apparatus that consists of a minimal number of individual parts, with an identical installation sequence for both sides of the jaw, in addition to the upper and lower parts of the jaw.

It is extremely intuitive and does not require elaborate laboratory work. This has been successfully achieved by taking an existing concept and rearranging it, thus creating a very compact, concise apparatus that is barely visible to the patient. It is also characterized by its small size and high comfort in wear, as well as freedom of movement. A treatment kit consists of a complete apparatus including all accessories. Two kits are needed for symmetrical Class II therapy (kits for the right left side are identical). The apparatus consists of a telescopic tube and a telescopic pole, each with a mounting lug. These include two pins for attachment. These are attached to the first molars with a band on the buccal tubes (headgear tubes). It is advisable to use double-welded loops in order to obtain the best possible shape and achieve a high level of stability of the bands even when very strong chewing forces are applied.

Correction of a bilateral Class II with a prominent lip In the case of a Class II in adolescents, there is the possibility to apply functional orthodontic treatment with removable

appliances, such as the Twin Block or similar equipment. In this situation, a complete permanent dentition was already present at the age of 11 years. It seemed effective to skip the pretreatment and combine the needed therapy with a multi-bracket appliance and the BMT (Figures 2A-2F: MB apparatus and BMT were used at the same time). During the leveling, only the molars are stabilized by the transpalatal and lingual arches. As a result, this treatment could be completed in just 16 months and proceed to the retention phase. The BMT was removed after 10 months, so that finishing and initial settling could be achieved without the use of a fixed Class II device (Figures 3A-3C). The ability to loosen the apparatus during each appointment is especially useful in the application of the BMT. For this purpose, the telescoping rod is pulled out of the tube during a maximum passive opening of the mouth. This takes about a minute per side, including the reactivation phase. It is then possible to check the actual bite of the patient while avoiding phenomena such as a dual bite. This case also shows very clearly the extent of possible movement while

Figure 1

Dr. Martin Baxmann has been a Registered Specialist in Orthodontics in Germany and the United Kingdom since 2005 and is also a visiting professor of the University of Seville in Seville, Spain. He is in private orthodontic practice in Kempen and Geldern, Germany. Since 2012, he has served as CEO of IZB-Institut (Institute for Development and Management in Dentistry) and MyOrthoLab (Orthodontic Laboratory Services). Dr. Baxmann is a reviewer of various orthodontic journals such as Angle Orthodontist, American Journal of Orthodontics and Dentofacial Orthopedics, and European Journal of Orthodontics. He is also editor and author of Festsitzende Apparaturen zur Klasse-II-Therapie (Fixed appliances for Class II treatment) (Quintessence). He has developed several orthodontic appliances and instruments, including the Baxmann Mini Telescope (BMT), SymBlock®, Baxmann Lingual O.S.A.S., Baxmann Lingual Wire Engager, and the Baxmann Lingual Distal End Cutter.

Volume 6 Number 3

Figures 2A-2F: The BMT™ allows for a variety of motions; it is characterized by high comfort in wear and is very pleasant for the patient. In addition, it is barely visible from the exterior

Figures 3A-3C: After the removal of the MB device, optimal occlusion has already been reached. In case of small deviations, especially posterior-vertical, natural settling during the retention phase can be extremely helpful Orthodontic practice 13

CASE STUDY

Figures 4A and 4B: A bite opening such as with elastic bands does not occur in the case of treatment using the BMT. Furthermore, the usual excessive protrusion of the anterior mandible can be avoided

Figures 5A and 5B: A comparison of the profile before and after the treatment: The good proportion of the visual profile becomes apparent

Figures 7A-7C: The cause of the increased overjet here is primarily the pronounced Curves of Spee in the upper and lower jaw. During the leveling process, a loss of anchorage can be triggered, which can be intercepted by the BMT™

Figure 6: Despite great sagittal overjet and the need for an appropriate treatment, some Class II cases are less likely to be caused by a skeletal component

Figure 8: The BMT™ was used here simultaneously with a 17 x 25 steel archwire after leveling. This enabled a stable occlusion

Figures 9A and 9B: Even with dentoalveolar treatment, we can observe a significant improvement of the profile

Figures 10A-10C: A complete Class I with optimal sagittal and vertical incisor positioning was achieved after only 6 months of wearing the BMT™

wearing the device. A lateral cephalogram can reveal that a bite gap may be almost completely avoided with the use of an intermaxillary elastic band (Figures 4A and 4B). At the same time, it is also possible to achieve an excellent profile improvement through the use of the BMT as illustrated in the reference profile photos (Figures 5A and 5B).

Greatly enlarged, heavily protrusive sagittal incisors (overjet) An enlarged overjet does not have to be caused by a pronounced skeletal Class II feature (Figure 6). In the case of this 13-year-old boy, an overjet of 7 mm is present at the start of treatment. However, this was mainly caused by the pronounced Curves of Spee in the upper and lower jaw, and less so by a heavy skeletal component (Figure 7). The goal of the treatment here was to reduce the overjet significantly in 14 Orthodontic practice

order to stabilize both sides of the Class I molar and canine region, and to regulate the overbite. To this end, a non-extraction treatment. was carried out with a multi-bracket appliance using the Straight Wire system. Additionally, a transpalatal arch was used to control the upper molars. For a precise leveling, .014 NiTi, .018 NiTi, and .018 steel archwires were used on both jaws. Then the BMT was used on both sides and treated further with the 19 x 25 NiTi, 17 x 25 steel arches (Figure 8). Following that, remaining gaps were closed using the 19 x 25 steel archwire, and final corrections applied. The BMT was then removed after a period of 6 months along with the rest of the MB device, which means that the apparatus was worn for a total of 13 months (Figures 9 and 10A-10C). If during that time, the equipment caused a minimal posterior open bite, this can easily be optimized by

Figure 11: The mandibular midline is shifted to the left — there is mandibular laterognathia

natural settling during the retention phase. Those who prefer to actively achieve this may choose a positioner, if necessary.

Correction of a unilateral Class II This case of a 12 year-old girl illustrates the correction of a unilateral Class II, which was primarily caused by a rotation of the mandible. While the center line in the upper jaw proceeded along the facial axis, the mandibular midline was, however, shifted to the left (Figure 11). Accordingly, an Angle Class I was present in the right molars region, as well as a ½ Class II to the left. The lower facial height was low, and there was a deep bite tendency. The treatment was carried out without extractions with a fixed appliance using the Straight Wire technique. After the leveling phase (from .018 steel arch in the 22nd slot system), the BMT was used on the left side to achieve a center Volume 6 Number 3

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CASE STUDY correction by a unilateral post-development of the mandible (Figures 12A-12C). At the same time, it is important to pay attention to the proper arch coordination of the upper and lower jaw, as well as to take into account vertical components in the unilateral Class II therapy. The treatment time was 18 months using the multi-bracket appliance. The BMT was used after 6 months and removed again after 15 months, which meant a total wearing period of 9 months. The therapy targets — the middle and neutroclusion correction — could therefore be successfully implemented in an acceptable time frame (Figures 13A-13C).

Figures 12A-12C: To correct the asymmetry, the BMT™ was used only on the left side and activated with a slight correction

Figures 13A-13C:The center and a bilateral Class I occlusion were successfully set and achieved the therapeutic goal

Class II therapy in adults If, in the absence of growth, the development of a Class II occurs, in the past, there was only the possibility to perform orthognathic surgery or to camouflage extraction therapy. Nowadays, however, it is also known that a fixed Class II device can be used successfully in these cases. Surgery was not an option for the 28-year-old female patient presented here. Due to her profile, an extraction treatment did not result in a satisfactory outcome either (Figure 14). Hence, the treatment of choice was a multi-bracket treatment with less esthetically pleasing ceramic brackets and a barely visible apparatus for correcting the skeletally caused defect of the mandible (Figures 15A and 15B). The Baxmann Mini Telescope was used directly together with the MB appliance. The upper molars were supported by means of transpalatal arches. It has now worked without complications with the standard arch sequence: .014 NiTi, .018 NiTi, .018 steel, 19 x 25 NiTi, 17 x 25, and 19 x 25 steel (Figures 16A-16C). The BMT (17 x 25 steel) was left in place for up to 12 months, and during each follow-up visit (every 6 weeks), the stability of the jaw position was checked. It was a simple and practical way to make sure that the new jaw position was set not only temporarily, but could actually be stabilized in the long term. The active treatment was completed after a total period of 15 months (Figures 17A-17C). Following that, the retention was performed with Hawley retainers and nightly Class II rubber bands. After another 3 months, the elastics were eliminated entirely, and the wearing time reduced from 14 hours a day to just nighttime. Further retention protocol proceeds individually after that.

Summary The BMT is a new apparatus that fits into the line of rigid, fixed Class II equipment. In this article, it was tested in practical cases 16 Orthodontic practice

Figure 14: Surgery, extraction therapy, or BMT™. In moderately severe Class II cases, fixed Class II appliances are certainly a very good alternative

Figures 15A and15B: Mandible with a three-quarter Class II right and left and steeply angled fronts in the upper and lower jaw

Figures 16A-16C: The BMT™ was already used right from the beginning of the treatment, during leveling. The molars were secured with a transpalatal arch. In patients with bruxism, temporary posterior bite blocks may be used as an option

Figures 17A-17C: After 15 months of total treatment time and 12 months with the BMT™, very nice and stable results were achieved in this adult patient.

and successfully used in various orthodontic situations. The BMT was used on just one side or used on both sides depending on the starting position. It is therefore particularly pleasing to the practitioner that the corresponding components are identical on the right and left, and that the attachment of the apparatus is performed identically to conventional molar bands in all four quadrants. Consequently, the use of the BMT does not require special skills or expensive laboratory steps. The range of its application is very broad thanks to the exclusive attachment in the molar region. As a result, the Baxmann Mini Telescope can be used early on, from treating children, all the way to adult therapy. Especially in the case of esthetically demanding patients, the small dimension

of the apparatus can be considered as “invisible,” which is very appropriate. Not only is it barely visible with the mouth open with the BMT, the pronounced protrusion of the lower lip, which is often observed when using larger equipment, does not occur. Those who have tried using the BMT have come to love the ease and reliability of the apparatus. Finally, it should be noted that the BMT has proven itself to be simple to use, in addition to achieving a high level of comfort in wear and very pleasing esthetics. It also has clinically proven effectiveness as an interesting and practical alternative within the family of Class II equipment. For more information, visit Adenta USA at www.adentausa.com, email info@adentausa. com, or call toll free 1-888-942-2070. OP Volume 6 Number 3

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Support for this activity is generously provided by Henry Schein ® Orthodontics ™, Henry Schein Dental, and i-CAT ™, Inc. 1. Ludlow JB, Walker C. December 2013. Assessment if phantom dosimetry and image quality of i-CAT FLX cone-beam computed tomography. Am J Orthod Dentofacial Orthop. 144(6):802-17. DOI: 10.1016/j.ajodo.2013.07.013. 2. Smith BR, Park JH, Cederberg RA. January 2011. An evaluation of cone-beam computed tomography use in postgraduate orthodontic programs in the United States and Canada. J Dent Educ. 75(1):98-106. 3. Bouwens DG, Cevidanes L, Ludlow JB, Phillips C. January 2011. Comparison of mesiodistal root angulation with posttreatment panoramic radiographs and conebeam computed tomography. Am J Orthod Dentofacial Orthop. 139(1):126-32. DOI: 10.1016/j.ajodo.2010.05.016. 4. Olmez H, Gorgulu S, Akin E, Bengi AO, Tekdemir I, Ors F. May 2011. Measurement accuracy of a computer-assisted three-dimensional analysis and a converntional two-dimensional method. Angle Orthod. 81(3):375-82. DOI: 10.2319/070810-387.1. 5. Chien PC, Parks ET, Eraso F, Hartsfield JK, Roberts WE, Ofner S. January 2014. Comparison of reliability in anatomical landmark identification using twodimensional digital cephalometrics and three-dimensional cone beam computed tomography in vivo. DentoMaxillofacial Radiography. Volume 38, Issue 5. DOI: http://dx.doi.org/10.1259/dmfr/81889955

ORTHODONTIST’S VIEWPOINT

Take only CBCTs on these types of orthodontic cases Dr. Jack Fisher discusses 10 reasons to use 3D imaging

he specialty of orthodontics has of recent years had an influx of technology within the industry. Intraoral scanners are now being used in many practices and residency programs. We are told that this technology will eliminate alginate impressions. We are told that 3D printers will replace plaster models and perhaps print out our brackets. We are told that aligners are now returned to the practice faster with this technology. l am still not sure how this new technology really benefits the care of our patients within the specialty of orthodontics. The advent of 3D imaging technology has also recently come to the forefront within the orthodontic specialty. Many have stated that this type of imaging does not significantly benefit patients or aid in the diagnoses and treatment planning of their patients. The amount of radiation from older machines certainly was a concern. The recent introduction to the market of a 3D machine by Planmeca is advertised to deliver a dose of 14 ms with an Ultra Low Dose™ setting.This is a full scan taken at a .06 voxel size. If this proves to be the true dose of radiation received by this machine, then the argument for too much radiation is now not an issue any longer. Many have argued that as orthodontists we are not trained to read this type of data of DICOM images. We are, or should be, trained within our residency training to read cephs, PAs, and submental vertex radiographs. The 3D scan of a typical patient is comprised of approximately between 450 and 600 DICOM images that are represented in the three planes of space: sagittal, coronal, and the axial planes. These are the same three planes of space we are trained to read — just many of them on the same patient. Jack Fisher, DMD, brings 28 years of experience to his practice. He attended the University of Louisville School of Dentistry and then continued to his residency at the Medical College of Georgia where he received a certificate in orthodontics. He is honored to serve and teach residents at New York University, University of Louisville, and Vanderbilt orthodontic Post-Graduate Residency Programs. He enjoys teaching orthodontists worldwide about various orthodontic topics and has lectured as far away as Australia. Dr. Fisher is an inventor of various orthodontic products and holds several U.S. Patents. His practice, Artistic Smiles Orthodontics, is based in Memphis, Tennessee. Disclosure: Dr. Fisher is a paid lecturer for Planmeca.

20 Orthodontic practice

Figure 1A

So let’s look at the only reasons to scan a patient seeking orthodontic treatment.

1. Many have advocated that the use of 3D imaging is certainly useful in treating patients with impacted maxillary canines. This is certainly true. However, only 1% to 2% of the population has impacted canines. Research shows that within the population of most orthodontic practices, 5% of the practice’s patients seeking treatment have impacted canines. If this is the main reason for taking DICOM images on patients, then these images should be outsourced. The cost of purchasing a 3D machine for 5% of the office’s patients does not make financial sense. A two-dimensional pan or ceph does not adequately image the impacted teeth for not only surgical planning but also the mechanics needed to move these teeth into alignment. It has been reported that 62% of palatally impacted canines are touching the roots of laterals and centrals. This is information that 3D imaging illustrates. This could often change the mechanics needed to properly position the canines without damaging the roots of adjacent teeth. However, the 3D imaging of impacted teeth certainly is advantageous to the orthodontist or oral surgeon who will surgically expose the nonerupted teeth. This is illustrated in Figures 1A, 1B, and 1C. The clinician can readily

Figures 1B-1C

see the benefits to the patient for using the 3D imaging technology for the treatment of impacted teeth.

2. Any patient needing orthognathic surgery should receive a scan. The scan is certainly more diagnostic in all three planes of space than a two-dimensional cephalometric image. Many oral surgeons can now use this scan to send to medical modeling companies for the construction of the splints used during the surgery. Not to mention the three planes of spaces gives the orthodontist a better perspective of the problem list prior to treatment planning and pre-surgery orthodontics. The models that are either acquired by a scan or with plaster models are incorporated in the patient’s 3D scan. The medical modeling companies can then do the surgery digitally and use the 3D models to make the surgical splints. These DICOM images give the orthodontist a more accurate visual treatment objective prior to treatment as also the digital surgery gives the oral surgeon a thorough perspective of pre-surgical planning. The patient illustrated in Figure 2 shows different types of images that can be generated from a set of DICOM images. With an exposure of only 14 microsieverts, the orthodontist can attain a pan, a ceph, and many different types of 3D images from the three simple planes of space to 3D images. Final records were acquired Volume 6 Number 3

ORTHODONTISTâ&#x20AC;&#x2122;S VIEWPOINT

Figure 2

Figures 3A1-3A3

with an additional scan totally another 14 microsieverts.

3. Any patients needing their anterior teeth moved in the sagittal plane. A traditional cephalometric image is a composite of the cephalic. The true amount of bone either anterior or posterior to the roots of these teeth is not visualized in the traditional cephalometric or panoramic images. When there is not adequate bone to move the roots of teeth into a space, the clinician has only two options: Either have bone placed by a periodontist or maintain the patientâ&#x20AC;&#x2122;s inclination of these incisors. The use of Class II correctors has grown tremendously in the past few years. These devices often flare the lower incisors as much as 10 degrees. Fenestrations and the lack of bone support results. Is this a stable environment for incisors? We also often recline the upper incisors. Is the alveolus wide enough in the sagittal plane to accommodate the roots of the teeth? Now with the use of skeletal anchorage devices, we are more likely to exceed the patientâ&#x20AC;&#x2122;s biological limit. Again, a traditional ceph or pan does not show the true anatomy in this plane. The axial plane is also available with a 3D scan. This plan also gives the clinician a more thorough understanding of the availability of bone to move the incisors. Figure 3A illustrates a patient seeking treatment for a severe overjet and overbite. The pan and ceph do not reveal the enough information to properly diagnose this case. After imaging in the sagital view with a CBCT, the clinician can readily see Volume 6 Number 3

Figures 3B1-3B3

Figures 4A1-4A2

there is a lack of bone to move the upper incisor. The patient in Figure 3B illustrates a patient with a lack of bone around the lower incisors. Again, the traditional pan and ceph do not give enough information to properly diagnose and treat this patient.

4. Any patient who will have a temporary skeletal anchorage device (TSAD) placed. Most clinicians that have become proficient and confident with the placement and use of TSADs place them on approximately 23% of the case treatments planned in their practices. When evaluating the placement

site in all three planes of space, the clinician can become very exact with locating structures that should be avoided. More TSADs are being placed in the infrazygomatic area. A 3D image is the best way to locate the best area of placement for stability in this area. See Figure 4A1 and note the thickness of the bone in the infrazygomatic crest. Compare the thickness of the bone in Figure 4A2. The bone in this figure demonstrates bone that is too thin for placement of the TSADs. More TSADs are being placed in to palatal approach. TSADs placed in the premaxilla are an area of placement that is vitally important to visualize the anatomy in this area. Orthodontic practice 21

ORTHODONTISTâ&#x20AC;&#x2122;S VIEWPOINT

Figures 4B1-4B3

Figures 5A1-5A4

Figures 5B1-5B4

The clinician should consider the thickness of bone in this area to avoid the tips of the TSADs from penetrating the nasal cavity and to avoid the roots of the teeth in this area. See Figures 4B1, 4B2, and 4B3. When skillfully placed in adequate bone, the use of TSADs certainly allows orthodontists to treat their patients more consistently and predictably. The use of 3D imaging aids the clinician in the placement and use of the TSADs.

Figures 6A-6B

5. Any case that needs expansion of the maxilla. Three-dimensional imaging in these cases allows the orthodontist to determine if a crossbite is skeletal or dental. The clinician can readily determine if the molars are inclined in a crossbite, or if the entire maxilla is constricted. This, in turn, then can determine what forces are desirable to correct the crossbite. The 3D images also allow 22 Orthodontic practice

the clinician to evaluate the amount of bone around the roots of the teeth that are to be expanded. This also can aid the orthodontist in the type of forces to be utilized. Maybe bone augmentation is indicated in certain areas, so the roots are not once again fenestrated through the cortical bone creating a less stable environment (see Figure 5). Figure 5A1 illustrates a maxilla that is constricted due to a narrow maxilla. Figure 5A2 illustrates the maxilla after expansion. Figure 5B1 illustrates a molar being tipped lingually. Thus a unilateral crossbite appliance was utilized.

6. Any case that possibly will be receiving a permanent implant. The clinician placing the implants will need to evaluate the bone to determine how much area is needed between the teeth and to evaluate the thickness of the bone receiving the implant. Permanent implants are also employed to be used as anchorage during orthodontic treatment. The evaluation of the bone in all three planes of space is important for the placement and stability of permanent implants. Figures 6A and 6B illustrate an example of implant placement. Volume 6 Number 3

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Figures 7A-7C

7. Any patient suspected of having a compromised airway. Granted, this is not known until the patient is scanned. However, if there is an inadequate airway, the location of the constriction could determine the type of treatment the patient receives. For example, it could change the treatment plan from a camouflaged treatment to a mandibular advancement. A traditional ceph is not adequate in determining the size of an airway. The subject of imaging and treating compromised airway patients is experiencing more advancements in dentistry than any other subject. It is this clinicianâ&#x20AC;&#x2122;s opinion that the orthodontic specialist should be the most qualified clinician to aid in the treatment of these types of patients. These patients deserve a multidisciplinary approach, perhaps more than any other type patient we see in our practices. DICOM images are vitally important for the proper diagnosis and treatment of these individuals. Figures 7A and 7B illustrate this. This patient had a chief complaint of overjet. She could be treated with the retraction of the upper anteriors. After further imaging, it was decided that a mandibular advancement would best serve her. Also, note the osteophyte on C1 that is constricting the airway. This is not a common occurrence. This osteophyte needs to be removed. So

the DICOM images changed our treatment plan. Figure 7C illustrates another patient seeking treatment after surgical relapse. This patient will need to be treated with surgery again. Note the restricted airway at the hypopharynx. This must be treated prior to the retreatment of this case. Also, note the upper centrals have been torqued through the lingual cortical bone. These two problems are not viewed with conventional 2D images.

8. Any patient with a temporomandibular joint (TMJ) disorder. Once again, this is not always known prior to the scan. Internal joint disorders are

often found during the manipulation of the DICOM images. For example, the etiology of an open bite in a female teenager may be due to idiopathic condylar resorption. Is it not best to know this on the front end of orthodontic treatment? Many joint conditions are asymptomatic for patients seeking routine orthodontic treatment. Most joint problems are not visualized on the routine pan and cephs. Being able to image the TMJ in all three planes of space is imperative in patients receiving comprehensive orthodontic treatment. Figure 8A illustrates a 14-year-old female with obvious challenges of her condyles. She

Figures 8A-8B

Figures 9A-9C 24 Orthodontic practice

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ORTHODONTIST’S VIEWPOINT

Figures 10A-10F2

happened to be asymptomatic. However, it is better to have the information before orthodontic treatment so the patient and the parent are fully informed of this condition. Figure 8B illustrates a bifid condyle that is also asymptomatic. Neither of these two conditions was visualized on the traditional pan and ceph.

9. Any patient having supernumerary teeth that are not imaged in a routine pan. Once again, this is not known until the scan is taken and read by the clinician. I personally have found supernumerary teeth that were not in the trough of the routine pan. We have found mesiodens that were not visualized on the pan. Figures 9A and 9B illustrate a patient for whom the mesiodens was not obvious on the pan or the ceph. However, the extra tooth is imaged on the sagittal view of the scan (Figure 9C). The etiology of the reclined centrals is the mesiodens. If the scan had not been taken, this may have been missed.

10. Any patient having pathology that is not imaged on the routine 2D radiographs traditionally taken on the orthodontic patient. Again, we are not aware of these conditions that may exist prior to making a decision of what kind of images we need on 26 Orthodontic practice

a patient presenting for orthodontic treatment. Figure 10 illustrates just a few of the conditions that were discovered on the 3D images but were not evident on the traditional 2D images. The first patient in Figure 10A shows a patient in the axial view where C1 is rotated to the patient’s left. This is also restricting the airway. Figure 10B illustrates a patient who was scheduled for a maxillary osteotomy. The maxillary left sinus is not present. This is reported to be a condition that is present in 1:100,000 people. I believe this condition to be more frequent, having seen this condition in three patients in the last 3 years. Figure 10C illustrates in all three planes of space an enlarged pituitary gland. This patient’s pituitary gland had to be removed. Figure 10D shows a patient with a large traumatic bone cyst. This was not readily evident on the pan because the lesion is so large. This was biopsied and was determined to be a traumatic bone cyst. Figure 10E illustrates a large nasal bone cyst. We have discovered several smaller ones over the past 3 years that were not evident on a pan. This one, however, was evident on the pan. The enlarged pineal gland was not demonstrated on the pan or ceph but is evident on this image in the sagittal plane of space. Figure 10F1 illustrates a osteophyte on C1 of a 26-yearold female. Figure 10F2 shows a different view. This patient was referred for a sleep

study and was diagnosed with severe sleep apnea. The osteophyte has been removed. We have illustrated only a few of the conditions we have discovered. The routine use of DICOM imaging in the specialty of orthodontics may be approaching. We actually just used the term “routine.” This raises a question. We as a specialty do not get to determine what is a standard of care. This is determined by the courts. Any of the 10 reasons discussed in this article that were not imaged thoroughly and perceived as less than adequate treatment delivered could be brought into question in a judicial environment. Yes, we are liable for all the data obtained with a scan. We are also liable for the data we do not care to image when more and more clinicians are using routine DICOM images. How and why did pans and cephs become routinely utilized in the specialty? We are specialists. We should educate ourselves accordingly and use the technology available to treat the patients who trust us with their care. If it is in fact a truth that the newer machines are delivering the dosages of radiation as advertised, there is no longer an excuse to not learn and educate ourselves to better treat our patients. OP Reprinted with permission of Dentaltown Magazine and Dentaltown.com

Volume 6 Number 3

ORTHODONTIC CONCEPTS

BioDigital Orthodontics Management of patients with transverse (midline) discrepancies (2): part 15 Drs. Rohit C.L. Sachdeva, Takao Kubota, and Kazuo Hayashi discuss how to plan care based upon an in-depth diagnosis and design therapeutics Introduction In a previous article,1 the importance of proper care planning in managing midline problems was discussed. Also, a step-bystep approach in designing a realistic Objective Driven Simulation (ODS) (Sachdeva) for correcting such malocclusions was presented. In this paper, the management of patients with complex midline discrepancies with Simulation Guided Orthodontics (SGO) (Sachdeva) enabled by suresmile® is shown.2-6

Patient YO Patient YO, a 40-year-old female, presented with a Class 2 subdivision right malocclusion with an upper dental midline shift of about 5 mm to the right of her facial midline. She showed no indication of a skeletal asymmetry. Both the upper and lower arches showed severe crowding. In addition, the patient presented with a missing upper left second molar and impacted lower third molars. The upper third molars were erupted (Figure 1). The facial midline was selected as the treatment midline, and the first bicuspids were planned for extraction to correct both the crowding and the midline and treated to a Class 1 occlusion. In addition, it was decided to close the upper left second molar extraction site by protracting the upper left third molar. It was also recommended that the patient have the remaining third molars extracted. The Virtual Diagnostic Simulation

(VDS) is shown in Figure 2. Also, note with the simulation, it was possible to anticipate the potential risk of black triangles appearing post orthodontic treatment (Figure 2B). Superimposition of the VDS against the VDM is planned, and the tooth displacements are shown Figures 2C-2F. Treatment was initiated by placing a fixed upper transpalatal arch with a distal extension arm on the left side to which elastic was attached to a lingual button placed on the buccal to move the upper third molar lingually, protract it, and partially derotate it (Figures 3A and 3J). Extraction of the lower first bicuspids was performed, and 3 weeks post extraction, separate canine retraction with ligature rope ties was initiated in the lower arch (Figure 3B). The upper first bicuspids were extracted, and 8 weeks from the start of treatment, separate upper canine retraction was initiated with a stainless steel ligature rope tie (Figure 3C). At the 12-week appointment, the upper arch was bonded with Tomy “CLIPPY-C” (In-Ovation® C, Dentsply GAC International bracket) with a slot width of .0180", and a .016" CuNiTi AF 35ºC upper alignment archwire was placed. Also, an open coil spring was inserted between the right upper canine and right central incisor to open space for the lingually blocked upper right lateral incisor and also shift the upper dental midline to the patient’s left (Figure 3D). Four months into treatment, the upper right lateral was bonded and engaged into the upper archwire, which remained unchanged (Figure 3E).

Rohit C.L. Sachdeva, BDS, M Dent Sc, is a consultant/coach with Rohit Sachdeva Orthodontic Coaching and Consulting, which helps doctors increase their clinical performance and assess technology for clinical use. He also works with the dental industry in product design and development. He is the founder of the Institute of Orthodontic Care Improvement. Dr. Sachdeva is the co-founder and former 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. In the past, he has held faculty positions at the University of Connecticut, Manitoba, and the Baylor College of Dentistry, Texas A&M. Dr. Sachdeva has over 90 patents, is the recipient of the Japanese Society for Promotion of Science Award, and has over 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.

28 Orthodontic practice

In month 5, all the space on the upper right side was closed. The space closed asymmetrically (more on the right side than the left), and both the buccal segments showed signs of tipping. Also, protraction and lingual movement of the upper right third molar proceeded well. At this time, the lower arch was bonded, and a lower .016" CuNiTi AF 35ºC was engaged to begin the alignment of the lower anteriors. The lower right lateral was not bonded as it had a severe rotation. Its bonding was deferred to the next appointment when sufficient space was available to derotate it. Bite turbos on the lower molars were placed to prop the bite open so that the upper right lateral could be brought out labially. Also, the distal extension arm on the transpalatal arch was cut while the arch was kept in place (Figure 3F). One month later (month 6), the lower right central was bonded and engaged with the archwire. The upper right third molar was also bonded and engaged with a .016" CuNiTi AF 35ºC archwire (Figure 3G). At the next appointment (month 7), the round archwires were replaced with .017" x .025" CuNiTi AF 27ºC archwires to achieve uprighting of the buccal segments (images not shown). The patient was seen in month 9, and substantial leveling of the tipped buccal segments had occurred by now. As a result, some spacing had opened distal to the canines. The upper left seven extraction site was completely closed. At this time, power arms were crimped on the archwire in both the upper and lower arches, and space closure initiated with power chain (Figure 3H). The patient was seen a month later (month 10).The upper archwire to the upper left 6 was cut since the patient had lost a bracket on the third molar. Note that space mesial to this tooth opened up (Figure 3I). At month 11, the patient was scanned (Figure 4). The Virtual Therapeutic Model (VTM), the Virtual Target Setup (VTS), and the .017" x .025" CuNiTi suresmile precision archwire designed is shown in Figure 5. The suresmile precision archwire was installed 6 weeks Volume 6 Number 3

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ORTHODONTIC CONCEPTS later. And the patient was seen 2 months later (3.5 months post therapeutic scan) as seen in Figure 6. The patient was debonded at the next appointment a month later (Figure 7). The total treatment time was 15.5 months. The VDS versus VFM is shown in Figure 8A. Most of the treatment objectives were met. The upper buccal segment anchorage was held according to plan; however, the lower was not slipped enough resulting in

a slight Class 2 occlusion. Complementing space closure with some Class 2 elastic wear to encourage lower molar protraction during treatment may have averted this situation. Also, slight spacing remained between the upper central incisors and the upper right canine. It is planned to close this with a Hawleyâ&#x20AC;&#x2122;s appliance. This will require removing the upper 3-3 fixed retainer. Once the space is closed, permanent retention

will extend to include the 5-5 segment to minimize any potential of space reopening since there is a high likelihood for this to recur. Note that some space also opened mesial to the upper left third molar. It is planned to leave this space open. Lastly, it should be noted that the black triangles as predicted in the VDS at the beginning of treatment did manifest themselves in vivo (Figure 8B).

Figures 1A-1B: Patient YO 1A. Initial intraoral photos. Note the patient has a Class 2 subdivision right malocclusion an upper dental midline shift of about 5 mm to the right of her facial midline and severe upper and lower arch crowding. 1B. Initial X-rays. The patient does not appear to have any skeletal asymmetry, and the midline discrepancy is primarily dental in nature VDM

VDS

VDS (blue) vs. VDM (white)

Figures 2A-2F: Patient YO. 2A. Virtual Diagnostic Model (VDM). 2B. Virtual Diagnostic Simulation: All first bicuspids have been extracted to correct the crowding and the midline and treat to a Class 1 occlusion. The upper left second molar extraction site is closed by protracting the upper left third molar. The potential areas at risk for the appearance of black triangles are identified 2C. VDS (blue) vs. VDM (white) 2D. Transverse clipping views of the upper and lower occlusal views showing the nature of space closure and midline correction. 2E. Crosssectional view of upper right central incisors further highlights the nature of retraction planned for the upper incisors. 2F. Shows the nature and magnitude of displacements of the dentition to correct the malocclusion 30 Orthodontic practice

Volume 6 Number 3

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ORTHODONTIC CONCEPTS

Figures 3A-3C: Patient YO. 3A. An fixed upper transpalatal arch with a distal extension arm on the left side to which an elastic was attached to a lingual button placed on the buccal to move the upper third molar lingually, protract it, and partially derotate it. 3B. Lower first bicuspids extracted separate canine retraction with ligature rope ties begun in the lower arch. 3C. Upper first bicuspids extracted and separate upper canine retraction initiated with ligature rope tie

Figures 3D-3F: Patient YO. 3D. Month 3: The upper arch is bonded and a .016" CuNiTi AF 35ºC upper alignment archwire placed. Also, an open coil spring is inserted between the right upper canine and right central incisor to open space for the lingually blocked upper right lateral incisor and also shift the upper dental midline to the patient’s left. 3E. Month 4: upper right lateral bonded and engaged into the upper archwire. 3F. Month 5: Space on the upper right side is closed. The space has closed asymmetrically (more on the right side than the left). Both the buccal segments have tipped. The lower arch is bonded at this appointment, and a lower .016" CuNiTi AF 35ºC is engaged to begin the alignment of the lower anteriors, (the lower right lateral is not bonded as it is severely rotated and would be difficult to engage with an archwire). Bite turbos on the lower molars are placed to prop the bite open so that the upper right lateral can be moved labially with minimal occlusal interferences. The distal extension arm on the transpalatal arch is cut while the transpalatal arch is kept in place

Figures 3G-3J: Patient YO. 3G. Month 6: Lower right central is bonded and engaged with the archwire. The upper right third molar was also bonded and engaged with a .016" CuNiTi AF 35ºC archwire (Month 7: Round archwires were replaced with .017" x .025" CuNiTi AF 27ºC archwires to achieve uprighting of the buccal segments — images not shown). 3H. Month 9: Substantial leveling of the tipped buccal segments has occurred. Some spacing has opened distal to the canines. The upper left seven extraction site is completely closed. At this time, power arms are crimped on the archwire in both the upper and lower arches and space closure initiated with power chain 3I. Month 10: The upper archwire to the upper left 8 is cut since the patient has lost a bracket on the third molar. Note space mesial to this tooth opened up. 3J. Upper left third molar protraction, lingual and rotation movement accomplished with power chain running from button on the buccal to the distal extension arm 32 Orthodontic practice

Volume 6 Number 3

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ORTHODONTIC CONCEPTS

Figures 4A-4B: Patient YO. Eleven months from start a therapeutic scan was taken. 4A. Mid-treatment photos. 4B. Mid-treatment X-rays

VTM

VTS

VTS (white) vs. VTM (blue)

Figures 5A-5E: Patient YO. 5A. Virtual Therapeutic Model (VTM). 5B. Virtual Target Setup (VTS) with suresmile precision archwire designed. 5C. VTM (blue) vs. VTS (white). 5D. suresmile precision archwire viewed against VTM. E. Shows the nature and magnitude of displacements of the dentition

Figures 6A-6B: Patient YO. 6A. suresmile precision archwire .017" x .025" CuNiTi installed 6 weeks later. 6B. Patient seen 2 months later (3.5 months post therapeutic scan) 34 Orthodontic practice

Volume 6 Number 3

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ORTHODONTIC CONCEPTS

Figures 7A-7B: Patient YO. The patient was debonded 1 month later. The total treatment time was 15.5 months. 7A. Final intraoral photos. B. Final X-rays VFM (white) vs. VDS (green)

Figures 8A-8B: Patient YO. Final outcome evaluation. 8A. VDS (green) vs. VFM (white). Note the treatment objectives were met. The upper buccal segment anchorage was held well; however, the lower was not slipped enough, resulting in a slight Class 2 occlusion. Also, slight spacing remained between the incisors and the upper right canine. It is planned to close these with a Hawley’s appliance. 8B. Noted that the location and extent of the black triangles predicted in the VDS at the beginning of treatment did manifest themselves in vivo

Patient TE Patient TE, a 22-year-old female presented with a Class 2 subdivision left malocclusion with a bimaxillary dental protrusion, a steep mandibular plane angle, a long lower facial height, and a skeletal mandibular asymmetry. Severe dentoalveolar compensations were present in the lower anteriors, which had tipped to the patient’s right causing the lower midline to deviate from the upper dental and facial midline by about 3 mm. Also, there was a slight clockwise cant in the upper esthetic occlusal plane. There was moderate crowding in the upper and lower arches. The patient also had a large asymmetric anterior overjet (Figure 9). The facial midline was chosen as the treatment midline. The maxillary functional occlusal plane was chosen as the treatment occlusal plane, and maximum retraction of the incisors was planned in order to reduce the bimaxillary protrusion. The lower archwidth at the first molar level was chosen for the limits of the archwidth. The treatment goal was to treat to a Class 1 occlusion. An asymmetric extraction pattern was planned. The upper first and the lower right first bicuspid and the lower left second bicuspid were extracted. 36 Orthodontic practice

The patient was also recommended to have all her third molars extracted. However, she chose only to have the lowers extracted. The Virtual Diagnostic Simulation for patient TE is shown in (Figure 10). The upper and lower arches were bonded with Sankin Clear brackets (Sankin Inc., Dentsply International, Tokyo, Japan) with slot width 0.0220". Four tads were placed to enable differential anchorage control. The upper left TAD was placed a little higher in order to enable the correct ion of the clockwise cant of the upper esthetic occlusal plane (Figure 11A). A .016" CuNiTi AF 35ºC was used as an initial archwire for both the upper and lower arches. Space closure was initiated on this archwire by sliding mechanics using a power chain. An upper transpalatal arch was placed to maintain intermolar width. Six weeks into treatment, the power chain was replaced with superelastic NiTi coil springs to facilitate space closure on .016" stainless steel archwires (figure not shown). By the 4th month, the lower incisors had uprighted, and separate canine retraction in both arches was almost 50% complete (Figure 11B). En masse upper incisor retraction was begun at

the 8th month with .016" x .022" stainless steel L-shaped closing loops. In the lower arch, anterior spacing was consolidated with a power chain on a .016" stainless steel archwire. At this time, the upper transpalatal arch was also removed (Figure 11C). All upper and lower space was closed by month 12. The upper closing arch was removed and replaced by a round 016" superelastic NiTi AF 27ºC, and the lower archwire was also replaced with a similar archwire. These wires were engaged just to hold the correction of the occlusion until the therapeutic scan was taken (Figure 11D). The therapeutic scan was taken 1 month later (Figure 12). At this stage in treatment, the buccal segments were Class 2, and a midline discrepancy was apparent. A Virtual Target Setup and a .019" x .025" CuNiTi AF 35ºC suresmile precision archwire were designed (Figure 13). The precision archwire was inserted in both the upper and lower arches 6 weeks post therapeutic scan (Figure 14A). The patient was asked to wear bilateral Class 2 elastics and double up on the left side. After 8 weeks, the upper asymmetric overjet and midlines were corrected with the buccal Volume 6 Number 3

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ORTHODONTIC CONCEPTS occlusion appearing symmetric and Class 1 (Figure 14B). At this stage, the patient was requested to wear some check elastics to help achieve better interdigitation. The patient was debonded 1 month later. The final intraoral photographs and models

are shown in (Figure 15). A superimposition of the Virtual Diagnostic Simulation (VDS) and the Virtual Final Model (VFM) clearly demonstrates that the treatment objectives were met (Figure 16). The total treatment time for the patient was 17.5 months.

Figures 9A-9B: Patient TE. 22-year-old female presented with a Class 2 subdivision left malocclusion with a bimaxillary dental protrusion, a steep mandibular plane angle, a long lower facial height, and a skeletal mandibular asymmetry. 9A. Initial intraoral photos. 9B. Initial X-rays VDM

VDS

VDS (white) vs. VDM (green)

Figures 10A-10G: Patient TE. 10A. Virtual Diagnostic Model (VDM). 10B. Virtual Diagnostic Simulation (VDS) simulating the maxillary functional occlusal plane was selected, and maximum retraction of the incisors was planned in order to reduce the bimaxillary protrusion. The lower archwidth at the first molar level was chosen for the limits of the archwidth. The treatment goal was to treat to a Class 1 occlusion. An asymmetric extraction pattern was planned, and this included the extraction of the upper first and the lower right first bicuspid and the lower left second bicuspid. 10C. VDS (blue) vs. VDM (white) 10D. Shows the nature and magnitude of displacements of the dentition to correct the malocclusion 38 Orthodontic practice

Volume 6 Number 3

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ORTHODONTIC CONCEPTS

Figures 11A-11D: Patient TE. 11A. Four tads were placed to enable differential anchorage control. The upper left TAD was placed a little higher in order to enable the correction of the clockwise cant of the upper esthetic occlusal plane. A .016" CuNiTi AF 35ºC was used as an initial archwire for both the upper and lower arches. Space closure was initiated on this archwire by sliding mechanics using a power chain. An upper transpalatal arch was placed to maintain intermolar width. (Six weeks into treatment, the power chain was replaced with superelastic NiTi coil springs to facilitate space closure on .016" stainless steel archwires (Figure not shown). 11B. At the 4th month, lower incisors had uprighted, and separate canine retraction in both arches was almost 50% complete. 11C. En masse upper incisor retraction was begun at the 8th month with .016" x .022" stainless steel L-shaped closing loops. In the lower arch, anterior spacing was consolidated with the power chain on a .016" stainless steel archwire. At this time, the upper transpalatal arch was also removed. 11D. By month 12, all upper and lower space was closed. The upper closing arch was removed and replaced by a round .016" superelastic Cu NiTi AF 27ºC, and the lower archwire was also replaced with a similar archwire

Technology such as suresmile is designed not to dominate the clinician’s judgment but to serve his needs to support the delivery of reliable care.

Figures 12A-12B: Patient TE. 13 months from start, therapeutic scan taken at this point in treatment. 12A. Mid-treatment photos. 12B. Mid-treatment X-rays 40 Orthodontic practice

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ORTHODONTIC CONCEPTS VTM

VTS (white) vs. VTM (blue)

VTS

Plan

Figures 13A-13E: Patient TE. 13A. Virtual Therapeutic Model (VTM). 13B. Virtual Target Setup (VTS) with suresmile precision archwire designed. 13C. VTM (blue) vs. VTS (white). 13D. suresmile precision archwire viewed against VTM. 13E. Shows the nature and magnitude of displacements of the dentition

Figures 14A-14B: Patient TE. 14A. suresmile precision archwire .019" x .025" CuNiTi AF 35ยบC was inserted 6 weeks post therapeutic scan. The patient was asked to wear bilateral Class 2 elastics and double up on the left side. 13B. 8 weeks later, the upper asymmetric overjet and midlines were corrected with the buccal occlusion appearing symmetric and Class 1. At this stage, the patient was requested to wear some check elastics to help achieve better interdigitation

42 Orthodontic practice

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ORTHODONTIC CONCEPTS Discussion/conclusions

VFM

Figures 15A-15C: Patient TE. The patient was debonded 1 month later. The total treatment time was 17.5 months. A. Final intraoral photos. B. Final X-rays. C. Virtual Final Model (VFM)

When considering the treatment of midline discrepancies, it is important to recognize the etiology of the malocclusion, the patient’s wants, and the potential limitations of orthodontic treatment in correcting the midline. Furthermore, one needs to recognize that in patients with skeletal midline discrepancies treated orthodontically, dentoalveolar compensations may need to be maintained or exaggerated. These may manifest as a cant in the esthetic occlusal plane. In addition, it is important to recognize that an upper midline up to 4 mm off the facial does not appear to impact the layperson’s impression regarding smile esthetics.7 The purpose of this series of articles has been to demonstrate that successful outcomes are driven by the ability of a doctor to plan care based upon an in-depth diagnosis and design therapeutics that are consistent with the treatment objectives. In addition, appropriate care surveillance through the patient’s care cycle is a vital ingredient to ensure planned outcomes. Patients do need to be encouraged to participate in their care. This increases the likelihood of successful care. Technology such as suresmile is designed not to dominate the clinician’s judgment but to serve his needs to support the delivery of reliable care. Future articles will expand on the application of suresmile in managing patients requiring interprofessional care. OP

Acknowledgments The authors express their sincerest gratitude and appreciation to Dr. Sharan Aranha, BDS, MPA, and Arjun Sachdeva for their incessant efforts in the preparation of this manuscript.

REFERENCES 1. Sachdeva RCL, Kubota T, Hayashi K, Uechi J, Hasuda M. BioDigital orthodontics: Management of patients with transverse (midline) discrepancies: Part 17. Journal of Orthodontic Practice (Japan). 2013:1-27. 2. Sachdeva RCL, Feinberg MP. Reframing clinical patient management with SureSmile technology. PCSO NewsWire. 2009;2(1):1-24. 3. Sachdeva R. Integrating digital and robot technologies: Diagnosis, treatment planning, and therapeutics. In: Graber LW, Vanarsdall RL, Vig KWL, eds. Orthodontics Current Principles and Techniques. 5th ed. Philadelphia, PA: Elsevier; 2012. 4. Sachdeva RCL, Kubota T, Hayashi K, Uechi J. Transforming orthodontics-4: BioDigital orthodontics (1): Planning care with SureSmile technology. Journal of Orthodontic Practice. 2012;7:83-97.

Figure 16: Patient TE. Final outcome evaluation. VDS (green) vs. VFM (white) superimposition of models clearly demonstrates that the treatment objectives were met

5. Sachdeva RCL, Kubota T, Hayashi K, Uechi J. Transforming orthodontics-5: BioDigital orthodontics (2): Planning care with SureSmile technology. Journal of Orthodontic Practice. 2012;8:91-99. 6. Sachdeva RCL, Kubota T, Hayashi K, Uechi J. Transforming orthodontics-6: BioDigital orthodontics (3): Planning care with SureSmile technology. Journal of Orthodontic Practice. 2012;9:1-18. 7. Kokich VO Jr, Kiyak HA, Shapiro PA. Comparing the perception of dentists and lay people to altered dental esthetics. J Esthet Dent. 1999;11(6):311-324.

44 Orthodontic practice

Volume 6 Number 3

Introducing

My Orthodontist mobile app for your patients

Put your practice at the center of THEIR lifestyle. My Orthodontist gives patients mobile access to information such as appointments; account balance; questionnaires; patient education videos; practice and staff info; social media links; and more! It’s entirely customizable with more than 25 color themes, and can be personalized with your practice logos, images and even practice videos! For more information visit www.dolphinimaging.com/myortho.

Imaging

Aquarium ©

PROPELLING ORTHODONTICS

The impact of integrating Acceleration Technology into your practice Dr. Lou Shuman discusses the benefits of Ortho Acceleration

technologies that impact the entire dentition when the treatment plan calls for treating only one arch. • Many times, it only takes one visit or application to provide 3-6 months of acceleration. This is far more efficient than relying on patients to be compliant on a daily basis and, in many cases, while also attempting to be compliant with aligner wear simultaneously.

• It is by far the most cost-effective treatment available today2 with pricing as low as $100 per patient. Similar to all Acceleration Technologies, your gross production per hour can easily double. • Your annual production is significantly increased as you have more open chair time for new patients by finishing cases so much faster.

46 Orthodontic practice

Volume 6 Number 3

“Last year Propel saved my practice over $100,000 in chair time, for an investment of about $6,000 in Propel devices!” – Thomas S. Shipley, DMD, MS Diplomate, American Board of Orthodontics

A meta description provides the search engines with a description of your website. It is your listing or essentially your elevator pitch n the digital context, giving a prospective patient more information about your practice.

° Send an educational piece to your referring GPs and their hygienists. ° Have a lunch and learn with your referring GPs and a separate one with their hygienists. Take advantage of the marketing ° and promotional tools provided by Propel. With every first purchase, Propel sends a Starter Kit to set up your practice with key advertising and sales pieces. ° Reach out to your local print and broadcast media with a press release to optimize your visibility in the surrounding community. ° Create custom-branded t-shirts for your patients with memorable slogans such as “I Excellerate faster than you do!” Sponsor a soccer team with ° soccer shirts with the Excellerator logo with slogans like “Better, Faster, Stronger.”

Just as I witnessed in the early days of Invisalign, the early adopters reaped significant practice growth and maintained those positions because of their added experience. For years, the last slide of my lecture presentation expressed this single take-away that still resonates today — “There are those who walk the path and those who follow the path.” The Propel bullet train is pulling out of the station — time to jump on before it is too far down the track. 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 Ortho. 2014;145(4 Suppl):S65-73. 2. Pobanz JM. Orthodontic Acceleration: PROPEL Alveolar Micro-Osteoperforation. Orthotown. May 2013;22-25.

This information is sponsored and provided by Propel Orthodontics.

Orthodontic practice 47

PROPELLING ORTHODONTICS

The opportunity to create significant practice differentiation is there for the taking, and there are many directions a practice can take to bring success to this initiative. • Place the word Propel and Acceleration in your title tags. ° Title tags help the search engines understand what your home page and other pages are about. The title tag is listed at the top of your Internet browser and consists of 140 characters. It is many times the first place the spiders, webranking programs, go in looking for relevancy and ranking your website on Google, Bing, and Yahoo. • Add the word Propel and Acceleration to your meta description ° A meta description provides the search engines with a description of your website. It is your listing or essentially your elevator pitch in the digital context, giving a prospective patient more information about your practice. • You have control of both areas above when working with a social media company. If you don’t create the words important to you and your practice, Google will do it for you, which is not a good idea, since it will not reflect your personal perspective of what is important to your practice. • Make your existing and prospective patient base aware that you have introduced a groundbreaking procedure that can cut their time in braces or aligners in half. ° Introduce a section or dedicated page about Propel on your website including a Patient Q and A to improve your ranking for anyone searching in the area. Send an eblast to your whole ° patient base. ° Utilize your social media to spread awareness — create a contest where the winner receives one Propel application at no extra charge. ° Ask patients to share their Propel experiences on your preferred social media property. This grows your reach and provides your practice with referrals and testimonials which are powerful tools. ° Send a direct mail piece within a 10-mile radius of your office.

CONTINUING EDUCATION

Current perception of optimal lip protrusion among African American laypersons Drs. Moshood B. Martins, Daniel Rinchuse, Lauren S. Busch, Anthony L. Farrow, and Thomas Zullo discuss the subtle differences in people’s esthetic preferences Abstract Objective: Patients of different races, genders, and generations have subtle differences in their esthetic preferences. The objective of this pilot study was to evaluate the preferred amount of facial protrusion among 21st-century African American laypersons. Methods: Profile photographs of a male and female subject were digitally altered using Adobe Photoshop to create three different profile types by manipulating the amount of lip protrusion in 3-mm increments. Lip protrusion amount was measured from glabella perpendicular to the outermost part of the upper and lower lip. Each photograph was rated based on level of attractiveness by 40 African American laypersons. Results: The profiles most preferred by the African American laypersons were profiles with natural lip position (0.0 mm-3.0 mm) and mild protrusion (3.1 mm-6.0 mm).There was no difference in preference between natural lip position (0.0 mm-3.0 mm) and mild protrusion (3.1 mm-6.0 mm). However, both were

Educational aims and objectives

This article aims to discuss the preferred amount of facial protrusion for orthodontic treatment among 21st-century African American people.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 52 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Realize that patients of different races, genders, and generations have subtle differences in their esthetic preferences. • Identify the characterization of African Americans’ historical perception of beauty. • Recognize the possible orthodontic esthetic preferences of African Americans. • Realize that esthetic preferences have changed from the early 1990s to the current time. • Realize the importance of understanding the patient’s preference regarding the protrusion threshold when planning orthodontic treatment.

preferred over the more protrusive profiles (6.1 mm-9.0 mm and 9.1 mm-12.0 mm). A few raters preferred the most protrusive profiles to the profiles with natural lip position and mild protrusion. Conclusion: This pilot study was designed after a study conducted by Farrow, et al., in 1993 that investigated optimal levels of lip protrusion among African Americans.

Moshood B. Martins, DDS, is a graduate of Seton Hill University. He was born and raised in Houston, Texas. He played Division 1 basketball at the University of Houston. After graduation, he decided to pursue his dream of becoming a healthcare provider. He went on to receive his Masters in Science from Hampton University and doctorate from Howard University. Dr. Martins currently is practicing orthodontics in Youngstown, Ohio. Daniel Rinchuse, DMD, MS, MDS, PhD, has enjoyed a career in orthodontics for almost 40 years in academics, research, and private practice. Dr. Rinchuse received his Doctorate of Dental Medicine (1974), MS (1974) in Pharmacology/ Physiology, MDS (1976) in Orthodontics, and PhD (1985) in Higher Education from the University of Pittsburgh. He has authored over 90 articles in peer-reviewed journals. Dr. Rinchuse co-authored Evidence-Based Clinical Orthodontics, published in 2012. In addition, he is a Diplomate of the American Board of Orthodontics and editorial consultant for various journals such as the American Journal of Orthodontics and Dentofacial Orthopedics, The Angle Orthodontist, and the European Journal of Orthodontics. Currently, Dr. Rinchuse is Professor and Program Director of Orthodontics at Seton Hill University Center for Orthodontics, Postgraduate Program in Orthodontics, Greensburg, Pennsylvania. Lauren Sigler Busch, DDS, is an orthodontic resident at Seton Hill University. She attended the University of Michigan for her Bachelor in Science and for dental school. Prior to attending dental school, she worked as a orthodontic research assistant for Dr. James McNamara in Ann Arbor, Michigan. She is committed to evidence-based orthodontics and clinically driven research. Thomas Zullo earned his PhD from the University of Pittsburgh where he was a faculty member for over 30 years and is currently Professor Emeritus of Dental Public Health. Dr. Zullo also serves as an adjunct faculty member at the Seton Hill University Center for Orthodontics where he directs dental residents in the design and analysis of their research projects. He has authored or co-authored over 100 articles that have appeared in refereed journals in the fields of dental medicine, medicine, nursing, and education as well as many presentations at professional meetings. Anthony L. Farrow, DMD, is a graduate of Temple University School of Dentistry in 1985 where he received his DMD degree. In 1988, he received a certificate in Orthodontics and an MS degree in Oral Biology from Temple University School of Dentistry. He has been in private practice for over 26 years in Philadelphia, Pennsylvania. He is published in the American Journal of Orthodontics and Dentofacial Orthopedics. Dr. Farrow is a member of the American Association of Orthodontics and the National Dental Association.

48 Orthodontic practice

The laypersons in Farrow’s study found mild protrusion to be the most favorable profile. In this pilot study, the layperson raters did not distinguish between mildly protrusive profiles and profiles with natural lip position. Results from this pilot study suggest that African American laypersons prefer different levels of lip protrusion than they did 20 years ago.

Introduction Upon initial examination and consultation with a patient, the astute orthodontist envisions the patient’s optimal facial esthetic end result.1 Facial esthetics influence an individual’s ability to integrate with society as well as his/her level of self-esteem and psychological well-being.2,3 Today’s orthodontic patients are becoming increasingly aware of the significance of a beautiful smile and overall facial beauty.2,4 In order to conceptualize the patient’s optimal end result, the practitioner should interview the patient.5-10 The patient has his/her own generational, racial, and cultural perceptions of beauty. During treatment planning, the orthodontist may need to set aside his/her own generational, racial, and cultural biases of beauty and treat to the patient’s preferences as long as it does no harm.4 Orthodontists must consider the role race plays in soft tissue profile preferences. Traditionally, African American patients with bimaxillary protrusion and dentoalveolar flaring of the upper and lower teeth would Volume 6 Number 3

African American soft tissue measurements between patients to be greater than in Caucasian patients.15 Farrow, et al.,11 studied African American protrusion in 1993 and found that African Americans prefer slight bimaxillary protrusion over straight profiles. Farrow, et al.’s11 study also found African Americans do not find moderate to severe bimaxillary protrusion as attractive as mild bimaxillary protrusion.

Materials and methods This pilot study aims to add more information regarding African American esthetic preferences — specifically the facial profile — by comparing this study’s results to findings published by Farrow, et al., in 1993. Prior to the collection of any data, approval for this study was obtained from Seton Hill University’s Institutional Review Board. The design of this pilot study was modeled after the study conducted by Farrow, et al.,11 which was published in 1993. This study differs from Farrow, et al.’s in three ways: 1. The scope was narrower since Farrow, et al., had layperson, orthodontist, and general dentist raters, whereas this study only had layperson raters. 2. More modern technology was used to digitally alter target person photographs. A professional graphic designer used Adobe Photoshop (Adobe Systems, San Jose, California) to manipulate lip protrusion and blend skin tone, providing a more natural appearance than Farrow, et al.’s black-and-white photos. P1

3. Era — Farrow, et al.’s study was conducted 21 years earlier. Selection of the target persons Two average level-of-attractiveness African American target persons were selected by one of the authors (MM). The author who selected the target persons (MM) is African American. Target person selection was based on the following inclusion criteria: 1. African American between the ages of 18 and 40 2. No obvious facial abnormalities The target persons were asked to remove all facial jewelry (nose ring, earrings, necklaces, and glasses). Upon each target person submitting a signed consent-toparticipate form, they were asked to identify their race and age. Lateral photographs of the male and female targets were taken against a whitecolored background using a Pentax Optio WG-1 camera. The protocol of a white background follows the standard of the American Board of Orthodontics photographic procedures. A fixed distance of 6 feet between the target person and the camera maintained consistency with each photograph taken. Digital photographs of the target persons were sent in JPEG (Joint Photographic Expert Group) format to a professional graphic designer for alterations of the maxillary and mandibular lips. This study used color profile photographs for the evaluation, P2

Figures 1A-1D N

Figures 2A-2D Volume 6 Number 3

Orthodontic practice 49

CONTINUING EDUCATION

have been treatment planned for extraction of four first premolars, producing a more straight facial profile.11,12 Possibly , this treatment plan may have led to disappointing results for an African American who would have preferred to maintain his/her protrusive profile. African Americans’ perception of beauty has been briefly characterized in the orthodontic literature, but as a whole the literature is limited.11 African American anatomical features lend them to having more protrusion and thicker lips than their Caucasian counterparts.11 In a study using 100 different photographs of African American soft tissue profiles, Sushner demonstrated that Ricketts’ esthetic plane, Holdaway’s “H line,” and Steiner’s “S line” were not applicable to African Americans because of their naturally fuller profiles.13 Further, cephalometric norms for African Americans also reflect more protrusive soft tissue profiles than Caucasians. While normative values of African American protrusion may remain relatively constant over time, the practitioner must constantly weigh what their African American patients consider to be the minimum and maximum threshold of esthetic facial protrusion.10,14 In a cephalometric study deriving soft tissue norms from 82 African American adolescents with Class I occlusions and well-balanced faces, Dr. Larry White concluded that the absence of strain in and around the lips when the patient is in centric occlusion translates into favorable soft tissue contour irrespective of lip thickness. He also found the range of acceptable

CONTINUING EDUCATION which allowed a more natural representation of facial esthetics than silhouettes and profile drawings.16 The graphic designer matched skin complexion and merged facial structures to mask the lips’ digital advancement. Lip protrusion was measured in the same manner used by Farrow, et al.11 The glabella perpendicular line, which is a line from the soft tissue glabella drawn perpendicularly to Frankfort horizontal was measured to the most prominent point on the upper and lower lip. The target persons’ profiles each began in the natural (N) category, with the outermost portion of the lips measuring 0.0 mm-3.0 mm from glabella perpendicular. From the target photo’s natural (N) position, the lips were digitally advanced horizontally using Adobe Photoshop (Adobe Systems, San Jose, California) in 3-mm increments. Lips in the range of 0.0 mm-3.0 mm of the line glabella perpendicular were classified as normal (N). Lip protrusion from 3.1 mm-6.0 mm was classified as protrusive one (P1). Lips that measured 6.1 mm-9.0 mm from glabella perpendicular were classified as protrusive two (P2). Finally, lips that measured 9.1 mm -12.0 mm from glabella perpendicular were classified as protrusive three (P3) (Figures 1A-1D and 2A-2D). Selection of the raters Fifty African American laypersons were recruited from a Bible study group in Washington, D.C., to evaluate four profile photos of the two target persons. Raters had to meet the following inclusion criteria in order to qualify to participate in the study: 1. African American male or female between the ages of 25-40 2. Identify themselves as African American 3. No experience in the field of dentistry From the group, 40 individuals (24 males and 16 females) met the inclusion criteria and agreed to participate in the study. Following signed consents, a folder was handed to each rater with detailed instructions. Raters were asked to report their age, race, and sex. Raters were given a two-page composite of eight randomly manipulated photographs of the male and female African American target persons to rank. The first page displayed the male target with four different profiles. (Figures 1A-1D) The second page displayed the female target person with four different profiles. (Figures 2A-2D) The raters were asked to rank each composite from one through four based on level of attractiveness. One was labeled as most unattractive, two unattractive, three second-most attractive, and four most attractive. The raters were told to assign only one number per profile. Rating 50 Orthodontic practice

Table 1: Lip Position Means 95% Confidence Interval Lower Bound

Lip Position

Mean Rating

Standard Error

Upper Bound

0.0-3.0 mm

3.229

.120

2.985

3.473

3.1-6.0 mm

3.104

.113

2.875

3.333

6.1-9.0 mm

2.354

.092

2.167

2.541

9.1-12.0 mm

1.302

.116

1.067

1.538

Table 2: Pairwise Comparisons of Lip Positions 95% Confidence Interval for Differenceb Lower Bound

(I) Lip Position

(J) Lip Position

Mean Difference (I-J)

Standard Error

Sig.b

0.0-3.0 mm

3.1-6.0 mm

.125

.151

.414

-.181

.431

6.1-9.0 mm

.875*

.197

.000

.476

1.274

9.1-12.0 mm

1.927*

.212

.000

1.497

2.357

6.1-9.0 mm

.750*

.180

.000

.385

1.115

9.1-12.0 mm

1.802*

.213

.000

1.370

2.234

9.1-12.0 mm

1.052*

.113

.000

.824

1.280

3.1-6.0 mm

6.1-9.0 mm

was requested in this particular manner to eliminate any mutual rating of any photographs. All data was collected and tabulated for statistical evaluation.

Results Analysis of variance showed that the only statistically significant difference was for the level of lip protrusion (F = 47.69, P< 0.0004). There were no statistically significant interaction effects for target photo gender versus rater gender (F = 0.661, P = 0.421) or gender of target photo versus lip protrusion (F = 1.187, P< 0.318). Pairwise comparison demonstrated no differences between the natural lip position (0.0 mm-3.0 mm) and protrusion one (3.1 mm-6.0 mm). The natural lip protrusion (0.0 mm-3.0 mm) is significantly more attractive than both protrusion two (6.1-9.0 mm) and protrusion three (9.1 mm -12.0 mm). Pairwise comparisons also revealed that protrusion one (3.1 mm-6.0 mm) was viewed as more attractive than protrusion two (6.1 mm-9.0 mm) and protrusion three (9.1 mm-12.0 mm). Additionally, protrusion two (6.1 mm-9.0 mm) was viewed as significantly more attractive than protrusion three (9.1 mm-12.0 mm) (Tables 1 and 2). However, four raters found protrusion three to be most attractive, and 10 raters found protrusion two to be the most attractive.

Discussion Darwin once wrote17: “It is certainly not true that there is in the mind of man any

Upper Bound

universal standard of beauty with respect to the human body. … The men of each race prefer what they are accustomed to behold.” Race plays one of the most central roles in patient esthetic preferences. However, orthodontic literature on esthetics is heavily Caucasian-centered with fewer studies on minority races. Therefore, when treating minority populations such as African Americans, the orthodontist may need to better familiarize himself/herself with the African American esthetic literature, interview the patient regarding esthetics, and set aside his/her racial preferences in order to properly treatment plan the case.18-29 Racial esthetic preferences are dynamic. Caucasian models from the early 1900s have straighter profiles than today’s super models, who have fuller profiles with more protrusive lips.18 African American optimal esthetics may be even more complex and changing than other races, as their makeup has so drastically changed in the past few decades, including a rise in the number of interracial children.30 Soft tissue profile preference among African American patients is further complicated by the fact that the term African American is an ambiguous term. The Census Bureau, for instance, identifies Black or African American according to the Office of Management and Budget’s definition as a “person having origins in any of the Black racial groups of Africa.”31 However, the Black category also includes respondents who report African American, Sub-Saharan Volume 6 Number 3

Volume 6 Number 3

patients through communication and not assumption.32 The orthodontist can theoretically influence the soft tissue profile through various techniques and procedures such as lip reduction through extraction of the maxillary and mandibular first premolars and/or surgery in extremely protrusive patients.33-36 However, treatment to enhance soft tissue profile in one patient could potentially detract from the esthetics of the optimal soft tissue profile in another patient. A few raters preferred the most protrusive of profiles (P3 and P4). To achieve the best esthetic final outcome in these outlier raters, an orthodontist treating these types of individuals need to know that their protrusion threshold is higher by questioning them about their preferences about facial profiles.

Conclusions 1. Raters agreed upon the optimal level of lip protrusion (<6.1 mm from glabella

perpendicular) irrespective of target photo gender or rater gender. 2. African American laypersons raters found natural lip position and slight protrusion to be the most attractive profiles when compared to profiles of greater protrusion, and found no difference between these two profile variations. 3. The results of this pilot study have similar findings to those published by Farrow, et al., in 1993. However, raters in this pilot study found the straight profile to be more acceptable than the layperson raters in 1993. This pilot study is too small to reflect a trend; however, a larger sample may also show that in the past two decades, African Americans find less protrusion more acceptable/attractive than they did 20 years ago. Continued research is recommended to follow changes in esthetic preferences among the African American race. OP

REFERENCES 1.

Collins M. The eye of the beholder: Face recognition and perception. Semin Orthod. 2012;18:229-234.

Howells DJ, Shaw WC. The validity and reliability of ratings of dental and facial attractiveness for epidemiologic use. Am J Orthod. 1985;88(5):402-408.

Knight H, Keith O. Ranking facial attractiveness. Eur J Orthod. 2005;27(4):340-348.

Arpino VJ, Giddon DB, BeGole EA, Evans CA. Presurgical profile preferences of patients and clinicians. Am J Orthod Dentofacial Orthop. 1998;114(6):631-637.

Riedel RA. An analysis of dentofacial relationships. Am J Orthod. 1957;43(2):103-109.

Burstone CJ. Integumental contour and extension patterns. Angle Orthod. 1959;29(2):93-104.

Merrifield LL. The profile line as an aid in critically evaluating facial esthetics. Am J Orthod. 1966;52(11):804-822.

Holdaway RA. A soft-tissue cephalometric analysis and its use in orthodontic treatment planning. Part I. Am J Orthod. 1983;84(1):1-28.

Arnett GW, Jelic JS, Kim J, Cummings DR, Beress A, Worley CM Jr, Chung B, Bergman R. Soft tissue cephalometric analysis: Diagnosis and treatment planning of dentofacial deformity. Am J Orthod Dentofacial Orthop. 1999;116(3):239-253.

10. Altemus L. A comparison of cephalofacial relationships. Angle Orthod. 1960;30(4):223-240. 11. Farrow A, Zarrinnia K, Azizi K. Bimaxillary protrusion in black Americans-- An esthetic evaluation and the treatment consideration. Am J Orthod Dentofacial Orthop. 1993;104(3):240-250. 12. Montini RW, McGorray SP, Wheeler TT, Dolce C. Perceptions of orthognathic surgery patient’s change in profile: A five-year follow-up. Angle Orthod. 2007;77(1):5-11. 13. Sushner NI. A photographic study of the soft-tissue profile of the Negro population. Am J Orthod. 1977;72(4):373-385. 14. Altemus LA. Comparative integumental relationships. Angle Orthod. 1963;33(3):217-221. 15. White L. A cephalometric search for the ideal African-American profile. Orthod Pract US. 2012;3:18-23. 16. Coben ES. Basion Horizontal. Jenkintown, Pennsylvania: Computer Cephalometrics Associated; 1986. 17. Darwin C. The Descent of Man, and Selection in Relation to Sex. Volume II. 1st ed. London, UK: John Murray; 1871: 337. 18. Auger TA, Turley PK. The female soft tissue profile as presented in fashion magazines during the 1900s: A photographic analysis. Int J Adult Orthodon Orthognath Surg. 1999;14(1):7-18. 19. Goldman S. The variations in skeletal and denture patterns in excellent adult facial types. Angle Orthod. 1959;29(2):63-92. 20. Cox NH, Van der Linden FP. Facial harmony. Am J Orthod. 1971;60:175-183. 21. Foster EJ. Profile preference among diversified groups. Angle Orthod. 1973;43(1):34-40. 22. De Smit A, Dermaut L. Soft-tissue profile preference. Am J Orthod. 1984;86(1):67-73. 23. Czarnecki ST, Nanda RS, Currier GF. Perceptions of a balanced facial profile. Am J Orthod Dentofacial Orthop. 1993;104(2):180-187. 24. Cochrane SM, Cunningham SJ, Hunt NP. Perceptions of facial appearance by orthodontists and the general public. J Clin Orthod. 1997;31(3):164-168. 25. Thomas RG. An evaluation of the soft-tissue facial profile in the North American black woman. Am J Orthod. 1979;76(1):84-94. 26. Martin JG. Racial ethnocentrism and judgment of beauty. J Soc Psychol. 1964;63:59-63. 27. Cross JF, Cross J. Age, sex, race and the perception of facial beauty. Dev Psychol. 1971;5(3):433-439. 28. Foster EJ. Profile preferences among diversified groups. Angle Orthod. 1973;43(1):34-40. 29. Lines PA, Lines RR, Lines CA. Profilemetrics and facial esthetics. Am J Orthod. 1978;73(6):648-657. 30. Nomura M, Motegi E, Hatch JP, Gakunga PT, Ng’ang’a PM, Rugh JD, Yamaguchi H. Esthetic preferences of European American, Hispanic American, Japanese, and African Judges for soft-tissue profiles. Am J Orthod Dentofacial Orthop. 2009;135(4Suppl):S87-S95. 31. Rastogi S, Johnson TD, Hoeffel EM, Drewery MP Jr .The Black Population: 2010. 2010 Census Briefs. Sept 2011;1-20. C2010BR06. http/www.census.gov/prod/cen2010/briefs/c2020br-06.pdf. 32. Proffit WR, Fields HW, Sarver DM. Contemporary Orthodontics. 4th ed. St. Louis: Mosby/ Elsevier; 2007. 33. DeLoach N. Soft Tissue Facial Profile of North American Blacks, a Self Assessment. [dissertation]. Detroit, MI: University of Detroit Mercy; 1978. 34. Oliver BM. The influence of lip thickness and strain on upper lip response to incisor retraction. Am J Orthod. 1982;82(2):141-149. 35. Garner LD. Soft tissue changes concurrent with orthodontic tooth movement. Am J Orthod. 1974;66(4);367-377. 36. Sarver D. The profession and business of orthodontics. Orthodontics (Chic.). 2011;12(3):173-175.

Orthodontic practice 51

CONTINUING EDUCATION

African, and Afro-Caribbean entries. However, in the Census, an individual can report more than one race that refers to the multiple-race Black population. Those who identify with the Black alone category number is 38,929,319 while those who identify as combination is 1,330,180. African Americans combined make up 13.6% of the U.S. population. The total African American population alone or in combination was 15.4% in 2010. Moreover the African American in combination, or multiracial, has risen 75% from 2000-2010.31 Therefore, Blacks who reported themselves as combination grew at a faster rate than the Black alone population. Because of the high number of Blacks who identify themselves as multiracial, the definition of African American esthetics may become more intertwined with other populations as more persons identify themselves as African Americans in combination. The black and white population was reported as the most frequent combination.31 Therefore, an orthodontist who is treating an African American may need to discuss with patients not only which race they identify with, but also if they identify themselves as being part of multiple races. Once an orthodontist determines which race patients are, he/she should ask which origin and then delve into that origin’s esthetics. Further, it is possible that a patient prefers a different race’s esthetic norm. This should also be discussed before treatment planning. This pilot study highlights the fact that within a minority race, esthetic preferences may have changed from the early 1990s to now. Farrow, et al.’s study found African American laypersons to prefer a mildly protrusive profile, comparable to this study’s protrusive one category (P1). However, while Farrow, et al., raters found the straight profile to be less desirable than P1, in this study, African American laypersons did not distinguish between N and P1. The most attractive profiles were those in which the lips were <6.1 mm from glabella perpendicular. Perhaps raters in this study are reflective of the more recent African American preferences, which likely come from a more mixed population than homogenous population. One of the limitations of this pilot study is that it did not ask raters to specify whether or not they considered themselves 100% African American or of multiple races. This pilot study is important to any orthodontic practitioner treating minority patients, particularly treating African American patients. It demonstrates that an orthodontist must evaluate the protrusion threshold of his/her

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REF: OP V6.3 MARTINS REF: OP V6.3 SCHUDY/WHITE

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Current perception of optimal lip protrusion among African American laypersons

Improving alignment by modulating archwire force

SCHUDY/WHITE

MARTINS, ET AL.

Facial esthetics influence an individual’s ability to integrate with society as well as his/her level of _______. a. self-esteem b. psychological well-being c. intelligence d. both a and b The patient has his/her own _______ of beauty. a. generational perceptions b. racial perceptions c. cultural perceptions d. all of the above Traditionally, African American patients with bimaxillary protrusion and dentoalveolar flaring of the upper and lower teeth would have been treatment planned for extraction of ________, producing a more straight facial profile. a. four second premolars b. two first premolars c. four first premolars d. two second premolars In a study using 100 different photographs of African American soft tissue profiles, Sushner demonstrated that __________ was(were) not applicable to African Americans because of their naturally fuller profiles. a. Ricketts’ esthetic plane b. Holdaway’s “H line” c. Steiner’s “S line” d. all of the above Further, cephalometric norms for African Americans also reflect ____ soft tissue profiles than Caucasians. a. less protrusive b. more protrusive c. less balanced d. more strained In a cephalometric study deriving soft tissue norms

52 Orthodontic practice

from 82 African American adolescents with Class I occlusions and well-balanced faces, Dr. Larry White concluded that _______ in and around the lips when the patient is in centric occlusion translates into favorable soft tissue contour irrespective of lip thickness. a. the absence of strain b. a minimum protrusion c. increase of protrusion d. a maximum protrusion 7.

10.

So perhaps, unwittingly, the addition of dual wires as in this experience has resulted in ______, which

increase the rate

decrease the rate

minimize the biomodulation

b. osteoperforation

identify the source

c. biomodulation

accelerates the movement of teeth.

Schwartz stated that capillary pressure of _____ would be the most physiologic with which to initiate

with increased bone turnover and faster tooth

tooth movement.

movement.

10 grams

a. platelets

15 grams

b. cytokines

20 grams

c. prostaglandins

25 grams

both b and c 8.

The passive self-ligating brackets do allow easier

Infrared laser has had a controlled evaluation that

sliding and apparently _______.

showed a ________ in cuspid retraction.

less friction

10% increase

less binding

22% increase

more friction

38% increase

both a and b

25% decrease 9.

activity of end stage cells

of _________ that are known to be associated

d. 3.

RAP (Regional Acceleration Phenomenon)

(In osteoperforation) These punctures physiologically mimic tissue trauma and bring about the release

The most attractive profiles were those in which the lips were _______ from glabella perpendicular. a. <4.1 mm b. <5.1 mm c. <6.1 mm d. <7.1 mm It (this pilot study) demonstrates that an orthodontist must evaluate the protrusion threshold of his/her patients through communication and ________. a. not assumption b. comparison with others of the same facial profile c. the orthodontist’s esthetic intuition d. the norms of the homogenous population

d. 2.

He (Dr. White) also found the range of acceptable African American soft tissue measurements between patients to be _____ in Caucasian patients. a. less than b. equal to c. greater than d. less moderate than Therefore, when treating minority populations such as African Americans, the orthodontist may need to _____ in order to properly treatment plan the case. a. better familiarize himself/herself with the African American esthetic literature b. interview the patient regarding esthetics c. set aside his/her racial preferences d. all of the above

Efforts have been made recently to _________ of our tooth movement.

Photo biomodulation or the use of near-infrared light

Obviously, clinicians save more time with patients who have greater ________.

is known to stimulate more cytochrome oxidase c

lip protrusion

production which mediates _____ ATP.

initial arch irregularity

a decrease in

pain tolerance

an increase in

cellular activity

an equalization of

elimination of

10.

There are a number of ________ forces at work currently that provoke less quality of orthodontic

Teeth move _______ during ligation with the dual-

therapy.

archwires despite increased friction.

a. dental

b. societal

extremely slowly

b. passively

c. economic

remarkably fast

all of the above

d. 30%

Volume 6 Number 3

CE CREDITS

ORTHODONTIC PRACTICE CE

Drs. George F. Schudy and Larry White explore acceleration of tooth movement

rom the beginning of the profession to the present time, orthodontists have been best known for aligning or straightening teeth. While our work involves much more — e.g., skeletal correction, TMJ harmony, bite correction, and so forth — it all begins with alignment. This is not only the phase for which we are best known, but alignment precedes the other phases. Frequently, our pivotal phases cannot be addressed properly before the alignment phase. Ironically, this perfunctory step stands timewise between us and the more complex and time-consuming aspects of our treatment. Any acceleration in this phase can be applied directly to our end goal of facilitating the other phases of treatment.

Literature — how fast do teeth move? Jones, et al.,1 and O’Brien, et al.,2 in benchmark alignment studies in 1990 tested .014 NiTi and .015 multistrand stainless steel (S.S.), .016 Nitinol and Titanol, respectively. Each wire was in place 35 days. Their average rates of tooth movement for their fastest alignment wires were 1.4 mm/month. Eighteen years later, Scott, et al.,3 were motivated to study Damon® self-ligating (SL) alignment versus synthesis conventional ligation (CL). The rate of alignment was measured through the use of three wires: .014 NiTi, .014 x .025 NiTi, and .018 x .025 NiTi. Alignment continued until placement of a S.S. rectangular wire was possible. The rate of alignment was greatest during the use of the .014 NiTi — i.e., 3.6 mm/month for (CL) and 3.0 mm per month for (SL). Overall, however, the rate dropped significantly. Total rate was slightly less (243 days) with the conventional ligation (CL) and 253 days for Damon (SL). The (CL) had an alignment rate of .056 mm per day, and (SL) had an alignment rate of .047 mm

George F. Schudy, DDS, MS, FACD, is in Private Practice of Orthodontics, Houston, Texas, and is Adjunct Professor of Orthodontics at The University of Texas School of Dentistry at Houston. Larry White, DDS, MSD, FACD, is in Private Practice of Orthodontics in Dallas, Texas, and is Adjunct Professor of Orthodontics at Texas A&M University Baylor College of Dentistry in Dallas, Texas.

Volume 6 Number 3

Educational aims and objectives

This article aims to discuss various methods of tooth movement during the alignment phase of treatment.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 52 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify some of the various methods of tooth movement. • Realize how any acceleration in this phase can facilitate the other phases of treatment. • See some examples of alignment during dual-arch use and after.

per day. For a 28-day month, this was a rate of 1.5 mm per month for (CL) and 1.3 mm per month for (SL). Ong, et al.,4 did a similar study to compare initial alignment of Damon self-ligation (SL) versus conventional ligation — Victory series (CL). In this study, two wires, .014 NiTi and .014 x .025 NiTi, were left in place for a fixed time interval of 10 weeks each. As with Scott, et al., the conventional ligation (CL) alignment produced faster tooth alignment than selfligation (SL). In the mandible, the (CL) alignment (or reduction in irregularity) for the first 10 weeks was 8.4 mm of the initial 12.5 mm of irregularity and (SL) reduced irregularity 6.5 mm of 10.8 mm. This produced a rate of 3.3 mm/28-day month for (CL) and 2.6 mm/ month for (SL). In the maxilla during the first 10 weeks, the (CL) reduced at a rate of 2.7 mm/month and the (SL) was 2.6 mm/month. During the second 10 weeks in the Ong, et al., study, the rates dropped as they did in the Scott study. The (CL) rate was .5mm/month, and the (SL) was .3mm/month. This fall off in rates in the second 10 weeks, when averaged with the first 10 weeks, slows the overall (20 weeks) rate of alignment. The (SL) was 1.5 mm/month for upper and lower and (CL) averaged 1.8 mm/month for upper and lower. Sebastian in 20125 studied alignment efficiency in the mandibular arches of 24 patients. Wires tested were .016" NiTi (single strand) versus .016" NiTi (woven, coaxial). Tooth movement was measured at 4 weeks, 8 weeks, and 12 weeks. The braided .016 NiTi produced the fastest alignment with average first month alignment of 4.9 mm/ month. The second and third months decreased to 3.6 and 3.1 mm per month respectively. Overall rate over 3 months was

3.9 mm/month. These rates were faster than those observed in past alignment studies by a factor of 2.6. The single strand .016" NiTi had an initial rate of 1.5 mm/month, and this decreased in the second and third months. Efforts have been made recently to increase the rate of our tooth movement. Some of these are vibration therapy, osteoperforation, infrared laser, and photo biomodulation. Most of these high-tech efforts are expensive, and some have not yet had control studies. Others have been studied relative to space closure and not initial alignment efficiency. Osteoperforation has been shown by Teixeira, et al.,6 to increase the rate of tooth movement in rats. The small tissue traumas elicit the regional accelatory phenomenon that occurs as a healing response to trauma or surgery. These punctures physiologically mimic tissue trauma and bring about the release of cytokines and prostaglandins that are known to be associated with increased bone turnover and faster tooth movement.7-10 This concept has only had a controlled clinical trial evaluating the effects in cuspid retraction.11 This showed a 130% increase over a 28-day period. It has also been shown in one patient study to increase Invisalign® movement by 28%.12 Infrared laser has had a controlled evaluation that showed a 38% increase cuspid retraction.13 Vibration therapy has had one university administered study14 that showed initial alignment improvement of approximately 30% in the mandible compared to benchmark studies (Jones, et al.; O’Brien, et al.). This study also showed maxillary alignment to be 3 mm/month or 100% more than the early studies. Orthodontic practice 53

CONTINUING EDUCATION

Improving alignment by modulating archwire force

CONTINUING EDUCATION Photo biomodulation or the use of nearinfrared light is known to stimulate more cytochrome oxidase c production15 which mediates an increase in ATP. It is assumed that more ATP would facilitate tooth movement. Exposure in the facial area over the alveolar processes at a 850 mm wavelength for 60 minutes per week resulted in a 120% increase in the rate of alignment.16 The control rate was 1.9 mm per month, and the test sample rate was 4.4 mm per month.

Figures 1A-1B: 1A. A maxillary arch with only a .014 annealed wire in place. They are usually pressed lightly into the interproximal. 1B. A mandibular annealed wire is used in the same way but is .012 in size. The annealed wires usually only extend to the first premolars and are placed first and held by one or two elastomers until the NiTi wire is placed

Modulating wire protocol review This dual-arch initial wire protocol as described in a previous article17 starts treatment with a round NiTi archwire, the force of which is modulated by an underlying annealed wire. Figure 1A shows an .014 annealed wire by itself in place in the maxillary arch and an .012 annealed wire in place in the mandibular arch (Figure 1B). This wire has no spring but is usually pressed lightly into the interproximal areas to assure passivity. Figure 2 shows a maxillary arch (2A) and mandibular arch (2B) with both wires in place â&#x20AC;&#x201D; maxillary .014 NiTi with a .014 annealed wire and a mandibular .012Â NiTi with an annealed .012 wire. After 3 to 5 weeks, the annealed wire is removed. Removal is demonstrated in Figure 3. Ties are removed from one to three teeth, and the annealed wire is clipped usually between the centrals. The patient bites tightly on a cotton roll, and the clinician pulls the wire through the brackets with a Weingart pliers. The patient experiences no discomfort in this procedure, and it takes only 1-2 minutes to perform. Teeth move remarkably fast during ligation with the dual-archwires despite increased friction. But after removal of the annealed wire, the teeth move at a particularly rapid pace.

Examples of alignment during dualarch use and after Each of the following patients shows the initial arch irregularity (as per Littleâ&#x20AC;&#x2122;s18 Irregularity Index), followed by the change while the two archwires are in place together and finally the change after the annealed wire was removed. The duration and rates of movement are noted.

Figures 2A-2B: 2A: A maxillary arch with an .014 NiTi and an .014 annealed wire together. 2B. A mandibular arch with an .012 NiTi and an .012 annealed wire

Figures 3A-3B: Annealed wire removal. 3A. Two to three elastomers are removed, and the annealed wire is isolated and cut between the central incisors. 3B. The patient bites on a cotton roll tightly, and the annealed wire is pulled out through the brackets. If significant irregularity is still present, additional elastomers may need removal

Figures 4A-4C: 4A. Patient A. S., 19.7 mm Irregularity Index (I.I.) Treatment started 8.20.13 with .014 annealed and .014 NiTi wires. 4B. 27 days later, annealed wire removed. 4C. Alignment 14 days later, rate = 14. mm/mo.

Figures 5A-5C: 5A. Patient A.M., 18.3 mm I.I, Tx. started 8.17.09 with a .014 annealed wire and a .014 NiTi wire. 5B. 37 days later, annealed wire removed. 5C. Alignment 18 days later, rate = 9.6 mm/mo.

The etiology of rapid alignment At this point, one can only conjecture about the mechanism that results in such rapid alignment, but it does call to mind the biological system known as Regional Acceleration Phenomenon (RAP), which was first described by Frost19 and noted earlier. Researchers have learned that RAP occurs 54 Orthodontic practice

Figures 6A-6C: 6A. Patient L.W., 10.5 mm I.I., Tx. started 10.27.11 with a .014 annealed wire and a .014 NiTi wire. 6B. 28 days later, annealed wire removed. 6C. Alignment 13 days later, rate = 7.1 mm/mo. Volume 6 Number 3

Figures 7A-7C: 7A. Patient M., 11. mm I.I., Tx. started 10.15.12 with a .014 annealed wire and a .014 NiTi wire. 7B. 21 days later, annealed wire removed. 7C. Alignment 14 days later, rate = 8.3 mm/mo.

Figures 8A-8C: 8A. Patient J.B., 13. mm I.I., Tx. started 10.27.09 with a .014 annealed wire and a .014 NiTi wire. 8B. 27 days later, annealed wire removed. 8C. Alignment 20 days later, rate = 7.6 mm/mo.

Figures 9A-9C: 9A. Patient D.T., 11.5 mm I.I., Tx. started 5.9.11 with a .014 annealed wire and a .014 NiTi wire. 9B. 7 days later, annealed wire removed. 9C. Alignment 29 days later, rate = 8.3 mm/mo. * Rate calculated on 10. mm I.I. since some irregularity remained

In vitro testing Drs. Freudenthaler and Pseiner at the University of Vienna Orthodontic Department tested this dual-wire protocol. They used a 3D testing device developed by Dr. Hans-Peter Bantleon. This device (Figure 12) is capable of simulating a three-tooth segment and testing the force from a deflection or rotation of the middle tooth. Testing was done for rotation of the maxillary canine. Brackets for the lateral, canine, and first premolar were placed, and the maxillary canine rotated 20Â°. In Figure 13, the test setup is shown with a twin bracket on the lateral and single brackets on the canine and first premolar. The lateral slot was .016 in.,

Figures 10A-10C: 10A. Patient V.H., 11. mm I.I., Tx. started 6.2.10 with a .014 annealed wire and a .014 NiTi wire. 10B. 26 days later, annealed wire removed. 10C. Alignment 15 days later, rate = 7.1 mm/mo. * Rate calculated on 10.0 mm I.I. since some irregularity remained.

Figures 11A-11C: 11A. Patient L.B., 11.1 I.I., Tx. started 11.8.11 with a .014 annealed wire and a .014 NiTi wire. 11B. 26 days later, annealed wire removed. 11C. Alignment 9 days later, rate = 7.2 mm/mo. * Rate calculated on 10.1 mm I.I. since some irregularity remained

Figure 12: This 3D testing machine at the Department of Orthodontics, Medical University of Vienna was used to measure the forces delivered by the dual-wire system Volume 6 Number 3

Figures 13A-13B: Test setup: 13A. The three-tooth (lateral, canine, first premolar) test setup with a .014 NiTi wire in place. 13B. The same test setup with a.014 NiTi and a .014 annealed wire in place Orthodontic practice 55

CONTINUING EDUCATION

with many provocations â&#x20AC;&#x201D; e.g., tooth extractions, gingival flap surgery, mini-implant insertion, orthognathic surgery, etc. â&#x20AC;&#x201D; and this causes a more rapid movement of teeth than otherwise might happen.20-22 Melsen23 has even suggested that intrusion of incisors resulted in RAP with dense woven bone as proof of its involvement. So perhaps, unwittingly, the addition of dual wires as in this experience has resulted in RAP, which accelerates the movement of teeth. Another possibility is that the resultant force to the periodontal membrane of this protocol may impart a force that dips below that of traditional wire bracket mechanisms and is more physiologic. Schwartz24 stated that capillary pressure of 25 gm would be the most physiologic with which to initiate tooth movement. Thilander, et al.,25 contend that most traditional initial orthodontic wires have the potential to impede tooth movement by causing sterile necrosis or hyalinization. Many orthodontists begin treatment with a NiTi wire of approximately .014 in size. Our initial hope and assumption were that the force produced by this protocol modulated the .014 NiTi and the .012 NiTi (mandibular) to result in substantially less force.

CONTINUING EDUCATION and the canine and first premolar were .018 in. The interbracket distances were set to simulate average sized teeth and were 7 mm. Figure 13A shows the setup with one traditional .014 NiTi in place and Figure 13B with a .014 NiTi wire in combination with the .014 annealed wire. The results of the testing for the maxilla are seen in Figure 14. For a 20° rotation, the .014 NiTi applied 722.6 cNmm and the .014 NiTi with the .014 annealed wire yielded 300.8 cNmm. This is 103.1 gms for the .014 alone and 42.8 gms when the annealed wire is present. The standard deviations were ± 56.1 and ± 44.2, respectively. Mandibular testing was done in exactly the same manner as the maxillary testing but with a .012 NiTi and a .012 annealed wire. With a 20° rotation, the .012 NiTi alone applied 588.1 (SD, 48) cNmm of force and the .012 NiTi with the annealed wire applied 221.5 cNmm (SD, 59) of force. This is 84.9 gms for .012 NiTi when applied alone and 31.5 gms when slowed by the annealed wire. Applying the standard deviations, the modulated .014 NiTi applied between 35-50 gm. The modulated .012 wire applied 23-40 gm. The mandibular test results are depicted in Figure 15.

The .014 by itself applies 2.4 times the force of the same wire when restrained by an annealed wire, and the .012 alone applies 2.7 more force when not restrained by an annealed wire. It may be that these very low forces are close to the true physiologic force and launch the cellular cascade of periodontal changes in nearly an ideal way. The cells of the periodontal membrane may be preconditioned, so to speak, to allow more efficient cellular activity. The force is extremely low, but also it is dispensed to the teeth at a gradual rate given the blocking nature of the annealed wire with the increased friction and resistance. The very instant that the annealed wire is removed, all patients report a sensation of increased force on their teeth. A preconditioned periodontal membrane may be able to embrace this greater force and allow for more physiologic development and activity of end stage cells (osteoclasts and osteoblasts). This would promote and/ or allow more efficient and therefore more rapid movement.

Discussion

Figure 14: Test results for the maxillary arch. The .014 wire by itself applies 2.4 times the force of the same wire applied with the .014 annealed wire

Figure 15: Test results for mandibular arch. The .012 NiTi by itself applies 2.7 times more force than when it is modulated by the .012 annealed wire

This initial alignment technique produces greater rates of tooth alignment than any other previously reported studies. We have measured a group of 17 patients. Basically, these represent all recent patients that fit the criterion of significant arch irregularity that would have previously been aligned with a continuous arch without coil springs. Certainly, a controlled study of this technique in the future would be appropriate and desirable. However, there is significant consistency in these patients with dramatic rates of movement. Table I shows the measured results of our patients. Table II shows a summary of results from previous alignment studies. The average rates of alignment from all previous studies is 2.6 mm/month. For this average, only the studies from 2006 forward were used. Where standard deviations were available, it was possible to calculate the fastest one rate measured in each study; these are also listed in Table II.

Table 1: Individual Dual-Wire Alignment Results Patient

Initial Irregularity

Rate of Change

Stogsdill

19.7 mm

14.0 mm/mo.

Jesse

16.5 mm

10.0 mm/mo.

Jamilah

13.0 mm

7.6 mm/mo.

Alexandra

18.3 mm

9.6 mm/mo.

McGee

11.0 mm

8.3 mm/mo.

Regan

9.5 mm

7.9 mm/mo.

Bocanegra

11.1 mm

7.2 mm/mo.

Wang

10.5 mm

7.1 mm/mo.

Vanessa

10.0 mm

7.1 mm/mo.

Tucker

11.0 mm

7.0 mm/mo.

Javier

12.5 mm

6.4 mm/mo.

Taubman

9.5 mm

8.3 mm/mo.

Caroline

9.6 mm

6.0 mm/mo.

Oliver

11.0 mm

Dumas

Table 2: Historical Alignment Study Results Study

Average Rate

Maximum Rate Measured

Jones, et. al 1990

1.5 m/mo.

3.3 m/mo.

O’Brien, et. al 1990

1.4 m/mo.

2.4 m/mo.

Mandall, et. al 2006

1.5 m/mo.

3.3 m/mo.

Scott, et. al 2008

1.5 m/mo.

4.9 m/mo.

5.7 mm/mo.

Pandis29, et. al 2009

1.5 m/mo.

5.4 m/mo.

8.0 mm

5.3 mm/mo.

Ong, et. al 2010

2.0 m/mo.

3.4 m/mo.

Perez

9.1 mm

4.7 mm/mo.

Sandu , et. al 2012

4.2 m/mo.

4.7 m/mo.

Xiaafeng

10.0 mm

3.7 mm/mo.

Sebastian 2012

3.9 m/mo.

5.7 m/mo.

Average

11.7 mm

7.5 mm/mo.

Avg of Past Studies Since 2006

2.4 m/mo.

4.8 m/mo.

All rates are based on 28 days 56 Orthodontic practice

Where possible rate was calculated on a 28-day month Volume 6 Number 3

What about friction? One of the anathemas for contemporary orthodontics has been friction. This has been encouraged by varied ways of securing wires in the brackets to produce less friction and binding. These are the “self-ligating” type brackets. The passive self-ligating brackets do allow easier sliding and apparently less friction and binding. If such movement is essential to initial alignment, and friction reduces this movement, then friction would be undesirable. Dr. Dwight Damon stated in 2012,26 “What I also find interesting in Dr. Burrow’s paper is that in utilizing small round wires (.014, for example), friction (not binding) constitutes more than 95% of the total resistance to sliding, and that is exactly why low-friction passive ligation is more efficient than conventional ligation during the alignment phase.” Dr. Damon indicates that his experience and observations concur with the notion that friction is bad for tooth movement and especially in the early alignment phase. A large segment of the profession has pretty much accepted this presumption. Our clinical observations and the finding of this investigation and others would render this fear of friction invalid. The studies of Scott Volume 6 Number 3

200833 and Ong 201034 noted above found self-ligating (SL) brackets slightly slower, not faster in initial alignment. The dual-wire protocol described herein produces more friction than any technique known. The annealed wire plus the active wire combine for a total width of .028 in. in the maxillary arch and .024 in. in the mandibular arch. This overfills the .018 x .025 bracket slots. Then the annealed wire moves randomly into the interproximal area touching wings and tooth surfaces, which causes more restrictions. Additionally, we used elastomers and stainless steel ligations, which produce even more friction. However, the rates of movement accelerate significantly.

Treatment advantages Treatment time saved The graph in Figure 17 shows a comparison between the rate of traditional alignment methods and this protocol for different levels of arch irregularity. Obviously, clinicians save more time with patients who have greater initial arch irregularity. From 5 to 19 mm irregularity, the time saved ranges from 1.3 months to 5.4 months. In patients with less arch irregularities, the dual-arch technique helps clinicians finish earlier. In patients with more arch irregularities, their treatments do not exceed the estimated dates of completion. In each case, patients and orthodontists experience more pleasant orthodontic therapy. More importantly, the dual-arch technique affords clinicians the flexibility to spend more time to detail tooth positions and finish with a higher level of quality. There are a number of dental, societal, and economic forces at work currently that provoke less quality of orthodontic therapy. This procedure affords us the opportunity to improve our results within a reasonable time. Less patient discomfort As was reported in a previous article in Orthodontic Practice US,35 this wire configuration dramatically reduces the patient discomfort experienced in the initial early alignment phase of our treatment. Of course, the early weeks and months of treatment build the foundational ties in a doctor-patient relationship that we all hope will have positive and mutually beneficial results. Patients and parents have an excitement during this early phase, and anything we can do to make the experience more positive (or less negative) produces pluses for our practice. Reduction of discomfort and allaying the apprehensive child certainly does this.

Figure 16: Graph of the previous study averages versus dualwire averages. The average rate of dual-wire movement is 3.12 times or 212% greater than past study averages. It is 1.56 times or 56% greater than the average of former study maximums. The maximum dual-wire rate (14 mm/mo.) is 2.45 times or 145% faster than the maximum rate found in all previous studies

Figure 17: Graph of the treatment time saved with dual-wire technique. X axis is months of time, and Y axis is degrees of irregularity present. Treatment time saved with the dual-wire varies directly with irregularity. The average gain ranges from 1.3 months at 5 mm of irregularity to 5.4 months at 19 mm of irregularity

Decreased root resorption Root resorption is an age-old nemesis for orthodontists and patients. Few initial alignment studies measure root changes, but Scott,3 Mandall,27 and Linge28 included this in their studies. Scott measured resorption at the mandibular central incisor. Sixty patients were divided between Synthesis™ (Ormco) brackets and Damon® 3 (Ormco) brackets. Root resorption was measured at 1.21 mm (SD 3.39) and 2.26 mm (SD 2.63) for Synthesis and Damon 3, respectively, Orthodontic practice 57

CONTINUING EDUCATION

These maximum rates range from 2.49 mm/month to 5.7 mm/month. Of the 17 patients we measured, only four had rates less than the maximum rate of all previous studies. Figure 16 shows a graph of the relationship between the average and maximum rates of previous studies and those of the dual-wire method. The average rate of our study group is 1.56 times the maximum average of all former studies, and the dual-wire average rate is 3.12 times faster than the average rate of other investigations. The maximum rate measured with the dual-wire protocol is 14. mm/month. This rate is 2.45 times the maximum rate from all previous studies, which was 5.7 mm in the Sebastian study. As you can see from Table I, this protocol produces consistently faster rates of tooth alignment. However, some patients do not respond as dramatically as others. Maxillary teeth align somewhat faster, and age seems to affect the outcome. Some adults do not align as quickly as the average adolescent. The specific geometry of each irregularity, as well as individual variation in physiology, also plays a significant role in the alignment response. These resistance factors have not been examined enough to accurately predict which patients’ teeth will not respond as efficiently as the average patient.

CONTINUING EDUCATION during the initial 18 weeks. The difference between appliances was not statistically significant. Mandall noted an average of 1.18 mm (SD 1.4) central incisor root resorption during early alignment. This represented 18% of patients studied. Linge and Linge noted similar resorption (1.5 mm) on 16.5% of their patients. While Scott, Mandall’s, and Linge’s levels of root resorption would typically not reach clinical significance, it is not insignificant as a treatment sequela. The extremes of resorption measured by Scott were 4.89 mm for Damon and 4.60 mm for Synthesis. These would have to be considered quite significant particularly for a lower incisor. Depending on the patient’s periodontal aging pattern, these could easily become clinically significant. This dual-wire protocol has been used exclusively for more than 20 years. During this time, our root resorption level has been extremely minimal and less than when we used a traditional one-wire treatment initiation. Of the patients presented in this study, one adult experienced slight mandibular incisor resorption while the other 16 had no root resorption. Universality of use This arrangement of wires should work with all bracket systems. Obviously, at this point only one bracket arrangement has used the dual-arch system, but it should enhance the alignment characteristics and reduce patient discomfort with any system.

Summary The profession has struggled for more than 90 years to produce more efficient tooth movement. The gold wires of Angle offered little hope in this pursuit. Stainless steel wires with greater resiliency and flexibility offered less force and more efficiency, but they did not increase patient comfort. Nickel-titanium archwires began to push orthodontics in the right direction by delivering wires with less force, more durability, and a greater range of action. However, this great advancement may have produced a generalized professional complacence. We have neglected the research of Schwartz24 and Reitan29 in our contentment over the amazing range and duration of action of the NiTi wires. While these wires work continuously, they still apply too much initial force to achieve more efficiency and a more comfortable level of tooth movement. In 2007 Berger and Waram30 did a test of the force levels of all initial NiTi wires. Of the 43 different NiTi wires measured, only 58 Orthodontic practice

one produced less than 4 gm of unloading force when deflected 1 mm. None yielded less than 57 gm when deflected 2 mm. Not surprisingly, that wire was the same woven NiTi wire studied by Sebastian. His study had the highest average rate of movement (3.6 mm) prior to the movement reported here. The efforts of 10 orthodontic30 supply companies in the development of numerous NiTi wires has not produced clinical forces in the 25 to 30 gms range suggested by Schwartz and Reitan. This modulating wire technique has produced forces at or near the target set by these pioneers. And efficiency has jumped by a factor of 3 times. Apparently, the initial alignment phase is more about force levels than friction. We have presented a new protocol for initial irregularity alignment that uses two juxtaposed initial wires that reduce the net force to the teeth to levels lower than currently possible with one wire. With one very small and inexpensive adjustment in initial clinical procedures, orthodontists, patients, and orthodontics generally receive several significant benefits. OP

13. Doshi-Mehta G, Bhad-Patil WA. Efficacy of low-intensity laser therapy in reducing treatment time and orthodontic pain: a clinical investigation. Am J Orthod. 2012;141(3):289-297. 14. Kao C, Nguyen J, English J. The clinical evaluation of a novel cyclical force generating device in orthodontics. Orthodontic Practice US. 2010;1(1):43-44. 15. Oron U, Ilic S, De Taboada L, Streeter J. Ga-As (808 nm) laser irradiation enhances ATP production in human neuronal cells in culture. Photomed Laser Surg. 2007;25(3):180-182. 16. Kau CH, Kantarci A, Shaughnessy T, Vachiramon A, Santiwong P, de la Fuente A, Skrenes D, Ma D, Brawn P. Photobiomodulation accelerates orthodontic alignment in the early phase of treatment. Prog Orthod. 2013;14:30. 17. Schudy G, White L. A dual-arch protocol with accelerated movement and less discomfort. Orthodontic Practice US. 2015;6(1):34-36. 18. Little R. The irregularity index: a quantitative score of mandibular anterior alignment. Am J Orthod. 1975;68(5):554-563. 19. Frost HM. The regional acceleratory phenomenon: a review. Henry Ford Hosp Med J. 1983;31(1):3-9. 20. Wilcko WM, Wilcko T, Bouquot JE, Ferguson DJ. Rapid orthodontics with alveolar reshaping: two case reports of decrowding. Int J Periodontics Restorative Dent. 2001;21(1):9-19. 21. Mostafa YA, Mohamed Salah Fayed M, Mehanni S, ElBokle NN, Heider AM. Comparison of corticotomy-facilitated vs standard tooth-movement techniques in dogs with miniscrews as anchor units. Am J Orthod Dentofacial Orthop. 2009;136(4):570-577. 22. Mueller M, Schilling T, Minne HW, Ziegler R. A systemic acceleratory phenomenon (SAP) accompanies the regional acceleratory phenomenon (RAP) during healing of a bone defect in the rat. J Bone Miner Res. 1991;6(4):401-410. 23. Melsen B. Biological reaction of alveolar bone to orthodontic tooth movement. Angle Orthod. 1999;69(2):151-158. 24. Schwartz AM. Tissue changes incidental to orthodontic tooth movement. Int J Orthodontia. 1932;18(4):331-352.

REFERENCES 1. Jones ML, Staniford H, Chan C. Comparison of superelastic NiTi and multistranded stainless steel wires in initial alignment. J Clin Orthod. 1990;24(10):611-613. 2. O’Brien K, Lewis D, Shaw W, Combe E. A clinical trial of aligning archwires. Eur J Orthod. 1990;12(4):380-384. 3. Scott P, DiBiase AT, Sherriff M, Cobourne MT. Alignment efficiency of Damon 3 self-ligating and conventional orthodontic bracket systems: a randomized clinical trial. Am J Orthod Dentofacial Orthop. 2008;134(4):470, e1-8. 4. Ong E, Ho C, Miles P. Alignment efficiency and discomfort of three orthodontic archwire sequences: a randomized clinical trial. J Orthod. 2011;38(1):32-39. 5. Sebastian B. Alignment efficiency of superelastic coaxial nickel-titanium vs superelastic single-stranded nickeltitanium in relieving mandibular anterior crowding: a randomized controlled prospective study. Angle Orthod. 2012;82(4):703-708. 6. 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. 7. Saito M, Saito S, Ngan PW, Shanfeld J, Davidovitch Z. Interleukin 1 beta and prostaglandin E are involved in the response of periodontal cells to mechanical stress in vivo and in vitro. Am J Orthod Dentofacial Orthop. 1991;99(3):226-240. 8. Dienz O, Rincon M. The effects of IL-6 on CD4 T cell responses. Clin Immunol. 2009;130(1):27-33. 9. Garlet TP, Coelho U, Silva JS, Garlet GP. Cytokine expression pattern in compression and tension sides of the periodontal ligament during orthodontic tooth movement in humans. Eur J Oral Sci. 2007;115(5):355-362. 10. Yoshimatsu M, Shibata Y, Kitaura H, Chang X, Moriishi T, Hashimoto F, Yoshida N, Yamaguchi A. Experimental model of tooth movement by orthodontic force in mice and its application to tumor necrosis factor receptor-deficient mice. J Bone Miner Metab. 2006;24(1):20-27.

25. Graber LW, Vanarsdall RL Jr, Vig KWL. Orthodontics, Current Principles and Techniques. 4th ed. St. Louis, MO: Elsevier/Mosby; 2005: 145-219. 26. Damon D, Keim RG. JCO interviews Dwight Damon, DDS, MSD. J Clin Orthod. 2012;46(11):667-678. 27. Mandall N, Lowe C, Worthington H, Sandler J, Derwent S, Abdi-Oskouei M, Ward S. Which orthodontic archwire sequence? A randomized clinical trial. Eur J Orthod. 2006;28(6):561-566. 28. Linge L, Linge BO. Patients characteristics and treatment variables associated with apical root resorption during orthodontic treatment. Am J Orthod Dentofacial Orthop. 1991;99(1):35-43. 29. Reitan K. Some factors determining the evaluation of forces in orthodontics. Am J Orthod. 1957;43(1):32-45. 30. Berger J, Waram T. Force levels of nickel titanium initial archwires. J Clin Orthod. 2007;41(5):286-292. 31. Pandis N, Polychronopoulou A, Eliades T. Alleviation of mandibular anterior crowding with copper-nickel-titanium vs nickel-titanium wires: a double-blind randomized control trial. Am J Orthod Dentofacial Orthop. 2009;136(2):152. e1-7, 152-3. 32. Sandhu SS, Shetty VS, Mogra S, Varghese J, Sandhu J, Sandhu JS. Efficiency, behavior, and clinical properties of superelastic NiTi versus multistranded stainless steel wires: a prospective clinical trial. Angle Orthod. 2012;82(5):915-921. 33. Scott P, DiBiase AT, Sherriff M, Cobourne MT. Alignment efficiency of Damon 3 self-ligating and conventional orthodontic bracket systems: a randomized clinical trial. Am J Orthod Dentofacial Orthop. 2008;134(4):470, e1-8. 34. Ong E, Ho C, Miles P. Alignment efficiency and discomfort of three orthodontic archwire sequences: a randomized clinical trial. J Orthod. 2011;38(1):32-39. 35. Schudy G, White L. A dual-arch protocol with accelerated movement and less discomfort. Orthodontic Practice US. 2015;6(1):34-36.

11. Alikhani M, Raptis M, Zoldan B, Sangsuwon C, Lee YB, Alyami B, Corpodian C, Barrera LM, Alansari S, Khoo E, Teixeira C. Effect of micro-osteoperforations on the rate of tooth movement. Am J Orthod Dentofacial Orthop. 2013;144(5):639-648. 12. Miraglia B. Innovative techniques: Predictable accelerated orthodontics using PROPEL and Clear Aligner therapy. J Am Orthod. 2013;November-December: 28-32.

Volume 6 Number 3

3M Unitek: experience the science behind performance and efficiency

ver wonder what the technologically advanced orthodontic products offered by 3M Unitek have to do with Post-It® Notes or Scotch-Brite™ sponges? They’re all backed by proprietary 3M science — which when applied to everyday life improves the way we live and work. At the 3M Unitek booth at this year’s AAO Annual Session, you’ll have the opportunity to see, touch, and demo products like Clarity™ ADVANCED Ceramic Brackets and the APC™ Flash-Free Adhesive Coated Appliance System. These products are designed by the top R&D minds at 3M to help practices move towards an esthetic treatment model that not only meets patient demand, but also maximizes performance and efficiency. Offering an unbeatable combination of performance and beauty, Clarity ADVANCED Ceramic Brackets are made possible by the combination of multiple advanced 3M

technologies, resulting in an innovative, finegrained ceramic material that resists staining and discoloration throughout treatment. The ultra small brackets are strong and durable, with a unique stress concentrator and innovative design that allows for easy debonding on or off the archwire. Clarity ADVANCED Ceramic Brackets are also available precoated with a proprietary adhesive that shortens bonding time. Born out of a strong history in adhesive technology, APC Flash-Free Adhesive allows orthodontists to move directly from bracket placement to bracket cure without removing the adhesive flash — eliminating the tedious cleanup step and reducing bonding time by up to 40% per bracket.* In addition to increased efficiency, the clear meniscus created by the APC Flash-Free adhesive minimizes gaps around the edges of the bonding base and the tooth surface, helping to protect the enamel under the adhesive

and contributing to a more beautiful smile after debonding. “We know that sometimes, it’s not enough to just talk about a product’s benefits; orthodontists need that hands-on, tactile experience,” said Mike Lane, Vice President, U.S. Sales and Marketing. “Our booth at AAO will be a truly interactive experience that allows the science behind these products to come to life.” To learn more about Clarity ADVANCED Ceramic Brackets and the APC Flash-Free Adhesive Coated Appliance System, visit the 3M Unitek booth at this year’s AAO Annual Session or 3MUnitek.com. *Based on feedback received from early users as part of 3M Unitek study #130220B, for direct bonding of brackets.

Visit 3M Unitek at Booth No. 1129

3Shape solutions for digital orthodontics

inner of numerous international technology and design awards, 3Shape’s innovative 3D dental scanners and CAD/CAM software solutions are used by orthodontists and lab professionals around the world. At this year’s IDS in Germany and Chicago Midwinter, 3Shape introduced several new products — scanners and software that topped the Top 10 lists of “mindblowing” launches by journalists covering the events.

Orthodontists The new TRIOS® 3 intraoral scanner, with its “Tesla Insane Mode” speed and accuracy, garnered tremendous attention. Featuring a smaller scanning tip in a pen grip design, TRIOS® delivers high-quality digital impressions in lifelike colors as well as captures the bite automatically in real-time. Studies have demonstrated that taking digital impressions saves you time and Visit 3Shape at Booth No. 1743 Volume 6 Number 3

scans and case information directly to TRIOS® Ready labs and orthodontic solution providers like 3M Incognito, ClearCorrect, AO Harmony, suresmile, and others.

Orthodontic Labs

enables you to see more patients. Digital Impressions also provide better patient comfort and enable orthodontists to save storage costs through digital archiving of cases. Coupled with 3Shape Ortho Analyzer™ and Ortho Planner™ — for analysis and treatment planning — orthodontists can now integrate all patient data, including IO and CBCT scans, to improve diagnostics, patient comfort, and treatment acceptance. Releasing later this year, Ortho System 2015 will enable indirect bonding of brackets. Orthodontists can also take advantage of TRIOS® cloud integrations to send TRIOS®

3Shape CAD/CAM solutions enable orthodontic labs to go digital at a speed to match their needs and budget. Labs can take advantage of four newly introduced 3Shape benchtop lab scanners, including the revolutionary R2000 scanner that simultaneously scans two models. Using 3Shape Ortho Analyzer™ and Ortho Planner™ software, labs can also deliver digital analysis services as well as create digital study models. And with 3Shape Appliance Designer™ software, labs can CAD/CAM design and manufacture clear aligners, night guards, retainers, palatal expanders, and more. And because Appliance Designer™ delivers open STL files, labs can manufacture appliances in-house or externally depending on their lab setup. Discover more at the 3Shape Booth No. 1743 in the Moscone Center. www.3shape.com Orthodontic practice 59

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American Orthodontics Ultimate CE World-class events for the world-class orthodontist

rthodontics is a profession requiring a lifetime of learning, and American Orthodontics is dedicated to delivering high-quality educational events that are relevant, enjoyable, and give attendees the most beneficial experience possible. A perfect example of this philosophy is American Orthodontics’ Ultimate CE courses. The name isn’t just for show — these events truly deliver the ultimate in orthodontic education. Each event features informative clinical lectures by expert speakers from around the world, speaking on a wide range of topics, including

treatment techniques, practice management, and more. Each of these intriguing lectures is complimented by amazing oncein-a-lifetime entertainment experiences. Upcoming events include the Indianapolis 500, the American Music Awards, the Kohler Food & Wine Event, and a private dining experience at New York’s Michelin three-star, award-winning Per Se. Courses fill up fast, with several already sold out for 2015, so sign up today! For more information, and to register for Ultimate CE events, please visit events. americanortho.com

Ultimate CE Indianapolis 500 Indianapolis, IN • May 22-24 Ultimate CE San Francisco Giants Experience San Francisco, CA • July 24 Ultimate CE Kohler Food and Wine Experience Kohler, WI • October 22-25 Ultimate CE American Music Awards Los Angeles, CA • November 21-22 Ultimate CE New York Dining Experience New York, NY • December 4

Visit American Orthodontics at Booth No. 815

AOA Investments show commitment to supporting your practice

uality and delivery are two of the most critical factors that influence the decision to partner with a laboratory. You want to select a lab that values the importance of these areas as much as you do. The right lab instills confidence that the appliance being constructed meets your design specifications, delivers the quality and fit you expect, and ships the appliance on time. You want a lab you can trust. Recently, AOA launched a campaign to hire skilled technicians, as well as to identify, hire, and train new technicians to meet the growing demand for both our current and future services. We have added nearly 30 new technicians, and there are plans to add more. This investment’s sole purpose is to provide the same quality, service, and delivery that AOA has been known for since 1984. 60 Orthodontic practice

“I have tried a number of different laboratories, and the quality from AOA is the reason I stay with them.” Dr. Mark Coreil, Houma, Louisiana Our second investment supports the growing trend of integrating technology into the laboratory market. Due to our commitment to quality and craftsmanship, our preferred model printing method is Stereo Lithography, commonly known as SLA. This technology is highly regarded as the premier method of rapid prototyping. Furthermore, AOA has gone one step further to incorporate a sophisticated print material developed specifically to produce digital-dental models with better accuracy and highend resolution. Additionally, AOA has developed a separating compound that does not interact with the product,

stick, or leave any residue on the model or appliance. This new separating agent allows us to build your appliance directly on the digital printed models, resulting in a more accurate product. AOA remains focused on the most important aspect of our laboratory, you, the customer. We look forward to continuing to find the right solutions that provide you the confidence in partnering with AOA as your laboratory of choice. To hear more, visit AOA at the Ormco Booth No. 1119 or contact our Customer Care Department at 800-262-5221. To learn more, connect to www.aoa access.com. Visit AOA at Booth No. 1119 Volume 6 Number 3

Carestream Dental’s CS 3500 intraoral scanner is now available for use by orthodontists

liminating the need to fill patients’ mouths with impression material, pour molds, or wait for stone models to set, the CS 3500 streamlines the entire impression-making process and provides a number of benefits to both patients and staff, including less time in the chair, shorter appointment times, and an overall more relaxed experience. As a truly portable scanner, the CS 3500 can be plugged directly into the user’s preferred laptop — making it easy to move from operatory to operatory. The CS 3500 scans to a depth ranging from -2 mm to +13 mm to deliver detailed 2D and 3D images with an average precision of 30 µm and a high resolution of 1024 x 768. The lightweight, ergonomic design of the CS 3500 scanner is easier to hold and handle than other units, making it more maneuverable within a patient’s mouth. The scanner tip is available in two different sizes — a standard tip for adults and a smaller, tapered tip

for children — which allows users to treat young patients more comfortably. Plus, these tips are autoclavable for infection control. The CS 3500 is part of an open computer-aided design/manufacturing (CAD/ CAM) system that features no click fees. Once images are captured with the CS 3500, CS Model design software is used to create accurate digital models within minutes. The files can then easily be shared with labs for appliance fabrication. The ease and efficiency of sharing digital files, rather than stone models, means faster turnaround for patients between diagnosis and treatment. Additionally, no stone models means no need to find extra storage space, as everything is stored virtually. Scans captured by the CS 3500 are accepted by the American Board of

Orthodontics, ClearCorrect™, and are certified by OraMetrix Inc. for use with suresmile® technology. Learn more about the CS 3500 intraoral scanner in Booth No. 1605 at the American Association of Orthodontists Annual Session, San Francisco, California.

Visit Carestream Dental at Booth No. 1605

BioBite Corrector® offers clinicians a new option in Class II cases

he BioBite Corrector® is a fixed, functional appliance designed to treat Class II cases. It was created to offer a clinically efficacious alternative to the Herbst appliance, eliminating many of its clinical and mechanical shortcomings. The BioBite Corrector has a wide range of indications. It can be used as an alternative to the traditional Herbst appliance and is ideal for Class II cases when esthetics is important or patient compliance cannot be guaranteed. The BioBite Corrector is constructed to withstand the unique forces exerted in the mouth during sleep, conversation, and mastication. It features solid body construction and is manufactured entirely from high-quality titanium. All of the connections are laser welded to ensure the utmost structural integrity. There are no bands that need to be placed with the BioBite Corrector as it Volume 6 Number 3

the archwire, even if the screw loosens. The BioBite Corrector is activated by means of crimpable spacers that get attached to the thinner telescope bar; the severity of the malocclusion will determine how many spacers are used. In addition to Class II cases, the BioBite Corrector can be used as an anchorage appliance for the closure of gaps in the posterior teeth of the lower jaw while correcting a distal occlusion. It can be used in conjunction with any bracket system or treatment philosophy so long as a minimum .017"×.025" archwire is used. The BioBite Corrector is available in Europe, Canada, and the United States from DENTSPLY GAC.

attaches directly to the archwire already being used. The ball joint mechanics in the upper and lower mandible allow the patient to enjoy a full-range of dynamic jaw movement. The screw-driven connection is easy to access, ensuring quick placement. This design guarantees the connection won’t slide on the archwire once it’s attached. Plus, the vertical orientation of the slot prevents Visit DENTSPLY GAC at Booth No. 1105 the screw body from loosening from

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MTM® Clear•Aligner — a simple, cost-effective turnkey solution MTM® Clear·Aligner is a simple, costeffective turnkey solution for correcting the minor anterior misalignments seen in up to 50% of your patients in as little as 3-6 months.* Made with quality Essix® Plastic, its unique “open pathway” architecture facilitates tooth movement and fit. MTM® Clear·Aligner uses integrated force points to move teeth without attachments so you save on chair time, and patients appreciate the excellent esthetics. The low flat fee, unlimited aligners, and free refinement** add up to a more predictable cost so you can confidently price MTM® Clear·Aligner to your patients. MTM® Clear·Aligner is easy to integrate into your practice, and you have full control of your cases. You can prescribe your desired tooth movements and IPR — or have a trained technician recommend them. Your treatment plan includes a 3D viewer to help you analyze your case and share it with patients.

MTM® Clear·Aligner with integrated force points moves teeth without attachments *Data on File **Initial treatment plan and first refinement, if needed

Visit DENTSPLY Raintree at Booth No. 1405

“Shouldn’t your software adapt to you instead of the other way around?”

hat is what we thought when we started Focus Software back in 2010. We began developing Focus Ortho with the newest tools for a cloud-based platform. We set a goal to minimize clicks. Once a patient is open, all patient data had to be available from a single screen. Our goal is to be the one solution for all your office needs. People and the way an office runs are different. We understand that everyone is not a computer whiz, so we gave Focus Ortho powerful functionality while making it simple to use and easy to customize. We modified our standards to fit you instead of the other way around. We believe that communication with your patients is essential to your success. So, we built a web portal exclusively for them. They can fill out forms, confirm upcoming appointments, reprint excuses and receipts, and even process online payments. No more syncing of data, since it is all part of one system. We did not stop 62 Orthodontic practice

there; you can reach patients, responsible parties, and referring doctors via text and email. Reduce no-shows through automated patient reminders, or send custom letters — it is all at your fingertips. Best of all, it’s all tracked in each patient’s record, back in the cloud.

We made our integrated imaging software intuitive and fast. Easily import images from digital cameras with a single click. Images are loaded to the cloud quickly and can be retrieved anywhere you have an Internet connection. We designed a reporting system that gives you unparalleled access to your data. Of course, we can create traditional reports that are printed easily from the system. We have taken this to a new level with interactive lists. We are constantly striving to make Focus Ortho the best practice management software available. With this in mind, we are constantly updating to include new features and functionality. Keep an eye out for our mobile app available later this year.

Visit Focus Ortho at Booth No. 2419 Volume 6 Number 3

i-CAT™ announces “Their Story”

ith compelling stories of real-world cases, dental professionals now have a chance to witness how i-CAT cone beam 3D imaging can help improve dental issues leading to a better quality of life. i-CAT, a brand of the KaVo Kerr Group, is proud to introduce a fresh new marketing microsite called “Their Story.” Through a fully integrated multimedia campaign, the platform casts a growing collection of stories that illustrates how doctors are changing patients’ lives every day. Each is told by the doctor (and in some cases his/her patients) and contains a rich set of information, including a case report, select videos, images, and more. These stories show clinical outcomes that changed the lives of 7-year-old Sebastian from Miami, Fiaz from Chicago, and Natalie near San Francisco — all with a variety of medical and dental issues. Now, these people

are experiencing a drastic improvement in quality of life. The i-CAT team is excited about this campaign and the impactful stories from using i-CAT technology. “We are grateful that these clinicians shared their powerful ‘Their Stories,’ and we are even happier that the treatment had a profound effect on their

health. By sharing these stories, we hope to show how 3D imaging can help in the process of diagnosis,” states Rick Matty, Director of Marketing for i-CAT. “We look forward to hearing many more accounts of how i-CAT showed the details that led to a life-changing diagnosis.” To read the case studies, view the videos, and see the images of these cases, visit stories.i-cat.com. i-CAT also welcomes dental professionals to share their own life-changing stories through this microsite. Join the conversation on i-CAT’s social media sites on Facebook, www.facebook. com/iCAT3D, and on Twitter, @iCAT3D, #Their3Dstory.

Visit i-CAT at Booth No. 2037

Grow your practice with esthetic brackets and a new interactive patient consultation tool!

n ideal solution for today’s imageconscious adults and teens, Damon™ Clear passive self-ligating brackets provide the performance and control needed to treat a wide variety of cases with outstanding results. Damon™ Clear2 brackets feature a new ultra-precision slot that provides two times the rotational control* for meticulous finishing and efficient treatment. With a completely clear and durable body and door manufactured with polycrystalline alumina (PCA) material, Damon Clear brackets are virtually invisible and resistant to staining. Additionally, Damon brackets’ innovative SpinTek™ slide facilitates fast and comfortable wire changes.

Volume 6 Number 3

Doctors treating with Damon Clear now have access to a powerful new online consultation tool offered by Ormco. My Smile Consult™ is designed to increase case starts by educating patients on the benefits of orthodontia and the Damon™ System, including Damon Clear. • 25+ videos and numerous photos • Interactive with unique dashboards for adult females, adult males, parents, and teens • For use before, during, and/or after the consultation • Customizable with your practice branding, patient photos, and testimonials “Damon™ Clear has helped differentiate my practice. My patients could not be happier with the brackets’ transparency and their results. Now with My Smile Consult™, I have a powerful education tool to make my consultations even more effective.” — Dr. Todd Bovenizer, Cary, North Carolina

Visit Ormco Booth No. 1119 at the AAO Annual Session for the following: • Special offers on Damon Clear • Hands-on demonstrations of My Smile Consult • In-booth lectures and one-on-one sessions with Drs. Stuart Frost, John Graham, and more! Contact your Ormco Representative to learn more, or visit www.ormco.com. *As compared to Damon Clear, data on file. Standard torque, upper 3-3 brackets.

Visit Ormco at Booth No. 1119 Orthodontic practice 63

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Ortho Classic’s 2nd annual Pinnacle event is heading to the Lone Star State

uilding on the amazing success of last year’s Las Vegas event, the Pinnacle is back with an even bigger lineup of progressive and captivating speakers and seminars. Led by the Master of Ceremonies and Keynote speaker, Dr. Tom Pitts, this 4-day event aims to be an arena for exciting and creative thinking among peers.

technology to an artistic end result is the art of case management, and the best case managers have a sound understanding of the technology they apply on a daily basis. The Pinnacle is an occasion to rediscover your passion and an opportunity to listen and interact with some of the most progressive educators in the industry, furthering your knowledge of both the art and technology of orthodontics.

Fearless, progressive ideas on display

Wisdom begins with wonder Today’s orthodontic practices are at the intersection of art and technology. The challenge of applying appropriate levels of

CE accredited presentations will cover everything from new clinical techniques to exciting treatment insights. The Pinnacle will be held in Texas, October 8-11, 2015. Visit www.orthoclassic.com for more information and to sign up for this fun and educational orthodontic event. Discover why many orthodontic professionals around the world are making this their one must-attend annual event! For more information contact Ortho Classic at 866-752-0065, or visit www. orthoclassic.com.

An incredible lineup of progressive thinkers and world-renowned speakers will deliver dynamic and innovative presentations in a fun and relaxed atmosphere. Dr. Pitts along with Drs. Duncan Brown, Tomas Castellanos, Daniela Storino, Sabrina Huang, and many others are excited to share their latest techniques and Visit Ortho Classic at Booth No. 2017 clinical outcomes.

Visit Ortho Technology Booth No. 1729 in the Henry Schein® Orthodontics’™ Pavilion Ortho Technology showcases exciting new products at the AAO

rtho Technology is an established leader in the orthodontic supply market, providing innovative and unique products to orthodontic professionals worldwide, for over 20 years. It will be showcasing exciting new products and promoting show-only special offers on several top-quality products like the X7® Orthodontic Instrument Line. X7 Orthodontic Instruments are a premium line of cutters and pliers. Precision manufactured in the USA with USA and/ or German stainless steel, they are handcrafted through a majority of the process and produced from a high-quality 400 series surgical stainless steel material blend with stringent quality control to ensure consistent performance and reliability. The handle is designed for optimal fit and comfort with contoured corners around the joint area to give a slim-line look and feel. 64 Orthodontic practice

The glare-minimizing shadow satin surfacing provides a long-lasting finish. Ortho Technology will also be showcasing its recently launched Ortho Performance® Advanced costs with the included trays and Teeth Whitening System. offer your patients a professional The advanced teeth whitening option to help promote whitening kit is an excellent item to offer your practice. patients currently in orthodontic treatment Based in Tampa, Florida, Ortho or who just had their braces removed. The Technology, Inc., is part of the orthodontic viscous Carbamide Peroxide gel contains portfolio of Henry Schein®. The Company is Potassium Nitrate to reduce sensitivity and engaged in the development, manufacturing, achieves professional whitening results for and marketing of products to enhance patients with or without braces. It is mint orthodontic treatment. flavored, and the neutral pH is safe for enamel. Visit Ortho Technology at the Visit Ortho Technology at Booth No. 1729 AAO, and learn how you can reduce lab Volume 6 Number 3

Edge, from Ortho2 — the industry leader in cloud practice management software

he superior features in Edge allow you to keep the focus of your practice where it should be — on your patients. Only Edge offers a truly optimized cloud experience. Meaning you will eliminate the cost, complexity, and risk associated with in-house servers and backups. And you don’t have to worry about security as your data is protected by world-class firewalls used by large financial institutions. With the Edge Cloud, you can access your data from anywhere with your PC, tablet, and smartphone.

The dynamic Dashboard lets you see the information you need right in one area. You choose your content — anything from quick reports to custom charts, or simply the weather or your favorite Web page. Each user defines how their individual Dashboard is set up. Widgets can even be rearranged on the screen or floating for maximum potential. Edge also lets you set up workflows — a feature used to automate your system for various tasks. For example, you can change a patient status, merge letters, add patients to a stack, or even open the patient’s treatment chart when you seat a patient. The possibilities of what workflows can do for you are almost endless. The Smart Scheduler improves your schedule with unmatched power and flexibility, including real-time statistics on procedure lengths, patient preferences, and instant access to sibling appointments. Doctor time is visually represented for each procedure to

manage time effectively. And using procedure groups ensures that coordinating sequences of procedures is easy. These and more features can be found in Edge. Check out the Ortho2 difference for yourself at www.ortho2.com. For more information contact our Systems Consultants at sales@ortho2.com, or call 800-678-4644. Visit Ortho2 at Booth No. 413

AcceleDent® praised by orthodontists and patients

roundbreaking. Revolutionary. Innovative. These are just some of the words that leading orthodontists have used to describe OrthoAccel® Technologies, Inc.’s AcceleDent®, the FDA-cleared, Class II medical device that speeds up orthodontic treatment by as much as 50%. Available in more than 2,300 practice locations in the U.S., AcceleDent is the only non-invasive accelerated orthodontic treatment technique. Patients use the prescription-only device by lightly biting on the mouthpiece for just 20 minutes per day. AcceleDent’s patented SoftPulse Technology® gently accelerates tooth movement using micro pulse technology similar to the latest orthopedic rehabilitation techniques. The Leader in Accelerated Orthodontics™, OrthoAccel has found that doctors across the country are eager to offer AcceleDent because they say it addresses the two primary concerns patients have with orthodontic treatment: length of treatment and discomfort associated with adjustments. As

Volume 6 Number 3

patients’ journeys to healthy, beautiful smiles while also helping them drive practice growth,” said Michael K. Lowe, president and CEO of OrthoAccel Technologies. “OrthoAccel is at the forefront of revolutionizing the orthodontic industry with accelerated treatment. So, while we’re excited about our rapid market growth and positive patient feedback, we’re also committed to presenting case studies and the clinical evidence that supports AcceleDent’s rapid growth within the orthodontic industry.” Orthodontists and staff members interested in learning more about AcceleDent or how to offer the technology at their practice can locate an OrthoAccel Technologies sales representative at AcceleDent.com/orthodontists, or call 866-866-4919.

such, patient feedback of AcceleDent has been just as positive. In a recent independent survey, 100% of patients surveyed reported that AcceleDent is easy to use and that they were satisfied with their experience using the technology. In fact, the majority of patients say they would recommend AcceleDent to a friend or family member. With patient demand for AcceleDent on the rise, orthodontists are finding that they are able to differentiate their practices, increase case starts and maximize treatment efficiencies by offering accelerated treatment with AcceleDent. “Our goal is to help orthoVisit OrthoAccel Technologies at Booth No. 615 dontists and their staff improve

Orthodontic practice 65

AAO PREVIEW

PREVIEW

AAO PREVIEW

AAO

Digital marketing to provide practice growth and profitability

he digital age is completely changing the way dental practices and patients interact. The need for personal contact from a patient’s perspective has been rendered less important with the advent of digital communications, as patients increasingly state they prefer the convenience of online, on-demand information. Interestingly, 93% of patients find it more convenient to find answers online compared to calling the office. Patients have embraced the digital age, and practices must adjust to their preferences and be where their patients are — online. A digital strategy focused directly on patient engagement is now imperative to grow and maintain a long-term, sustainable practice. Practice website — this is the cornerstone of your online presence, and the most comprehensive articulation of your practice brand.

Search Engine Optimization — this is a critical complement to your practice website as it ensures you are featured prominently within local search results. Social media — this is your primary method for creating a consistent online dialog with existing patients and sharing their positive experiences with prospective patients in their network of friends, family, and colleagues. Patient communications — this online accessibility is a great benefit to patients and greatly improves efficiencies for the practice. Listings on vertical topical search portals and directories — this ensures your practice brand and value are shared with the Visit Sesame Communications at Booth No. 2305 ever-increasing volume of

prospective patients that look for information and online reviews on specific portals such as Healthgrades.com. Your practice faces more competition than ever — and the right approach to digital marketing can ensure prospective patients are choosing your practice over that of your competition. Your ability to get found online, appeal to patients no matter what device they are using to access your practice website, communicate with them through an online portal, and provide a robust strategy for review syndication will help you rise above competitors in your area and bring more new patients into your practice.

Specialty Appliances — digital innovation with indirect bonding

orkflow efficiency and precision bracket placement are two top priorities for every orthodontist. For many, a quality indirect bonding (IB) system is the answer for both. Recent technology advancements have greatly improved the success of IB, creating a new wave of orthodontists using indirect bonding in their practices. Since 1981 Specialty Appliances has led indirect bonding innovation. Over the years, material and process enhancements have evolved to produce near-perfect transfer trays. Adhesives are better and more specialized to securely transfer brackets from tray to tooth. Model accuracy is the remaining piece and most critical key to IB success.

An exciting IB development is the use of highly accurate intraoral scanners. We have noticed a substantial improvement in model accuracy from digital scans. Over 50% of our current IB cases are submitted digitally, and those customers report minimal if any bond failures due to inaccurate models. In other words, IB trays fit better than ever from scanners! Specialty Appliances continues to develop solutions that meet the demands of innovative orthodontists. Digital bracket placement for IB is one that shows much promise. First, we produce a digital setup of the finished case in ideal occlusion. Brackets are then digitally placed on the ideal setup using a full size straight wire to ensure slot alignment. Doctors then have the ability to review and approve the bracket position. The software remembers

the exact 3D bracket location from the ideal model to the malocclusion. Specialty’s proprietary process accurately transfers the digital bracket placement to the physical model. Transfer trays are then constructed and shipped to the orthodontic practice. Specialty Appliances continues to enhance precision indirect bonding, and digital advancements will drive this evolution. At the same time we believe our experience with manual bracket placement on malocclusion models is extremely accurate. Simply eliminating bad models by adopting digital scanning can tremendously improve the accuracy of IB trays. Both manual and digital bracket placement methods offer a tremendous value to the profession, as witnessed by our many satisfied customers. To learn more, please call Specialty Appliances toll free at 1-800-522-4636.

Visit Specialty Appliances at Booth No. 3103 66 Orthodontic practice

Volume 6 Number 3

Objet260 Dental Selection: maximum versatility for your dental lab

D printing takes the efficiencies of digital design to the production stage. By combining oral scanning, CAD/CAM design, and 3D printing, dental labs can accurately and rapidly produce crowns, bridges, stone models, and a range of orthodontic appliances. Now the next level in digital dentistry and orthodontics is here. The Objet260 Dental Selection 3D Printer brings advanced triple-jetting technology, which is PolyJet™ 3D printing at its most advanced. 3D print impressively realistic models with true-to-life look and feel and lifelike textures for precise evaluation in a wide range of shades for customized color matching. The Objet260 Dental Selection delivers: • Lifelike color, texture, and detail: 3D print rigid and gum-like features in a range of realistic tooth and gum shades. • Many materials in one job: Build multi-material dental models in one

piece, or complete several small models from diverse materials in one unattended job. • Efficient workflow: Maximize uptime by running your three most-used materials simultaneously.

Unmatched model realism The Objet260 Dental Selection supports all Stratasys dental materials (VeroDent™, VeroDentPlus™, Clear Bio-compatible, and VeroGlaze™), plus an array of dental specific palettes to produce lifelike colors and textures for teeth and gums. Create: • Stone models for implant testing with gum-like texture for accurate functional evaluation • Models with gum-like features or a mix of rigid and gum-like components • Jaw models printed directly from CBCT scan data with high-definition

tooth, root, and nerve canal anatomy rendered in contrasting materials Easily integrate the Objet260 Dental Selection into your dental or orthodontic lab experience. Increase productivity and capacity, and create models with realistic accuracy and detail with this easy-to-use and environmentally safe process. The Objet260 Dental Selection creates models with true-tolife look and feel in your lab. Create a competitive point of difference by using a digitized workflow to generate faster turnaround and greater production capacity. Operate your business more efficiently, effectively, and profitably while also increasing customer satisfaction with the Objet260 Dental Selection. Visit Stratasys at Booth No. 3147

Introducing elemetrix™ Powered by suresmile®

ew elemetrix gives you the power to bring suresmile technology to aligner design, indirect bonding, and diagnostics … on a case-by-case basis.

be performed before removal of braces, eliminating an office visit and become the start of a practice retention program.

elemetrix aligner design

elemetrix indirect bonding

elemetrix aligner design is fully adjustable throughout each case, allowing for customization of tooth movement over the course of treatment. Choose elemetrix aligner design for cases requiring moderate tooth movement, including: • 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

Finally, indirect bonding is made easy. Simply send us an intraoral scan (stl file), and we’ll create a model that will allow you to quickly set up your bracket prescription, bracket slot heights, and then run an automated bracket placement simulation. You can make any minor adjustments to bracket placement, then place your order for customized indirect 3D printed trays. Once you receive the elemetrix bonding trays, simply load your brackets, and you’re

ready to bond the patient, saving chairside time and improving the consistency of bracket placement.

elemetrix diagnostics The elemetrix diagnostics model tool set includes a powerful array of treatment planning features, including 3D viewing tools that provide 6 set views with the ability to manipulate the model from any angle, automated analytics (Bolton, arch width), and quality grading tools. Want to share your vision? elemetrix diagnostics enables unlimited treatment simulations to evaluate and present the best course of treatment to patients, parents and referring doctors — space closure vs. restorations, extraction vs. non-extraction, surgical vs. nonsurgical, to name a few. To learn about special elemetrix introductory offers, call suresmile at 855-501-7967.

See elemetrix @ suresmile Booth No. 905 Volume 6 Number 3

Orthodontic practice 67

AAO PREVIEW

PREVIEW

LABORATORY LINK

Digital impression scanning — improving workflow and the orthodontic experience James Bonham discusses how the modern laboratory can benefit the patient and the practice

oday’s technology-centric world associates high-tech with high quality. This holds true in orthodontics, and we have experienced meaningful advancements in recent years. These innovations save time, advance diagnostics, and greatly improve the patient experience in an orthodontic practice. The ability to take digital impressions is a game-changing technology that delivers meaningful benefits to doctors, staff, and patients — and also to the modern orthodontic laboratory. Forward-thinking laboratories are searching for ways to improve orthodontic practice efficiency and overall appliance quality. Their experience can be an asset to new digital-scanning offices, offering process implementation assistance and tips for improving scanning techniques. Orthodontists will appreciate the benefits that digital impression systems can provide — optimized workflow, improved case acceptance, reduced impression redundancy, eliminated appointments, and best of all, the ability to produce precision-fit custom lab appliances. One of the most important aspects of any orthodontic practice is case acceptance. What better selling point to a new patient than discovering that this technology eliminates those goopy, gag-inducing impressions. Patients and orthodontists alike appreciate the fact that after the scan is achieved, treatment options can be reviewed and discussed immediately, and postorthodontic treatment scenarios can be simulated. This instant consultation tool provides a high-tech educational experience for the patient in addition to providing important information for the doctor.

Digital bracket removal

Digital scanning also improves efficiency by avoiding impression redundancy. The traditional process requires multiple impressions, one for records and a second for any lab appliance. A single digital impression produces 3D models for diagnostic records, and can also be sent to the lab for appliance production or indirect bonding trays. While patients want the best treatment possible, they also want to achieve their results in the shortest time possible. The timesaving begins by eliminating the conventional separator appointment. The laboratory can digitally separate and fit the bands from the original records scan. Simply place the separators after taking the scan, and then deliver the appliance at the next appointment. Also, a technology-centered lab can make multiple appliances, like an expander and transpalatal arch (TPA), from this single scan. Sophisticated software allows the lab to expand the virtual model to the doctor’s

specifications before printing both construction models. The result is the ability for the orthodontist to deliver TPA appliances on the same day of expander removal. This example of digital workflow eliminates two appointments and several weeks of treatment time. Fixed and removable retainers can also be delivered on bracket-removal day. Many patients will inevitably misplace their removable retainers, causing their teeth to shift. Replacement retainers require a new appointment for impressions. The ideal solution to minimize relapse is to provide back-up retainers for the patient. Digital technology in the lab makes this a simple and affordable solution. Multiple removable retainers with integrated digital enhancements can be produced from one printed model. Orthodontists can increase efficiency and ensure longterm stability with new digital products like the GUARDIAN smile retention system from Specialty Appliances. Retainers can even be

Digital model pre-expansion

Digital model post-expansion

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.

68 Orthodontic practice

Volume 6 Number 3

The

Best-Kept Secret in Profitable Adult Re-Alignment

• Superior Accuracy and Fit Proprietary Design Techniques Computer-Aided Manufacturing

• Unbeatable Value

Attractive Pricing per Arch 2 Refinements Included

• No Hassles

5-Day In-Lab Service NO ClinCheck®

“With the low price and ability to submit digital scans, I make a nice profit on these cases with little chair time.” Dr. Richard Ingraham n SFO! Visit us ith #3103 o

AAO Bo

CALL 800.522.4636 TODAY speci a l t y a p p l i a n c e s . c o m

LABORATORY LINK delivered at the debonding appointment, as explained in the GUARDIAN process below: 1. One appointment before debonding, remove the archwires and acquire a digital impression, including brackets. 2. Digital technicians use 3D software to carefully remove all appliances from the digital model. 3. Upon request, technicians can also manipulate the model before printing it to include minor anterior refinements and band space closure. 4. The model is printed, and undercuts are blocked out. 5. Multiple retainers can be affordably fashioned from one durable printed model, eliminating the need for future retainer impressions and improving long-term retention potential. 6. Retainers are delivered the same day the braces come off. The patient receives back-up retainers and the printed models for future needs. Digital impressions equal or exceed the accuracy of conventional impressions, according to full arch impression studies.

70 Orthodontic practice

GUARDIAN retainers

Deleting multiple traditional impressiontaking steps will improve accuracy and greatly reduce distortions. Orthodontic laboratories have corroborated this by reporting a substantial drop in remakes after practices switch to digital impressions. Specialty Appliancesâ&#x20AC;&#x2122; laboratory also reports dropping from around 7% impression rejections compared to less than 1% with digital impressions. High-resolution accuracy and the scanning softwareâ&#x20AC;&#x2122;s ability to immediately identify missing data

give clinical assistants an opportunity to capture a new image of the area. Advancements in technology flourish for the orthodontic practice. Digital enhancements like intraoral scanning are revolutionizing the way orthodontists operate in the modern practice. Taking advantage of these efficiency gains can optimize their scanner investment in a very short time. Partnering with an experienced digital lab will also save orthodontists time and money, and improve their patientsâ&#x20AC;&#x2122; experience as well as their reputation. OP

Volume 6 Number 3

IN FOCUS

Focus Ortho — Software that adapts to you

“S

houldn’t your software adapt to you instead of the other way around?” That is what we thought when we started Focus Software back in 2010. We began developing Focus Ortho with the newest tools for a cloud-based platform. We set a goal to minimize clicks. Once a patient is open, all patient data had to be available from a single screen. We also made it easy to switch between patients and functionality. No more getting stuck in one screen when you need to take a patient call. But we wanted to do more. We added features that require third-party software from other companies. Our goal is to be the one solution for all your office needs. We have a management team with decades of experience in the Orthodontic Industry. Charlie Dunham, our president and CEO, was the founder of an industry-leading orthodontic software division. The software he created while there has been used by over 5,000 orthodontic offices around the world. This experience building a business from the ground up gave him valuable insight on how to build a successful software company. This knowledge is essential since Focus Software now supports over 300 users throughout the United States and Canada. When designing the software, we worked closely with a group that runs 15 orthodontic practices. They have over 100 users working on the program at the same time. They have been running Focus Ortho exclusively for the

Quickly schedule anywhere in the office

last 3 years. If you have a single office or multiple locations, we are sure we can handle your needs.

Customization — give them what they want! People and the way an office runs are different. We understand that everyone is not a computer whiz; so, we gave Focus Ortho powerful functionality while making it simple to use and easy to customize. You can customize the system for different users

with a few clicks and modify our standards to fit you instead of the other way around.

Payment processing — easy integration All our payment processing is ridiculously easy, because getting paid should never be your problem. We also believe in options; so, we gave them to you. Our integrated payment processing stores all credit card and bank account data offsite, and we even help you with your PCI compliance. We automatically process payments either through our built-in interface or through integration with OrthoBanc. Focus Ortho goes as far as to email you when a payment is denied.

Communication — choose the option that works the best

Customize Focus Ortho for any role in the office 72 Orthodontic practice

We believe that communication with your patients is essential to your success. So, we built a web portal exclusively for them. They can fill out forms, confirm upcoming appointments, reprint excuses and receipts, and even process online payments. No more syncing of data, since it is all part of one system. We did not stop there; you can reach patients, responsible parties, and referring doctors via text and email. Reduce no-shows through automated patient reminders, or send custom letters; it is all at your fingertips. Best of all, it’s all tracked in each patient’s record, back in the cloud. Volume 6 Number 3

IN FOCUS

Imaging — available anytime and anywhere We made our integrated imaging software intuitive and fast. Easily import images from digital cameras with a single click. Quickly crop photos for quality records. You shouldn’t have to worry about where your X-rays are coming from; so, we made Focus Ortho integrate with the major digital X-ray systems. Images are loaded to the cloud quickly and can be retrieved anywhere you have an Internet connection.

Scheduling — work with precision We designed an intuitive schedule that uses drag and drop and expanded on this by making it simple to create custom templates and assign them to any day. You can also modify a specific day without affecting the standard template. Our office flow allows you to follow patients from the moment they reach the office; you can see if they are waiting, seated in a chair, or checked out from one intuitive screen. But, once again, we wanted more. So, we used the same screen to track doctor location and even show the order that patients should be seen. Easily enter treatment data by typing information or choosing from the pull downs. We even added the flexibility of entering next appointments from the back or the front desk.

Easily store and view images in the cloud

All you need is an Internet connection — because it’s all waiting for you, in the cloud.

Reporting — find your data Your software system is only as good as the data you can get from it. So, we designed a reporting system that gives you unparalleled access to your data. Of course, we can create traditional reports that are printed easily from the system. We have taken this to a new level with interactive lists. Reports can be displayed in list view, and we have screens that allow you to choose financial and patient data from pull-down menus. Lists are easily exported in multiple formats, including Microsoft Excel. Using interactive lists, you can sort and filter data and directly open the patient. Interactive lists will reduce printouts, save trees and your time.

What does the future hold? We are constantly striving to make Focus Ortho the best practice management software available. With this in mind, we are constantly updating to include new features and functionality. Keep an eye out for our mobile app available later this year. Make sure to visit us at our next trade show to see what new and exciting developments we have. Volume 6 Number 3

Focus Ortho features an efficient interface that is truly amazing

You owe it to yourself to take a look at Focus Ortho. It’s so simple; a written description can’t possibly do it justice. Let us give you a demo. All you need is an Internet connection — because it’s all waiting for you, in the cloud. OP

This information was provided by Focus Ortho.

Orthodontic practice 73

TECHNOLOGY

Clear Collection instruments for clear aligner treatments In part 1 of a series, Dr. S. Jay Bowman explores instruments that help increase the utility of aligners and expand the scope of appropriate applications Let’s be clear: enhancing aligner treatments As clear aligner treatments have evolved and been progressively refined in the past 15 years, more advanced applications and increasingly complex malocclusions have been addressed.1-4 In addition, there has been more interest in tackling some of the specific limitations of moving teeth with plastic.5-7 Obviously, the progress of orthodontic treatment with traditional wires and braces has been advanced throughout the past century, but the techniques associated with a sequence of aligners are relatively recent phenomena. Orthodontists with the most experience and enthusiasm in using aligners have worked diligently to improve the concept through better understanding of the limitations involved in more advanced treatment planning, especially when using adjuncts to enhance the associated biomechanics.4,8-13 The Clear Collection of instruments from Hu-Friedy (Chicago, Illinois, at www. hu-friedy.com) was developed with that aim in mind; namely, to help to increase the utility of aligners and expand the scope of appropriate applications (Figure 1).13

“Innovation is taking two things that already exist and putting them together in a new way.” – Tom Freston

Adding intra- and intermaxillary forces The Clear Collection instruments have streamlined and standardized some procedures that orthodontists had already been providing, while opening up more options for other methods to accentuate or refine treatment. In the past, attempting to add intermaxillary elastics for correction of

Class IIs, IIIs, or midlines was problematic. Some were cutting notches in plastic trays using scissors or nail clippers10 or attempting to adhere buttons to the trays — all unwieldy endeavors. The Tear Drop There are occasions when orthodontic elastics are needed to assist with specific tooth movements or growth modification when using aligners. For instance, it may be beneficial to add elastic hooks or bonded buttons in different locations along the arch form on either the buccal or lingual. It would be beneficial to incorporate an elastic hook that cannot be dislodged from the aligner and that only requires a simple one-step squeeze of a pair of pliers to create. Most importantly, a hook that actually holds the elastic in place on the aligner. The Tear Drop pliers (Figure 2) is an instrument created for the purpose of adding a notch or hook at the gingival margin of clear aligners. A standardized notch is easily cut in a single step, creating a teardrop-shaped

Figure 1: Hu-Friedy’s Clear Collection of instruments designed to enhance clear aligner treatment (Images courtesy of Hu-Friedy Mfg. Co., LLC, Chicago, Illinois) S. Jay Bowman, DMD, MSD, is a Diplomate of the American Board of Orthodontics and a member of the Edward H. Angle Society of Orthodontists. He developed and teaches the Straightwire course at the University of Michigan, is an Adjunct Associate Professor at Saint Louis University, an Assistant Clinical Professor at Case Western Reserve University, and Visiting Clinical Lecturer at Seton Hill University. He maintains a private specialty practice of orthodontics in Portage, Michigan.

74 Orthodontic practice

Figures 2A-2D: The Tear Drop pliers was created to produce a notch in clear aligner plastic to facilitate the application of orthodontic elastics Volume 6 Number 3

Figures 4A-4B: The Hole Punch pliers was created to produce a half-moon cutout to permit the addition of bonded buttons or brackets

Figures 5A-5B: A variety of methods to connect orthodontic elastics can be added to clear aligners using the Hole Punch and the Tear Drop instruments. 5A. Class I intramaxillary elastics connected from teardrop hook to a miniscrew (i.e., to support molar distalization) plus Class II intermaxillary elastics from teardrop notch to bonded button. 5B. Intermaxillary elastics hooked to bonded buttons to assist with seating of teeth into aligners and improve occlusion

Figures 6A-6D: The Hole Punch pliers can be used to relieve plastic impingement of gingival tissues anywhere along the aligners (e.g., incisive papilla irritation) Volume 6 Number 3

The Hole Punch The Hole Punch (Figure 4) is used to cut a half-moon shaped hole at the gingival margin of aligners. These half-circle cuts permit the addition of bonded buttons, bonded orthodontic tubes or brackets with associated hooks, or are simply used to relieve impingement of plastic on soft tissue. The Hole Punch can be used to produce cuts on either the facial or lingual of any tooth, anywhere along the aligners, whenever needed. Buttons bonded to teeth, rather than to the trays, do not cause dislodgement of the aligner. During the progress of some patients’ treatments (after a series of aligners has already been fabricated and delivered), an orthodontist may wish to add elastics. Bonded buttons can be added to hook up Class II or III intermaxillary elastics, biteseating elastics, Class I intramaxillary elastics to miniscrews (Figure 5), or elastomeric chain connected to buttons to correct dental rotations. The combination of buttons on molars (plastic relieved using the Hole Punch) along with elastic hooks cut into the plastic at the cuspids (using the Tear Drop) is a common method of employing orthodontic elastics. In other instances, aligners will occasionally impinge upon gingival tissues and cause gingival pain or inflammation. The Hole Punch can be used to clear the impingement of plastic in each of a series of aligners. A common location for that type of irritation is at the incisive papilla, behind the maxillary central incisors (Figure 6). Nipping along the gingival margin of a tray with the Hole Punch is also an option to relieve marginal gingival impingement on either the buccal or lingual. Orthodontic practice 75

TECHNOLOGY

Figures 3A-3B: Teardrop-shaped hooks retain elastics when aligners are seated, making the addition of “rubber bands” easier for patients to manipulate. Notches are made at an angle to resist forces applied by the elastics

“reservoir” to hold the elastic on the tray (Figure 3), thereby making it easier for the patients to seat their aligner and connect their elastics. In this manner, the patient is not fumbling with elastics, attempting to hook them in two locations since the elastic accompanies the aligner as it is seated over the teeth. Teardrop notches should be cut at an angle to resist the line of force of elastics that are being employed (e.g., the notch is angled anteriorly at the mesial of the upper cuspid for Class II elastics; Figure 3). These hooks can be added anywhere along the clear aligner arch at the gingival margin on either the facial or lingual, whenever elastic forces need to be applied.

TECHNOLOGY Bootstrap mechanics If certain teeth are not “tracking” or are lagging13 behind (i.e., not fitting into the tray; Figure 7) Aligner Chewies™ are employed (Chewies™ Aligner Tray Seaters, Dentsply Raintree Essix, York, Pennsylvania). Patients are asked to hold the Chewie between the teeth in question and squeeze 10-15 seconds, release, and repeat for 5 minutes, 2-3 times per day 8,13 (Figure 8). In addition, Chewies are routinely used for the first few days when patients switch to a new pair of aligners to help them seat more completely. Another option is to add elastics to forcibly erupt the teeth into the aligner tray.13,14 There are several methods to generate so-called “bootstrap mechanics” (Figure 9):13 1. An orthodontic elastic is stretched over the plastic aligner to connect to a combination of bonded buttons on both lingual and buccal of the tooth. 2. A bonded button is placed on the lingual of the tooth (plastic cleared with the Hole Punch). The Tear Drop notches are cut into the tray at the gingival embrasure spaces in the

buccal plastic on both the mesial and distal of the problematic tooth, and an elastic hooked from the buccal notches and stretched over the aligner tray to the button to produce an extrusive force.13 The Tear Drop and/or Hole Punch cuts are made in each tray in the series of aligners prior to their being delivered to the patient.

This concept is also useful when the extrusion of a tooth is needed for restorative purposes. Other biomechanics that benefit from the application of elastic forces to aligner trays include the correction of severe rotations, posterior or anterior intrusion mechanics for open bites,11,12 and forces to control anchorage during molar distalization or

Figure 7: Aligner “lag” or lost tracking is most often characterized as an “air gap” between the incisal or occlusal of teeth and the plastic, indicating teeth are not following the prescribed tooth movement13

Figures 8A-8B: Aligner Chewies are held tightly been specific “lagging” teeth for 10-15 seconds. This process is repeated for 5 minutes, 2-3 times daily, especially when changing to a new pair of aligner trays A.

Figures 9A-9C: Bootstrap mechanics13 to forcibly erupt a “lagging” tooth using orthodontic elastics (9A-9B). The Hole Punch is employed to clear aligner plastic to permit the addition of bonded buttons. The Tear Drop is used to cut notches in mesial and distal embrasures (9C-9F). 76 Orthodontic practice

Volume 6 Number 3

CLEAR SOLUTIONS FOR CUSTOMIZED EFFICIENCY

Introducing Hu-Friedy’s CLEAR COLLECTION Hu-Friedy’s Clear Collection consists of innovative instruments designed to accent, individualize and optimize the biomechanics of the invisible aligner experience with no heat required. THE TEAR DROP Creates a reservoir to use with elastic hooks

THE HORIZONTAL Produces indentations for torque & retention

THE VERTICAL Produces indentations for rotation & retention

THE HOLE PUNCH Creates half-moon cutouts for bonded buttons & tissue impingement clearance

TECHNOLOGY D.

REFERENCES

1. Clements KM, Bollen AM, Huang G, King G, Hujoel P, Ma T. Activation time and material stiffness of sequential removable orthodontic appliances. Part 2: Dental improvements. Am J Orthod Dentofacial Orthop. 2003;124(5):502-508. 2. Djeu G, Shelton C, Maganzini A. Outcome assessment of Invisalign and traditional orthodontic treatment compared with the American Board of Orthodontics objective grading system. Am J Orthod Dentofacial Orthop. 2005;128(3):292-298. 3. Phan X, Ling PH. Clinical limitations of Invisalign. J Can Dent Assoc. 2007;73(3):263-266. 4. Tuncay O. The Invisalign System. London: Quintessence Publishing; 2007. 5.

Kravitz ND, Kusnoto B, BeGole E, Obrez A, Agran B. How well does Invisalign work? A prospective clinical study evaluating the efficacy of tooth movement with Invisalign. Am J Orthod Dentofacial Orthop. 2009;135(1):27-35.

Krieger E, Seiferth J, Marinello I, Jung BA, Wriedt S, Jacobs C, Wehrbein H. Invisalign速 treatment in the anterior region: were the predicted tooth movements achieved? J Orofac Orthop. 2012;73(5):365-376.

7. Chisari JR, McGorray SP, Nair M, Wheeler TT. Variables affecting orthodontic tooth movement with clear aligners. Am J Orthod Dentofacial Orthop. 2014;145(4 suppl):S82-91. 8. Tuncay O. Clinical Reports & Techniques. 2005;6(2):1.

Figures 9D-9H: The Tear Drop is used to cut notches in mesial and distal embrasures (9C-9F). Orthodontic elastics are stretched from the button to the teardrop notches or to another button on the opposite side of the tooth (9G-9H)

9. Daher S. Techniques for Class II correction with Invisalign and elastics. Align Technology, Inc. Web site. Published 2013. Accessed April 11, 2015]. https://s3.amazonaws.com/learninvisalign/docs/06840000000GHgmAAG.pdf 10. Paquette D. Temporary Anchorage Devices in Combination with Aligners 2009. Invisalign Web site. http://www.aligntechinstitute.com/files/ATEArchive/pdf/ate_110609.pdf

en masse movements when employing miniscrews (Figure 5).13 Cutting notches and relieving the plastic to add buttons or brackets facilitate the application of these innovative mechanics. It is important to remember that indiscriminate alteration of the integrity of clear aligners may reduce their structural strength or may impair the intended biomechanics programmed into an aligner. 78 Orthodontic practice

The instruments in the Clear Collection help the orthodontist to better customize clear aligner treatments, enhance their desired biomechanics, and streamline the addition of adjunctive forces during the course of a series of aligners. For information on the use and applications of the Clear Collection, instructional videos are available on YouTube at https://www.youtube.com/ watch?v=hrs2VfnImLY. OP

11. Boyd R. How successful is Invisalign for treatment of anterior open bite and deep overbite? Presented at: American Association of Orthodontists Annual Session; May 5, 2013; Philadelphia, PA. https://www.aaoinfo.org/system/files/media/documents/Boyd,%20Robert%20--%20Treatment%20of%20 Deep%20and%20Open%20bite%20with%20Clear%20 Aligners.pdf 12. Dayan, W. Techniques for Posterior Intrusion with Invisalign to Correct Anterior Open Bites. Techniques White Paper 2010. http://www.cityortho.ca/Portals/0/City%20Ortho-%20 Open%20Bite%20Blog.pdf. 13. Bowman SJ, Celenza F, Sparanga J, Papadopoulos MA, Ojima K, Lin J. Creative adjuncts for clear aligners, Part 1: Class II treatment. J Clin Orthod. 2015;49(2):83-94. 14. Giancotti A, Ronchin M. Pre-restorative treatment with the Invisalign system. J Clin Orthod. 2006;40(11):679-682.

Volume 6 Number 3

Dr. Mark S. Sanchez offers practical steps to keeping your private and professional information from the ne’er-do-wells

“Y

ou’ve just been infected. Send $500 within 72 hours, or we’ll wipe your computers.” That was the message one office administrator read after clicking on the icon that was supposed to provide her with information on how to run her office more efficiently. So what did she do? More importantly, what would you do? Unfortunately for the medical doctor’s office in Macon, Georgia, the administrator rebooted her computer thinking that would solve the issue and didn’t mention the incident to anyone. Not at first. Not even at a time when the ransomware Trojan, Cryptolocker, was playing a starring role in world news. And, days later, the practice started to notice things going awry. Schedules wiped. Files corrupted. Computers acting funny. True to their threat, the ransomware Trojan that hijacked their computers

Mark S. Sanchez, DDS, is the founder, CEO, and chief developer of tops Software. He practices in Atlanta. Sanchez developed his programming skills while pursuing a doctorate in physics at Georgia Tech. He earned his dental degree and certificate in orthodontics at Emory University.

Volume 6 Number 3

was now wreaking havoc on their system. An emergency office meeting was held, and through the discussion, the administrator finally realized her error. She just didn’t know. It was an honest mistake. None of the data was stolen (whew!) but in the end, the mistake forced the practice to manually re-enter 3 months’ worth of office notes, which increased labor costs by a quarter that year. So, what would you have done? Still don’t think about it much? Yikes! Well, it’s OK that I do, and that’s why I wrote this article — to help you keep your valuable information from the destructive ways of those hackers, thieves, and no-good pilferers of the world. I know that people want convenience above all else. Incredibly, a third of smartphone users in the United States still don’t set up password security on their phones. According to Confident Technologies, 65% of users have corporate data on their phone, even though only 10% actually have a corporate-issued device. That’s pretty scary. Security measures are now an absolute must, especially if your patients’ precious information is in your hands. Thankfully, it

doesn’t have to be all that daunting. Here are a few safety measures I require my staff to incorporate in my practice. And, I also encourage them to do the same in their personal online lives. This stuff is important. Security rule No. 1: When in doubt, don’t click. Ever. When it comes to links and attachments in emails — even if it’s from someone you know and trust — resist temptation. Just give them a call to confirm they did indeed send it. And if it’s from your bank or other vendor, well, go ahead and check the safe way — by typing in the company’s website in your browser. Why the super-security measure here? Well, because websites can be faked when opened by email links. Security rule No. 2: Open an online account the safe way. If the site lets you use a non-email address username, use a word or code that no one would guess. That way, you effectively have two passwords to double up on security. Security rule No. 3: Give admin passwords for every computer. And make sure those passwords are at least 16 characters. To keep it memorable, try stringing together Orthodontic practice 79

SECURITY GUARDS

Your data: (Relatively) convenient ways to keep it safe and secure

SECURITY GUARDS three or four words to create a phrase that’s not a common phrase or popular lyrics. Something like “Cats grace the dance floor” or something nonsensical but easy to remember. Security rule No. 4: Accommodate guests with a separate WiFi access point. Prevent the accidental access to your practice and patient data with this very simple measure. An easy password like “MakeMeSmile” can add a little fun to the security measure, too. Security rule No. 5: Limit laptop access. Grant few people on staff your admin access to laptops — I suggest just you and the office manager. For daily use by the rest of the staff, a non-admin account on each computer will work just fine. Security rule No. 6: Think screensaveras-security-measure. Set your screensaver to turn on after your computer has been idle for 5 minutes and to ask for a password once you’re ready to get back on again. Security rule No. 7: Create a hotspot lock. Create a hotspot in your lower left corner that instantly activates your locked screensaver. So the moment you have to leave your computer unattended, just move the cursor to the lower left corner of the screen and — bam! — instant lockout. Security rule No. 8: Never store your PIN. Never. Don’t store credit card numbers or PINs to bank accounts anywhere on your computer. Nowhere. Really. Don’t do this. Thieves are very clever and will find the information. Security rule No. 9: Don’t be so obvious. Forget your password a lot? I do, too. To reset your password, many sites send you emails to reset information. They try to be secure but, really, m***z@gmail.com is pretty easy to guess. So I set up a special email that serves as the only avenue to retrieve my passwords via email should I forget. I never use it for anything else and, of course, I use a name that is not easily deduced. For example: CatsGraceTheDanceFloor@gmail. com becomes c***r@gmail.com. Security rule No. 10: Use proven security-enhancing tools. I really like the password generator called 1Password because it keeps all the important information encrypted and secure. Even better, it helps me manage all the different usernames and passwords for every online account I have. That’s something to think about for your own accounts. Just think of it this way: You need to protect your house and safeguard it against thieves in the physical world. A sign that 80 Orthodontic practice

Security measures are now an absolute must, especially if your patients’ precious information is in your hands. Thankfully, it doesn’t have to be all that daunting.

says you have an alarm is usually enough to discourage a thief, so he moves on to the next house. So you get an alarm to go with the sign as well as a giant Doberman pinscher named “Killer,” and chances are you’re going to be just fine. The same concept applies in the virtual world. By now, you can tell I’m a bit obsessed with security. That’s why I made sure that topsOrtho™ software has built-in, thief-foiling measures, too. I know, shameless plug, but since you’ve read this far, here’s what we’re doing for orthodontist offices: We started with a Mac-based software system, so topsOrtho is just inherently more secure than its PC-based counterparts. To augment safeguarding measures, we added an increasingly long wait between each misguided password entered into the topsOrtho log-in window. Each incorrect passcode that is entered results in an increased delay before

topsOrtho will accept another passcode attempt. This is to slow down the ne’er-dowells who might use an automated passcode entry tool to try and guess your password. The delay time increases exponentially with each incorrect entry, so that only a small number of attempts can be made. That’s just one of many security measures we included in our software. Of course, we’re always looking to add more. There are so many more discussions and tips on the topic of security but only so much space on the page. But if you’re interested, I talk a lot about security on social media, so if you want to keep abreast of the latest without doing the all that exhausting research yourself, you can follow me and topsOrtho on LinkedIn (tops Software), Facebook (facebook.com/@topsOrtho), and Twitter (@ topsOrtho) for more on the subject. Don’t let them win. Stay safe. OP Volume 6 Number 3

My IT guy said, ‘If you go with Mac, you won’t need us.’ Dr. Alex Cranford Cranford Orthodontics

topsOrtho has a 99% customer retention rate, so it's TM

not too hard to ﬁnd orthodontists willing to go on record to rave about us. Dr. Cranford went on to say, “If I ever need support, I call up and get a very friendly human. No attitude. It's so refreshing.” What else is there to love about topsOrtho ? Security. TM

Reliability. Intuitiveness. Mature, native-Mac platform. And speed, speed, speed. Actually, there's even more, so why not email sales@topsortho.com or call 770-627-2527 for a demonstration. We'd love to hear from you.

TOWNIE CHOICE AWARD® WINNER topsOrtho : Best Orthodontic Practice Management Software TM

topsCephMate : Best Practice Management Enhancements TM

PRODUCT PROFILE

American Orthodontics PowerScope™ Class II Corrector Innovative, effective Class II correction

merican Orthodontics is revolutionizing Class II correction with PowerScope™ — a ready-to-use chairside solution that delivers an unmatched combination of patient comfort and ease of use. American Orthodontics developed PowerScope in conjunction with Dr. Andy Hayes, a clinical instructor in the St. Louis University Department of Orthodontics, who runs a private practice in Ballwin, Missouri. PowerScope is a one-piece, one-sizefits-all appliance that goes from package to treatment in just seconds. There’s no need for any lab setup, assembly, or measuring. It attaches wire-to-wire for quick, easy installation and eliminates the need for headgear tubes or special band assemblies. Wire attachment mechanisms hang on the archwire, and the screw then acts as a “fourth wall” that holds the appliance in place. PowerScope does not “lock” onto the wire and freely slides to allow for any dentoalveolar correction associated with a Class II malocclusion. PowerScope’s internal NiTi spring delivers 260 grams of force throughout treatment, which can translate to reduced treatment time compared to other Class II Herbst appliances. Crimpable shims then facilitate activation and advancement control throughout treatment. American Orthodontics is dedicated to continuous improvement and has made several recent enhancements to PowerScope.

They include: • A prominent laser marking ID for quick and easy activation of the appliance • A magnetic hex head driver for safe delivery of appliance during installation • Improved screw and attachment mechanism design for increased durability against patient abuse during treatment “The large learning curve associated with other multi-piece appliances is eliminated,” says Dr. Hayes. “PowerScope is a simple, extremely efficient appliance that can be the ‘go-to’ treatment for Class II correction that you can count on to work every time. “Installation of PowerScope takes very little time and offers a much more favorable force vector for Class II correction than other appliances,” says Dr. Graham Jones of Monroe, Washington. “PowerScope’s design and the direction of its forces means compensations like Class II overcorrection or complicated anchorage techniques common for other fixed Class II correctors aren’t necessary.” Patients will be pleased with the increased comfort PowerScope brings. There are no external springs or distally extending pistons; lateral movement is maximized with ball and socket joints; and smooth, rounded edges and a low profile mean the cheeks won’t get that “puffed out” look that comes with other Class II solutions.

“My patients find PowerScope to be by far the most comfortable fixed Class II appliance of those that I have used,” says Dr. Jones. “Range of motion is not impaired by the PowerScope, and there’s virtually no tissue impingement.” To learn more about PowerScope, visit www.americanortho.com/PowerScope.

About American Orthodontics American Orthodontics is the largest privately held orthodontic manufacturer in the world, proudly based in Sheboygan, Wisconsin. American Orthodontics has been manufacturing quality orthodontic products and peripherals for customers in more than 100 countries since 1968. 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 This information was provided by American Orthodontics.

Class II patient treated with PowerScope (left) and posttreatment photo (right) (Photos courtesy of Dr. Graham Jones) 82 Orthodontic practice

Volume 6 Number 3

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

Objet30 OrthoDesk: digital orthodontics from your desktop

ompact, affordable, and easy to use, the Objet30 OrthoDesk empowers dental labs and practices to build surgical guides, veneer models, orthodontic appliances, delivery and positioning trays, and models in-house. In addition to its smaller desktop size, the Objet30 OrthoDesk 3D printer features a quiet, clean process that wonâ&#x20AC;&#x2122;t disrupt your lab. The OrthoDesk can be easily integrated into your lab to dramatically cut production time with cutting-edge 3D printing technology. Like an inkjet printer, PolyJet 3D printing technology jets liquid photopolymer onto a build tray, creating dental models layer by layer from the bottom up. Each dental model produced is highly accurate with fine-feature quality and smooth surface finish. Multiple models can be produced simultaneously on the OrthoDesk build tray, increasing your labâ&#x20AC;&#x2122;s production capacity and making it possible to handle new orders with ease. With a completely digital workflow, your lab can eliminate the need to store bulky physical models and experience fewer remakes by avoiding the inaccuracies of hand-milling. By moving to a digital process, smaller orthodontic labs can stay competitive while still providing best-in-class results. Objet30 OrthoDesk

Objet Eden260VS Dental Advantage: efficiency for growing labs

Objet Eden260VS Dental Advantage 84 Orthodontic practice

Streamline in-house production of dental models, orthodontic appliances, and surgical guides with the Objet Eden260VS Dental Advantage. Using PolyJetâ&#x201E;˘ technology, the Objet Eden260VS Dental Advantage functions by jetting drops of liquid photopolymer in tiny layers and then curing them with UV light. Plus, it takes workflow automations a step further with a soluble support material that dissolves easily from tiny cavities, overhangs, and crevasses. The Objet Eden260VS Dental Advantage delivers the lowest cost per part with

the accuracy and consistency needed for fine details and complex surface geometries. With four specialized materials, it has the versatility to handle a variety of dental and orthodontic applications, including stone models, surgical guides, veneer or denture try-ins, and delivery trays. The Objet Eden260VS Dental Advantage is the essential 3D printer to make precision dental modeling a reality in your dental or orthodontic lab. Create a competitive point of difference by using a digitized workflow to generate faster turnaround and greater production capacity. OP This information was provided by Stratasys.

Volume 6 Number 3

THE SECRET TO ORTHODONTIC LAB SURVIVAL IN THE NEXT DECADE? GO DIGITAL.

For an orthodontic lab to survive in today’s market you need to expand your reach. Win new customers. Open fresh markets. In short – you need to go digital. 3D printing helps you better plan and execute your digital workflow. Now you can digitally manufacture stone models, orthodontic appliances, delivery and positioning trays, clear aligners and retainers faster than ever. Labs like ClearCorrect and ClearStep have already transitioned to a digital workflow and have done away with bulky physical model storage. So why wait? Contact Stratasys to find out why now is the right time to move to digital production with Stratasys Objet 3D Printers.

INDUSTRY NEWS Henry Schein® Orthodontics’™ 1st Annual Orthodontic Excellence and Technology™ Symposium Enhancing the Practice of Orthodontics Henry Schein® Orthodontics™ (HSO) is hosting its first Orthodontic Excellence and Technology™ Symposium. During this event, industry leaders will share cutting-edge technologies and treatments that enhance the practice of orthodontics. This is a must-attend event in beautiful San Diego at the Omni La Costa Resort and Spa, July 24-25, 2015. Learn from industry leaders: Dr. Sean Carlson, Dr. Luis Carriere, Dr. Lou Chmura, Dr. Scott Frey, Dr. Dave Paquette, Dr. Juan-Carlos Quintero, Rosemary Bray, and Charlene White. Hot topics for progressive orthodontists that will be addressed include Sleep Apnea and Orthodontics; Soft Tissue Orthodontics™; Facial, Skeletal, and Dental Harmony; Embracing Technology; and Practice Integration. Contact Henry Schein Orthodontics at 888-994-7374, or visit HenryScheinOrtho.com.

M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT tops Software to Release 6.2, featuring topsChecklist™ for iPad for simple, customized checklists tops Software is scheduled to release topsOrtho 6.2 within the next few weeks. Included in the update is topsChecklist for iPad. The app allows doctors and staff to customize and track checklists, such as medical history forms, new patient forms, HIPAA forms, and others, right on the iPad for a more streamlined process. With topsChecklist, staff can assign checklists to patients on an iPad, give the tablet to patient (or guardian) to verify and sign, and hand back to staff. Upon staff approval of inputted information, the data is linked directly to topsOrtho. For more information, visit www.topsOrtho.com, or call 770-627-2527.

86 Orthodontic practice

Forestadent presents Achieving True Practice Success Discover the hidden bridge to true practice success in Booth No. 605 during the 2015 AAO! Forestadent will feature a meet and greet with Dr. Ron Roncone, Dr. Doug Knight, and Dr. Straty Righellis during the main event on Sunday from 2:30 p.m.-4:30 p.m. Stop by and enjoy a glass of wine from the well-known Napa Valley while these distinguished speakers present their paths to Achieving True Practice Success. During your visit to the booth, don’t forget your Passport to Practice Success. Participation in this promotion could result in a trip for two to the Bellagio ~ Las Vegas! This is just a little taste of the excitement planned for this year’s show. Stop by, see everything that we have to offer, and plan to take your practice to greater heights!

CBCT in Orthodontics program launches This two-day, comprehensive program, led by Drs. Sean K. Carlson and Juan-Carlos Quintero, will prepare you for the future and help transition your practice from 2D to 3D imaging. These industry-leading CBCT instructors will show you how to elevate your quality of care, thrive in the new 3D era, and experience practice growth like never before. The course is designed to help you succeed with every aspect of CBCT technology in your orthodontic practice. 2015 programs will be held June 12-13 in San Jose, California, and September 18-19 in Miami, Florida. Call 877-448-8606 to register, or visit CBCTOrtho.com.

Ortho2 Announces Edge 5 Ortho Computer Systems, Inc., announces the release of its cloud-based Edge 5. This new version of Edge features deeper integration with their patient-centered Practice Connect mobile app and Patient Rewards features. In addition, Edge 5 includes countless enhanced features and improved functionality designed to optimize the efficiency of the practice. Now Edge users can enhance their practice with the use of Patient Rewards and Practice Connect. Patient Rewards allows users to calculate points and track rewards offered as incentive to motivate patient attendance, treatment cooperation, oral hygiene, and more. The Practice Connect app is branded with your practice name, logo, and customizable content for your patients and parents. Practice Connect is available for both Android and iOS devices and builds on Ortho2’s library of practice and patient focused apps. Edge users can now also customize the content and layout of the Home ribbon bar by including only the icons used most frequently, and making the icons larger or smaller. In addition, users can add words into custom dictionaries and use spell check in the Notepad, Treatment Hub, and Treatment Plan. Edge 5 also features a custom text box in the Treatment Findings for additional text for each finding. Additionally, the Help topics have been centralized in one location in the Home ribbon bar. From this button, users can easily access videos, white papers, online help, and even contact our Software SupportTeam through email. For more information about Ortho2, visit www.ortho2.com.

Volume 6 Number 3

Carestream Dental released the Logicon Caries Detector 5.1

3M Unitek announced the launch of AlastiK™ Lingual Ligatures, the first ligatures specifically designed for the Incognito™ Appliance System. Enabling faster and easier ligation, AlastiK Lingual Ligatures are the latest in a series of innovative upgrades to the Incognito System, including Incognito™ Clear Precision Trays and customization for the Forsus™ Fatigue Resistant Device. Together, these improvements maximize ease of use, efficiency, and patient comfort during lingual treatment. AlastiK Lingual Ligatures improve ease of lingual bracket ligation while exhibiting the same wire fixation and force as an overtie. The innovative design means wire changes can be accomplished more than 20% faster than current techniques, and the ligatures are shown to break less than commonly used chains during installation and between appointments. When used as plain ties, AlastiK Lingual Ligatures apply similar tip control compared to overties with powerchain without compromising patient comfort. For more information, visit 3MUnitek.com/Incognito, or call the Incognito Customer Care Team at 800-401-3001.

Carestream Dental’s latest release of Logicon Caries Detector 5.1 further automates the detection process and produces improved displays of caries sites, making exams and diagnoses even more efficient than in the past. Logicon 5.1, the only commercially available FDA-approved computer-aided radiographic caries diagnosis software, is a unique and clinically proven tool that helps practitioners detect and treat interproximal caries at an early stage, enabling minimally invasive treatments. In fact, studies show that Logicon more than doubles dentists’ capability to find early caries in the dentin over traditional visual diagnostic methods.* For more information, call 800-944-6365, or visit www. carestreamdental.com. *Tracy KD, Dykstra BA, Gakenheimer DC, Scheetz JP, Lacina S, Scarfe WC, Farman AG. Utility and effectiveness of computer-aided diagnosis of dental caries. Gen Dent. 2011;59(2):136-144.

A perfect fit. “I have been using clear aligners to treat a broad spectrum of my orthodontic patients since 2000 and have grown to appreciate the quality and capability of the ClearCorrect system: the online portal is simple and easy to utilize; I do not have to frequently return setups for revision; the aligners always fit well; the staff and support personnel are responsive and pleasant to work with when needed. For the best ROI and ‘bottom line’, ClearCorrect is my choice for a comprehensive clear aligner system.” —Dr. Ken Fischer, orthodontist.

(888) 331-3323 Call or visit booth #545 at AAO to receive 50% off your first case.

The most affordable & doctor-friendly alternative in clear aligners. Offer expires 6/30/2015

Volume 6 Number 3

Orthodontic practice 87

MATERIALS & EQUIPMENT

3M Unitek announces AlastiK™ Lingual Ligatures for the Incognito™ Appliance System

29.2 μSv

PRACTICE PLANMECA OWN THE FUTURE™

See Planmeca at the American Association of Orthodontists Annual Session Booth # 1437

For a free in-office consultation, please call

1-855-245-2908

or visit us on the web at www.planmecausa.com

7 μSv

4 μSv

7 μSv

OWN THE FUTURE™

PRACTICE PLANMECA

The ProMax® 3D Family Ultra-Low Dose protocol achieves an average of

77% reduction in radiation dose WITHOUT COMPROMISING IMAGE QUALITY*

*When compared with standard imaging protocols, according to “Dosimetry of Orthodontic Diagnostic FOVs Using Low Dose CBCT Protocol” by JB Ludlow and J Koivisto. For a copy of this study, please contact Planmeca USA.

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