Orthodontic Practice US - July/August 2015 - Vol6.4 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews

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July/August 2015 – Vol 6 No 4

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Cantilevers — a simple method for Class II corrections

Drs. Rohit C.L. Sachdeva, Takao Kubota, and Jun Uechi

Drs. George J. Cisneros, Matthew Miller, and Shira Bernstein, BA

Practice profile Dr. Lisa Alvetro

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BioDigital Orthodontics part 16

A historical and orthodontic perspective on white spot lesions — a literature review: part 1

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Dr. Larry White

INTRODUCTION

Technology streamlines workflow

ll doctors want to provide their patients with the best care, but as specialists, we orthodontists often feel a stronger sense of duty to go above and beyond — especially when dealing with young patients and their parents. As such, I’m always looking for ways to (1) work with the latest technology, (2) provide less stressful and fewer time-consuming appointments to my patients, and (3) offer quicker turnaround from initial appointment to appliance delivery. Fortunately, there’s technology that lets me do all three: Enter, the digital intraoral scanner. The technology behind the intraoral scanner is not new. General dentists have been using them for about a decade for restorative work, but only in the past few years have scanners entered the field of orthodontics. I find the intraoral scanner plays an integral role in my workflow. First, scanners alleviate one of the biggest pain points for both staff and patients — taking impressions. Consider traditional impressions: the cost of materials, the prep work of readying those materials, the potential struggle with a nervous young patient followed by disinfecting and pouring up the impression, factoring in time to dry, separating the impression, and so on. However, with an intraoral scanner, the process is nearly cut in half. The workflow with a scanner is turn on scanner; select scanner tip; scan arches; and upload STL files to the lab the same day. Since there are no trays, alginate, or polyvinyl materials, prep work is minimal, with cost savings in both time and materials. Even better, patients appreciate not having their mouths filled with the “goo” associated with traditional impressions. Immediately after the digital impressions are captured, the software can make measurements of overjet, overbite, pressure map, arch length, tooth size, crowding measurements, and more. Plus, some software can automatically mount the model in a finished base — perfect for case presentation. Since the software creates a digital 3D model and stores it on the computer, physical storage is no longer an issue — saving money if you’re currently paying for offsite storage (or freeing up extra office space for another chair or larger piece of equipment). The space-saving and immediate access factors of virtual versus physical models are reasons enough for some orthodontists to use a digital scanner. However, I maximize efficiency by sending the 3D impressions to a lab to fabricate appliances. A final scan is taken during the patient’s last appointment following cessation of movement with brackets still on the teeth. The digital impression is sent to my lab of choice using a web-hosted platform. The lab digitally removes the brackets and returns a retainer (as well as a spare) before patients have even had their braces removed. Since the printed model is on file, I can have replacement retainers made when needed. This means that if a retainer is lost or broken, a new one can be ordered without scheduling the patient to have a new impression taken; the replacement is mailed directly to the patient. A similar process can be used fabricating clear aligners or other orthodontic appliances. Like all new technology, it’s important to consider how it will fit into your workflow. Fortunately, scanners are becoming even more tailored to the requirements of orthodontists. For example, there’s no longer a need to pull a cart and computer system from operatory to operatory; there are now scanners on the market that are truly portable — simply plug into your chairside computer’s USB. Also, software updates and ever-faster computers mean the time it takes to scan a patient is consistently decreasing. Scanners work in real-time; images appear on the computer screen within seconds. Also, it is truly a sign of how far scanners have come in the field of orthodontics that some now feature smaller, interchangeable, sterilizable tips to better serve our school-aged patients. It has been my experience that intraoral scanners greatly contribute to improving workflow in my orthodontic practice. Between the convenience, speed, and efficiency that they offer doctors, staff, and patients, I predict that scanners will soon become the new standard of care in the field. Dr. Robert Waugh has practiced orthodontics full time in Athens, Georgia, since 1989 and is also an Assistant Professor at Georgia Regents University (USA) College of Dental Medicine’s Orthodontic Residency Program. Dr. Waugh’s interests include using new technologies that help deliver better care for his patients. In 2008, he merged three offices into one facility of 24 chairs that allows him to deliver care using a wide variety of advanced modalities in hygiene, patient scheduling, treatment delivery, and more. Dr. Waugh graduated from GRU College of Dental Medicine in 1987 with both a DMD and a master’s in Oral Biology and was elected to Omicron Kappa Upsilon (OKU), the national dental honor society. He earned his orthodontic certification and a second master’s degree at Baylor University in 1989. In 2000, he was board-certified by the American Board of Orthodontics. Dr. Waugh has served as President of the Georgia Association of Orthodontists and is a member of the International and American Colleges of Dentists.

2 Orthodontic practice

July/August 2015 - Volume 6 Number 4 EDITORIAL ADVISORS Lisa Alvetro, DDS, MSD Daniel Bills, DMD, MS Robert E. Binder, DMD S. Jay Bowman, DMD, MSD Stanley Braun, DDS, MME, FACD Gary P. Brigham, DDS, MSD George J. Cisneros, DMD, MMSc Jason B. Cope, DDS, PhD Neil Counihan, BDS, CERT Orth Eric R. Gheewalla, DMD, BS Dan Grauer, DDS, Morth, MS Mark G. Hans, DDS, MSD William (Bill) Harrell, Jr, DMD John L. Hayes, DMD, MBA Paul Humber, BDS, LDS RCS, DipMCS Laurence Jerrold, DDS, JD, ABO Chung H. Kau, BDS, MScD, MBA, PhD, MOrth, FDS, FFD, FAMS Marc S. Lemchen, DDS Edward Y. Lin, DDS, MS Thomas J. Marcel, DDS Andrew McCance, BDS, PhD, MSc, FDSRCPS, MOrth RCS, DOrth RCS Mark W. McDonough, DMD Randall C. Moles, DDS, MS Elliott M. Moskowitz, DDS, MSd, CDE Atif Qureshi, BDS Rohit C.L. Sachdeva, BDS, M.dentSc Gerald S. Samson, DDS Margherita Santoro, DDS Shalin R. Shah, DMD (Abstract Editor) Lou Shuman, DMD, CAGS Scott A. Soderquist, DDS, MS Robert L. Vanarsdall, Jr, DDS John Voudouris (Hon) DDS, DOrth, MScD Neil M. Warshawsky, DDS, MS, PC John White, DDS, MSD Larry W. White, DDS, MSD, FACD CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day BDS, VT Julian English BA (Hons), editorial director FMC Dr. Paul Langmaid CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-in-chief Private Dentistry Dr. Chris Potts BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon

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Volume 6 Number 4

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

Case study ClearCorrect as a solution when traditional bracket bonding fails Dr. Matthew Fortna finds a solution for a patient with enamel defects..........16

Practice profile Lisa Alvetro, DDS, MSD

Making a world of difference

Class II correction with maxillary dentoalveolar distalization using the Liberty Bielle® Dr. Bradford Edgren illustrates a case study with a new Herbst-type appliance.........................................19

Orthodontic concepts BioDigital Orthodontics Management of skeletal deformities with orthognathic surgery-fusion model: part 1 Drs. Rohit C.L. Sachdeva, Takao Kubota, and Jun Uechi discuss the application of suresmile® in conjunction with orthodontic treatment and orthognathic surgery........................26

Propelling orthodontics

In focus American Orthodontics’ Ultimate CE — a unique educational experience

Increasing case acceptance and practice differentiation with PropelD Dr. David R. Boschken discusses a practice-building tool.......................34

ON THE COVER Cover photo courtesy of Dr. Rohit C.L. Sachdeva. Article begins on page 26.

4 Orthodontic practice

Volume 6 Number 4

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TABLE OF CONTENTS

Industry study Study finds Planmeca ProMax® 3D Ultra-Low Dose™ protocol reduces patient radiation exposure by an average of 77% without loss of diagnostic quality.....................36

Continuing education

Cantilevers — a simple method for Class II corrections Dr. Larry White discusses a simple and easily managed apparatus...............37

Drs. George J. Cisneros, Matthew Miller, and Shira Bernstein, BA, research a longstanding issue for orthodontists

A historical and orthodontic perspective on white spot lesions — a literature review: part 1

Technology Clear Collection instruments for clear aligner treatments: part 2 In part 2 of a series, Dr. S. Jay Bowman continues his look at instruments that help increase the utility of aligners and expand the scope of appropriate applications..............48

Product profile My Smile Consult™ Online Patient Education Tool by Ormco Corporation.................53

Product profile Introducing the all-new Carriere® SLX™ Bracket System See what you’ve been missing........54

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

6 Orthodontic practice

Laboratory link Indirect Bonding 2.0

Scott Huge, Paul Gange, and Dr. Michael Mayhew discuss the evolution and clinical benefits of indirect bonding

Volume 6 Number 4

PRACTICE PROFILE

Lisa Alvetro, DDS, MSD Making a world of difference What can you tell us about your background? I grew up in Cortland, Ohio, a small town in northern Ohio. No one in my family was involved in dentistry; however, I did have a childhood friend whose dad was a dentist. In the seventh grade, I had to interview a professional. He was the only one I knew and was kind enough to give me his time for an interview. Neither he nor I would have guessed that a simple middle school project could start the wheels in motion to get me to the incredible place I am now.

When did you become a specialist, and why? I graduated summa cum laude from Youngstown State University in 1987 and then attended The Ohio State University College of Dentistry where I graduated summa cum laude in 1991. I was undecided at the beginning of dental school what specialty to pursue, but in the end, orthodontics was by far the most intriguing. It was the perfect combination of the science of dentistry and the art of esthetics. It also had the greatest potential to form lasting relationships with your patients. Besides, every orthodontist I met really loved their work. The fact that so many stayed in their practices well beyond retirement years proved to me this must be something special.

Why did you decide to focus on orthodontics? After being treated orthodontically as a dental student in the orthodontic residency program, I knew this is what I wanted for a career.

What training have you undertaken? I completed my residency in orthodontics and master’s degree from Case Western University where I still currently am on the faculty. My position as associate professor allows me to help residents and my future colleagues transition into their careers and practices. 8 Orthodontic practice

Dr. Lisa Alvetro of Alvetro Orthodontics

How long have you been practicing orthodontics, and what do you do to set your practice apart? At Alvetro Orthodontics, we have two locations, with me as the sole orthodontist and a team of 20 staff. Our staff has a combined total of 252 years of orthodontic experience. They regularly attend continuing education seminars to bring the latest advancements and technology to our practice. We strive to create a fun atmosphere for our patients. One of the ways we do this is by decorating each office with a theme. In our Sidney office, you can experience an “African safari”; and

in Tipp City, you can “tour around the world” with each area of the office decorated with a different country. It’s evident that we, along with our patients, have a lot of fun with each of these themes. They are seen on T-shirts, bags, patient reward prizes, sports apparel, ink pens, travel mugs, and many other things.

Do your patients come through referrals? Some of our referrals come from dental professionals; however, the majority of our referrals come from patients or members of our community who respect our reputation and dedication.

What is the most satisfying aspect of your practice? What is exciting is that after being an orthodontist for 22 years, I am beginning Volume 6 Number 4

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PRACTICE PROFILE to treat the kids of my past patients. It is rewarding to see patients whom I last saw as teenagers now as adults with children of their own. To me, it is the biggest compliment that they want their children to be treated by me.

What are your top tips for maintaining a successful specialty practice? Our vision statement in the office is to “create an orthodontic experience that lasts a lifetime.” Our mission is to not only create great smiles and lasting results, but for all patients to remember their time spent in our office as some of their favorite memories. We believe orthodontics is more than moving teeth; it is about “moving people.” I often say a smile is the direct link to the heart. Some patients just need the look, which may be a great smile — and the confidence to express their inner beauty to the world.

What do you think is unique about your practice? A unique aspect of our practice is our involvement with advancing education in orthodontics. It is unusual for a private practitioner to be able to be involved in clinical research. Researchers at U.S. universities

and international research facilities access our database to conduct research on Class II corrections. Often we are asked to collect data and create samples to answer prevalent questions in orthodontics. Alvetro Orthodontics is proud to have been published 4 times in respected, peer-reviewed journals.

Professionally, what are you most proud of? Another unexpected aspect of my career as an orthodontist is the opportunity I have to be an advocate for 3M Unitek. For the past 6 years, I have been invited to lecture worldwide — giving over 200 lectures in over 40 countries. This is so exciting to be able to share ideas and friendship with colleagues throughout the world. I believe these experiences have truly shaped how I practice orthodontics. A recent event that was exciting for the practice and our patients was a Designing Spaces™ “Kids Spaces™” segment on Lifetime television that highlighted our office and patients, along with the 3M Unitek orthodontic solutions we use in our practice. It was exciting and rewarding to see my patients, office, and team presented in the media.

What advice would you give to a budding orthodontist? When young doctors ask what the keys to success are, I always answer hard work and an attitude of gratitude. Since the communities I practice in have been so supportive of my practice, it is my obligation to be supportive of them. We need to be involved in our communities to help them serve their citizens and be great places to live. From the very beginning, we invested in our community. Not only do we contribute

Dr. Alvetro and her team 10 Orthodontic practice

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PRACTICE PROFILE

Dr. Alvetro treating a patient in her African-themed, Sidney, Ohio office

funds, but we also share our resources. The team from Alvetro Orthodontics can be found volunteering for organizations, planning fundraising events, and supporting organizations that need us. As a team, we are proud of the difference that we have made.

What are your passions, and what do you do in your spare time? To be able to expand our outreach beyond our borders, Alvetro Orthodontics has also founded Smiles of Hope. Through this foundation, my staff and I have organized five dental mission trips to Tarime, Tanzania. Tarime is in a remote region of Tanzania where there is no access to dental care, a region where a toothbrush is a luxury item. On our first trip, we made a commitment to the orphans of the Gamasara region to provide them a home, food, and education. Smiles of Hope has been able to help this promise through the Angel House Orphanage - Secondary School.

What products help you make your practice successful? What does this mean for your patients? I believe to provide quality treatment, you need to use quality products. We also need to give patients choices for their treatment that will allow them to get the results they want. We offer patients the choice of SmartClip™ SL3 Self-Ligating Appliance System, Clarity™ ADVANCED Ceramic Brackets (an ultra-esthetic bracket with the newest APC™ Flash-Free Adhesive Coated Appliance System technology), and lastly, the Incognito™ Appliance System (a lingual system for those who want an invisible 12 Orthodontic practice

treatment system that doesn’t hinge on patient compliance) — all offered by 3M Unitek. For Class II corrections, we utilize the Forsus™ Fatigue Resistant Device from 3M Unitek. With Forsus Correctors, we are confident that we can correct a Class II malocclusion that results in a great esthetic result independent of patient compliance. Our success with this appliance has made it very popular in our community with patients and parents of children with overbites. The introduction to our practice of the 3M™ True Definition Scanner is allowing us to expand into the digital area of custom appliances and digitally directed indirect bonding. To manage our office and schedule, we utilize Dolphin Imaging and Dolphin Management Software. OP

Creating an orthodontic experience that lasts a lifetime

Top 10 favorites 1. Spending time with my family. My husband and I have four children who keep us on the move. 2. Being in my offices and working with my team and patients. Every patient is such a unique individual, so no two days are ever the same. 3. Corresponding with my Tanzanian friends, children of the Angel House Orphanage, and getting updates on Smiles of Hopes projects in Tarime, Tanzania. The Internet and social media have made a remote part of Africa very close on a daily basis. 4. Taking on projects for local community organizations. 5. Teaching and sharing my experience with orthodontists throughout the United States and abroad as an advocate for 3M Unitek. 6. Adventure travel with family and friends to just about anywhere. 7. Coordinating research projects for orthodontic residents and researchers who utilize our clinical database. 8. Being in my kitchen baking or cooking for family and friends. 9. Working on remodeling, construction, or interior decorating in my home or offices. 10. Reading nonfiction books.

Volume 6 Number 4

Big innovations that start with a smaller footprint The new iTero® Element™ intraoral scanner is engineered to deliver everything doctors look for in digital impression technology in a compact footprint design with even bigger capabilities. The iTero Element is designed with speed in mind. It’s portable, powerful, and intuitive, demonstrating our continued investment in clinical precision and patient satisfaction. Now is the perfect time to add intraoral scanning to your practice.

Visit iTero.com to schedule a demo or to learn more.

IN FOCUS

American Orthodontics’ Ultimate CE — a unique educational experience

he orthodontic profession is one driven by education. Doctors and staff must be constantly learning in order to keep up with the latest technology, clinical techniques, and more. Continuing education (CE) credits help the orthodontic professional maintain, develop, or increase knowledge, but these events are often attended strictly as a requirement for professional development. American Orthodontics (AO) decided to take the idea of CE a step further by not only offering CE, but also once-in-a-lifetime experiences. This concept became AO’s Ultimate CE. Each AO Ultimate CE event features informative clinical lectures by expert speakers covering a wide range of topics, including treatment techniques, practice management, and more. Each of these intriguing lectures is complemented by an amazing entertainment experience. All of the 2015 Ultimate CE Events held so far have sold out. These include events at the Academy of Country Music Awards in Dallas, Texas, and the Indianapolis 500. Here’s a detailed look at upcoming AO Ultimate CE for 2015.

day will be capped off by watching the Giants take on the Oakland A’s from the comfort of our suite.

Kohler Food and Wine Experience October 22, 2015 — Kohler, Wisconsin This exciting weekend features a lecture on 3D Orthodontics and Self-Ligation in your practice from Dr. Ed Lin and a tour of AO’s state-of-the-art manufacturing facility. The weekend also includes the best of the famous Kohler Food and Wine Experience, which includes cooking events with world-renowned chefs, plus the extraordinary Taste of the Vine wine tasting with live music and hors d’oeuvres from the Kitchens of Kohler.

New York Dining Experience — Per Se Restaurant December 4, 2015 — New York, New York This unforgettable Ultimate CE experience at the acclaimed New York City restaurant Per Se is a gourmand’s delight! Attendees will first enjoy a captivating lecture on 3D Orthodontics and Self-Ligation from Dr. Ed Lin. Everyone’s taste buds will then take a once-in-a-lifetime journey at a private dinner courtesy of the Michelin 3-star Per Se restaurant, run by world-renowned Chef Thomas Keller. Ultimate CE events fill fast. Registration is available at events.americanortho.com.

About American Orthodontics

San Francisco Giants Baseball Experience

American Music Awards Experience

July 24, 2015 — San Francisco, California This event begins with an up-close tour of AT&T Park — one of the nation’s premier ballparks and home to the World Series Champion San Francisco Giants. Following the tour, attendees will head up to our suite for lunch, then an engaging lecture by Dr. Troy Christensen, who will explain why he made the switch to the Empower® Dual Activation System, and how the increased efficiency and exceptional value of self-ligation and the Dual Activation System can be utilized. The

November 21, 2015 — Los Angeles, California This amazing event includes a lecture by Dr. Brandon Comella, who will demonstrate the value to offering only esthetic options to patients as a way to differentiate your practice. Attendees will then head to the American Music Awards at the famous Nokia Theater, experience all the glitz and glamour of the Red Carpet, and see incredible performances from some of the world’s top artists.

14 Orthodontic practice

American Orthodontics is the largest privately held orthodontic manufacturer in the world, proudly based in Sheboygan, Wisconsin. Since 1968, American Orthodontics has been manufacturing quality orthodontic products and peripherals for customers in more than 100 countries. More than 90% of American Orthodontics’ products are manufactured at its Sheboygan headquarters using highly automated production equipment and a skilled, dedicated workforce. With 11 wholly owned subsidiaries, a direct sales force in North America, and a global team of exclusive distributors, American Orthodontics is a true orthodontic industry leader, committed to providing customers quality products, personalized service, and dependable delivery. OP Volume 6 Number 4

ONE SYSTEM. MULTIPLE APPLICATIONS. ZERO COMPROMISE. Discover the Empower Dual Activation System – a system designed to enhance your treatment philosophy with the time-saving benefits and

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CASE STUDY

ClearCorrect as a solution when traditional bracket bonding fails Dr. Matthew Fortna finds a solution for a patient with enamel defects

his 9-year-old female patient presented to our office with narrow and tapered arches, posterior crossbite, crowding, and impacted maxillary canines. She was referred by her pediatric dentist. The decision was made to expand and develop both arches as the patientâ&#x20AC;&#x2122;s teeth erupted (Figures 1-8). Following a brief interceptive phase of treatment, all permanent teeth erupted into position. The patient, now age 13, wanted her teeth aligned with clear aligners, rather than traditional braces. The decision was made to further develop the arches and improve alignment with fixed appliances in the hopes of creating an ideal aligner patient (Figures 9-16).

Early in fixed appliance treatment, however, there were many debonded brackets and multiple unplanned visits for repairs. Different adhesives were used, all with a similar result. The quality of this patientâ&#x20AC;&#x2122;s enamel did not seem very conducive to adequate bonding of brackets. After several months of emergency visits to our office, the decision was made to remove the remaining brackets and initiate ClearCorrect therapy. We highlighted the esthetic and hygienic advantages of aligner therapy to the patient and her mother. Mom appreciated that the visits would be less frequent and with fewer emergencies. Records were taken for ClearCorrect, including a PVS impression, bite registration, and photos (Figures 17-24). We also

submitted a pano of the patient, and digital dental casts were created by ClearCorrect based on the impressions that were sent in (Figure 25). We submitted the case to ClearCorrect with the chief complaint of crowding and tapered arches. We requested both arches be treated as well as an improvement of midlines, overjet, overbite, and idealized archforms. We requested to expand arches, and noted to only use proclination, distalization, and IPR if needed. At this point in her treatment, the patient had Class I molar and canine relationships. ClearCorrect presented a treatment setup, which included their proposed treatment plan. At this same time, ClearCorrect

Figures 1-8

Dr. Matthew Fortna was born and raised in southeastern Pennsylvania. He attended Cornell University and the University of Pennsylvania School of Dental Medicine. After dental school graduation, he served as a Lieutenant in the United States Navy, during which time he completed an Advanced Education in General Dentistry residency. He returned to the University of Pennsylvania for his orthodontic residency and later served as faculty in the Department of Orthodontics while in private practice. After spending 10 years in the Philadelphia suburbs, he moved to western New York and started his own practice. Dr. Fortna enjoys winter and summer sports, and traveling with his wife and four children. He is an active member of his small-town community and church and enjoys coaching and supporting various local sports teams. While enamored with the science of orthodontics, he most enjoys the life-changing effects that orthodontic care can have on children and adults. Disclosure: Dr. Fortna is not affiliated with ClearCorrect.

16 Orthodontic practice

Volume 6 Number 4

CASE STUDY

Figures 9-16

Figures 17-24

Figure 25 Volume 6 Number 4

Orthodontic practice 17

CASE STUDY

Figures 26-33

sent a set of starter aligners for the patient to wear, which were designed to ease the patient into treatment while treatment planning was completed. The treatment setup was approved, and production of the aligners began. Treatment included four estimated phases of treatment, each phase consisting of four sets of aligners. ClearCorrect shipped aligners four sets at a time, which allowed for revisions to be made to treatment at no added cost. After the first phase was received from ClearCorrect, the patient was seen in our office for fitting of the first set of aligners. The aligners fit well, and the patient was instructed to wear this set of aligners for 3 weeks. She was given a second set of aligners to take home, which she would change out at home. She would return to our office in 6 weeks to be seen again. Treatment progressed smoothly, and once the second phase was received from ClearCorrect, engagers were placed on teeth Nos. 6, 7, 8, 9, 10, 22, and 23. An engager template was provided by ClearCorrect for easy placement of the engagers. We always test the fit of the template first. If the fit is good, we then air-dry, followed by lubricating the engager wells and flashing areas of the template with petroleum jelly. Next, we fill the wells of the template with G-aenialâ&#x201E;˘ Universal Flo (GC America) and set aside. We then condition the engager areas of the teeth with one-step 18 Orthodontic practice

The process of wearing clear aligners was far more bearable for this patient than fixed appliances (braces). ... We were happy to be able to deliver the modality of care that the patient wanted given these limitations, thanks to ClearCorrect.

etch and primer (Unitek Transbondâ&#x201E;˘ Self Etching Primer), and lightly air-dry again. Finally, we seat the engager template, light cure, and carefully remove the template. We polish flash with a dry high-speed and polishing bur (Reliance). Once completed, the aligner will snap into place, as it is essentially identical (thickness aside) to the template used. After the fourth phase of treatment was received and administered, a refinement to treatment was requested in order to detail the alignment further and attempt more maxillary arch expansion. After this phase of treatment, the patient was happy with the results and was anxious to receive retainers (Figures 26-33). While the posterior occlusion was not yet completely ideal at this

point (as is the case with most clear aligner cases upon completion), we anticipated the occlusion would settle into proper occlusion during the retention phase. We decided to have Hawley retainers made for the patient, and we incorporated an expansion screw in the maxillary retainer to titrate additional expansion during retention. Overall, the patient and mother were thrilled with the transformation of her smile. The process of wearing clear aligners was far more bearable for this patient than fixed appliances (braces). As it turned out, the patient was not a good candidate for traditional braces due to enamel defects. We were happy to be able to deliver the modality of care that the patient wanted given these limitations, thanks to ClearCorrect. OP Volume 6 Number 4

Dr. Bradford Edgren illustrates a case study with a new Herbst-type appliance Introduction Orthodontic treatment should be designed around the patient’s total dentofacial complex, including future dentofacial growth, rather than the narrower objective of treating just the teeth and/or the occlusion. Consequently, diagnosis, treatment planning, and management of Class II malocclusions can be difficult when extraction and surgical options are not viable/ practical when fully evaluating the patient in all three dimensions: antero-posterior, transverse, and vertical. Furthermore, when considering the importance of future growth, successful treatment may become daunting. This patient presented with just such a malocclusion. Distalization of the maxillary dentition can be difficult, but for this patient’s malocclusion, distalization of the posterior maxillary dentition would help in the resolution of her problems. The Liberty Bielle® is a Herbsttype appliance from Rocky Mountain Orthodontics (RMO) that can be directly attached to the archwires. Because it can be directly attached to the archwires, it can be used to distalize individual maxillary teeth, reducing the proclination of the mandibular incisors. This patient presented as a new patient exam with her mother on December 3, 2008, as a healthy 12-year 2-month-old female. Her stated chief complaint was that she had dental crowding with not enough room for her maxillary canines and that she wanted her lower teeth straightened.

Diagnosis and etiology Intraoral examination revealed a Class II malocclusion, a left maxillary lateral incisor Bradford Edgren, DDS, MS, earned both his Doctorate of Dental Surgery, as Valedictorian, and his Master of Science in Orthodontics from the University of Iowa, College of Dentistry. He is a Diplomate, American Board of Orthodontics, and a member of the Southwest Component of the Edward H. Angle Society. Dr. Edgren has presented nationally and internationally to numerous orthodontic groups on the importance of orthodontic diagnosis, early interceptive orthodontic treatment, CBCT, and upper airway obstruction. He has been published in AJO-DO, the American Journal of Dentistry, as well as other orthodontic publications. Dr. Edgren currently has a private practice in Greeley, Colorado. Disclosure: Currently, Dr. Edgren is not receiving compensation from RMO on this appliance.

Volume 6 Number 4

Figure 1: Pretreatment photographs Table 1: Treatment plan

crossbite, a left posterior crossbite, and impacted maxillary canines. Her overbite (OB) was 15% and overjet (OJ) was 2 mm. Significant arch length deficiencies were present in both dental arches with the maxillary arch length at -10 mm and the mandibular at -7 mm. The upper arch form was significantly tapered with an anterior maxillary constriction resulting in the impaction of the maxillary canines. There was a discrepancy in the dental midlines with the lower dental midline being 3 mm to the left of the already 1 mm left displaced upper dental midline (Figure 1). Clinical frontal evaluation demonstrated a mesofacial facial pattern with a symmetrical and well-balanced facial pattern for the upper, middle, and lower facial heights. A facial asymmetry to the left was noted

Bonded RME with occlusal coverage — expand 6.0 mm

Band and bond upper and lower arches

Level and align

Regain space for impacted maxillary canines

Correct Class II with the Liberty Bielle®

Obtain and maintain Class I canines

Detail and finish

Retain with removable Hawley retainers

concomitant with the lower dental midline being displaced to the left 3 mm. Lateral evaluation displayed that the patient’s lips were significantly retrusive with a concave facial profile. Orthodontic practice 19

CASE STUDY

Class II correction with maxillary dentoalveolar distalization using the Liberty Bielle®

CASE STUDY

Figure 2: Pretreatment panoramic image

Figure 4: Pretreatment frontal cephalometric image

Radiographic evaluation of the panoramic image revealed bilaterally impacted maxillary canines and asymptomatic chronic sinusitis with inflammation in the left maxillary sinus. All four third molars were present and unerupted (Figure 2). A Ricketts’ cephalometric evaluation by Rocky Mountain Orthodontics Data Services RMODS® revealed a Class II malocclusion due to both the maxillary and mandibular dentitions. A skeletal Class II component due to a short anterior cranial base and a tendency for a skeletal open bite was also present. Upper airway obstruction due to adenoid blockage was not likely. Frontal cephalometric analysis confirmed a lingual crossbite pattern due to both arches with the mandibular arch being wide compared to the mandible. The mandibular midline asymmetry was due to a left positional asymmetry of the mandible. Ricketts’ growth to maturity without orthodontic intervention revealed approximately 3 years of additional dentofacial growth (Figures 3-8). 20 Orthodontic practice

Figure 3: Pretreatment lateral cephalometric image

Figure 5: Pretreatment tomographic images

Figure 6: Pretreatment lateral cephalometric tracing

Figure 7: Pretreatment frontal cephalometric tracing Volume 6 Number 4

CASE STUDY

Treatment summary Due to the retrusive lips and concave facial profile, a non-extraction treatment plan was recommended. Initial expansion of the maxilla with a bonded rapid palatal expander incorporating the first premolars, second premolars, and first maxillary molars was implemented to correct the left posterior lingual crossbite. After 2 weeks of single ¼ mm turns, one in the morning and one in the evening, a total of 6 mm of expansion and correction of the lingual crossbite was accomplished. Bonding of the upper incisors with RMO Minitaurus™ brackets, Andrew’s Rx, with molar tubes attached to the bonded expander at the level of the first premolars was performed 3 weeks later. The bonded expander was removed 7 months later after correction of the left maxillary lateral incisor crossbite. The remaining maxillary dentition and mandibular dentition were banded and bonded at that time. Leveling and aligning of the maxillary and mandibular dentitions continued for the next 21 months. During this period, space was regained for the natural eruption of impacted maxillary canines with the maxillary right canine being bonded 9 months and the maxillary left canine bonded 16 months after RME removal. After 27 months of treatment, the Liberty Bielle Class II corrector was placed (Figure 9). Note that the Liberty Bielle is placed mesially to the maxillary second molars. This placement provides initial distalization of the second molars with subsequent distalization of individual teeth of the maxillary dentition, minimizing protrusion of the mandibular incisors. This appliance placement also takes advantage of the remaining mandibular growth.

Figure 8: Superimposition of pretreatment lateral cephalometric tracing and growth forecast to maturity without treatment.

The Liberty Bielle was removed after 5 months of activation. Nine months of detailing and finishing was performed to solidify the Class II correction. A total of 41 months of treatment was necessary to accomplish a Class I mutually protected occlusion for this difficult case. Removable maxillary and mandibular Hawley retainers were fabricated and delivered 13 days after deband. The patient was instructed to wear the retainers 24 hours a day for the next 18 months and then at night indefinitely. Following deband, the patient was referred to an oral surgeon

It’s nice to have an appliance that can treat outside the box.

Table 2: Actual treatment 1.

Bonded RME with occlusal coverage — expanded 6.0 mm

Banded and bonded upper and lower arches

Leveled and aligned arches

Bonded maxillary right canine at 16 months and left canine at 23 months after start of treatment

Liberty Bielle® Class II correction for 5 months

Obtained and maintained Class I canines with mutually protected occlusion

Detailed and finished for 9 months

Debanded and retained the orthodontic correction with maxillary wrap around and mandibular removable Hawley retainers

Figure 9: Initial placement of the Liberty Bielle Fixed Class II corrector. Volume 6 Number 4

Orthodontic practice 21

CASE STUDY for removal of the impacted third molars. The third molars were extracted 1 month later.

Summary and conclusions

Figure 10: Posttreatment photographs

This patient had an excellent result achieved with combined orthopedic and dental alveolar changes. Skeletal and dental treatment objectives were obtained through good mechanical control of the dentition and utilization of the remaining craniofacial growth. Expansion of the maxilla provided additional dentoalveolar width correcting the lingual crossbite and providing space for the natural eruption of the impacted maxillary canines. A nice Class I occlusal relationship, with a mutually protected occlusion, was established with appropriate overjet and overbite (Figure 10). The posttreatment panoramic image displayed proper root parallelism and four impacted third molars. The left maxillary sinus displayed inflammation from chronic sinusitis (Figure 11). Tomography of the temporomandibular joints revealed that both condyles were well seated within their respective fossa (Figure 12). Retention cephalometric analysis revealed a Class I occlusion and resolution of the lingual crossbite (Figures 13-16). Lateral cephalometric superimposition of initial and retention cephalometric tracings demonstrated very

Figure 11: Posttreatment panoramic image

Figure 12: Posttreatment tomographic images

Figure 13: Lateral posttreatment cephalometric image

Figure 14: Frontal posttreatment cephalometric image

22 Orthodontic practice

Volume 6 Number 4

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CASE STUDY

Figure 15: Lateral posttreatment cephalometric tracing

Figure 16: Frontal posttreatment cephalometric tracing

Figure 17: Lateral cephalometric superimposition

Figure 18: Maxillary superimposition

Figure 19: Mandibular superimposition

Figure 20: Frontal cephalometric superimposition

good control of the lower incisor angulation (Figure 17). The mandibular incisor position was maintained with no additional proclination. The technique of placing the Liberty Bielle appliance just mesial of the maxillary second molars and the initial distalization of the second molars with subsequent distalization of the individual teeth of the maxillary dentition reduced the tendency for

the proclination of the mandibular incisors typical of Class II correction appliances. Cephalometric superimposition of the maxilla confirmed distalization of the first molar as well as improvement in the angulation of the incisor (Figure 18). Superimposition of the mandible revealed mesial movement of the lower dentition concomitant with mandibular growth (Figure 19). Frontal cephalometric

24 Orthodontic practice

superimposition demonstrated an increase in maxillary width and an improvement in the mandibular asymmetry (Figure 20). This new Herbst-type appliance can be used not only for orthopedic purposes but also for dental aveolar change with increased efficiency and improved results. Itâ&#x20AC;&#x2122;s nice to have an appliance that can treat outside the box. OP Volume 6 Number 4

THE DIGITAL ADVANTAGE IS SO POWERFUL Success will be defined by those that have and those that have not* From the creation of intraoral and benchtop scanner data, combined with Cone Beam CT and 2D images, to the planning, design and manufacture of orthodontic treatment solutions, award-winning solutions from 3Shape are fundamentally improving patient care and the way orthodontists and labs work together. WHY 3SHAPE ORTHODONTIC DIGITAL SOLUTIONS • 3D RealColor™ intraoral scanning with TRIOS® • ISO-documented accuracy with R-series lab scanners • Improved diagnostics, patient comfort and treatment acceptance with 3Shape Ortho Analyzer™ and Ortho Planner™ • The design and manufacture of clear aligners, night guards, retainers and more, in-house and externally with 3Shape Appliance Designer™ • Digitally create and archive study models • Share files simply with major orthodontic solution providers like 3M™ Incognito™, ClearCorrect™, SureSmile®, TRIOS® Ready labs and more using 3Shape Communicate™

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ORTHODONTIC CONCEPTS

BioDigital Orthodontics Management of skeletal deformities with orthognathic surgery-fusion model: part 1 Drs. Rohit C.L. Sachdeva, Takao Kubota, and Jun Uechi discuss the application of suresmile® in conjunction with orthodontic treatment and orthognathic surgery Introduction The versatility of using suresmile® technology based upon the principles of BioDigital Orthodontics in managing various orthodontic malocclusions has been described in previous articles.1-15 In this article and the next, the application of suresmile in planning, designing, and achieving controlled and predictable outcomes for patients requiring correction of their skeletal deformities with the aid of orthodontic and orthognathic surgery is discussed.

CBCT (Direct)

Fusion

OraScan

Care planning with suresmile suresmile software provides the clinician the flexibility of planning care that is soft tissue, hard tissue, or dental driven. In other words, any of these craniofacial dental components may be used in singular or in tandem to develop the orthognathic surgical treatment objectives. (Currently, suresmile does not offer an approach to animate the integumental profile changes in response to hard tissue or dental changes. Dolphin 3D software (Dolphin Imaging & Management Solutions, Chatsworth, California) maybe used in conjunction with suresmile to demonstrate soft tissue changes. Skeletal and dental movements can be simulated with suresmile software providing the doctor has a cone beam computed tomography (CBCT) image taken using a

Figures 1A-1C: Surgical treatment planning with suresmile. A doctor may consider three approaches. 1A. Direct: A CBCT image of craniofacial complex is taken at 0.2-mm resolution and used for planning. This does not require an intraoral scan. 1B. Fusion: An intraoral scan is fused to the 3D image of the craniofacial complex. This is a two-step process for creating a model for planning care. Furthermore, displacement coordinates from the surgical movements on the craniofacial model need to be transferred to the suresmile intraoral scan model to represent the surgery and to design the archwire. 1C. Intraoral scan: The treatment objectives are designed with 2D cephs and the displacement coordinates transferred to the intraoral scan to design the archwire

certified suresmile imaging system (Figure 1A). Currently, four systems are certified for use with suresmile: namely, i-CAT® Next Generation, i-CAT®, i-CAT® FLX (Imaging Sciences International, Hatfield, Pennsylvania), and Kodak® CS 9300 (Carestream Dental LLC, Atlanta, Georgia). This obviates the necessity

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 co-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. Please contact improveortho@gmail.com for access information. Dr. Takao Kubota is in private practice in Yours Orthodontic Clinic, 378-6 Motomura Yame City, Fukuoka 834-0063 Japan. He is also the co-founder of the Instiute of Orthodontic Care Improvement in Japan. Dr. Jun Uechi is from the Department of Orthodontics, School of Dentistry, Health Sciences University of Hokkaido, 1757, Kanazawa, Ishikari-Tobetsu, Hokkaido 061-0293, Japan.

26 Orthodontic practice

of using the “fusion” technique to relate the dental models to the skeletal structures. However, if the doctor prefers the “fusion” technique, he/she may plan the surgery and then transfer the coordinates to the suresmile software to design the dental movements and the surgical archwires (Figure 1B). In case the doctor does not have access to 3D images of the craniofacial complex, he/she can scan the dentition intraorally and plan surgical movements by using 2D cephalometricdriven surgical treatment objectives and then applying the displacement values to simulate the movements of the 3D suresmile VDM (Virtual Diagnostic Model) or VTM (Virtual Therapeutic Model) (Figure 1C). The doctor should note the coordinate transformation from a 2D simulation to a 3D may not be as accurate but nevertheless provides for a reasonable alternative to planning customized care for a patient requiring orthognathic surgery. Volume 6 Number 4

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ORTHODONTIC CONCEPTS Customized therapeutics with suresmile suresmile software can be used to design many different types of archwires to suit the stage of treatment, i.e., pre-surgical or

post-surgical, active, or passive. The design of the archwires is driven by the nature of the plan. Table 1 provides a summary of the various types of archwires that may be fabricated to achieve the planned results.

Patient R.S.

Table 1: Surgical archwires with suresmile

Pre-surgical

Type

Cross-section

Material

Active

Round or rectangular with torque

TMA Elgiloy® NiTi

Passive

Rectangular

Segmental 2

Post-surgical

Refinement

Passive

Round or rectangular with torque

Table 1: Types of surgical archwires that may be designed with suresmile

Patient R.S. presented at 25 years old with a Class 3 skeletal malocclusion and chief complaint of “I do not like my appearance and especially the protrusion of my lower jaw.” Both 2D and 3D initial diagnostic records of the patient were taken. The initial photographs, cephalometric records, and analysis are shown in Figures

2A-2C. The suresmile Virtual Diagnostic Model (VDM) is shown in Figure 2D. In addition, a 3D CAT scan image at 1 mm resolution of the patient was taken with the ProSpeed F II (General Electric Systems, Milwaukee, Wisconsin) high-resolution medical CT scanner. The patient was bonded, and an intraoral therapeutic scan with the brackets on was taken of the patient (Figures 3A-3B). The “fusion” technique was used to merge the intraoral Virtual Therapeutic Model (VTM) to the CBCT scan to create an accurate representation of the dentition with respect to the craniofacial complex (Figure 4). Note: Details of the preparation of the “fusion” technique have been described elsewhere.16, 17

VDM

Figures 2A-2D: Patient R.S. 2A. Initial intraoral photographs. 2B. Lateral ceph, PA, and panorex. 2C. Ceph analysis 2D. suresmile Virtual Diagnostic Model VTM

Figures 3A-3B: Patient R.S. 3A. Intraoral images of the patient at bonding. 3B. Virtual Therapeutic Model (VTM)

Figures 4A-4D: Patient R.S. 4A. Initial 3D Model. 4B-4D. The “fusion” technique was used to merge the intraoral VTM to the CBCT scan to create an accurate representation of the dentition with respect to the craniofacial complex 28 Orthodontic practice

Volume 6 Number 4

ORTHODONTIC CONCEPTS

Figures 5A-5B: Patient R.S. STO prediction and analysis

Figure 6: Patient R.S. STO on the 3D fusion model. Note. The mandible has been set back further to allow for decompensation of the lower incisors

Initially, a 2D Surgical Treatment Objective (STO) with a mandibular setback using BSSO was planned using the planning software that was created as a personalized program using C++ software (Figures 5A-5B). Note a surgical-first approach to treatment was planned for this patient. To allow for the postsurgical decompensation of the lower incisors, the mandibular setback was increased. Displacement values derived from the 2D STO were used as a guideline to design the surgical movements on the 3D-fused model (Figure 6). The surgical planning software used for this procedure was Rapidform 2006 (INUS Technology, Inc., Seoul, South Korea).18 Since the patient was planned for a surgery-first procedure, suresmile precision archwires were designed in advance of the planned surgery with the hope that they would be inserted immediately postsurgery to control Orthodontic Tooth Movement (OTM). To enable the design of the suresmile precision archwires, the displacement Volume 6 Number 4

Figure 7: Patient R.S. 3D displacement coordinates of the planned surgery

Figure 8: Patient R.S. Displacement coordinates from fusion model transferred to VTM Orthodontic practice 29

ORTHODONTIC CONCEPTS coordinates from the fusion model were first used to simulate the mandibular setback on the Virtual Therapeutic Model (VTM) (Figures 7-8). Next, the decompensation of the lower incisors and the coordination of the archwidth were planned on the VTM (Figure 9). The surgical splint was designed by using the software Rapidform 2006 (INUS Technology, Inc., Seoul, South Korea),18 and the splint was printed using stereolithography (STL). Since the material is not biocompatible, a 3D impression of the splint was taken and poured in acrylic to create the biocompatible splint (Figure 10). Just prior to surgery, standard 018" and .016" SE NiTi (GAC International, Bohemia,

New York) wires were installed. Figure 11 shows patient R.S. 1-week post-surgery. The initial wires were maintained for 4 weeks to achieve alignment in the upper arch and decompensation in the lower arch. Check light Class 3 elastics were also used. At the 4-week appointment, the wires were replaced with standard 19 x 25 and 16 x 22 SE NiTi in the maxillary and mandibular arch, respectively (Figure 12). An .036" transpalatal arch (TPA) was inserted to ensure stability of the maxillary arch, and light Class 3 elastics continued. Six weeks later, suresmile precision archwires were inserted upper 19 x 25 SE NiTi, and 16 x 22 CuNiTi were inserted (Figure 13). Twelve weeks post-surgery, the upper

VTS (white) vs. VTM (blue)

arch was replaced with a 19 x 25 suresmile Elgiloy archwire and the lower arch with a 19 x 25 CuNiTi suresmile. 17 x 25 TMA tipback springs were placed in the lower arch to augment the leveling of the arch (Figure 14). Twenty-one weeks post-surgery, the lower archwire was replaced with a 19 x 25 suresmile precision archwire and check triangular elastics continued (Figure 15). Figure 16 shows the patient at the 25-week appointment The patient was debonded 3 weeks later. Figure 17A shows the final extraoral and intraoral images. The final pano and ceph and the superimposition of the initial, the plan, and the final are shown in Figures 17B-17C. VTS

Figures 9A-9D: Patient R.S. 9A. Virtual Target Setup (VTS) and Virtual Therapeutic Model (VTM). Note: Both the surgical and dental movements are planned. 9B. Final Virtual Target Setup. 9C. Design of suresmile precision archwire against the VTM. 9D. The displacement values of the planned OTM

Figure 11: Patient R.S. One week post-surgery. Upper 018" NiTi and lower 016" NiTi

Figure 10: Patient R.S. Surgical splint was manufactured using STL 30 Orthodontic practice

Fig 12. Patient R.S. Four weeks post-surgery. Upper 19 x 25 NiTi and lower 16 x 22 NiTi Volume 6 Number 4

Figure 15: Patient R.S. Twenty-one weeks post-surgery. The lower archwire was replaced with a 19 x 25 suresmile precision archwire, and check triangular elastics continued

Figure 14: Patient R.S. Twelve weeks post-surgery. suresmile precision archwires upper 19 x 25 Elgiloy and lower 19 x 25 CuNiTi inserted. 17 x 25 TMA tip-back springs were placed in the lower arch to augment its leveling. Class 3 elasticwear was continued

Figure 16: Patient R.S. at the 25-week appointment. Note the occlusion is well settled

Initial vs. Final Superimposition

Figures 17A-17C: Patient R.S. 17A. Final extraoral and intraoral photos. 17B. Final lateral ceph, PA, and panorex. 17C. Cephalometric superimposition of initial versus final Volume 6 Number 4

Orthodontic practice 31

ORTHODONTIC CONCEPTS

Figure 13: Patient R.S. Six weeks post-surgery. suresmile precision archwires upper 19 x 25 SE NiTi and lower 16 x 22 CuNiTi inserted. Anterior box elastics were used with Class 3 vector to control both the overjet and overbite

ORTHODONTIC CONCEPTS VFM vs. VTS

VFM

Figures 18A-18D: Patient R.S. 18A. 3D Virtual Final Model (VFM). 18B. Superimposition of the VFM to VTS (Virtual Target Setup) demonstrates that the treatment outcome closely matches the plan. 18C. VTS superimposed on the lateral ceph. 18D. VFM superimposed on the lateral ceph. The total treatment time for this patient was 28 weeks

The 3D Virtual Final Model (VFM) is shown in Figure 18A. Also, note the superimposition of the VFM to the VTS (Virtual Target Setup) demonstrates that the treatment outcome closely matches the plan (Figures 18A-18C). The total treatment time for this patient was 28 weeks. A summary of the various steps in executing treatment for patient R.S. is shown in Table 2.

Table 2: Surgery — First clinical pathway (fusion + suresmile) — Sachdeva-Uechi protocol Phase

Action

Step 1

Consultation

•

Patient’s chief complaint. Determining patient’s needs and wants

Step 2

Diagnostic record coalition

• •

2D photos, ceph, PA, and panorex 3D Virtual Diagnostic Model (VDM) and CAT scan*

Step 3

Preparation of fusion model

• • •

Bond patient Perform Virtual Therapeutic Scan (VTS) Fuse VTM on CAT scan image using fiducial markers

Step 4

Treatment design

• • • • • •

Perform cephalometric analysis Establish treatment objectives Simulate 2D surgical planning and use to guide 3D planning on fusion model Measure 3D displacement coordinates of surgical displacements on fusion models Transfer coordinates of surgical movements to suresmile VTM Plan dental movements of VTM

Step 5

Therapeutic design

• •

Design and stage surgical archwires Design surgical splint

Step 6

Therapeutics

•

Insert initial alignment archwires

Step 7

Surgery

•

Perform surgery within 1 week of archwire insertion

Step 8

Post-surgical orthodontic management

• • •

Place suresmile precision archwires within 4-6 weeks post-surgery Stage suresmile archwire use as per plan Evaluate patient in 4-6 week intervals

Step 9

Final records

• •

2D photos, ceph, PA, and panorex 3D Virtual Final Model (VFM); CAT/CBCT if needed

Step 10

Outcome evaluation

• •

2D cephalometric superimposition of initial versus final 3D superimposition of the VFM to VTS

Conclusions Patient R.S. was treated with a surgeryfirst approach and using the “fusion” technique with suresmile to plan and design customized care. The “fusion” technique was used to reconstruct the dental component of the craniofacial complex to allow for planning with suresmile because the CBCT scanner was not available on-site. With a CBCT scanner (certified by suresmile) the necessity of using the “fusion” technique could have been circumvented and the entire plan designed with suresmile software tools. In addition, the number of archwires used in the treatment of the patient could have been reduced especially with regard to stiffer alloys such as Elgiloy®. OP

Acknowledgments For contributing to the surgical management of this patient, the authors wish to thank Dr. Takanori Shibata, Professor of Health Sciences University of Hokkaido, Japan. We also wish to thank Dr. Sharan Aranha and Arjun Sachdeva for all their hard work in helping us prepare this manuscript for publication. REFERENCES 1. Sachdeva R. BioDigital orthodontics: Planning care with SureSmile technology: part 1 Orthodontic Practice US. 2013;4(1):18-23. 2. Sachdeva R. BioDigital orthodontics: Designing customized therapeutics and managing patient treatment with SureSmile technology: Part 2. Orthodontic Practice US. 2013;4(2):18-26. 3. Sachdeva R. BioDigital Orthodontics: Diagnopeutics with SureSmile technology (Part 3). Orthodontic Practice US. 2013;4(3):22-30. 4. Sachdeva R. BioDigital orthodontics: Outcome evaluation with SureSmile technology: part 4. 2013;4(4):28-33.

32 Orthodontic practice

*With an approved CBCT scanner fusion is not required unless a very high resolution dental model is required

Table 2: Summarizes the various steps in executing treatment for Patient R.S. 5. Sachdeva R. BioDigital orthodontics. Management of Class 1 non–extraction patient with “Fast–Track”©– six month protocol: Part 5. Orthodontic Practice US. 2013;4(5):18-27.

12. Sachdeva RCL, Kubota T. BioDigital orthodontics. Part 1 - Management of patients with openbite (1): Part 12. Orthodontic Practice US. 2014;5(6):22-31.

6. Sachdeva R, Kubota T, Hayashi K. BioDigital orthodontics. Management of Class 1 non–extraction patient with “Standard–Track”©– nine month protocol: Part 6. Orthodontic Practice US. 2013;4(6):16-26.

13. Sachdeva RCL, Kubota T, Lohse.J. BioDigital orthodontics. Management of patients with openbite (2): Part 13. Orthodontic Practice US. 2015;6(1):13-23.

7. Sachdeva R, Kubota T, Hayashi K. BioDigital orthodontics. Management of space closure in Class I extraction patients with SureSmile: Part 7. Orthodontic Practice US. 2014;5(1):14-23. 8. Sachdeva R, Kubota T, Moravec S. BioDigital orthodontics. Part 1-Management of Class 2 non–extraction patients: Part 8. Orthodontic Practice US. 2014;5(2):11-16.

14. Sachdeva RCL, Kubota T, Hayashi K, Uechi J, Hasuda M. BioDigital orthodontics: Management of patients with transverse (midline) discrepancies: Part 14.Orthodontic Practice US. 2015;6(2):25-36. 15. Sachdeva RCL, Kubota T, Hayashi K, . BioDigital Orthodontics-: Management of Patients with Transverse (Midline) Discrepancies (2):part 15. Orthodontic Practice. US. 2015;6(3):28-44.

9. Sachdeva R, Kubota T, Hayashi K. BioDigital orthodontics. Part 2-Management of patient with Class 2 malocclusion non–extraction: Part 9. Orthodontic Practice US. 2014;5(3):29-41.

16. Uechi J, Okayama M, Shibata T, Muguruma T, Hayashi K, Endo K, Mizoguchi I. A novel method for the 3-dimensional simulation of orthognathic surgery by using a multimodal image-fusion technique. Am J Orthod Dentofacial Orthop. 2006 Dec;130(6):786-798.

10. Sachdeva R, Kubota T, Hayashi K. BioDigital orthodontics. Part 3- Management of patients with Class 2 malocclusion extraction: Part 10. Orthodontic Practice US. 2014;5(4):27-36

17. Hayashi K, Hayashi M, Reich B, Lee S-P, Sachdeva AU, Mizoguchi I. Functional data analysis of mandibular movement using third-degree b-spline basis functions and selfmodeling regression. Ortho Waves. 2012;71(1):17-25.

11. Sachdeva R, Kubota T, Hayashi K. BioDigital orthodontics. Management of patients with class 3 malocclusion: Part 11. Orthodontic Practice US. 2014;5(5):28-38.

18. Lee SP, Delong R, Hodges JS, Hayashi K, Lee JB. Predicting first molar width using virtual models of dental arches. Clin Anat. 2008;21(1):27-32.

Volume 6 Number 4

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PROPELLING ORTHODONTICS

Increasing case acceptance and practice differentiation with Propel Dr. David R. Boschken discusses a practice-building tool

hat differentiates your practice? Customer service, technology, team, doctor skills? Perhaps all of these? However, there is still a special ingredient missing. The why of your business. Why do we do what we do? What drives companies to greatness while other companies fail? My why has always been delivering an exceptional customer service experience while offering innovative orthodontic technology, AND by the way, my customers get straight teeth. We are not just about straight teeth or a certain product. We are about connecting with people, establishing amazing experiences, and growing from all these experiences to make us better. Defining who we are and why our businesses exist is crucial to building a lasting and healthy work and personal life. Treating aligner therapy customers for over 15 years with nearly 3,000 Invisalign® patient-starts has helped develop my practice as a leader. As Align Technology’s brand awareness has grown so has the innovation of aligner therapy. Even with all the latest advancements from Align Technology (G1-6, iTero® scanner) there are still stubborn teeth

that do not track through aligners. Treatment that was supposed to finish in 12-14 months drags out with case refinements resulting in additional treatment time. Frustrated doctors and patients are not uncommon, resulting in the why not being achieved.

Clinical case A 28-year-old male patient with a Class 1 occlusion came to me concerned about his lower crowding. He presented with a moderate upper (3 mm) and lower (4 mm) crowding, 30% overbite, 2 mm overjet, lower midline shifted to the right .5 mm, and crossbite on upper 2s and lower 3s (Numbers 7, 10, 22, 27). (Figures 1-9). Treatment was designed to address the crowding and establish an ideal functional alignment using Invisalign and Propel. Once the ClinCheck Treatment Plan was designed and accepted, the final number of aligners for the patient was 31 upper and 31 lower. Approximate treatment time was 16-18 months. The patient became concerned about the number of aligners and the length of treatment time. My treatment coordinator and I presented Propel during the consultation, suggesting that we could reduce the treatment length by 40%-50% and minimize the

Figures 1-8

need for additional refinement aligners to which the patient agreed with an additional fee of $750-$1,000 to cover one to two recommended Propel appointments. Aligner No. 1 was delivered along with the Invisalign Patient Cooperation and Instruction Acknowledgment Contract (in-house form) signed. The patient was instructed to wear the first aligner for 14 days and then come back for attachment placement. Once Aligner No. 2 and attachments were placed a few weeks later, a third appointment was scheduled a week later for the first Propel treatment. Micro-osteoperforation (MOP) is an accelerated orthodontic technique that uses one of the Propel Excelleration drivers. These drivers are specifically designed to create microosteoperforations, which activate the cytokine immune response enabling an increase in tooth movement rates and resulting in speeding up treatment (Figure 10). This technique is performed chairside with the use of local infiltration or topical anesthetic. MOPs were performed near the mid-toapical interproximal root locations around the first bicuspids, canines, and laterals. Important to note is that each MOP has a 10 mm diameter effect resulting in cytokine immune response and temporarily decreasing bone density. This is the critical reason why

Figure 9

David R. Boschken, DMD, graduated from the University of California, Berkeley, with a double major in Biology and Anthropology. He received his DMD from the University of Pennsylvania Dental School. He completed a Guy’s and St. Thomas Hospital Residency in London, England, and a University of Pennsylvania Orthodontic Residency. He serves on the Clinical Advisory Board (CAB) for Propel® Orthodontics.

Figure 10 34 Orthodontic practice

Volume 6 Number 4

perforations do not need to be done around every bone surface. Aligner Nos. 2-15 were given with instructions to wear each aligner 20 hours per day and switch out every 7 days. Ten weeks later, the second Propel treatment was initiated with the same MOP locations. Aligner Nos. 16-25 were delivered with the continual progression of 7 days per aligner. Ten weeks later, the final 6 aligners were delivered. This case was completed in 7 months (28 weeks) compared to the suggested 16-18 months originally recorded on the ClinCheck Treatment Plan. No refinement was done. Final Vivera® (Invisalign retainers) were ordered and delivered (Figures 11-12). While evaluating the final records, arch alignment and crowding correction were considerably improved. I would have liked to activate a refinement to help expand the left posterior occlusion and couple the left first molars. However, this patient was on a mission to finish fast and move on despite my plea to refine and detail the posterior occlusion. With that said, Propel clearly shows that predictable and safe accelerated orthodontic treatment can be done within modern orthodontic offices. As you can see with the preceding case results, Propel has changed the way I present my Damon® System and Invisalign. In the past, many teen and adult patients wanted a faster treatment option without compromising quality and predictability. As with many orthodontic providers who offer an active or passive self-ligating bracket system, predictability and speed go hand in hand. However, with Invisalign, the movements are predetermined using Align’s software and resulting in a set of aligners made to slowly move teeth. There is minimal room for shortening the treatment time from the prescribed 14 days/aligner protocol. Movements that look predictable on the ClinCheck Treatment Plan can move off track quickly resulting in midcourse correction, auxiliary elastic techniques, case refinements, and even fixed orthodontics. All these options Volume 6 Number 4

Figure 12

have become “normal” in the course of treatment with Invisalign. When presenting the records (pano, ceph, photos, study models, iTero scans, etc.) in the consultation room, we try to emphasize the problem, consequence, solution (PCS) model. Showing the patients their photos on a large screen TV helps illustrate the esthetic, function, and access to cleaning issues while seamlessly threading through the PCS model. Once the treatment solution is explained (Damon System, Invisalign, TADs, etc.) we offer the option of accelerated orthodontics. Now that my practice is consistently offering Propel to every teen and adult patient who can benefit from accelerated orthodontics, we have seen an increase in our existing patients asking for the same options. Offering mid-treatment Propel has opened the door to speeding up braces and Invisalign cases, redirected cases going sideways, and managing patient’s motivation with the never-ending number of aligners. For example, if the existing patient is on Aligner No. 15 out of 30 switching out every 14-16 days per aligner coupled with 25-45 degree rotated anterior teeth, we offer them the opportunity to switch out every 7 days and finish in half the time. The cost to the patient is from $250-$750 depending on the number of treatments needed, cost to the doctor can be as low as $100. One final perspective on differentiating my practice using the Propel technique is many of my general practitioner referral sources are excited to promote me as “the accelerated orthodontic doctor.” My treatment coordinators and I have worked tirelessly in the last 2 years promoting all of our orthodontic advanced techniques, especially Propel. Nearly 100 lunch meetings later, we are seeing patients asking for Propel, excited to learn they qualify for the procedure. Propel has not only helped differentiate my practice as a leader in advanced accelerated orthodontics and delivered consistent clinical results, but completely changed referral patterns in many dental offices in my area. I have not seen

this much shift in referral patterns since Align Technology started training general dentists with Invisalign, requiring my orthodontic help with simple cases. Changing referral patterns gives the doctor a distinct advantage when competing in this modern orthodontic market. When considering if Propel is right for you in your modern orthodontic practice, keep in mind a few key points. Early adopters are generally less than 15% of technology users, and yet they drive innovation and initial branding of your name synonymous with the products. Remember in 2000 at the AAO San Diego when hundreds of orthodontists got “certified” with Invisalign to discontinue use after only a few cases. Reasons varied from lack of control to patients who were not compliant. Fast-forward 15 years and 3 million treated patients later, and Align Technology is the clear definitive leader in aligner therapy. Customers are asking for Invisalign for a myriad of reasons, but mostly due to marketing and innovation. However, Invisalign is the No. 1 orthodontic brand in the world. All within a short amount of time, Align Technology has changed the way we think about orthodontic treatment, driven more patients into our offices than anytime in history, and rewarded the early adopters who stuck with the product. Those early adopters make up the majority of Elite and Super Elite Invisalign providers. In short, Propel has been an integral tool and technique to building my accelerated orthodontic practice. No longer are we concerned about cases taking 2-3 years with countless aligners and refinements, bracket systems that struggle to finish difficult movements, and patients constantly asking the question, “When am I done with treatment?” Offering the latest accelerated orthodontic technology to improve our predictability and efficiency has made my practice more profitable and streamlined all systems, which in turn allow me more time to work on my why, offering exceptional customer service with every patient. OP This information is sponsored and provided by Propel Orthodontics.

Orthodontic practice 35

PROPELLING ORTHODONTICS

Figure 11

INDUSTRY STUDY

Study finds Planmeca ProMax® 3D Ultra-Low Dose™ protocol reduces patient radiation exposure by an average of 77% without loss of diagnostic quality

new study performed by J.B. Ludlow and J. Koivisto has found that dentists can reduce the amount of patient radiation from Planmeca ProMax® 3D products without losing the diagnostic quality of images.* This research is published in the April issue of the Journal of the International Association of Dental Research. Researchers from the University of North Carolina School of Dentistry tested the imaging units to determine if reduced radiation exposure would result in a reduction in diagnostic quality of CBCT images taken. Dose values were noted using various combinations of

field size and exposure parameters necessary for children and adult settings for typical orthodontic diagnostic practices on the Planmeca ProMax 3D products. According to Planmeca, its ProMax units were designed around the ALARA principle of radiation exposure, which is also known as “As Low As Reasonably Achievable.” The study examined images taken using the ProMax’s 3D Ultra-Low Dose™ protocol with standard exposures. Images were taken at 24 locations in a 10-year old child and adult phantom, with multiple exposures made for each imaging location. Dosimeters

were read 3 times, and dosimeter values were adjusted for sensitivity of dosimeters to affect kV or X-ray source. The researchers found that using the Ultra-Low Dose protocol resulted in an average of 77% reduction in radiation exposure when compared with standard imaging protocols. The researchers also found that while the imaging methods reduced exposure, they found no “statistical reduction in image quality between ULD and standard protocols, suggesting that patient doses can be reduced without loss of diagnostic quality.” “In my opinion, the ULD images acquired by the Planmeca ProMax in this study meet the standards of the ALARA radiation safety principle,” comments Dr. Jack Fisher, professor of dentistry and orthodontics at Vanderbilt University School of Dentistry. “Why would anyone take a 2D image with this amount of exposure when they can get a 3D image with excellent diagnostic quality at an ultra-low dose of radiation?” The study was supported, in part, by a grant from the National Institute of Dental and Craniofacial Research (NIDCR). For copies of this study, please contact Planmeca at (855) 245-2908. OP *According to “Dosimetry of Orthodontic Diagnostic FOVs Using Low Dose CBCT Protocol.”

This information was provided by Planmeca.

36 Orthodontic practice

Volume 6 Number 4

Dr. Larry White discusses a simple and easily managed apparatus Introduction Cantilevers offer orthodontists perhaps the most simple and easily managed apparatus for solving Class II malocclusions because they give clinicians statically determinate and efficient mechanisms that they can employ without fears of uncontrollable and unneeded side effects. Cantilevers are simple beams secured at one end and free on the other. The secured end will carry a load and produce a force and a moment, whereas the free end will attach with a one-point contact and produce only a force with no accompanying moment. Orthodontists will use cantilevers as Class I levers where the effort is usually applied via a single point of contact with a tooth or wire and where the resistance will be within a tube or bracket. Orthodontic cantilevers can also have a reactive anchor within the acrylic of a removable or fixed appliance and the free end touching a tooth or wire at only one point.1

Educational aims and objectives

This article aims to discuss a solution to the most difficult feature of Class II malocclusions at the initiation of treatment when patients are likely to display more enthusiasm and compliance.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 43 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify some cantilever corrector designs. • Identify an alternate strategy for producing similar movements on the molar. • Recognize a simplified Class II cantilever that requires minimal instrumentation.

mechanism, while the free end of the wire makes a one point contact within the lingual sheath of the molar. The Carriére® Motion™ Appliance (Figure 5), on the other hand, has the fixed, reactive part of the cantilever beam attached to the canine or premolar, while the active part has a one point contact via the rotational balland-socket that works against the molar. This mechanism is totally dependent upon

Figure 1: A schematic of a .032 x .032 TMA attached to the molar through a bonded hinge-cap lingual tube with the free end of the cantilever touching the Class II elastic

Cantilever corrector designs Nanda2 fabricated a cantilever for correcting Class II malocclusions (Figure 1) using a design by Burstone.3,4 The elastic activates the cantilever by providing a distal force to the molar, which creates a strong moment that tips the molar distally. The resultant force from the cantilever and the elastic is downward and backward (Figure 2). An alternate strategy for producing similar movements on the molar is with a two-piece cantilever that uses an anterior sectional arch in the incisor brackets. This cantilever design has the disadvantage of intruding the maxillary incisors, which is seldom indicated. Clinicians can offset this intrusion by applying Class II elastics to the anterior sectional wire. The Pendulum Appliance5 (Figure 4) offers another illustration of a cantilever that fixes the wire within the acrylic of the 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 4

Figure 2: The force system from the appliance shown in Figure 3

Figure 4: Pendulum Appliance pre-activated before the .036 TMA cantilever wire is inserted into the .036 doubled lingual sheath

Figure 3: A schematic for a cantilever from the molar attached to an anterior sectional wire. Note the intrusion of the maxillary incisors

Figure 5: Carriére® Motion™ Appliance illustrates the fixedanchored part of the appliance bonded to the canine and the one-point contact via the ball-and-socket arrangement against the molar Orthodontic practice 37

CONTINUING EDUCATION

Cantilevers — a simple method for Class II corrections

CONTINUING EDUCATION

Figures 6A-6B: Unbent 8 mm crimpable tube and bent tube from two views

Figure 8: Note the compression of the omega loop and the slight bowing of the cantilever as it responds to the length of the wire

Figure 7: Bent crimpable tube bonded to the maxillary canine

Figure 9: Adding a Class II force with elastics or springs can negate the anterior and intrusive forces on the canine. The hooks on the mandibular molar tube and canine need closure to maintain the spring in place

the patient wearing Class II elastics to the anterior part of the cantilever to effect movement of the teeth.

A new and different Class II cantilever This article displays a simplified Class II cantilever that requires minimal instrumentation, which orthodontists typically have in their armamentarium. An 8 mm crimpable hook is bent 90째 twice to give a horizontal span to which a sectional archwire hook can attach (Figures 6A and 6B). The bent tube is then bonded to the canine with a light-cured composite (Figure 7). A slightly long .016 x .022 stainless steel sectional archwire is made with a large omega loop that abuts the molar tube on one end and a hook that will have a one-point contact against the bent crimpable hook bonded to the canine. The sectional archwire is tipped upward about 45째, and when the omega loop touches the molar tube, the anterior cantilever hook will lie forward of the bonded canine attachment by 1 mm-2 mm. 38 Orthodontic practice

Figure 10: Initial Class II subdivision malocclusion Volume 6 Number 4

As the sectional archwire is brought occlusally and attached to the horizontal span of the crimpable hook, it will slightly compress the omega loop, which will created a distal force on the molar along with a strong clockwise moment and, simultaneously, will produce a forward and intrusive force on the canine but no moment (Figure 8). Class II elastics or NiTi springs will cancel the intrusive and anterior forces on the canine (Figure 9). Figures 10-13 illustrate an adolescent female patient treated with this Class II cantilever mechanism.

Figure 12: Class II malocclusion resolved and complete appliances added to finish therapy

Cantilevers offer orthodontists perhaps the most simple and easily managed apparatus for solving Class II malocclusions ...

Conclusion Class II malocclusions account for some of the most formidable challenges orthodontists encounter, which clinicians have sought to solve with complicated and expensive mechanisms — e.g., Herbst, Jasper Jumpers, Forsus, MARA, Distal Jet, Pendulum, Carriére® Motion™, etc. The Class II cantilever corrector featured in this article offers the profession a simple, effective, efficient, and inexpensive technique of correcting Class II malocclusions with sound Newtonian principles without the harmful side effects of the aforenamed appliances. The Herbst, Jasper Jumper, MARA, and Carriére Distalizer and other fixed interarch functionals ordinarily displace the mandibular incisors excessively facially, while the Pendulum, Distal Jet, and other intraarch appliances force the maxillary incisors facially. This cantilever corrector requires a minimum of instrumentation, instruction, and skill to implement and permits clinicians to solve the most difficult feature of Class II malocclusions at the initiation of treatment when patients are likely to display more enthusiasm and compliance. Once the Class II malocclusion has changed into Class I, the malocclusion becomes much easier to complete. OP Volume 6 Number 4

Figure 13: Class II malocclusion completed therapy

REFERENCES

Hoederath H, Bourauel C, Drescher D. Differences between two transpalatal arch systems upon first-, second-, and third-order bending activation. J Orofac Orthop. 2001;62(1):58-73.

Nanda R. Biomechanics in Clinical Orthodontics. Philadelphia, PA: W.B. Saunders; 1997.

Hilgers JJ. The pendulum appliance for Class II noncompliance therapy. J Clin Orthod. 1992;26(11):706-714.

Burstone CJ. Precision lingual arches. Active applications. J Clin Orthod. 1989:23(2):101-109.

Carrière L. A new Class II distalizer. J Clin Orthod. 2004;38(4):224-231.

Melsen B, Fiorelli G. Biomechanics in Orthodontics. 3rd ed. Aarhus, Denmark: 2013. http://www.ortho-biomechanics. com.

2. 3.

Orthodontic practice 39

CONTINUING EDUCATION

Figure 11: Cantilever and Class II elastics effect after a few weeks of application

CONTINUING EDUCATION

A historical and orthodontic perspective on white spot lesions — a literature review: part 1 Drs. George J. Cisneros, Matthew Miller, and Shira Bernstein, BA, research a longstanding issue for orthodontists Historical perspective While orthodontics can markedly improve our patients’ sense of well-being, as they leave our offices with corrected malocclusions, properly aligned teeth, and a significant boost in self-confidence, such positive gains can become shattered by the all too familiar esthetically negative side effect of demineralized white spot lesions (WSL). Such frustrating consequences can certainly diminish a clinician’s practice reputation and in the extreme may even lead to litigious follow-up. The fact that our care is focused on the 11- to 17-year-old patient population, a group very susceptible to WSLs, should keep us on the lookout for potential problems. But this has been an issue that humanity has been battling with throughout the millennia! Since the advent of civilization, dental caries have been the scourge of humankind. There is evidence that hominids such as Australopithecus suffered from cavities.1 Archeology has proven that there was a sharp spike in dental caries during the Neolithic period — roughly 10,200 bc to 2000 bc. Archeologists believe the Shira Bernstein is a third-year dental student at NYU College of Dentistry. She has received honors from the OKU society for her academic achievements. Shira graduated from Queens College in 2011 summa cum laude. She hopes to pursue a postgraduate certification in orthodontics following her graduation from NYU. Dr. Matthew J. Miller is an orthodontic resident at NYU College of Dentistry. He graduated from NYUCD in 2012, completed a General Practice Residency at SUNY Stony Brook in 2013 and expects his certificate in orthodontics in 2016. Dr. George J. Cisneros received his BS from Manhattan College, DMD from the University of Pennsylvania School of Dental Medicine, and his MMSc from Harvard University School of Dental Medicine. He is a Professor of Orthodontics at New York University College of Dentistry and is a Diplomate of the American Board of Pediatric Dentistry and the American Board of Orthodontics, serving on both of their advisory committees. Dr. Cisneros is a reviewer for various journals, including the American Journal of Orthodontics and Dentofacial Orthopedics, the Angle Orthodontist, the Journal of Dentistry for Children, and the Journal of Pediatric Dentistry where he also served as a member of the Editorial Board.

40 Orthodontic practice

Educational aims and objectives

This article aims to discuss the all too familiar esthetically negative side effects of demineralized white spot lesions (WSL).

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 43 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Read some history on dental caries. • Identify some ways to keep tooth surfaces free of plaque. • Identify some ways to introduce fluoride into patients’ treatment.

Neolithic Revolution, with its domestication of horticulture, contributed to an increase of ingested plants and carbohydrates that caused this spike2 (Figure 1). There was a belief among ancient civilizations that dental caries were caused by a dental worm, and the ADA website has a copy of an ancient Sumerian manuscript that subscribes to this belief.3 The next uptick in dental caries came during the Middle Ages due to availability of sugar cane to the Western world.4 With the 17th century came the Enlightenment, which questioned many old beliefs, including the dental worm theory.5 The first person to reject the theory of dental worms was Pierre Fauchard. He theorized that sugar was responsible for dental caries, and for this he is known as “the father of modern dentistry.”6 The 1850s saw another sharp increase in the prevalence of dental caries. Dental historians attributed this to an overall change in worldwide diet as a result of the Industrial Revolution, which brought with it a wide availability of processed foods like white sugar, refined flour, bread, and sweetened tea.7 Before the Industrial Revolution, the most common type of caries was cervical or root caries, but with the advent of processed foods, pit and fissure caries became the most common form of caries. In the 1890s, Dr. W.D. Miller hypothesized that there were bacteria in the oral cavity, and when fermentable carbohydrates were ingested, an acidic byproduct was produced causing caries formation.8 Dr. Miller’s hypothesis later became known as the “chemoparasitic caries theory.”9 Drs. G.V. Black and J.L. Williams’ research on dental

Figure 1: Caries in ancient human Legend from USA Today — Photo of a jaw found in the Grotte des Pigeons in Morocco shows heavy tooth wear, multiple cavities and, at lower right, a tooth abscess. The jaw is missing a front incisor because the ancient inhabitants of the cave pulled it out in early adulthood. (Photo: Isabelle De Groote)

plaque also contributed to the modern explanation of how dental caries form. In 1924, Killian Clarke first suggested Streptococcus mutans as the primary organism responsible for dental caries.10 Today we know that Streptococcus mutans and Lactobacilli are the primary bacterial sources for dental caries. When Streptococcus mutans and Lactobacilli are combined with fermentable carbohydrates, such as glucose, fructose, or sucrose, lactic acid is produced resulting in a decrease in the intraoral pH, creating an acidic environment initiating enamel decalcification. Intraoral pH rebounds after 30-60 minutes due to the body’s natural buffering capacity, but by then enough time has occurred for the decay process to begin. Dr. Robert Stephan was first to describe this Volume 6 Number 4

Volume 6 Number 4

Figure 2: Progression of decalcified enamel (WSL) At the microscopic level of a white spot lesion, demineralization creates pore spaces in the enamel, which can increase in size and eventually cause complete undermining of the enamel surface. (As modified from Silverstone LM. Structural alterations of human dental enamel during incipient carious lesion development. In Rowe NH, ed. Proceedings of Symposium on Incipient Caries of Enamel. Ann Arbor, MI: University of Michigan Press; 1977: 3-49.)

Figure 3: Longitudinal section of a deciduous central incisor Cool colors are at the least dense end of the mineralization density spectrum, and warm colors are at the most dense. Blue is the embedding resin. The pink is enamel, which is increasingly demineralized from red, to yellow, to green, to blue. You can see that its center is a subsurface demineralization of the tooth. Green, along with a lower density blue below the DEJ, is all normal dentin. (Photo courtesy of Dr. Timothy Bromage)

While orthodontics can markedly improve our patients’ sense of well-being, as they leave our offices with corrected malocclusions, properly aligned teeth, and a significant boost in self-confidence, such positive gains can become shattered by the all too familiar esthetically negative side effect of demineralized white spot lesions (WSL).

has been estimated that children who brush with fluoridated toothpaste and are exposed to fluoridated water have an 18%-40% reduction in caries.15 Another method used to introduce fluoride into patients’ mouths is through fluoride varnishes.16 Varnishes are available for professional use in a dental office, as well as for home use. The office products have 5% NaF varnish with a concentration of 22,600 ppm of fluoride. They are painted onto teeth, but care should be given to ensure that the teeth are absolutely dry before the varnish is applied, as it will adhere to only a dry enamel

surface. The patient is then instructed to not eat or drink for 30 minutes to allow the varnish to sufficiently penetrate the tooth structure. The at-home varnish contains 100-1,500 ppm with the same instructions. Office fluoride gel treatments are also available for patients with weak enamel. A tray of 1.23% fluoride gel with a concentration of 12,300 ppm of fluoride is applied directly to the dentition and let sit for 4 minutes, delivering a high dose of fluoride.17 MI Paste Plus™ is another product on the market, manufactured by GC America. MI Paste contains Recaldent™, which is Orthodontic practice 41

CONTINUING EDUCATION

pH change in 1943. Once lactic acid is introduced into the oral environment, there is a rapid drop in pH that rebounds at a much slower rate than it took for it to drop. There must be three factors present: the surface of the tooth, the bacteria, and fermentable carbohydrates. As the intraoral pH drops below 5.5, enamel begins to demineralize, the initial step in dental caries formation (Figures 2 and 3). Caries do not form immediately on healthy teeth, as our teeth naturally develop a biofilm that forms from proteins from our food and bacteria that colonize on the tooth surface.11 Interestingly, our teeth are the only natural surface of our body that does not shed, facilitating bacteria colonization on our teeth allowing dental caries to eventually develop.12 Over the centuries, humans have grappled with the problem of having to keep the surfaces of their teeth free of plaque. No matter the method or device, the goal has always been to remove this soft plaque and ensure that decay does not occur. Brushing twice every day with fluoride toothpaste, using mouthwash, and flossing daily has been part of the therapeutic dental mantra for decades. The effectiveness of this method has been well documented, supporting neglect as the primary cause for caries development. As there is a need for proper oral hygiene instruction, our patients are not the only negligent parties, simply because such routine instruction rarely occurs in today’s orthodontic offices. Fluoride has evolved as our main preventative chemotherapeutic agent against caries. As stated previously, once an acidic environment develops in the oral cavity, enamel begins to demineralize resulting in white spot lesions (WSL) and eventually decay. If fluoride is introduced early enough, a chemical reaction occurs, whereby the hydroxyapatite crystals in the enamel lose their OH-ion and are replaced with an F-ion, leading to the formation of fluorapatite. This process has proven to occur even when mere trace amounts of fluoride are present in the mouth, with 0.01-10 parts per million (ppm) being sufficient.13 Aside from being added to most toothpastes sold in the United States, fluoride has been added to mouthwashes and restorative materials such as resin-modified glass ionomer (RMGI). Another common method to introduce fluoride to the public is by adding it to the tap water. Although controversial in some areas, fluoridated water is delivered to approximately two-thirds of the U.S. population.14 It

CONTINUING EDUCATION made by Recaldent Pty Ltd., and marketed as an anti-sensitivity agent. Dental sensitivity is caused by the wearing away of the enamel surface. This can be due to mechanical forces such as bruxism, or chemical forces such as patients suffering from gastroesophageal reflux disease (GERD). Its active ingredients are casein phosphopeptide (CPP) and amorphous calcium phosphate (ACP). Such agents work with fluoride to deliver calcium and phosphate ions to the enamel and into the oral environment. This allows the enamel surface to remineralize, preventing sensitivity from occurring.18,19,20,21 But what is it that we can do in our daily practices to create a more proactive approach in dealing with a problem that continues to be all too prevalent in contemporary society? Is there something that we can do as oral health providers to protect our patients that can fit readily within our practice regimens so that we can continue to create not only functional and beautiful smiles, but ones that are healthy as well? OP

42 Orthodontic practice

REFERENCES 1. University of Illinois at Chicago. Epidemiology of Dental Disease online course notes. http://www.uic.edu/classes/ osci/osci590/11_1Epidemiology.htm. 2. Richards MP. A brief review of the archaeological evidence for Palaeolithic and Neolithic subsistence. Eur J Clin Nutr. 2002;56(12):16. 3. American Dental Association. History of Dentistry Timeline. http://www.ada.org/en/about-the-ada/ada-historyand-presidents-of-the-ada/ada-history-of-dentistry-timeline. 4. University of Illinois at Chicago. Epidemiology of Dental Disease online course noes. http://www.uic.edu/classes/ osci/osci590/11_1Epidemiology.htm. 5. Gerabek WE. The tooth-worm: historical aspects of a popular medical belief. Clinical Oral Investig. 1999;3(1):1–6. 6. de Vaux JC. Who is Pierre Fauchard. Pierre Fauchard Academy Web site. http://www.fauchard.org/publications/ 47-who-is-pierre-fauchard. 7. Suddick RP, Harris NO. Historical perspectives of oral biology: a series. Crit Rev Oral Biol Med. 1990;1(2):135-51. 8. Kleinberg I. A mixed-bacteria ecological approach to understanding the role of the oral bacteria in dental caries causation: an alternative to Streptococcus mutans and the specific-plaque hypothesis. Crit Rev Oral Biol Med. 2002;13(2):108-125. 9. Baehni PC, Guggenheim B. Potential of diagnostic microbiology for treatment and prognosis of dental caries and periodontal diseases. Crit Rev Oral Biol Med. 1996;7(3):259–277. 10. Grönroos L. Quantitative and Qualitative Characterization of Mutans Streptococci in Saliva and in Dentition. [dissertation]. Helsinki: University of Helsinki; 2000. 11. Penn State University. BioFilm Primer online. http://www. personal.psu.edu/faculty/j/e/jel5/biofilms/primer.html

12. Marsh PD. Are dental diseases examples of ecological catastrophes? Microbiology. 2003;149(2):279–294. 13. Rošin-Grget K, Peroš K, Sutej I, Bašić K. The cariostatic mechanisms of fluoride. Acta Med Acad. 2013;42(2):179-188. 14. American Dental Association. Fluoridation Facts. http:// www.ada.org/~/media/ADA/Member%20Center/FIles/fluoridation_facts.ashx . 15. CDC. Recommendations for using fluoride to prevent and control dental caries in the United States. MMWR Recomm Rep. 2001;50(RR-14):1–42. http://www.cdc.gov/mmwr/ preview/mmwrhtml/rr5014a1.htm 16. DA Division of Communications, Journal of the American Dental Association, ADA Council on Scientific Affairs. Fluoride treatments in the dental office extra protection for your teeth. J Am Dent Assoc. 2007;138(3):420. http://www.ada. org/~/media/ADA/Member%20Center/FIles/patient_72. ashx 17. Newbrun E. Topical fluorides in caries prevention and management: a North American perspective. J Dent Educ. 2001;65(10):1078-1083. 18. Reynolds EC. Anticariogenic complexes of amorphous calcium phosphate stabilized by casein phosphopeptides: a review. Spec Care Dentist. 1998;18(1):8-16. 19. Reynolds EC. The role of phosphopeptides in caries prevention. Dent Perspectives. 1999;3:6-7. 20. Sato T, Yamanaka K, Yoshii E. Caries prevention potential of a tooth-coating material containing casein phosphopeptide – amorphous calcium phosphate (CPP-ACP). [abstract]. International Association for Dental Research general session: Goteborg; 2003. 21. Reynolds EC, Cain CJ. Webber FL, Black CL, Riley PF, Johnson IH, Perich JW. Anticariogenicity of tryptic caseinand synthetic-phosphopeptides in the rat. J Dent Res. 1995;74:1272-1279.

Volume 6 Number 4

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Cantilevers — a simple method for Class II corrections

A historical and orthodontic perspective on white spot lesions — a literature review: part 1

WHITE

Orthodontists will use cantilevers as Class I levers where the effort is usually applied via a single point of contact with a tooth or wire and where the resistance will be within a _______. a. lingual sheath b. tube c. bracket d. both b and c

Nanda fabricated a cantilever for correcting Class II malocclusions using a design by _______. a. Burstone b. Jasper c. Melsen d. Carrière

The elastic activates the cantilever by providing a distal force to the molar, which creates a strong moment that tips the molar distally. The resultant force from the cantilever and the elastic is ______. a. pre-active b. downward c. backward d. both b and c

____ offers another illustration of a cantilever that fixes the wire within the acrylic of the mechanism, while the free end of the wire makes a one point contact within the lingual sheath of the molar. a. The Pendulum Appliance b. The Carriére® Motion™ Appliance c. Herbst appliance d. Jasper Jumpers This article displays a simplified Class II cantilever that requires minimal instrumentation, which orthodontists typically have in their armamentarium. An 8 mm crimpable hook is bent _______ to give a horizontal span to which a sectional archwire hook can attach. a. 90° once b. 90° twice c. 45˚ once d. 45° twice

Volume 6 Number 4

10.

The sectional archwire is tipped upward about 45°, and when the omega loop touches the molar tube, the anterior cantilever hook will lie forward of the bonded canine attachment by _____. a. 0.5 mm b. 1 mm-2 mm c. 3 mm-4 mm d. 5 mm-6 mm _______ will cancel the intrusive and anterior forces on the canine. a. Class I elastics b. Class II elastics c. NiTi springs d. both b and c The Class II cantilever corrector featured in this article offers the profession a simple _____ technique of correcting Class II malocclusions with sound Newtonian principles without the harmful side effects of the aforenamed appliances. a. effective b. efficient c. inexpensive d. all of the above This cantilever corrector requires a minimum of ____________ to implement and permits clinicians to solve the most difficult feature of Class II malocclusions at the initiation of treatment when patients are likely to display more enthusiasm and compliance. a. instrumentation b. instruction c. skill d. all of the above Once the Class II malocclusion has changed into Class I, the malocclusion becomes ________ to complete. a. much easier b. more complicated c. unnecessary d. more expensive

CISNEROS, ET AL.

Archeology has proven that there was a sharp spike in dental caries during the _______ period — roughly 10,200 bc to 2000 bc. a. Paleolithic b. Neolithic c. Early medieval d. Byzantine There was a belief among ancient civilizations that dental caries were caused by ____, and the ADA website has a copy of an ancient Sumerian manuscript that subscribes to this belief. a. a dental worm b. an evil spirit c. poor water quality d. acidic foods In the 1890s, Dr. W.D. Miller hypothesized that there were bacteria in the oral cavity, and when fermentable carbohydrates were ingested, an acidic byproduct was produced causing caries formation. Dr. Miller’s hypothesis later became known as the _____. a. “fluorapatite theory” b. Pierre Fauchard theory c. “chemoparasitic caries theory” d. “OH-ion theory” Today we know that ______ is(are) the primary bacterial sources for dental caries. a. Veillonella b. Streptococcus mutans c. Lactobacilli d. both b and c Intraoral pH rebounds after ______ minutes due to the body’s natural buffering capacity, but by then enough time has occurred for the decay process to begin. a. 10-15 minutes b. 20-25 minutes

c. d.

30-60 minutes at least 90 minutes

As the intraoral pH ____, enamel begins to demineralize, the initial step in dental caries formation. a. drops below 5.5 b. rises above 6 c. reaches 7.3 d. reaches zero

____ has been part of the therapeutic dental mantra for decades. a. Brushing twice every day with fluoride toothpaste b. Using mouthwash c. Flossing daily d. all of the above

____ has evolved as our main preventative chemotherapeutic agent against caries. a. Casein phosphate b. Fluoride c. Protein d. Sodium bicarbonate

The office products have ____ NaF varnish with a concentration of 22,600 ppm of fluoride. a. 1% b. 5% c. 20% d. 35%

10.

Dental sensitivity is caused by the wearing away of the enamel surface. This can be due to ___. a. mechanical forces such as bruxism b. chemical forces such as patients suffering from gastroesophageal reflux disease (GERD) c. brushing 5 times a day d. both a and b

Orthodontic practice 43

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Indirect Bonding 2.0 Scott Huge, Paul Gange, and Dr. Michael Mayhew discuss the evolution and clinical benefits of indirect bonding

rthodontic indirect bonding delivers undeniable clinical advantages. Many practices recognize efficiency gains through office delegation, improved bracket placement, and chair time reductions. Despite these benefits, fewer than 20% of orthodontic specialists use the technique. However, recent numbers indicate an upward trend of new practices implementing indirect bonding (IDB), and many industry experts believe this trend will continue due to recent technological advancements. This article presents recent innovations and perspectives from three leading indirect bonding experts. Their knowledge represents decades of laboratory experience, adhesive development, and the clinical implementation of indirect bonding.

Scott Huge founded Specialty Appliances orthodontic laboratory in 1981 and quickly became a leader of IDB development and production. When introducing an updated product or service, it is interesting to review the history. Despite over 40 years of reported advantages with indirect bonding, the technique has never gained more than an estimated 15% market share among clinicians. Although surveyed IDB users say they cannot imagine practicing without the established benefits, we also know that there are many orthodontists who have tried IDB and abandoned the technique. Their typical reason generally falls into one of three categories — bond

Scott Huge founded Specialty Appliances orthodontic laboratory in 1981. He quickly became a leader in indirect bonding and orthodontic appliance innovation, developing several widely used patented appliances. Scott’s dedication to orthodontics remains strong, as he volunteers his time on the Board of Directors for the American Association of Orthodontics Foundation. Paul Gange is the founder and president of Reliance Orthodontic Products. His experience in the orthodontic-bonding field spans 4 decades. He has lectured on bonding worldwide, holds several patents, and is a published author. Michael Mayhew, DDS, MS, PA, is a dual-trained Pediatric Dentist and Orthodontist practicing in Boone, North Carolina. Dr. Mayhew has utilized indirect bonding and played a key role in the development of digital bracket placement software over the past 12 years. Dr. Mayhew is recognized as a published author and has lectured worldwide.

44 Orthodontic practice

Digital indirect bonding software promotes optimum bracket placement

failure, inconsistent bracket positioning, and practice integration difficulties. Why does it work so well for some offices, but not for others? Let’s address some indirect bonding issues and highlight the innovations that provide solutions. We obviously have a vested interest in promoting our IDB service, but there is another link that needs to be considered. Previously, there has been only a handful of commercial labs offering a consistently high-quality IDB service, so practices had to simultaneously conquer both the clinical and laboratory sides of the process. Many offices simply lack the necessary laboratory systems experience to produce IDB trays that deliver consistent clinical results. Unlike an invisible retainer, which can be made predictably by the “in-office” lab with minimal training, indirect bonding requires experience and fine-tuned laboratory processes. Even if a practice wants to manufacture IDB trays in-house, we recommend sending the first 15-20 cases to an experienced lab like Specialty Appliances. Once the staff has mastered chairside delivery of the trays and experienced the benefits, they can tackle tray production. Inconsistent trays resulting from inexperience will create a bad IDB experience in your practice. Regardless of the source of fabrication, brackets must stay on the teeth. The first input to successful clinical delivery is accurate models. We constantly stress this

issue with all appliance fabrication. However, accuracy is absolutely critical with indirect bonding. The practice must commit to taking high-quality impressions and pouring the models immediately in hard stone. For guaranteed success with IDB, there are simply no shortcuts allowed at this stage. The most exciting development in model accuracy is the widespread adoption of intraoral scanners. Presently, over 50% of our incoming IDB cases are submitted from an intraoral scanner. The improved accuracy of scanners is evident with our digital customers reporting minimal, if any, bond failures due to inaccuracies. In other words, the IDB trays fit better than ever when using scanners. Assuming we have accurate models, we turn to the bracket bases adhering to the teeth. At Specialty, all IDB cases (labial and lingual) are processed with custom adhesive bases as the interface between the bracket and tooth surfaces. This has been our standard for many years and is by far the most predictable method. For our

Accurate models are the No. 1 key to IDB success Volume 6 Number 4

Double-layer clear transfer trays deliver the custom base brackets to a predetermined position on the teeth

Specialty Appliances’ new digital IDB process improves workflow and bracket precision while maintaining doctor control

custom base production method, we use thermal-set adhesive. This allows our senior technicians ample time to check all cases and make minor adjustments to bracket positions prior to tray fabrication. Custom bases require higher quality models due to the precision fit of the bases to the teeth, but they are extremely advantageous. Only a small amount of flowable adhesive is needed in the clinical delivery, minimizing flash around the brackets. Once the brackets are set, we process the transfer trays using the traditional “2 tray” technique, consisting of a softer inner tray coupled with a harder outer material. All trays are made from clear pressure-formed blanks using a BioStar® (Great Lakes Orthodontics), another tool proven to deliver consistent results. We prepare the brackets for tray processing by blocking out the significant undercuts in the bracket architecture to prevent the soft inner tray from forming too tightly around the brackets. We are aware of practices using a clear silicone to make transfer trays. In our experience, the silicone does work. However, we believe the clear dual tray system to be an easier technique in production on a high-volume basis. Volume 6 Number 4

For practices wanting to completely outsource their IDB fabrication, Specialty can accommodate even the most demanding offices. This includes our expertise in bracket placement and tray fabrication, managing digital files, printing models, and ensuring on-time deliveries. At Specialty, a senior technician oversees and checks brackets on 100% of cases. In addition, we have the ability to assign a specific senior technician to an individual practice to guarantee placement nuances of that doctor are followed on all cases. Specialty’s most recent IDB development uses advanced CAD software to meet the demand for high-precision bracket positioning. 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, manipulate, and approve the bracket position. The software replicates 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.

The first custom base indirect bonded technique utilized a two-part chemical cure bonding resin (Concise™, 3M Unitek) to transfer the brackets from the tray onto the enamel. With regards to clinical durability, the shear bond strength with this method was determined by how well the custom composite pad on the bracket base fit each specific tooth. Any voids between the custom pad and dental anatomy, due to inaccuracies in the models or trays, would result in failure at some point. In addition, original IDB systems did not have adhesion boosters to promote an improved bond to enamel, porcelain, metal crowns, or the composite custom pad. All these factors, coupled with the challenges in fabricating accurate transfer trays, produced inconsistent results, and subsequently, clinicians abandoned the technique. Today, we have universal bonding resins such as Enhance™, Assure® and Ortho Solo that promote a strong bond to wet or dry enamel. Additionally, Enhance and Assure will increase the chemical bond to the composite custom base on the bracket. These universal resins are applied to the etched enamel and custom base before the application of the transfer adhesive. From clinical feedback we’ve received, it is estimated that at least 75% of practices using indirect bonding are adding some type of adhesion “booster” to their clinical protocol. One proven method of transferring the brackets into the mouth uses a two-part chemical cure no-mix resin such as Custom IQ Maximum Cure®. Once the indirect trays are seated in the mouth, this adhesive polymerizes much quicker and produces a

Bond enhancers have greatly improved IDB success Orthodontic practice 45

LABORATORY LINK

Paul Gange founded Reliance Orthodontics in 1981 and is widely recognized as a leading expert in orthodontic bonding materials.

LABORATORY LINK

Flowable light-cured composite is applied to the custom bracket pad

higher strength than previous chemical cure materials. The second and most popular method uses a single paste, light cure, flowable composite such as Flow Tain (Reliance Orthodontics) or Transbond™ Supreme LV (3M Unitek). The advantages of light-cured adhesives are a longer working time, coupled with the ability to fill any micro-gaps between the custom pads and tooth surfaces. In the event there is not a perfect flush fit between the custom pad and tooth when the bracket is transferred in the mouth, the 65% filled paste will occupy that void and maintain bond strength, unlike the two-part chemical cure liquid resin. Due to the reduced amount of filler and application of flowable paste to the gingival half of the custom pad only, the polymerized peripheral flash is easily removed. Remember, when light curing through a clear tray, cure 10 seconds per bracket through the tray from the incisal edge. Remove the trays, and cure an additional 3 seconds each (from two angles) regardless of light intensity. In summary, modern indirect bonding techniques are much more dependable. Now, we also have universal bonding resins used to prep tooth surfaces and the custom pads, increasing adhesion at the tooth and bracket base. The fast-reacting chemical cure resins and light-cure flowable composites are stronger than their predecessors, making the shear bond strength of indirectly transferred brackets as strong and successful as direct bonding.

Michael Mayhew, DDS, MS, PA, is a dual-trained Pediatric Dentist and Orthodontist practicing in Boone, North Carolina. Dr. Mayhew has utilized indirect bonding and played a key role in the development of digital bracket placement software over the past 12 years. Utilization of indirect bonding offers multiple benefits for our practice. The most realized advantages appear in practice 46 Orthodontic practice

User-friendly, cloud-based software allows the doctor to adjust brackets and individual teeth before approving the IDB case

management, clinical, and ergonomic efficiencies. IDB enables us to delegate the majority of chairside bonding time to our clinical staff, freeing the orthodontist to perform other doctor-required procedures, like new patient examinations. Recent laboratory innovations use state-of-the-art bracket placement software, allowing us to review a virtual treatment and even alter the positioning of teeth and brackets. Once approved, the lab sends us indirect trays ready for patient bonding. The most significant benefit of computerassisted bracket placement is best-realized chairside. Clinical advantages are gained as initial alignment, archwire progression, and anticipated occlusal schemes develop readily due to optimal bracket positioning. Ergonomic efficiencies are realized through fewer repositions and detail bends, easier wire changes, and better clinical management of the patient. These benefits evoke confidence in doctors and staff as well as our patients and parents. Also, manipulating the digital models to demonstrate treatment goals for patients and parents is seen as “high tech.” We find that it improves patient education, case acceptance, and orthodontic practice marketing within our offices. Indirect bonding provides reliable bond strength in our practice. Advancement in bonding techniques and materials with proper isolation eliminate past concerns. Our delivery system is an inner soft and outer hard clear tray with custom base brackets. After applying a bond enhancer to both pad and enamel surfaces, a small amount of flowable light-cured adhesive is placed on the back of each bracket pad. The flowable adhesive fills any small imperfections in the

Chairside bracket delivery is efficiently delegated to staff members

custom base, and minimal flash is created. We experience bond strength equal to direct bonding with this bracket delivery system. Training your clinical staff to manage chairside IDB delivery presents a moderate learning curve, but our team has thrived with the additional responsibility. Each clinical staff member follows our precise IDB bonding protocol. It is important to emphasize extra detail on proper isolation in tooth preparation. An experienced clinical staff member can deliver bonding trays without an assistant, maximizing efficiency in the practice. Indirect bonding can contribute many efficiency gains in the orthodontic practice. Increased staff utilization, decreased doctor chair time at bonding, increased doctor time availability, decreased repositioning and detailing requirements, and shorter treatment times with fewer appointments are noted advantages of this procedure. IDB systems are more reliable with today’s specialized bond enhancers, adhesives, and consistent delivery systems. The evolution of digital technology in orthodontics has optimized bracket placement and promises an exciting future for indirect bonding in orthodontics. OP Volume 6 Number 4

TECHNOLOGY

Clear Collection instruments for clear aligner treatments: part 2 In part 2 of a series, Dr. S. Jay Bowman continues his look at instruments that help increase the utility of aligners and expand the scope of appropriate applications Contact points to accent aligners The two accent pliers in the Clear Collection (i.e., The Horizontal and The Vertical) (Figures 1-2) were designed to enhance desired tooth movements by employing “contact points.” Although overcorrection is a critical aspect that is integral to aligner treatment planning, there are occasions when the virtual setup does not predictably produce the desired result. In fact, researchers have reported that a percentage of tooth movement prescribed for a setup is simply not translated from plastic into the dental results.1-4 The flexibility of plastic, the potential errors transmitted from inaccuracies of PVS or scanned “impressions” and creation of models, imprecisions in the vacuum process of fabricating aligners, and the fact that all teeth do not move to the same degree when exposed to forces exerted by the trays can all lead to incomplete correction. To improve the predictability of desired tooth movement, The Vertical and The Horizontal pliers were designed to produce shallow impressions in the aligner plastic to contact specific surfaces of individual teeth. These indentations are intended to generate an enhanced “contact point” and/ or to create a mechanical couple to move a tooth in a desired direction. These “accents” may help avoid another series of “refinement” aligners with their attendant additional scans/ impressions and associated virtual setups — potentially reducing treatment delays and the “hassle factor.”

“We will control the horizontal. We will control the vertical. You are about to participate in a great adventure. You are about to experience the awe and mystery which reaches from the inner mind to —” — “The Outer Limits” TV Series (1963)

(Figure 1) is an instrument designed specifically for enhancing the correction of rotated teeth with clear aligners or even during minor tooth movement when using simple, clear retainers. Rotating upper laterals and cuspids is often problematic,5,6 especially

since aligners do not have a large surface area contact on laterals. Consequently, these incisors can get left behind, resulting in another form of “lag” or loss of tracking. The Vertical is used to produce an indentation at the mesial or distal of a specific tooth in the

The Vertical The control of rotations is often a challenge with clear aligners. The Vertical 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.

Figure 1A-1F: The Vertical pliers are used to accent rotational tooth movement. 48 Orthodontic practice

Volume 6 Number 4

The Horizontal There are instances where we would like to accentuate root torque for specific teeth during clear aligner treatment. In other instances, there is a need to increase the retentiveness of aligners or clear retainers. The Horizontal (Figure 2) is an instrument designed to accent labial or lingual torque for individual teeth, and it can also be used to simply increase the retentiveness of clear aligners or retainers.

Figures 2A-2C: The Horizontal pliers are specifically designed to add individual root torque Volume 6 Number 4

Orthodontic practice 49

TECHNOLOGY

Figures1G-1I: The shallow indentations are produced without heating the pliers, producing “contact points” to assist with rotational couples, including situations with composite “attachments” (1G,1H), enhancing molar distalization (1I), or root paralleling

facial and/or lingual aspects of the aligner plastic. These indentations are made without heating the pliers and at a very shallow depth so as to not compromise the integrity of the plastic (Figure 1). The intent is to add contact points to accent the rotational couples that were prescribed when creating a virtual treatment setup. This certainly contributes to the concept of overcorrection that is key to correcting rotations with aligners. The Vertical can also be used at the line angles of teeth to accent other types of tooth movement. For example, placing a vertical indent at the mesial of maxillary first molars (in the buccal and/or lingual plastic) will enhance molar distalization (Figure 1). When placed at the distal, the indent will assist molar protraction. Vertical indents at the embrasures of incisors or premolars will assist root paralleling, especially in extraction scenarios. Another option is to use The Vertical to produce a very slight indent at the junction between the incisal or gingival surface of the plastic and a composite aligner attachment. This may enhance the sharpness of the conformation or contact between plastic and attachment to avoid loss of tracking noted as an “escaped attachment.” The Vertical can also be used to produce an indent in aligner plastic in the middle one-third of the facial or lingual of a tooth to give a mild nudge for in-and-out or labiolingual discrepancies, including minor tooth movement with clear retainers.

TECHNOLOGY

Figures 2D-2F: In addition, the Horizontal is used to reduce “lag” by accenting extrusive or intrusive movement by applying contact points immediately adjacent to composite attachments

Either labial or lingual root torque can be a challenging aspect of tooth movement for clear aligners. This is typically due to the fact that the plastic is more flexible near the gingival margins, diminishing the required forces. The Horizontal can be used to produce an indentation on either the lingual, buccal or both sides of the aligner, anywhere along the aligner plastic to emphasize torque (Figures 2A-2B). Commonly, these “impressions” in the plastic are positioned at the gingival margin on the facial of an incisor to apply a contact point to emphasize lingual root torque. In contrast, the indent is placed on the lingual to enhance labial root torque. Another option is to use The Horizontal to produce a very slight indent at the right angle junction between a rectangular aligner composite attachment and the facial surface of a tooth (Figures 2C-2E). This indent may enhance the sharpness of conformation or contact between the plastic and the attachment to reduce the risk of lost tracking during either intrusive or extrusive movements. The Horizontal can also be used to produce a mild force to address labiolingual discrepancies (like The Vertical) — pushing a tooth facially or lingually. Finally, the Horizontal can be utilized to place an indent at the undercut of the crown of a tooth near the gingival margin to enhance the retentiveness of aligners (Figure 2F). 50 Orthodontic practice

Figure 2G: Indents can also be created to increase the retentiveness of aligners or retainers Volume 6 Number 4

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

Standardized clinical process In order to streamline the process of integrating individualized enhancement for a series of aligners, a prescription form is used to note the specific sites where Clear Collection instruments will be applied to each tray (Figure 3). In preparation to address each aligner, the prescription is completed in anticipation of the specific procedures needed for the trays. Notes regarding any mechanics to be employed are added (e.g., Class II elastics, bootstrap elastic, chain for rotation, molar distalization, protraction, intrusion, extrusion, etc.). The prescription accompanies the aligners that are to be dispensed at the patient’s next appointment along with the necessary Clear Collection pliers needed. A copy or scan of the prescription is kept for reference in the patient’s chart. In this manner, clinical coordination and consistency are communicated clearly.

Clear conclusions The Clear Collection can assist in the application of adjunctive forces to broaden the variety of malocclusion problems that may benefit from aligner treatments. Enhancing and accentuating chosen biomechanics helps reduce the known limitations of aligners and orthodontists’ occasional frustrations. In this manner, the clinician can more efficiently individualize treatment for each patient by altering the aligner trays in a series by adding appropriate forces to affect desired tooth movements. Specifically, The Hole Punch and The Tear Drop instruments facilitate the addition of elastic forces necessary for the correction of a significant number of malocclusions. Much like bending wires with orthodontic pliers, The Vertical and The Horizontal provide an added dimension for individualizing specific tooth movements in “real time” at the clinic chair. 52 Orthodontic practice

Figures 3A-3B: Clear Collection prescription sheet is prepared for each patient to specify the instruments that will be used for a series of aligners along with the exact sites where they will be employed. Figure 3C: Completed prescription sheet with notations (in red) accompanies the required instruments and the series of aligners to be enhanced. A copy of the Clear Collection prescription sheet is available for download and duplication at: http://www.hu-friedy.com/clear-collection

Enhancing and accentuating chosen biomechanics helps reduce the known limitations of aligners and orthodontists’ occasional frustrations.

The instruments in the Clear Collection help the orthodontist to better customize clear aligner treatments, enhance his/her 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: https://www.youtube.com/ watch?v=hrs2VfnImLY. OP

REFERENCES 1. 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. 2. Krieger E, Seiferth J, Marinello I, Jung BA, Wriedt S, Jacobs C, Wehrbein H. Invisalign® treatment in the anterior region: were the predicted tooth movements achieved? J Orofac Orthop. 2012;73(5):365-376. 3. 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. 4. Tuncay O. Clinical Reports & Techniques. 2005;6(2):1. 5. Nicozisis JL. Tripping the plastic fantastic. Orthodontic Products. 2013;Nov:28-34. 6. Humber P. Rotating canines using the Invisalign system. Aesthetic Dentistry Today. 2013;7(1):30-34.

Volume 6 Number 4

rthodontics has changed more in the past 20 years than in the previous 100 years. Today, orthodontists can offer a treatment experience that’s healthier, more comfortable, more aesthetic, and faster than ever before. While this is great news for our industry, it’s important to keep in mind that many consumers don’t understand how advanced orthodontics has become. The old consumer mindset is that orthodontic treatment is painful, takes too long, and only straightens teeth. This message no longer resonates with today’s health-conscious and aesthetically minded consumer who expects instant gratification. To differentiate an orthodontic practice, a new era of consumer education must take place, where patient dialogue addresses treatment advancements beyond straightening teeth. Through education, orthodontists can help patients better understand the versatile benefits of treatment, directly impacting patient starts. This is where Ormco’s new My Smile Consult™ comes in — to help motivate patients to start treatment.

My Smile Consult My Smile Consult is a new online consultation tool from Ormco that can increase case starts by educating patients on the benefits of orthodontia and the Damon™ System. By utilizing the interactive solution, practices can more efficiently and effectively present the benefits of treatment — before, during, and after the consultation. Exclusive to Damon System providers, My Smile Consult features include: • Personalized user experience — consumers can answer a short series of assessment questions upon arrival to the platform’s homepage. Based on the answers provided, My Smile Consult directs consumers to one of four intuitive dashboards with content that’s tailored to their profile — adult female or male, teen, or parents seeking treatment for their child or children. Doctors and staff members may also jump directly to any of the dashboards based on the audience being consulted. • Multimedia library — consumers can browse relatable multimedia content that is personalized to match their gender and age profile. This tailored approach ensures patient engagement through material that will best resonate with them and have a greater influence. To portray the diverse benefits of treatment, the library features over 25 high-quality patient testimonial and educational videos and numerous before and after photos. • Practice customization — doctors can create customized versions of My Smile Consult to showcase their practice branding and contact information, Volume 6 Number 4

By utilizing the interactive solution, practices can more efficiently and effectively present the benefits of treatment — before, during, and after the consultation.

patient photos, and testimonials. Doctors may then advertise their customized My Smile Consult via pre-designed web banners for their practice websites and social media pages and via pre-designed emails to patients. • Aesthetic appliance options — with My Smile Consult, patients can explore the clear benefits of virtually invisible treatment such as Damon™ Clear. • Treatment benefits — My Smile Consult helps educate audiences on why smiles are important and what an ideal smile looks like through photos, graphics, and figures. Topics addressed include ideal tooth display, upright teeth, broadening smiles, and more. To see this dynamic online tool, visit mysmileconsult.com. To learn how your practice may benefit from My Smile Consult, visit ormco.com, or speak with your Ormco representative. OP This information was provided by Ormco.

Orthodontic practice 53

PRODUCT PROFILE

My Smile Consult™ Online Patient Education Tool by Ormco Corporation

PRODUCT PROFILE

Introducing the all-new Carriere® SLX™ Bracket System See what you’ve been missing

t’s the most exciting news in orthodontic appliance design in years. Henry Schein® Orthodontics™ has introduced a completely re-engineered SLX Self-Ligating Appliance System. The SLX Bracket System resets the standards for excellence and performance in passive self-ligating brackets with numerous clinician-driven innovations for clinical effectiveness and efficiency. Discover the many innovative features of the SLX Bracket System — all designed to meet your ultimate goals — effective case management, optimal tooth positioning, and meticulous finishes.

Performance and finishing • Tooth-specific bracket widths for improved rotational control • Deeper tie wings for easy, secure chain, and elastic ligature use • Reduced slot depths for more precise tooth control

Exceptional clinical control and meticulous finishes — outperforming the competition.

Efficiency — a matter of time • Upper and lower brackets open to the occlusal to avoid tissue interferences • External clasp and spring with easy access for brushing ensure effortless, reliable functionality throughout treatment • Smooth, secure, and simple to operate slides with audible and tactile cues • Lower profile design for patient comfort and less occlusal interference • Adhesive Guard Rail™ (AGR) Technology directs adhesive mesial-distal for faster, easier cleanup • Fully integrated (optional) hooks mean no need for expensive, hardto-handle drop-in hooks

.091"

.083" .028"

Carriere SLX U1R

.033"

Ormco Damon® Q U1R

Don’t take our word for it. Your peers are raving about the SLX bracket! • “The switch from Damon to SLX has been a big win in simplicity, cost, chair time, and treatment outcomes.” — John Stieber, DDS, PS • “SLX brackets include important design enhancements to improve tooth control and, as such, will enable clinicians to take their SL cases to the next level.” — David Paquette, DDS, MS, MSD • “The SLX Bracket System has the features to provide clinicians with greater efficiency, better finishes, and a lower price … I couldn’t be happier.” — Michael Ragan, DDS Outperforming the competition, the SLX System brings extraordinary finishes to your practice. For more information on the SLX Bracket System, visit HenryScheinOrtho.com or call 888-851-0533.

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

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Volume 6 Number 4

INTRODUCING

A REMARKABLE BREAKTHROUGH IN CLASS III CORRECTION

INTRODUCING THE ALL-NEW CARRIERE® MOTION™ CLASS III APPLIANCE The Carriere Motion Class III Appliance provides a new, remarkably easy-

Pre-Treatment

In Treatment

to-use and patient-friendly solution for Class III treatment. This discreet, comfortable appliance is direct bonded in just minutes, and is as easily tolerated as elastics alone! Imagine an appliance that gives you and your Class III patients an option without surgery or cumbersome, uncomfortable, and unsightly extra-oral devices. If you’ve ever struggled while tackling Class III cases, take a look at the all-new Motion Class III Appliance today!

Learn more about the Motion Class III Appliance at 888.851.0533 or HenryScheinOrtho.com.

Post-Treatment

INDUSTRY NEWS

Planmeca begins open registration for Power of Digital Dentistry conference Planmeca has announced open registration for The Power of Digital Dentistry conference, the first-ever conference bringing together Planmeca Romexis® imaging and CAD/CAM users. The conference will be held October 16-17, 2015, at the Gaylord Texan Resort in Grapevine, Texas. Topics include: • Restorative success with digital dentistry • Advanced utilization of 3D technology • Patient virtualization — digital implant diagnosis • The ultimate dental assistant • The power of teamwork in restorative diagnosis and care • Marketing your high-tech practice To register, visit www.powerofdigitaldentistry.com.

M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT Ortho2 announces free Animations app Ortho Computer Systems, Inc., has released the Edge Animations app, a free Apple/Android application for all orthodontists and orthodontic residents. The app contains a compelling “Introduction to Orthodontics” video that clearly explains to consulting patients and parents why treatment from a certified orthodontist matters! The Edge Animations app also includes many essential compliance videos to help ensure patients are fully informed about their treatment with videos on brushing, foods to avoid, and much more. This free Android and iOS app builds on Ortho2’s library of practice and patient-focused apps and is available to all orthodontists (regardless of practice management affiliation), and can be shown to or even installed and viewed by prospective patients. For more information about Ortho2, visit www.ortho2.com.

56 Orthodontic practice

Dolphin’s partner Sirona heralds new CEREC Ortho software compatible with Invisalign® and symposium CEREC 30 Dolphin’s partner, Sirona, has introduced a new version of CEREC Ortho software, CEREC Ortho SW 1.1, which can generate output that is fully compatible with Invisalign®. CEREC Ortho, with an exclusive integration with Dolphin Imaging software, allows CEREC Omnicam scans to be stored directly in Dolphin 3D for archival, diagnostic, and patient education purposes, while a dedicated file transfer to Align Technology allows for the production of Invisalign aligners. Dolphin also is partnering with Sirona for a special Orthodontic Symposium at the upcoming “CEREC 30” event, scheduled for September 17-19 at The Venetian® and The Palazzo® Hotel in Las Vegas. They have carefully curated the curriculum to offer a comprehensive, well-rounded educational experience for the orthodontists and their staff. Clinical courses by world-renowned lecturers will be presented, along with other general sessions, keynote presentations, and social functions. For more information on CEREC Ortho software, call 800-5487241, or email sales@dolphinimaging.com, and for more on the symposium, visit http://www.cereconline.com/cerec30.

DEXIS™ unveils the all-new DEXcam™ 4, the next generation of intraoral camera As a leading provider of digital diagnostic imaging solutions, DEXIS™, a brand of KaVo Kerr Group has released the DEXcam™ 4 intraoral video camera designed for patient communication and case documentation. This new easy-to-use camera includes a higher resolution sensor, dual capture buttons, one-touch focus, and a detachable cord — all contained within an aluminum housing. DEXcam 4 seamlessly integrates with DEXIS™ imaging software. To learn more about DEXcam 4, call 888-883-3947, or visit http://www.dexis.com/dexcam4.

3M Unitek Treatment Management Portal now fully integrated with 3Shape TRIOS scanner 3M Unitek has announced the latest productivity booster in digital orthodontics: Unitek™ Treatment Management Portal (TMP) and 3Shape Communicate™ software systems have been fully integrated, enabling orthodontists to take advantage of a simplified workflow when using the 3Shape TRIOS® Intraoral Scanner to create Incognito™ Appliances or Unitek™ Digital Models. For TRIOS® users, the integration eliminates the steps of manually selecting and uploading patients’ files to Unitek™ TMP. To learn more about the integration, visit 3MUnitek.com/TMP.