Orthodontic Practice US January/February 2016 Vol 7., No 1 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews January/February 2016 – Vol 7 No 1

PROMOTING EXCELLENCE IN ORTHODONTICS Current concepts in data capture for sequential aligner therapy Dr. David Penn

BioDigital Orthodontics part 19 Drs. Rohit C.L. Sachdeva, Takao Kubota, Eric Howard, and Kazuo Hayashi

Using V-bends on NiTi wires for nonsurgical correction of Class III malocclusions Dr. Suhail A. Khouri

Cash balance plans Tony Robbins and Tom Zgainer

Practice profile Dr. Dan Bills

PAYING SUBSCRIBERS EARN CONTINUING EDUCATION CREDITS PER YEAR!

Secure Communication Platform

For Dental Professionals ey n o M ack tee B ran Gua

CONNECT SIMPLIFY GROW HIPPA Compliant

SECURE COMMUNICATION

REPUTATION MANAGEMENT

SCHEDULING

Visit RECORDLINC.COM Call 415.749.1444

INTEGRATION API

EASY MESSAGING

PATIENT eFORM

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

PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com MANAGING EDITOR | Mali Schantz-Feld Email: mali@medmarkaz.com Tel: (727) 515-5118 ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkaz.com EDITORIAL ASSISTANT | Mandi Gross Email: mandi@medmarkaz.com NATIONAL ACCOUNT MANAGER | Adrienne Good Email: agood@medmarkaz.com CREATIVE DIRECTOR/PRODUCTION MANAGER | Amanda Culver Email: amanda@medmarkaz.com FRONT OFFICE MANAGER | Theresa Jones Email: tjones@medmarkaz.com

MedMark, LLC 15720 N. Greenway-Hayden Loop #9, Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 Web: www.orthopracticeus.com www.medmarkaz.com SUBSCRIPTION RATES 1 year (6 issues) 3 years (18 issues)

$129 $319

© FMC 2014. All rights reserved. FMC is part of the specialist publishing group Springer Science+Business Media. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Orthodontic Practice US or the publisher.

Volume 7 Number 1

Not what you look at, but what you see

“T

he question is not what you look at, but what you see.” This philosophy from the journal of author Henry David Thoreau, written in 1851, still rings true in 2016. Perception has the potential to skew people’s views in every facet of daily life. This is evident in the 2012 “Behind the Smile” perception study, conducted by market research consultancy Kelton Global (known as Kelton Research at the time of the study) for Invisalign®. For the study, non-dentist respondents were shown images of people and asked to give their honest opinion. While the images depicted people with varying tooth issues, the study participants (1,047 nationally representative Americans) were unaware that their answers were Mali Schantz-Feld providing insight into a dental-related topic. Results probably reflect many of the reasons that orthodontists work so hard to create beautiful smiles. • Nearly one-third (29%) of respondents said the first aspect of someone’s face they typically notice is his/her teeth, and 24% said this is also the facial aspect that they remember the most after meeting someone. • When people with similar skill sets and experience vie for a job, respondents perceived those with straight teeth to be 45% more likely than those with crooked teeth to get the job, as well as 58% more likely to be successful, and 58% more likely to be wealthy. • When it comes to attracting a possible mate on a dating site, those with straight teeth are seen as 57% more likely than those with crooked teeth to get a date based on their picture alone. • Those with straight teeth are 21% more likely to be seen as happy, 47% more likely to be viewed as healthy, and 38% more likely to be perceived as smart. • Nearly three in four (73%) respondents would be more likely to trust someone with a nice smile than someone with a good job, outfit, or car. • Close to three in five (57%) Americans would rather have a nice smile than clear skin. • In order to have a nice smile for the rest of their life, 87% would forego something for a year; more than one-third would give up dessert (39%) or vacations (37%). Keeping in mind those perceptions regarding straight teeth, it is important to keep ahead of all of the technologies, techniques, and materials that result in those beautiful smiles. There are many decisions — metal, ceramic, or lingual braces? Clear aligners? Accelerated orthodontics? From adding another dimension to imaging with CBCT, to robotic archwire customization, to CAD/CAM, orthodontists have access to more precise data than ever before to move teeth more efficiently. Techniques regarding sleep disorders and airway issues also have become more evolving aspects of the specialty. Orthodontic Practice US presents articles about the newest and most innovative systems and devices. We know that while some like to be pioneers of new concepts, others like to wait and see all of the options on the horizon before implementing newly developed products. We strive to provide articles that interest the gamut of our loyal and appreciated readers. I am very enthusiastic about receiving emails with new article ideas. So, since this is the first issue of 2016, I would like to start the year off right — thank you to those who on a regular basis email me with their ideas for submissions. I look forward to your insights! Also, I invite new authors to submit articles for publication. Call me or email, and discuss the possibilities. Back to Mr. Thoreau. In Walden, he asked, “Could a greater miracle take place than for us to look through each other’s eyes for an instant?” As managing editor, looking through your eyes at orthodontics is exhilarating. It is a specialty filled with purpose. Please join us in 2016. Read us, write for us — help change patients’ lives not only for an instant, but for a lifetime. Until next time, Mali Schantz-Feld, MA Managing Editor

Orthodontic practice 1

INTRODUCTION

January/February 2016 - Volume 7 Number 1

TABLE OF CONTENTS

Financial focus Cash balance plans Tony Robbins and Tom Zgainer discuss an option to accelerate retirement savings and lower tax liability...............................................15

Practice profile Dan Bills, DMD, MS

Empowered in orthodontics

Orthodontic concepts BioDigital Orthodontics Management of patients with suresmileÂŽ Lingual: part 19 Drs. Rohit C.L. Sachdeva, Takao Kubota, Eric Howard, and Kazuo Hayashi illustrate how suresmile expands orthodontistsâ&#x20AC;&#x2122; esthetic appliance options............................ 16

Book review The Biomechanical Foundation of Clinical Orthodontics

Technology 12

by Charles J. Burstone, DDS, MS, and Kwangchul Choy, DDS, MS, PhD ........................................................23

A new method of controlling gingival hypertrophy with orthodontic patients Drs. Rajab Zaza and Larry White discuss a newer, simpler, and less invasive method of gingival control

2 Orthodontic practice

Volume 7 Number 1

Naturally translucent ceramic Strong enough to rebond Resists staining and discoloration Makes debonding predictable

Crumbling Brackets Are Costing You More Than Just Time Itâ&#x20AC;&#x2122;s time to stop making excuses for your ceramics and start making promises. Ovation C is the all new ceramic bracket from DENTSPLY GAC. Unlike other ceramic brackets that can crumble when you debond them, Ovation C ceramic brackets are strong enough to remove and reposition as needed. Esthetically engineered to blend seamlessly with enamel, the Ovation C low-profile brackets resist staining and discoloration for a new bracket look that lasts the duration of treatment. Stop covering for your old ceramic and start expecting more with Ovation C, the premier esthetic choice from DENTSPLY GAC.

The Ceramic Bracket Strong Enough to Rebond

Part Art. Part Science. All Orthodontics.â&#x201E;˘

800.645.5530 | www.dentsplygac.com

TABLE OF CONTENTS

Continuing education Current concepts in data capture for sequential aligner therapy Dr. David Penn examines the accuracy and precision of the traditional versus digital impression techniques.......... 30

Continuing education

Using V-bends on NiTi wires for nonsurgical correction of Class III malocclusions

Dr. Suhail A. Khouri discusses a method of delivering light and consistent forces over a long range of effective intrusive tooth movement

Practice management Research Laboratory link Intraoral scanners — an independent laboratory review James Bonham explores several aspects to consider when shopping for intraoral scanners......................36

4 Orthodontic practice

Orthodontic personnel principles Dr. James Morris Reynolds offers some wise counsel on assembling an effective office team..........................39

Industry news................42

Volume 7 Number 1

WOULD AN EXPERT DIAGNOSIS OF YOUR 401(k) PLAN REVEAL EXCESSIVE FEES AND POOR PERFORMING MUTUAL FUNDS? A Complimentary Offer For Orthodontic Practice Subscribers Americas Best 401k will provide a complimentary side by side “plain English" diagnosis of your 401(k) plan (which also happens to be your legal obligation by the Department of Labor so this is a no brainer!)

START LIN G S TATIS TICS : • A 1% reduction in annual fees means an additional 10 years of retirement security • Hidden fees and backdoor payments are costing Americans over $17 Billion annually • For 30 years the 401(k) industry was not legally required to disclose their fees

AME RI CA’S BE S T 4 0 1 (k ) NO BROKERS. NO COMMISSIONS. NO NONSENSE.

Call: 855 905 4015 A M E R I C A S B E ST 4 0 1 K .CO M /M E D M A R K

PRACTICE PROFILE

Dan Bills, DMD, MS Empowered in orthodontics What can you tell us about your background? I grew up in Southern New Jersey, just outside of Philadelphia. Both of my parents were teachers, so the importance of education was instilled in me at a very young age. I traveled out of state for dental school and my residency, but ultimately returned to my roots to start a family and practice. After associating for a couple of years, I started my private practice, Innovative Orthodontics, from scratch in 2007. In addition to my intense passion for clinical orthodontics, I absolutely love to teach. I am a Clinical Associate in the University of Pennsylvania Department of Orthodontics. I also lecture regularly, both stateside and abroad, about a variety of clinical topics as well as how to better utilize technology to connect with orthodontic and dental patients. I am honored to have the opportunity to not only provide my own patients with the highest quality of orthodontic care, but also to share my ideas with others.

Dr. Dan Bills maintains a private practice, Innovative Orthodontics in Southern New Jersey, just outside of Philadelphia

Why did you decide to focus on orthodontics? Orthodontics is the perfect blend of art, science, and customer-centered patient care. I get to spend my days creating beautiful, confident smiles for people that they will have for the rest of their lives. I can think of very few things more rewarding than that!

How long have you been practicing, and what systems do you use? I completed my orthodontic residency in 2004 and have been practicing clinical orthodontics ever since. I started my practice utilizing a popular passive self-ligating (SL) bracket and worked successfully with that for many years. About 3 years ago, I discovered the concept of Dual Activation in self-ligation — i.e., using passive SL brackets in the posterior with interactive SL brackets in the anterior. This allowed me to enjoy all of the benefits of passive SL that I loved in the early and middle stages of treatment, with better control and ease of finishing at the end. I have been utilizing Dual Activation™ with Empower® SL from 6 Orthodontic practice

Dr. Bills is a firm believer that communicating and connecting with patients and their parents are the keys to practice success

American Orthodontics ever since. It has been a game changer for me!

What training have you undertaken? I received my Bachelor of Arts degree in Biology from Lafayette College and my dental degree from Harvard University, both with Honors, after which I completed a 3-year orthodontic residency at the University of Illinois. In addition, I am a boardcertified Diplomate of the American Board of Orthodontics.

Who has inspired you? Personally, the biggest inspirations in my life are my parents. As the son of two teachers, obviously education was always stressed in my home. Without the untiring love and support of my parents throughout the years, I would most certainly not be where I am today. My wife inspires me every single day. She is a full-time pediatric dentist, as well as a full-time mom — and she is amazing at both! How she keeps all of those balls in the air without dropping any, Volume 7 Number 1

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

INTERACTIVE

ease of self ligation plus the best of both interactive and passive systems. • Interactive anterior brackets

PASSIVE

• Passive posterior brackets • Extensive prescription and wire options • A system you can truly make your own

NOW AVAILABLE WITH EMPOWER CLEAR!

PRACTICE PROFILE I will never understand! And, of course, my beautiful 18-month old daughter is an inspiration in every possible way. The intense joy that she gets from every new experience and adventure (no matter how small) forces me to focus on all of the little things in life that really matter. Professionally, the biggest inspirations for me have been Dr. Carla Evans and the Faculty at the University of Illinois, who gave me the orthodontic foundation that I still build upon today. In addition, I have to thank Dr. Dwight Damon for opening my eyes to the amazing world of self-ligation and Dr. Bob Waugh for making me realize that there are many different ways to utilize this powerful tool. And, of course, I am inspired daily by my ridiculously talented orthodontic team, without whom I would never be able to deliver the quality patient care that is a hallmark of my practice.

Pennsylvania. Helping to train the next generation of orthodontists is something about which I am ridiculously proud. In addition, I have been honored to lecture at a variety of orthodontic meetings (AAO, PCSO, SAO, MASO, GLAO, Dolphin User’s Meeting, etc.) over the last few years. The fact that anyone wants to hear what I have to say and what we do in our office still amazes me sometimes!

What do you think is unique about your practice? What has been your biggest challenge? The ability to integrate new and emerging technologies into my practice without sacrificing customer service and the overall patient experience has been a tremendous challenge for us. However, the fact that we have been able to pull it off definitely makes us unique. New technologies are emerging daily with claims of treating patients faster, increasing

practice efficiencies, and increasing the envelope of orthodontic tooth movement. However, I feel that often the patients’ perceptions of these technologies are often overlooked. For example, there are technologies that exist to decrease “doctor time” on certain procedures, but I am not convinced that patients necessarily perceive this as an added benefit. Before we incorporate any new technology into our practice, we take a good, hard look at how our patients will view this technology, and how it will affect our customer service experience. If something may make my life a little bit easier, but decreases the patients’ orthodontic experience in my office, we pass.

What would you have become if you had not become an orthodontist? From the second I decided that I was going to be an orthodontist, I never really

What is the most satisfying aspect of your practice? The most satisfying aspect of my practice is seeing our patients’ reaction to their new smile when we remove their orthodontic appliances. The pride and confidence that we have helped them achieve is obvious from their first look at themselves without braces. We have actually been recording each and every one of these “reveals” for over 3 years, and we create and publish a monthly video series called “iOrtho Smile Transformations.”

Professionally, what are you most proud of? I feel like I have found a very nice balance between clinical and academic orthodontics, both of which are huge passions of mine. In addition to my full-time private practice, I am also a Clinical Associate in the Department of Orthodontics at the University of

Dr. Bills is certain that his practice would be nothing without his amazing orthodontic team!

The design aspects of Dr. Bills’ office are a direct representation of his innovative approach to orthodontic treatment 8 Orthodontic practice

Volume 7 Number 1

We Know Digital Great Lakes has the complete solution for your practice.

3Shape TRIOS®3 Intraoral Scanner with Ortho System™ software

Stratasys Objet30 OrthoDesk 3D Printer

Choosing the right digital solution doesn’t have to be complicated. Great Lakes will get you up and running with an intraoral scanner, 3D printer, desktop scanner, or digital software that’s right for your orthodontic practice.

We’ve done the homework for you. We know digital. For years, Great Lakes has been immersed in digital technology–from appliance fabrication to offering digital lab services. We are confident we’ve selected the best digital solutions for our customers. TRIOS®3 Pod shown with Handle Grip

One source for everything Great Lakes is the only distributor to offer a full-line 3D solution for orthodontic practices and labs. We represent products from industry leaders including the ultra-fast 3Shape TRIOS®3 with Ortho System™ software and the Objet30 OrthoDesk 3D Printer from Stratasys. We , R750™, R500™ , and Maestro also carry the 3Shape R2000™ ® desktop scanners as well as netfabb and CAMbridge® automated manufacturing software.

R750™ Workhorse of productivity

With you every step From the decision process through installation, Great Lakes will partner with you to ensure a successful experience. Join us for a live webinar. Learn how this technology can enhance your practice by registering for The Future of Digital Orthodontics. To sign up for this webinar, visit www.digital-ortho.com or call 1.800.828.7626.

R500™ Cost efficient entry scanner

R2000™ Upper/lower simultaneous scans

Contact our digital experts today!

SMLP577Rev120315

Call 1.800.828.7626 Email info@greatlakesortho.com or visit www.digital-ortho.com

Maestro 3D Desktop Scanning System

Your digital solutions partner

PRACTICE PROFILE Top 10 favorites

Family is everything! Dr. Bills with his wife, Emily, and his daughter, Caroline

Orthodontics is the perfect blend of art, science, and customer-centered patient care. thought of a backup plan! I just decided that I would do whatever it took to make my dream a reality. However, looking back, the only other careers that I could really see myself doing would be to be a college biology professor or a professional golfer. Considering how bad my golf game is, I am really glad that this whole orthodontic thing has worked out!

What is the future of orthodontics and dentistry? The value of a beautiful, confident smile has never been higher; therefore, the future of orthodontics and dentistry is incredibly bright. The role of technology in how we deliver orthodontic and dental care will continue to grow as time goes on, so being able to navigate these changes will be incredibly important moving forward. For me, the most exciting orthodontic innovation in quite some time has been intraoral scanning. We are now utilizing scanners in every aspect of the practice and are completely impression free — a fact that patients really appreciate. In addition, scanning and 3D printing have streamlined our lab and retention process, saving several uncomfortable and time-consuming appointments while producing appliances that fit better than ever before. This is a completely win-win 10 Orthodontic practice

situation for orthodontic practices and patients alike.

What are your top tips for maintaining a successful practice? If I could offer one piece of advice for maintaining a successful practice, it would be to closely monitor and maintain your online reputation. The Internet has made our world extremely small. I am an optimist by nature, so I view the ease by which patients can now sing your praises online as being a tremendous opportunity for “raving fans” to help you grow your practice. However, you also need to be aware of the incredibly large “megaphone” that the Internet has given unhappy patients to voice their concerns. In today’s digital world, your online reputation is the lifeblood of your practice, so please treat it as such!

What advice would you give to budding orthodontists? We are in the midst of a very interesting time in American healthcare. Unfortunately, people are becoming more and more used to being treated like a number by healthcare professionals. Patient volume and wait times are on the rise, and customer service and individual attention are on the decline. Be the exception. Treat patients and parents with

1. My beautiful wife and daughter! None of these other things matter without them! 2. A good round of golf (although I am still waiting to have one). 3. Sharing ideas with colleagues and friends across the country and around the globe. 4. The look on patients’ faces when they see their confident, new smile for the first time. 5. Dolphin Imaging and Management Software. 6. Teaching my orthodontic residents at the University of Pennsylvania. 7. Dual Activation™ Self-Ligation with Empower® from American Orthodontics. 8. Intraoral scanning in orthodontics. 9. Exceeding patient and parent expectations. 10. Taking a perfectly smoked rack of ribs out of the smoker.

the type of customer service that they would expect from a high-end resort or department store, not a doctor’s office. Legitimately care about them. Spend the time to get to know them, not just their teeth. Talk to them about what is going on in their lives. Become a part of their family, and make them a part of yours. Make a visit to your office a bright spot in their day and not an inconvenience. Give them the amazing smile that they want and deserve, but do it in a way that shows them that they are special. If you can do this, you will ensure that every patient who leaves your office knows that there is no place else that they, or any of their family and friends, should receive their orthodontic care. Achieve that, and success is inevitable.

What are your hobbies, and what do you do in your spare time? Most of my spare time these days is spent with my wife and our 18-month old little girl. Family means everything to me. I am also an avid golfer and skier, and definitely try to get out on the links or on the slopes as much as possible. I am a wine enthusiast and an amateur BBQ aficionado. I entered my first BBQ competition with some friends this past summer, and we did extremely well; however, I don’t think you will be seeing me on BBQ Pitmasters any time soon! I am enjoying this whole tooth-straightening thing a little too much! OP Volume 7 Number 1

Brackets. On Target

COMPUTERIZED PRECISION BRACKET PLACEMENT SERVICE • Increases predictability. • Reduces adjustments. • Saves time!

eXceed Provides Unprecedented Accuracy

eXceed Gives You Ultimate Control

Powerful software scientifically calculates the ideal position of the brackets on the teeth:

• Prior to tray fabrication, the file will be sent for your review and approval. The user-friendly software will allow you to adjust the bracket placement giving you ultimate control.

• Outcomes are more predictable and consistent. • Adjustments to brackets and wire are minimized or eliminated. • Patient satisfaction is increased.

• We can use your brackets or you can select ours. eXceed is compatible with most popular bracket systems.

FREE EXCEED WEBINAR: Join our 30-minute overview of eXceed during lunchtime or between patient visits. To register, click the FREE WEBINARS button on our homepage or scan QR code.

eXceed is Fast and Efﬁcient • eXceed significantly reduces time spent placing brackets. • eXceed minimizes chair time and increases patient comfort.

www.exceed-glo.com Indirect bonding is efﬁcient and precise.

GETTING STARTED WITH EXCEED IS EASY! Call: 1.800.828.7626 | Email: exceed@greatlakesortho.com

SMLP556Rev060415

TECHNOLOGY

A new method of controlling gingival hypertrophy with orthodontic patients Drs. Rajab Zaza and Larry White discuss a newer, simpler, and less invasive method of gingival control Introduction Poor oral hygiene habits of orthodontic patients frequently result in chronic gingivitis and gingival hypertrophy, both of which impede treatment progress and threaten patients’ general oral health. Dentists have resorted to several remedies for the results of such patient neglect — e.g., improved oral hygiene techniques, fluoride rinses, enamel varnishes, quartz-filled enamel sealants, silane-enriched sealants, chlorhexidine rinses, Provantage applications, gingivectomies, and gingivoplasties, among other solutions. However, once the gingival hypertrophy passes a certain threshold, the removal of the swollen gingiva remains the only viable and certain method of restoring the integrity of the soft tissue. A brief review of familiar techniques of gingival removal is offered along with a newer, simpler, and less invasive method of gingival control.

Classical techniques of gingival hypertrophy control In the past, the most common method of restoring gingival contours to normality was through gingivectomies, which were ordinarily done by a periodontist with a scalpel and local anesthesia. The invasiveness, bleeding, posttreatment discomfort, and duration of recovery made this a last resort for orthodontists, and they would often defer such therapy until the cessation of orthodontic treatment.1-3 Electrosurgery has been advocated for several decades for the reduction and contouring of gingival tissues, and it offered the opportunity to resect gingiva without the subsequent bleeding, discomfort, and

long-term healing of the classical gingivectomy.4-6 Nevertheless, it does require local anesthesia, and many orthodontists have not the instrumentation nor desire to do injections for any procedure. Some clinicians have advocated using piezoelectric instruments for soft tissue excision,7 but this method of gingival removal has not proven popular. Recently, lasers have ignited interest among dentists as a means of reducing gingival hypertrophy. Lasers have several functions such as cosmetic contouring of gingiva, crown lengthening, removal of gingiva from slowly erupting teeth, excising opercula from erupting second molars to allow banding of those teeth, and, of course, the removal of hypertrophic gingiva. Three types of lasers have the capability of cutting soft tissue: the CO2 laser, the erbium laser, and the diode laser. The erbium laser does not control bleeding, while the CO2 laser is difficult to use due to a lack of tactile feedback. The diode laser (Figure 1) has found the most support among dentists because of its size, portability, hemostatic properties, and minimal discomfort.8-10 The wavelength of the diode laser also prevents it from damaging dental or osseous tissues. Some have suggested the possibility of using the diode laser without anesthesia, but personal experience has not validated this. In

fact, even the use of a typical topical anesthetic often proves inadequate, which has encouraged the authors to use a specialized topical anesthetic11 that has more absorptive power due to mannitol, a 6-carbon sugar (Figure 2). The gingiva readily absorbs the mannitol, which subsequently carries the combination of three topical anesthetics with it — lidocaine 20%, tetracaine 4%, and pentacaine 2% (Apotheca Compounding Pharmacy, 14603 Huebner Road, Suite 2602, San Antonio, Texas 78210).

The CeraTip™ — a new method of soft tissue management The CeraTip™ (Figures 3 and 4), distributed by Komet USA, provides dentists with a cermet bur. A cermet is a composite material composed of ceramic (cer) and metallic (met) materials. A cermet is ideally designed to have the optimal properties of both a ceramic, such as high temperature resistance and hardness, and those of a metal, such as the ability to undergo plastic deformation. The CeraTip™ is made of a mixed ceramic composed of zircondioxide oxide partly stabilized by yttrium and aluminum ceramic. This rotary bur provides clinicians an ideal soft tissue trimming instrument that produces enough heat in its application to coagulate blood from the tissue cut.

Dr. Rajab Zaza completed his orthodontic residency at Yousef Al-Azmeh Hospital in Damascus, Syria and is now enrolled in an AEGD program developed by NYU Lutheran Dental Health Program and is located in Dallas, Texas where he works under the auspices of Community Dental Care who partners with NYU Lutheran Hospital. Larry White, DDS, MSD, FACD, is in private practice of orthodontics in Dallas, Texas.

Figure 1: Diode laser 12 Orthodontic practice

Figure 2: Topical anesthetic Volume 7 Number 1

H 4 ™ B u cc al Tu be

H4 ™ S e l f - L ig ating Br acke t H4 ™ A e s t h e t ic S e l f - L ig at in g B r a c ke t

In n o v at ing Innovat ion

Introducing the Complete H4 ™ Self-Ligating Suite Toll Free: 1.866.752.0065 | www.orthoclassic.com | Fax: 1.866.752.0066 | International: 1.503.472.8320

TECHNOLOGY

Figure 3: CeraTip™ in an air turbine handpiece

The CeraTip™ has many uses: • exposure of intra-osseous implant sites (Figure 5); • dilation of the sulcus following crown build-ups (Figure 6); • exposure of cavities at the cementumenamel junction; • removal of hypertrophied gingiva (Figure 7); • the exposure of unerupted teeth (Figures 8 and 9); • gingival depigmentation.12 The CeraTip™ offers clinicians a more than acceptable alternative to other popular and better established methods of soft tissue management with the following advantages: • it does not require additional expensive equipment; • clinicians can use it with topical anesthetic; • it has a short learning curve; • the heat it produces has a hemostatic effect that prevents bleeding; • minimal posttreatment discomfort; • minimal time for setup, cleanup, and maintenance; • minimal invasivness. As with any soft tissue removal technique, the CeraTip™ has some caveats. Clinicians should use a slow, steady, and light touch as they sculpt the gingiva and not move the tip with a back-and-forth sweeping motion. By proceeding slowly, the tip can transfer the heat to the cut tissue and coagulate any

Figure 4: CeraTip™ Kit

Figure 6: Dilation of sulcus

Figure 5: Exposure of implant

Figure 7: Gingival hypertrophy

blood produced. Additionally, the CeraTip™ should be used without a water spray since that will negate the heat and encourage site bleeding. Clean the bur with a nylon brush as metal brushes can cause discoloration.

Conclusion The introduction of the electrosurge and/ or diode lasers has allowed orthodontists to manage the soft tissue needs of their patients, whereas before they had to send them to their referring dentists or periodontists. Such management, of course, has required additional equipment, investment, and training, and that has discouraged some from endorsing and using these practical techniques. The CeraTip™ offers clinicians a simpler, inexpensive, and essentially painless strategy for providing their patients with effective and beneficial soft tissue care. OP

Figure 8: Uncovering an unerupted canine

Figure 9: Exposed canine. Note lack of bleeding

REFERENCES 1. Graber, TM. Orthodontics, Principles and Practice. 1st ed. 1961, Philadelphia:W. B. Saunders Company:803. 2. Vanarsdall R. Periodontal considerations in corrective orthodontics. In: Clark JW, ed. Clinical Dentistry. Vol. 2. Chapter 22. Hagerstown: Harper & Row; 1978. 3. Benoist HM, Ngom PI, Seck-Diallo A, Diallo PD. Gingival hypertrophy during orthodontic treatment: contribution of external bevel gingivectomy. Odontostomatol Trop. 2007;30(120):42-46. 4. Anderman I. Orthodontic and pedodontic electrosurgery. Int J Orthod. 1976;14(3):14-22. 5. Fricke LL, Rankine CA. Comparison of electrosurgery with conventional fiberotomies on rotational relapse and gingival tissue in the dog. Am J Orthod Dentofacial Orthop. 1990;97(5):405-412. 6. Miles, PG. Electrosurgery: an alternative to laser surgery in orthodontics. J Clin Orthod. 2007;41(4):222-223. 7. Grenga V, Bovi M. Piezoelectric surgery for exposure of palatally impacted canines. J Clin Orthod. 2004;38(8):446-448. 8. Hilgers JJ, Tracey SG. Clinical uses of diode lasers in orthodontics. J Clin Orthod. 2004; 38(5):266-273. 9. Sarver D. and Yanosky M. Principles of cosmetic dentistry in orthodontics: part 2. Soft tissue laser technology and cosmetic gingival contouring. Am J Orthod Dentofacial Orthop. 2005;127(1):85–90. 10. Jarjoura, K., Soft tissue lasers. Am J Orthod Dentofacial Orthop. 2005;127(5):527–528. 11. White, L. Orthodontic Pearls: A Clinician’s Guide. Vol. 1. Dallas, Texas: Taylor Specialty Books;2011. 12. Sharath KS, Shah R, Thomas B, Madani SM, Shetty S. Gingival depigmentation: case series for four different techniques. Nitte University Journal of Health Science. 2013;3(4):132-136.

14 Orthodontic practice

Volume 7 Number 1

Tony Robbins and Tom Zgainer discuss an option to accelerate retirement savings and lower tax liability

ach year around this time, we can all see the inevitable not too far in the distance. Our tax liability — and how we manage it — is generally not as festive as the recently past holiday season. However, your retirement planning and the type of plan you establish can offer a reduction of tax liability and accelerated contributions to help produce additional income when you’ll need it most — at retirement after active work. There are two general types of pension plans — defined-benefit plans and definedcontribution plans. In general, defined-benefit plans provide a specific benefit at retirement for each eligible employee, while definedcontribution plans specify the amount of contributions to be made by the employer toward an employee’s retirement account. In a defined-contribution plan, the actual amount of retirement benefits provided to employees depends on the amount of their contributions, along with employer contributions such as Safe Harbor or profit-sharing contributions, as well as the gains or losses of the account over time. Many of our dentist clients take advantage of this combination by “maxing” out the total allowable contributions, currently $53,000 if under age 50 or $59,000 if over age 50, while giving a needed ratio of contributions to eligible staff as well. However, we often are asked, “What else can I do aside from after tax investing? What other types of retirement plans are available?” Enter the cash balance plan, a type of defined-benefit plan that when paired with a 401k/profit-sharing plan provides an opportunity to essentially squeeze 20 years of saving into 10, while at the same time significantly reducing your tax liability along the way. As the chart accompanying this article shows, the benefits of the cash balance plan really start to accelerate as the business owner gets beyond age 45-50. While employer matching and profitsharing contributions are discretionary, cash

Peak performance strategist Tony Robbins and Tom Zgainer, founder and CEO of America’s Best 401k, offer advice on growing retirement savings.

Volume 7 Number 1

2016 Contribution Limits 401(k) PROFIT-SHARING AND CASH BALANCE PLANS Age

401(k) with Profit Sharing*

Cash Balance

Total

Tax Savings**

$59,000

$237,000+

$296,000+

$133,200

$59,000

$237,000

$296,000

$133,200

$59,000

$243,000

$302,000

$135,900

$59,000

$248,000

$307,000

$138,150

$59,000

$254,000

$313,000

$140,850 $135,000

Above 65

$59,000

$241,000

$300,000

$59,000

$228,000

$287,000

$129,150

$59,000

$216,000

$275,000

$123,750

$59,000

$205,000

$264,000

$118,800

$59,000

$194,000

$253,000

$113,850

$59,000

$184,000

$243,000

$109,350

$59,000

$175,000

$234,000

$105,300

$59,000

$165,000

$224,000

$100,800

$59,000

$157,000

$216,000

$97,200

$59,000

$149,000

$208,000

$93,600

$59,000

$141,000

$200,000

$90,000

$59,000

$133,000

$192,000

$86,400

$53,000

$126,000

$179,000

$80,550

$53,000

$120,000

$173,000

$77,850

$53,000

$114,000

$167,000

$75,150

$53,000

$108,000

$161,000

$72,450

$53,000

$102,000

$155,000

$69,750

$53,000

$97,000

$150,000

$67,500

$53,000

$92,000

$145,000

$65,250

$53,000

$87,000

$140,000

$63,000

$53,000

$82,000

$135,000

$60,750

$53,000

$78,000

$131,000

$58,950

$53,000

$74,000

$127,000

$57,150

$53,000

$70,000

$123,000

$55,350

$53,000

$66,000

$119,000

$53,550

$53,000

$63,000

$116,000

$52,200

35 Under 35

$53,000

$59,000

$53,000

Up to $56,000

*401(k): $18,000; $6,000 catch-up; $35,000 profit sharing

balance plans require more of a commitment to fund the plan by the employer. Most plans are set up with a 3-5 year funding period, so they work well in environments where the business owner will have predictable income over that time frame. Different from a 401k plan where participants generally choose their investment options, the assets of a cash balance plan are managed by the employer or an investment manager. In a typical cash balance plan, a participant’s account is credited each year with a “pay credit” (such as 5% of

$112,000 Up to $109,000

$50,400 Up to $49,050

** Assuming 45% tax, varies by state. Taxes are deferred

AMERICA’S BEST 401k

compensation from the employer) and an “interest credit” (either a fixed rate or a variable rate that is linked to an index such as the 1-year Treasury Bill rate). To determine if a cash balance plan is right for you, enlist an actuary who is an expert in retirement plan design to analyze your practice demographics with a current census of full-time employees. If this plan design can meet your individual and corporate objectives, you have a far greater pool of income available when the time comes to hang up the white coat. OP Orthodontic practice 15

FINANCIAL FOCUS

Cash balance plans

ORTHODONTIC CONCEPTS

BioDigital Orthodontics Management of patients with suresmile® Lingual: part 19 Drs. Rohit C.L. Sachdeva, Takao Kubota, Eric Howard, and Kazuo Hayashi illustrate how suresmile expands orthodontists’ esthetic appliance options Introduction In previous articles,1-18 the versatility of suresmile® technology in enabling the orthodontist to manage a broad range of malocclusions using customized target prescription archwires with fixed labial edgewise brackets has been discussed comprehensively. Suresmile provides the orthodontist unprecedented versatility to control orthodontic tooth movement by choosing the appropriate timing for customized therapeutics. In addition, it enables the orthodontist to preferentially affect the expression of the prescription archwire (staging subtractive or additive bends) based upon the patient’s needs and bracket system employed.

Suresmile also expands the abilities of the orthodontist to fulfill the patient’s desire for esthetic appliance systems. These include both lingual fixed appliances and aligners. The purpose of this article is to discuss two patient histories that demonstrate the treatment of a patient with suresmile Lingual.

Patient S.N. (suresmile Lingual appliance) Patient S.N., a 21-year-old female patient presented with a chief complaint of “I do not like the appearance of my teeth” and very much insisted on having hidden braces. Her clinical and cephalometric findings suggested that she had a skeletal Class

II pattern and a long lower facial height. She presented with a Class 1 dental malocclusion with an anterior openbite. There were no signs of TMJ symptoms. Her lower first molars were restored with crowns and a pulpotomy. Her upper-right first molar was heavily restored. Her oral health was good. Her initial records are shown in Figure 1. It was decided to treat Patient S.N. in a non-extraction manner with minor dental expansion in both the upper and lower arches. Lower arch crowding was corrected with minor interproximal reduction. Figure 2 shows the Virtual Diagnostic Simulation (VDS) demonstrating the treatment plan.

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 to access information. Takao Kubota, DDS, PhD, is in private practice at the Yours Orthodontic Clinic, 378-6 Motomura Yame City, Fukuoka 834-0063 Japan. He is also the co-founder of the Institute of Orthodontic Care Improvement in Japan, and Associate Professor in the Department of Orthodontics, Kanagawa Dental College, Yokosuka, Japan. Dr. Eric Howard, DDS, PhD, is in private practice at Long Orthodontic Associates, 519 E. Main Street, Lititz, Pennsylvania. Dr. Kazuo Hayashi practices at the Hokkaido Health Sciences Center, Tobetsu, Japan.

16 Orthodontic practice

Figures 1A-1B: Patient S.N. 1A. Initial intraoral photographs. 1B. Initial X-rays — lateral ceph and panorex Volume 7 Number 1

VDS (white) vs. VDM (green)

Figures 2A-2C: Patient S.N. 2A. Virtual Diagnostic Model (VDM) 2B. Virtual Diagnostic Simulation (VDS) B. VDS (white) vs. VDM (green). 2C. Planned orthodontic tooth displacements

Figures 3A-3E: Patient S.N. Indirect bonding (IDB) jigs were designed. 3A. 3D print of Virtual Diagnostic Simulation model. 3B. Impression of 3D-printed VDS. 3C. Plaster model of the VDS set up from the impression. 3D. Brackets bonded on the plaster model. 3E. Individual jigs fabricated on plaster models

Indirect bonding (IDB) jigs for the patient were designed in the following manner. First, the Virtual Diagnostic Simulation that represented the setup (target occlusion) was converted to an STL file, which enabled its 3D printing (Figure 3A). Next, an impression of the 3D printed setup was taken and the impression poured in plaster (Figures 3B-3C). Brackets were bonded on the plaster model. Indirect individual tooth bracket jigs were then fabricated (Figures 3D-3E). It should be noted that with suresmile Lingual, the clinician may bond the patient directly and circumvent the use of IDB. This requires appropriate adjustments be designed in the archwire based upon a target setup designed from a virtual therapeutic scan. This approach is best considered in patients presenting with minimal crowding. Recently, suresmile has developed technology to directly print an IDB tray for both lingual and labial indirect Volume 7 Number 1

Figure 4: Patient S.N. Quadhelix appliance used on both lower and upper arches to gain minimal uprighting of the buccal segments though expansion

bonding of fixed appliances. This enables the doctor to initiate orthodontic treatment with indirect bonding and circumvents the need for a therapeutic scan. The entire design of the target setup and the accompanying IDB trays with the complementary archwires (if needed) is based upon an

initial diagnostic scan. A future article will discuss the design and clinical use of the suresmile IDB system. Initially, a Quadhelix was used in both lower and upper arches to gain minimal uprighting of the buccal segments though expansion (Figure 4). Orthodontic practice 17

ORTHODONTIC CONCEPTS

VDS

ORTHODONTIC CONCEPTS

Figures 5A-5B: Patient S.N. 5A. Midtreatment intraoral photos were taken at 8 weeks into active treatment. 5B. Midtreatment X-rays

VDS (white) vs. VTM (green)

Figure 6: Patient S.N. Superimposition of the VTM against the VDS shows that the planned archwidth was achieved with Quadhelix appliances in both the upper and lower arches

Eight weeks later, the patient was bonded using the customized jigs. The teeth were bonded with DENTSPLY GAC In-Ovation速 L (www.gac inovation.com) brackets with 0.018" slot width. At this appointment, a therapeutic scan of the patient was taken (Figure 5). Super-imposition of the VTM against the VDS shows that the planned archwidth was achieved with Quadhelix appliances in both the upper and lower arch (Figure 6). The Virtual Target Setup (VTS) is shown in Figure 7B. Superimposition of the Virtual Target Setup against the Virtual Therapeutic Model (VTM) is shown in Figure 7C. The archwire designed against the VTM is shown in Figure 7D.

Figures 7A-7E: Patient S.N. 7A. Virtual Therapeutic Model (VTM). 7B. Virtual Target Setup (VTS) with suresmile precision archwire designed. 7C. VTS (white) vs. VTM (green). 7D. Suresmile precision archwire viewed against VTM. 7E. Planned orthodontic tooth displacements 18 Orthodontic practice

Volume 7 Number 1

What’s your game plan? Ever started treatment of a case and come across unexpected challenges? Of course, everyone has. Using the latest in suresmile’s digital diagnostics to plan cases minimizes the unexpected and provides a dependable clinical support network throughout treatment. The suresmile comprehensive Treatment Management System gives you the tools you need to plan and manage every case to its desired finish.

August 2006 Frontal initial

“When the rest of the field is struggling just to make par, we are consistently scoring eagles.” Mark Feinberg, DMD

May 2007

Shelton, CT

Planned non-surgical result

July 2008 Final result

suresmile, it’s your game plan for success. To learn more call 877.787.7645.

suresmile.com

to be sure.

Great finishes start with a great game plan. That’s exactly what suresmile gives you.

ORTHODONTIC CONCEPTS No interim archwires were placed. Upper and lower .016" CuNiTi AF 35°C suresmile precision archwires were installed 1 month post therapeutic scan (Figure 8). One month later, both upper and lower .016" x .016" CuNiTi AF 35°C suresmile square precision archwires were inserted (Figure 9). Six weeks later, both upper

and lower .016" x .022" CuNiTi AF 35°C suresmile precision archwires were placed (Figure 10). The patient was next seen a month later. At this stage in treatment, it was decided to have the patient wear up-anddown elastics to settle down the canines. Buttons were bonded on the right buccal

segment on the upper and lower canines and the lower premolar to attach the elastics (Figure 11). The canines settled within 2 weeks (Figure 12), and the patient was debonded 1 week later. The final records are shown in Figure 13. The total active treatment time for patient was 7 months. The Virtual Final Model (VFM) is superimposed

Figure 8: Patient S.N. Upper and lower .016" CuNiTi AF 35°C suresmile precision archwires were installed 1 month post therapeutic scan

Figure 9: Patient S.N. A month later, both upper and lower .016" x .016" CuNiTi AF 35°C suresmile square precision archwires were inserted

Figure 10: Patient S.N. Six weeks later, both upper and lower .016" x .022" CuNiTi AF 35°C suresmile precision archwires were inserted

Figure 11: Patient S.N. Note the triangular settling elastics on the right side

Figure 12: Patient S.N. Note 2 weeks later, the right canine has settled down

VFM

Figure 13: Patient S.N. One week later, the patient was debonded 13A. Final intraoral photos taken at debond 13 weeks post suresmile wire insertion and 7 months from start of treatment. 13B. Final X-rays. 13C. Virtual Final Model (VFM) 20 Orthodontic practice

Volume 7 Number 1

VDS (green) vs. VFM (white)

Hybrid Lingual appliance Patient KEH It is common to see patients who are accepting of a treatment regimen that involves upper lingual fixed appliances coupled with a lower labial appliances. This approach to care addresses their primary concern of not displaying upper fixed appliances. Moreover, it also provides a more cost-effective solution for the patient as compared to a total lingual fixed appliance approach. Figure 15 provides a brief overview of a patient history (KEH)

Figure 14: Patient S.N. The Virtual Final Model (VFM) is superimposed on the Virtual Diagnostic Simulation (VDS). Note how closely the outcome matches the plan

Figures 15A-E: Patient KEH. 15A. Presented with a class1 bimaxillary prousion with severe crowding in the maxillary arch and minimal in lower arch. 15B. All second bicuspids were extracted and the patient bonded using indirect bonding. Note upper lingual and lower labial fixed appliances were used. 15C. Immediately post bonding, a therapeutic scan of the patient was taken to design the target setup and the appropriate 3D customized prescription archwires. 15D. The virtual 3D target setup. 15E. After initial alignment space closure using sliding mechanics accompanied with the use of intermaxillary elatics to control anchorage was initiated. Table 1 shows the archwires used.

Volume 7 Number 1

Orthodontic practice 21

ORTHODONTIC CONCEPTS

on the Virtual Diagnostic Simulation (VDS). Note how closely the outcome matches the plan (Figure 14).

ORTHODONTIC CONCEPTS

Figures 15F-15G: Patient KEH. 15F. Post space closure 7 months into treatment. The finishing stage of treatment was initiated using suresmile prescription archwires. See Table 1 for details. 15G. Total treatment time 13 months

using a hybrid lingual appliance approach in managing extraction therapy.

Discussion and conclusions Both patients S.N. and K.E.H. demonstrate the broad capabilities of suresmile technology in enabling the orthodontist to address patients’ needs for an esthetic-appliance solution involving lingual fixed appliance treatment. And equally important is not sacrificing the doctor’s ability to achieve complete control of orthodontic tooth movement with lingual therapy. Future articles will discuss the use of both suresmile IDB and aligner solutions for the orthodontic professional. OP

Table 1: Patient KEH — Shows the appliances used in the treatment of the patient Phase

Action

Step 1

Consultation

•

Patient referred for extractions

Step 2

Bonding

• •

.013 CuNiTi upper standard archwire .018 CuNiTi lower standard archwire

Step 3

Therapeutic scan (Immediately post bonding)

Step 4

suresmile customized wire #1

• • • •

16 x 16 CuNiTi upper 17 x 25 CuNiTi lower Chain Class I and Class II elastics

Step 5

suresmile customized wire #2

• • •

16 x 22 CuNiTi upper 19 x 25 copper niti lower Chain

Step 6

suresmile customized wire #3

• •

17 x 25 CuNiTi upper 16 x 22 beta titanium lower

Step 7

Debond

•

Delivered Essix retainers

Acknowledgment The authors wish to express their gratitude to Nikita Sachdeva for her assistance in the preparation of this manuscript.

Total treatment time 13 months

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. Orthodontic Practice US. 2013;4(4):28-33. 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. 6. Sachdeva R, Kubota T, Hayashi K. BioDigital orthodontics. Management of Class 1 non–extraction patient with “Standard–Track”©– nine month protocol: Part 6. Orthodontic Practice US. 2013;4(6):16-26. 7. Sachdeva R, Kubota T, Hayashi K. BioDigital orthodontics. Management of space closure in Class I extraction patients with Suresmile: Part 7. Orthodontic Practice US. 2014;5(1):14-23. 8. Sachdeva R, Kubota T, Moravec S. BioDigital orthodontics. Part 1-Management of Class 2 non–extraction patients: Part 8. Orthodontic Practice US. 2014;5(2):11-16. 9. Sachdeva R, Kubota T, Hayashi K. BioDigital orthodontics. Part 2-Management of patient with Class 2 malocclusion non–extraction: Part 9. Orthodontic Practice US. 2014;5(3):29-41. 10. Sachdeva R, Kubota T, Hayashi K. BioDigital orthodontics. Part 3- Management of patients with Class 2 malocclusion extraction: Part 10. Orthodontic Practice US. 2014;5(4):27-36 11. Sachdeva R, Kubota T, Hayashi K. BioDigital orthodontics. Management of patients with class 3 malocclusion: Part 11. Orthodontic Practice US. 2014;5(5):28-38. 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. 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. 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. 16. Sachdeva RCL, Kubota T, Hayashi K, Uechi J, . BioDigital Orthodontics. Management of skeletal deformities with orthognathic Surgery-fusion model (part 1). Orthodontic Practice US. 2015;6(4):26-32. 17. Sachdeva RCL, Moravec S, Kubota T, Uechi J. BioDigital orthodontics. Management of skeletal deformities with orthognathic surgery — Direct (CBCT) (2): part 17. Orthodontic Practice US. 2015;6(5):28-35 18. Sachdeva RCL, Kubota T, Uechi J. Management of skeletal deformities with orthognathic surgery (OraScan) (3): part 18. Orthodontic Practice US. 2015;6(6):30-36.

22 Orthodontic practice

Volume 7 Number 1

BOOK REVIEW

The Biomechanical Foundation of Clinical Orthodontics by Charles J. Burstone, DDS, MS, and Kwangchul Choy, DDS, MS, PhD, Quintessence Books Hanover Park, Illinois, 580 pages

t is altogether appropriate that Dr. Charles Burstone’s valedictory publication should be on his orthodontic oeuvre — biomechanics. Drs. Burstone and Kwangchul Choy have combined their considerable knowledge and expertise with eight other internationally known and respected colleagues to produce the most extensive and instructive treatise on biomechanics ever completed in a single text. The quality of the book is what the profession has come to expect from the expertise and competence of Quintessence Books. The illustrations and photographs are copious and exemplary, printed on thick durable pages with ample references for each chapter and a glossary that will aid orthodontic novices. Dentists by training and patient expectation are therapists not diagnosticians, and consequently, they typically have more interest in applying the forces that produce tooth movements rather than understanding how these force systems work. The authors of this fine text acknowledge that few orthodontic textbooks now describe biomechanics in a clinically useful and comprehensive manner and intend for this tome to fill that void. With myriad additions to the orthodontic armamentarium in the 21st Century, it is essential that clinicians understand the force systems available, and how they can simulate the application of a chosen scheme prior to therapy rather than relying on clinical trial and observation, aka, therapeutic diagnosis. They understand that the typical orthodontic clinician has limited knowledge in mathematics and physics and have developed a simple but effective step-by-step

Volume 7 Number 1

Drs. Burstone and Kwangchul Choy have combined their considerable knowledge and expertise ... to produce the most extensive and instructive treatise on biomechanics ever completed in a single text. approach by which a reader can use the force diagrams and clinical photographs to clarify seemingly complicated ideas. At the end of each chapter, the authors have designed a series of problems that the reader is encouraged to solve. Answers to these problems lie in the Appendices. I cannot imagine a better method of helping people learn a subject so germane to the practice of orthodontics. The book has five sections, each of which harbors several chapters regarding specific topics: • The Basic and Single-Force Appliances • The Biomechanics of Tooth Movement • Advanced Appliance Therapy • Advanced Mechanics of Materials • Appendices

The authors cover the biomechanics of contemporary orthodontics in a comprehensive manner by addressing the force systems of temporary anchorage devices (TADs), aligners, orthognathic surgery, and of course, fixed appliances. This publication should easily become the go-to text on biomechanics for every orthodontic graduate program because it furnishes the foundation for mastery in the management of malocclusions. Of course, orthodontic clinicians can solve some malocclusions with only scant knowledge of biomechanics, but they should never delude themselves into thinking they understand the mechanisms by which teeth move. This book, above all others, will end any such misconception. OP Review by Larry White, DDS, MSD

Orthodontic practice 23

CONTINUING EDUCATION

Using V-bends on NiTi wires for nonsurgical correction of Class III malocclusions Dr. Suhail A. Khouri discusses a method of delivering light and consistent forces over a long range of effective intrusive tooth movement Abstract Orthodontic correction of Class III malocclusions in growing adolescent and adult patients has long challenged orthodontists due to the extreme difficulty in disengaging the locked-out maxillary teeth without surgery. Currently available treatment modalities include various functional appliances, maxillary protraction and cervical headgears, and reversed twin blocks1,2 for growing prepubertal patients. Although these approaches are successful for this group of patients, nevertheless, such clinical triumphs depend totally on patient compliance, and they have high genetically determined potential for relapse. That is why establishing normal overjet in Class III patients is often onerous with orthodontic therapy alone. On the other hand, orthognathic surgical treatment offers dental, skeletal, and esthetic improvement in deep bite skeletal Class III patients; however, the trauma, high cost, and possibility of growth-related relapse of this approach discourages many patients and their parents from accepting it. The advent of superelastic wires and the ability of Bendistal Pliers (DynaFlex®) to activate them with permanent V-bends, enhanced by the composite build-ups' bite raisers, evolves into a new treatment protocol that shows efficiency and effectiveness in incisor intrusion and the correction of deep overbite patients.3 Utilizing the same concept to intrude and disengage the locked-out maxillary incisor teeth in Class III patients demonstrated efficiency in the retraction of mandibular incisors into available or created spaces and correction of this malocclusion. This article introduces this methodical treatment approach aimed at simply correcting Class III malocclusions without patients’ cooperation or orthognathic surgery and presents patients who Suhail A. Khouri, DDS, is an orthodontist in private practice in Ballwin, Missouri. Disclosure: Dr. Khouri is the inventor of Bendistal Pliers.

24 Orthodontic practice

Educational aims and objectives

This article aims to introduce a methodical treatment approach aimed at simply correcting Class III malocclusions without patients’ cooperation or orthognathic surgery.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 29 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Recognize the basic concepts behind this technique. • Identify some of the biomechanics of the intrusive V-bends. • Realize the reasons behind the various stages of the technique. • Realize when this technique should be used or when other treatment options should be implemented.

Figures 1A-1B: 1A. A set of Bendistal Pliers used in placing the intrusive V-bends intraorally and extraorally, showing printed abbreviations of the mouth quadrants each pair serves. 1B. The intrusive sharp and permanent V-bends that can be placed behind canine areas in maxillary and mandibular superelastic archwires

This article introduces this methodical treatment approach aimed at simply correcting Class III malocclusions without patients’ cooperation or orthognathic surgery ... have been successfully treated with this V-bend technique.

Concept of the technique The primary objective in correcting Class III malocclusions is restoring the anterior overjet. Since there was no effective standard clinical method to free the locked-out maxillary teeth, orthognathic surgery became the clinician’s only choice to elicit the jump in adult patients. Once this difficult task had occurred, orthodontists could routinely perform all remaining tooth movements.

This technique aims primarily at disengaging maxillary and mandibular incisors nonsurgically by intruding them, with the help of bite-raising composite build-ups. Following bonding of both arches and initial alignment, intrusion of maxillary and mandibular incisors is started by placing sharp and permanent V-bends on the superelastic archwires with the Bendistal Pliers (Figure 1). These V-bends3,4 on round and rectangular superelastic archwires have demonstrated effectiveness in activating them to deliver light and consistent intrusive forces over a long range of activation, Volume 7 Number 1

Figures 2A-2C: 2A. Bonded mandibular teeth in the alignment stage with blocked-out maxillary incisors. 2B. Initial aligning 0.016" round NiTi wires with intrusive V-bends. Note the amount of incisor intrusion evident in the distance between mandibular incisor edges and maxillary incisor brackets. 2C. A lateral intraoral view showing the extent of intrusion achieved by the V-bends for the maxillary and mandibular anterior teeth disengagement. It shows the ongoing mandibular incisor retraction into the first premolars’ extraction spaces

Technique description 1. Alignment stage Since the mandibular incisors typically block out the maxillary incisors, mandibular teeth are bonded first, and a 0.016" round NiTi archwire is placed for initial alignment (Figure 2A). If there is an adequate underjet space or bite-free areas on labial surfaces of the maxillary incisors, clinicians can bond the maxillary teeth and start intrusion mechanics in both arches simultaneously. Bite-opening composite build-ups on mandibular posterior teeth will open the occlusion enough and allow maxillary teeth bonding and enhance incisor disengagement to shorten treatment time (Figures 2B and 2C). To intrude the incisors, place the V-bends behind canine areas in both archwires with the tips of V-bends always directed occlusally on the NiTi archwires. The V points down in the maxillary archwire and points up in the mandibular archwire. If more intrusion is required, in deep-bite Class III malocclusions, the initial archwires should graduate to 0.016" x 0.022" NiTi archwires to increase the light intrusive force level. Further bite opening, if needed in the case of severe deep bite of an individual tooth, may be achieved by tucking the elastic wire underneath the maxillary incisor bracket tie wings and on top of the mandibular incisor bracket tie wings (Figure 4A). Once intrusion and composite build-ups disengage incisors, as seen in Figure 2C, the clinician can retract mandibular incisors. Biomechanics of the intrusive V-bends: To obtain maximal central and lateral incisor intrusion, V-bends work most efficiently when located behind the canines. V-bends deliver an apically directed intrusive force at the bracket sites of the farthest teeth from the V-bends — namely, the central incisors and the terminal molars. These forces act at the bracket site buccal to the center of resistance and cause rotation of Volume 7 Number 1

Figures 3A-3B: 3A. Diagram showing analysis of the force system created by V-bends located between canine and first premolar teeth. Note the long range of NiTi archwires’ activation of the V-bend before tying it in anterior teeth brackets. To bring the system into equilibrium, the anterior apically directed intrusive force on the incisors results in a moment M1, which must equal the intrusive force-creating moment acting on the terminal molar M2. 3B. Shows the effects of the force system, i.e., incisor and molar intrusions and extrusive forces acting on canine and first premolar located adjacent to the V-bend

Figures 4A-4C: 4A. Shows locations and orientation of V-bends on maxillary and mandibular aligning archwires. To maximize intrusion, wires are placed occlusally to the anterior bracket tie wings of the mandibular incisors. 4B. Demonstrates incisors’ disengagement that allows mandibular incisors’ space closure and retraction with a power chain. Also note the extent of bite opening achieved by the V-bends without bite raisers. 4C. Shows ideal overjet and overbite with rectangular stainless steel archwires

the incisors in line with their long axis, while simultaneously intruding them. This creates a clockwise moment (M1) that intrudes the incisors anterior to the V-bend and an equal and opposite anticlockwise moment (M2), that intrudes the terminal molar posterior to the V-bend. As the force system of the V-bend establishes equilibrium, the incisors and molars will intrude, while the canines and first premolars extrude. The collective effects of this force system results in efficient bite opening8 (Figure 3). 2. Intrusion and disengagement stage Anterior teeth intrusion and disengagement is the primary objective of this technique. This crucial stage of treatment begins immediately after mandibular arch alignment by placing intrusive V-bends behind the mandibular canines on the aligning .016" NiTi archwire to start mandibular incisor intrusion. Once mandibular incisors intrude halfway and expose part of the labial

surfaces of the maxillary incisor crowns, they can be bonded, the aligning archwire is tied in, and similar V-bends can be placed on it (Figures 2A-2B). Clinicians can combine the intrusion mechanics on both archwires with composite build-ups9-11 on mandibular molars to speed up anterior disengagement and start mandibular incisor retraction. Later on, clinician can graduate archwires to intrusive .016" x .022" NiTi to increase force level and accelerate treatment (Figure 2C). 3. Mandibular incisors retraction stage Clinicians should decide during treatment planning how to provide spaces for mandibular incisor retraction. Several options exist for creating mandibular dental spaces — i.e., using residual spaces if any, and creating spaces with interproximal enamel reduction and/or mandibular first premolar extraction. Retraction starts as soon as full disengagement occurs by using a power chain with the mandibular V-bends in place. The V-bends' Orthodontic practice 25

CONTINUING EDUCATION

which intrudes anterior segments and efficaciously opens deep overbites.3-5 Applying the intrusion mechanics of the V-bends6-8 on superelastic wires to correct most Class III malocclusions has unlocked and disengaged maxillary incisors and allowed the retraction of mandibular incisors, thus restoring the normal overjet. Although this technique functions well in dental and moderate skeletal Class III malocclusions, complicated cases with skeletal bilateral crossbites and/or skeletal open bites, and excessive mandibular growth tendency will eventually need orthognathic surgery.

CONTINUING EDUCATION intrusive force acting on mandibular incisors should continue during their retraction, not only to maintain incisor disengagement, but also more importantly, to provide the moment necessary to translate them and prevent their uncontrolled tipping, according to Burstoneâ&#x20AC;&#x2122;s segmented arch technique. Once mandibular incisor retraction into the created spaces is completed, and a positive overjet occurs, the intrusion process is discontinued and followed by placing the same size rectangular archwires without V-bends in both arches. 4. Incisors bite jump and finishing stage Once the mandibular spaces close and proper overjet occurs, the finishing stage can commence. The incisal jump achieves a customary overjet following completion of the retraction of the incisors into the created spaces. Clinicians can start the detailed finishing stage by establishing normal overbite, overjet, and closure of the posterior open bite affected by the V-bends' intrusion mechanics. Posterior bite-closing intermaxillary elastics are used to achieve proper teeth intercuspation. Rectangular 0.016" x 0.022" NiTi followed by stainless steel archwires without bends are used as the finishing wires to correct the final root positions (Figure 4C). Any other detailed tooth movements to achieve standard molar/cuspid relations and overbite/overjet may be carried out in a routine manner.

Patient 1

Patient 1: Top row: Pretreatment models of a 15-year-old female patient with a molar and cuspid relations Class III malocclusion complicated by bilateral crossbites. Note existing interdental spaces existed in the mandibular canine areas that provided space for incisor retraction without premolar extraction. Middle row: Shows mandibular teeth bonded with 0.016" NiTi wire and intrusive V-bends. The mandibular incisors intruded enough to bond the maxillary teeth without a bite-raising plate. Later, simultaneous intrusive V-bends were placed on both arches with 016" x .022" NiTi archwires, which disengaged the anterior teeth while the mandibular incisors were retracted with an elastic chain. It is crucial to continue the V-bends in the mandibular archwire during anterior retraction to avoid mandibular incisorsâ&#x20AC;&#x2122; root dehiscence. Also note the transverse-oriented V-bend in the maxillary midline that expanded maxillary molars and corrected the posterior crossbites. Bottom row: Post non-extraction treatment intraoral photographs showing a normal overbite, overjet, and Class I molar/cuspid relations with a correction of the bilateral posterior crossbites

Patient 2 Patient 2: Top row: Pretreatment models of a 14-year-old female patient with a Class III malocclusion complicated with a right side posterior crossbite. Middle row: shows the alignment and intrusion stages with maxillary and mandibular V-bends (right) that accomplished incisor disengagement and the beginning of mandibular incisors' retraction (middle). Mandibular and maxillary 0.016" x 0.022" NiTi archwires restore proper overjet and overbite (left) just before repositioning maxillary incisors' brackets for the finishing stage. Bottom row: Shows posttreatment photos with normal overbite and overjet, Class I molar/cuspid relations, and corrected crossbite. The panoramic radiograph before debanding shows no root resorption from using this V-bend technique

26 Orthodontic practice

Volume 7 Number 1

Patient 3: Top row: Pretreatment intraoral photographs of a 14-year-old male patient with an interlocking incisal Class III malocclusion and Class I molars. Middle row: 0.016" NiTi aligning maxillary archwires with V-bends between maxillary incisors. Also, 0.016" x 0.022" NiTi archwires with V-bends, tucked occlusally to affected maxillary and mandibular incisor bracketsâ&#x20AC;&#x2122; tie wings to maximize incisors intrusion, disengagement, and subsequent retraction. Note opening spring on the maxillary wire to open space for an unerupted maxillary right canine. Also note restoration of normal overbite and overjet relations. Bottom row: Final intraoral nonextraction treatment photographs with normal overbite, overjet, and Class I molar/cuspid relations. Note the improved gingival level of the previously traumatized mandibular incisors. The panoramic radiograph shows no sign of root resorption from this technique

Patient 4 Patient 4: Top row: Pretreatment photos of a 14-year-old female patient with a severe deep-bite Class III malocclusion. Second row: Shows bite-raising composite build-ups on the mandibular molars that enabled simultaneous bonding of the maxillary teeth. The lateral views illustrate 0.016" x 0.022" NiTi archwires with intrusive V-bends. Third row: Wide step-up bends on maxillary NiTi wire that enhanced the maxillary incisorsâ&#x20AC;&#x2122; intrusion and disengagement, which enabled mandibular incisor retraction with V-bends and power chains. The mandibular spaces were created by interproximal enamel reduction. Note the finishing stage with posterior bite closing and anterior side-to-side crossbite-correcting elastics. Bottom row: Final intraoral photos of the patient whose continual mandibular growth lengthened the treatment to 3 years

Volume 7 Number 1

Orthodontic practice 27

CONTINUING EDUCATION

Patient 3

CONTINUING EDUCATION Patient 5

Patient 5: Top row: Intraoral photos of a 15-year-old female patient with a Class III malocclusion and a right-side posterior crossbite. Middle row: Maxillary and mandibular .016" x .022" NiTi archwires with intrusive V-bends after incisor disengagement without bite raisers and a mandibular power chain that retracted mandibular incisors into the mandibular first premolarsâ&#x20AC;&#x2122; extraction spaces. Note that mandibular intrusive V-bends should remain during incisor retraction to prevent their root dehiscence. The maxillary and mandibular molar intrusion effected by V-bends unlocked their cusps and facilitated correction of the right-side posterior crossbite without palatal expander. Bottom row: Posttreatment intraoral photos with normal overbite and overjet and crossbite correction. This Illustrates that this V-bend technique, and the mandibular premolars' extraction allowed the patient to avoid orthognathic surgery

Discussion Placing sharp and permanent V-bends on superelastic wires to activate them and deliver light and consistent forces over a long range of effective intrusive tooth movement comprises the essence of this technique. These bends are not to be placed on superelastic wires without the unique bending ability of Bendistal Pliers. Although V-bend mechanics, elastic properties of NiTi wires, and the bite-raising composite may not be new to orthodontists, orchestrating and employing these elements to correct such difficult orthodontic problems are a new approach. Combining such elements has evolved into developing this therapeutic method as a new simple and clinically applicable technique. It proved its efficiency in nonsurgical correction of Class III malocclusions, and I have used it throughout my entire 35-years of orthodontic practice. The bite-raising composite build-ups were used to enhance anterior teeth disclusion in deep bite cases to shorten treatment time. The patients presented have varying degrees of difficult Class III malocclusions that were successfully treated by this alternative therapy without using any removable functional appliances, headgear, or surgery. This patient therapy illustrated the possibility of using anterior intrusions alone, or combined with the bite raiser composite-build-ups, to 28 Orthodontic practice

Patient 6

Patient 6: Top row: Intraoral photos of a 6 ft. 5" tall, 12-year-old female (one of twins), with a severe dental and skeletal Class III malocclusion complicated by bilateral posterior skeletal crossbite and maxillary deficiency. Parents declined a surgical option and requested only orthodontic treatment, with mandibular first premolar extractions. Middle row: Composite build-ups on the mandibular molars allowed simultaneous bonding of maxillary and mandibular dental arches. After alignment, maxillary and mandibular .016" x .022" NiTi archwires with intrusive V-bends were placed, and mandibular incisors were retracted into the extraction spaces while incisors were disengaged. Mandibular incisor retraction and space closure continued until the overjet was corrected. Expanding maxillary and constricting mandibular rectangular NiTi archwires and subsequent stainless steel rectangular archwires with the composite build-ups were in place to unlock molar cusp interference and facilitated posterior crossbite correction. Treatment time was 3 years. The finishing stage used Class III and posterior bite-closing elastics to consolidate the occlusion. Bottom row: Posttreatment intraoral photos achieved, despite pubertal mandibular growth of this patient that complicated the corrective measures and lengthened the treatment time

simplify and shorten treatment time necessary for disengaging the blocked out anterior teeth, leading to Class III non-surgical complete correction. Patients with severe Class III malocclusion and skeletal deformities may require orthognathic surgery; patients and parents should be informed that orthodontic treatment alone could not achieve the needed therapy. To avoid surgery for moderate Class III malocclusions, patients

should be informed that mandibular first premolar extractions might be needed to provide spaces into which mandibular incisors will be retracted. They should also know that esthetic improvement in facial soft tissue might not match the improvement that orthognathic surgery often gives. OP

Acknowledgment With great appreciation, the author thanks Dr. Larry White for his outstanding help in editing this article.

REFERENCES 1. Westwood PV, McNamara JA Jr., Baccetti T, Franchi L, Sarver DM. Long-term effects of Class III treatment with rapid maxillary expansion and facemask therapy followed by fixed appliances. Am J Orthod Dentofacial Orthop. 2003;123(3):306-320. 2. Shastri D, Nagar A, Tandon P. Treatment of pseudo-Class III malocclusion with a modified reverse twin block and fixed appliances. J Clin Orthod. 2015;49(7):470-476. 3. Khouri SA. Correcting deep bites with V-bends and superelastic wires. World J. Orthod. 2006;7(2):213-217. 4. Khouri SA. The bendistal pliers: a solution for distal end bending of superelastic wires. Am J Orthod Dentofacial Orthop. 1998;114(6):675-676. 5. Khouri SA. Using the bendistal pliers for the correction of common orthodontic problems. World J. Orthod. 2002;3(2):172-174. 6. Tran PH. The three-tooth problem: a facial plane force system delivered by a gabled archwire segment. [Masterâ&#x20AC;&#x2122;s thesis] St. Louis, Mo.: Saint Louis University; 2004. 7. Lopez I, Goldberg J, Burstone CJ. Bending characteristics of nitinol wire. Am J Orthod. 1979;75(5):569-575. 8. Burstone CR. Deep overbite correction by intrusion. Am J. Orthod. 1977;72(1):1-22. 9. Nanda R. Correction of deep overbite in adults. Dent Clin North Am. 1997;41(1): 67-87. 10. Tzatzakis V. A new clinical approach for the treatment of anterior crossbites. World J of Orthod. 2008;9(4):355-365. 11. Tzatzakis, V, Gidarakou I. Correcting of anterior crossbite using occlusal build-ups. J Clin Orthod. 2007;4(7):393-397.

Volume 7 Number 1

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

REF: OP V7.1 KHOURI

CONTINUING EDUCATION BROUGHT TO YOU BY

FULL NAME

Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 24 CE credits for only $129. To receive credit, complete the 10-question test by circling the correct answer, then either: n Post the completed questionnaire to: Orthodontic Practice US CE 15720 N. Greenway-Hayden Loop. #9 Scottsdale, AZ 85260 n Fax to (480) 629-4002.

AGD REGISTRATION NUMBER

LICENSE NUMBER

ADDRESS

CITY, STATE, AND ZIP CODE

To provide feedback on this article and CE, please email us at education@medmarkaz.com Legal disclaimer: The CE provider uses reasonable care in selecting and providing accurate content. The CE provider, however, does not independently verify the content or materials. Any opinions expressed in the materials are those of the author and not the CE provider. The instructional materials are intended to supplement, but are not a substitute for, the knowledge, skills, expertise and judgement of a trained healthcare professional.

TELEPHONE/FAX

Please allow 28 days for the issue of the certificates to be posted.

Using V-bends on NiTi wires for nonsurgical correction of Class III malocclusions KHOURI

1. Orthognathic surgical treatment offers dental, skeletal, and esthetic improvement in deep bite skeletal Class III patients; however, the _______ of this approach discourages many patients and their parents from accepting it. a. trauma b. high cost c. possibility of growth-related relapse d. all of the above 2. The primary objective in correcting Class III malocclusions is _________. a. restoring the anterior overjet b. engaging mandibular incisors c. activating intrusive forces over a short range d. preparing the patient for surgical intervention 3.

Since there was no effective standard clinical method to free the locked-out maxillary teeth, _______ became the clinicianâ&#x20AC;&#x2122;s only choice to elicit the jump in adult patients. a. using bite raisers b. orthognathic surgery c. bonding teeth in the alignment stage d. using graduated archwires

4. Following bonding of both arches and initial alignment, intrusion of maxillary and mandibular incisors is started by placing _______ on the superelastic archwires with the Bendistal Pliers.

Volume 7 Number 1

a. non-intrusive V-bends b. sharp and permanent V-bends c. temporary V-bends d. brackets

b. 0.016" c. 0.022" d. 0.025" 8.

5. These V-bends on round and rectangular superelastic archwires have demonstrated effectiveness in activating them to deliver ______ over a long range of activation, which intrudes anterior segments and efficaciously opens deep overbites. a. heavy forces b. light forces c. consistent intrusive forces d. both b and c 6. Although this technique functions well in dental and moderate skeletal Class III malocclusions, complicated cases with __________ will eventually need orthognathic surgery. a. skeletal bilateral crossbites b. skeletal open bites c. excessive mandibular growth tendency d. all of the above 7. Since the mandibular incisors typically block out the maxillary incisors, mandibular teeth are bonded first, and a _____ round NiTi archwire is placed for initial alignment (Figure 2A). a. 0.014"

To obtain maximal central and lateral incisor intrusion, V-bends work most efficiently when located _____ the canines. a. in front of b. beside c. behind d. around

9. Once mandibular incisor retraction into the created spaces is completed, and a positive overjet occurs, the intrusion process is ____________ placing the same size rectangular archwires without V-bends in both arches. a. discontinued and followed by b. followed by c. continued, followed by d. re-created by 10. These bends are not to be placed on superelastic wires without the unique bending ability of __________. a. Weingart pliers b. Reynolds pliers c. Bendistal Pliers d. Force module separating pliers

Orthodontic practice 29

CE CREDITS

ORTHODONTIC PRACTICE CE

CONTINUING EDUCATION

Current concepts in data capture for sequential aligner therapy Dr. David Penn examines the accuracy and precision of the traditional versus digital impression techniques Abstract As the demand and sophistication for sequential aligner therapy continues to grow, orthodontists are treating patients, (especially esthetically biased cases) with an expectation of the shortest possible treatment period. This paper examines the accuracy and precision of the traditional versus digital impression techniques for full-arch capture and presents an improved technique using the conventional methodology. The conclusion, which needs further investigation, is that more accurate initial data will produce more intimate fitting aligners, greater accuracy of force propagation, and hence more predictable outcomes.

Clear aligner therapy Clear aligner therapy is an orthodontic treatment in which the patient wears a series of clear, removable aligners that gradually move the teeth to improve the occlusion, function, and/or esthetic appearance. Much of its success depends upon the understanding, cooperation, and compliance of the patient. The idea of an invisible appliance was first introduced by Kesling in 1945.1 As an alternative to the bracket system, the invisible method of orthodontic tooth movement was introduced commercially in 1999 by Align Technology with the trade name of Invisalign®. This invisible appliance uses the principles of Kesling setup through virtual digital models and computer-aided design and manufacturing process (CAD-CAM). Since Invisalign was first introduced, Align Technology has widened its range of products to now include treatment of minor tooth movements, esthetically biased cases, and comprehensive orthodontics involving 3D tooth movement. Subsequently, a plethora of competing clear aligner manufacturers have come to Dr. David Penn is Head of the School of Aesthetic Orthodontics, Postgraduate School of Dentistry in Sydney, Australia.

30 Orthodontic practice

Educational aims and objectives

This article aims to establish a thorough understanding of the recent advancements in data capture for sequential aligner therapy and its impact upon tooth movement predictability.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 35 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Recognize the burgeoning demand for sequential aligner therapy, particularly esthetically biased adult orthodontics. • Recognize recent advancements in data capture concepts and techniques. • Identify ways of optimizing fit, movement, and speed with aligner de-slippage devices.

the market invoking different manufacturing processes, aligner materials, clinical protocols, and treatment plans. The introduction of clear aligner therapy was treated with significant skepticism by orthodontists in its early days. The predictability of individual tooth movement varied significantly, and the degree of complexity of suitable cases was somewhat limited. Within the last decade in particular, considerable investment in the research and development has taken place in almost every aspect of clear aligner therapy. Demand continues to grow significantly, with Align Technology alone claiming to have treated more than 3.4 million cases since its inception and more than a 23% increase in cases for the same quarter (119.6K cases versus 147.5K cases in Q3 of 2015).2 While logic would suggest that the more precise the capturing of the original tooth morphology, then the more intimate will be the fit of the aligners and the force application more accurate, is this necessarily true? Given that there are both variations and limitations to the manufacturing process (vacuum formed and pressure formed), the materials employed, and the fact that the aligners are not permanently affixed to the tooth surface, we need to ensure that the data that we record initially gives us every possible advantage in order to apply forces as efficaciously as practicable. Given that the environment is wet, the teeth are generally smooth, and the aligners are shaped so that removal is possible and, indeed, relatively easy, we have many factors to overcome.

As a new aligner is placed in situ, a force or multiple force systems are applied to one or more teeth. Given that the three fundamentals required for tooth movement are in place — force, space, and time — then the movement should occur. Assuming that the patient is compliant and the “time” element is assured, the key issue then becomes the accurate application of these “force” systems.

Effective data capture concepts Two methods of capturing initial data for sequential aligner therapy remain popular: the use of conventional impression materials and, more recently, the use of intraoral scanners. Both options are highly material/ device- and technique-employed sensitive, and a broad range of clinical outcomes are produced that impact on aligner fit. However, the concept of digital impressioning being more accurate, faster, and more cost-effective than conventional PVSE/ PVS impressions remains controversial, especially in full-arch capture for sequential aligner therapy. Since first being introduced in the 1990s, the expectation that every practice would be exclusively digital within 5-10 years has not eventuated.3 With the increase in the use of CAD/CAM, not only in restorative dentistry but also in surgery, orthodontics, diagnostics, and treatment planning, digital impressioning must meet a high level of accuracy if it is to be accepted as a viable alternative. Ender and colleagues compared the precision of conventional and digital methods Volume 7 Number 1

Volume 7 Number 1

Table 1: Precision of conventional and digital impression (µm) Characteristic

Mean (SD)

Median

95% Confidence Minimum Interval

Maximum

Vinylsiloxanether (VSE)

17.7(5.1)

17.5

14.6, 20.2

10.0

28.0

Direct scannable vinylsiloxanether (VSES)

18.3(8.8)

18.0

16.1, 20.5

19.0

23.0

Digitized scannable vinylsiloxanether (VSES-D)

36.7(3.8)

35.5

34.0, 39.4

32.0

42.5

Polyether (POE)

34.9(8.8)

35.0

29.6, 40.2

19.0

54.0

Irreversible hydrocolloid (ALG)

162.2(71.3)

146.5

122.7, 201.7

84.0

337.1

CEREC Bluecam (CER)

56.4(15.4)

53.5

47.9,64.9

35.7

86.4

CEREC Omnicam (OC)

48.6(11.6)

45.5

42.2,55.0

34.3

72.0

Lava COS (LAV)

82.8(39.3)

76.5

61.0,104.6

37.0

170.5

Lava True Definition Scanner (T-Def)

59.7(29.4)

52.4

43.4,76.0

24.9

120.1

Cadent iTero (ITE)

68.1(18.9)

65.9

57.6,78.6

39.2

103.9

3Shape TRIOS® (TRI)

47.5(21.4)

41.9

35.7,59.4

25.5

89.3

3Shape TRIOS® Color (TRC)

42.9(20.4)

41.1

31.6,54.2

25.2

105.7

Figure 1: Difference pattern between repeated impression (precision); color graded from -100 μm (purple) to +100 μm (red). A. VSE. B. VSES. C. VSES-D. D. POE. E. ALG. F. CER. G. OC. H. LAV. I. T-Def. J. ITE. K. TRI. L. TRC Orthodontic practice 31

CONTINUING EDUCATION

for complete arch impressions.4 The purpose of this study was to assess the accuracy of both techniques in vivo. In order to supersede the capabilities of conventional impressions, digital impressions must perform at least at the same level of quality and accuracy as current conventional techniques. On the basis of the results of the in vivo study listed earlier, the null hypothesis that conventional and digital impression systems are equally accurate must be rejected. This study revealed significant differences in precision according to the method used to obtain the complete-arch impression.4 Large differences were visible in the conventional impression materials and in the digital impression techniques. Conventional impressions using vinylsiloxanether material showed the highest precision, while those using the irreversible hydrocolloid showed the lowest precision (as shown in Table 1).4 The digital intraoral impression systems resided in between these extremes; the digital systems were significantly less precise than the highly precise conventional impression materials.4 The precision achieved across the complete arch scans did not differ significantly among the various digital impression systems. All of the digital systems showed a larger standard deviation compared with the highprecision conventional impression materials. The anterior region has little geometric information and was particularly difficult to scan with the digital intraoral cameras (Figure 1).4 Significantly, in relation to clear aligner therapy and where forces need to be applied most accurately, error propagation in this region leads to increased deformation toward the distal end of the dental arch. Figure 1 shows the typical deviation pattern between repeated complete-arch scans within the test groups. The conventional impressions in the VSE and VSES groups showed minimal deviation (≤40 μm) across the incisal edges of the anterior teeth and at the buccal surface of the premolars, which has critical clinical manifestations given that is where attachments are placed and that much of the specific force application and tooth movement is expected to occur.4 In general, the digital impression systems with high frame rates (video-based systems and the OC, LAV, T-Def, TRI, and TRC groups) began to deform distal to the anterior region of the dental arch. Single images based on the digital impression system (CER, ITE) primarily showed local deviation with increasing deformation toward the distal end

CONTINUING EDUCATION of the cast. In contrast, while the conventional impressions showed local deviation, the deviation did not increase in magnitude toward the distal arch.4 What are the clinical implications of a 25 to 40 micron difference in accuracy between a precision conventional impression and a quality digital scan? Given that sequential aligners generally program movements of between 125 to 250 microns per aligner over each 2-week period, this differential may have significant clinical impact. Further research needs to be conducted in this area. Additionally, concerns over larger distortion in particular segments of the arch need to be investigated closely. While the use of PVSE and PVS impressions are still fraught with the drawbacks of drags, tears, voids, tray-to-tooth contact, temperature sensitivity, limited working time, and material shrinkage, this technique should not be readily discarded lightly from orthodontic practice.5 The principal advantage of digital impressions would be that they are less stressful and uncomfortable for many patients, and additionally, there is no need to select a tray, apply tray adhesive, clean impression trays, assemble impression guns and tips, or disinfect impressions. Digital impressions with a deficient area can also be rescanned rather than retaking the entire impression. For the orthodontist, the obvious advantages of digital scanning include accelerated diagnosis and treatment planning, rapid submission to aligner manufacturers, minimal retakes, and a reduced impression material inventory expenditure and storage. Open and trusted connections with orthodontic laboratories, merging of CBCT and DICOM files, increasing file transfer among manufacturers, and in-practice 3D printing will open a myriad of possibilities for this technology, but only when a consistent degree of uniform accuracy can be demonstrated. However, given that their remains doubt that digital impressioning may be more accurate, faster, and more economical, do the supposed benefits justify the large initial capital investment that needs to be made? Although most manufacturers claim that the scanning procedure requires roughly the same amount of time as traditional impression materialsâ&#x20AC;&#x2122; setting time, the experience of the scanner operator, technique employed, and the scanning technology employed by each machine impinge significantly on the efficiency and accuracy of the process.6 Not all orthodontic staff are trained with all scanners, and the learning curve to master 32 Orthodontic practice

Considerable investment in the research and development has taken place in almost every aspect of clear aligner therapy the use of new technology can be lengthy and expensive. Alternatively, proficiency with traditional impression techniques is common to all orthodontic staff, and the process is generally highly predictable. Many orthodontists still struggle to decide whether intraoral scanning technology is actually worth the investment. Although digital scanners currently range from around $10,000 to the mid-$30,000 range, this cost may be recovered in reduced overheads and increased practice efficiency if the machine is used regularly and staff turnover is minimal (especially if the practice is prescribing a large volume of clear aligner cases).

Optimizing traditional impression techniques The process of taking impressions is simply to transfer 3D physical data from the patientâ&#x20AC;&#x2122;s mouth as accurately and comfortably as possible. In theory, the greater the transfer accuracy, the more intimate the aligners will fit, thus increasing the chance of tooth movement being expressed completely and heightening the predictability of the treatment plan. Traditional impression materials are used with a wide range of clinical techniques for accurate capture of the critical elements for successful clear aligner therapy. Hence they all require excellent material property predictability and can cope with a broad spectrum of clinical applications. Most practitioners do not have the time to address the science and technology that goes into the development of a clinically successful impression material and the behind-the-scenes work that facilitates and optimizes chairside procedures. The ideal impression material reflects all the hard- and soft-tissue details, including their static relationship in the mouth. This data is transferred during the relatively short working time (30 to 90 seconds) and fixed (polymerized) into the impression material memory during the setting time (60 to 240 seconds). The shape of the impression is unalterable after this: impressions should work perfectly the first time, every time. Given the degree of discomfort and the time-consuming and expensive nature of capturing dual full arches for clear aligner

treatments, the importance of utilizing the most efficacious materials and technique is paramount.7 The 2013 study by Dugal and colleagues demonstrated that the two-step light body/ putty technique with a 1.0 mm spacer (for light body capture of critical data) delivered the most accurate results with polyvinyl siloxane impression materials.8 This technique has been designed and taught by the School of Aesthetic Orthodontics, Postgraduate School of Dentistry (Sydney, Australia) (Figure 2). This technique relies on the following material properties and clinical protocols: 1. The putty material should be softer and exhibit flow characteristics that allow for capture of the sulcular regions 4 mm-5 mm beyond the margins of the teeth (low viscosity). 2. The correctly selected impression tray (adequate width and length, no contact with tooth structure, and with sufficient retentive elements to ensure delamination or debonding will not occur) should be firmly seated, with adequate putty in situ, especially in the posterior segments, briefly muscle trimmed, and removed after 45 seconds. Flow into sulcular areas is mandatory. 3. The occlusal anatomy captured should be partially obliterated using a mirror handle or light finger pressure, with great care taken not to distort the periphery. The aim is to create an even distribution for 1.0 mm of light body material and for it all to be supported by the correctly extended putty (Figure 3). 4. Additional putty can be added in areas of under-extension, and overextended areas can be trimmed with a scalpel or scissors. 5. The putty is left to cure completely, and then the copious addition of light body occurs, ensuring that the mixing tip is completely embedded in the light body at all times to ensure no introduction of air bubbles (Figure 4). 6. The loaded tray is seated completely, anchored with one hand, and muscle trimming is performed, Volume 7 Number 1

Enhancing the delivery of forces from the aligners

Figure 3: Putty base with good extension into sulcus and occlusal anatomy obliterated

If the most accurate data can be recorded, and the aligner manufacturer can supply devices with optimal physical characteristics to deliver these forces, it would be essential then that the aligners are correctly anchored and placed, especially immediately after removal and replacement. Devices to aid in the seating of aligners have been employed since aligner therapy

commenced. The aim is to promote a more intimate fit of the aligner against the tooth. Aligner “Chewies™” from DENTSPLY Raintree Essix are a rubber material that were introduced to help close any spaces between the teeth and aligners. As expected, the insertion of a new aligner should have a small allowance for programmed tooth movement, and the concept of the device was to minimize the space by forcing the aligner to interact with the tooth surface more effectively. The primary drawback from this design is that it acts upon only one point of the incisal edge of the anterior teeth, which can aid in seating, but also causes distortion of this area of the aligner with repeated use.9 Munchies® are an anatomically enhanced orthodontic enhancement device designed to accelerate aligner therapy by maximizing the accuracy of fit of each aligner. Using a series of differing Shore Hardness medicalgrade silicones and capturing up to 30% of the clinical crown, these visco-elastic devices deform momentarily to grab the aligner and aid in complete seating.10 The patient engages his/her upper or lower anterior teeth into anatomically designed grooves on each Munchies device and applies apical pressure from the opposing arch (Figures 6 and 7). The device deforms as pressure is increased to encase the aligner and drive it into the most intimate fit. In a pilot study by Sharp A and Dove E in 2015, 100% of patients reported significantly improved seating of their aligners when Munchies were used immediately after reinsertion.11 In addition, 70% of patients

Figure 4: PVS light body material (SAM, EOCA USA) being carefully loaded into putty base to ensure no introduction of bubbles

Figure 5: One-stage impression technique yields poor accuracy as light body (yellow) has been forced into peripheral areas by the putty material Volume 7 Number 1

Figure 6: Cross-sectional representation of anatomically shaped visco-elastic acceleration and seating device (Munchies) capturing a significant section of the aligner and returning forces Orthodontic practice 33

CONTINUING EDUCATION

Figure 2: All aspects of a quality impression are represented here. Capture of all critical data in light body, no tears or drags, and adequate extension

driving the light body toward the gingival margins to minimize voids. 7. Upon setting, the tray is removed rapidly. Slow, teasing removal increases the likelihood of tearing, especially in black triangular embrasures in the lower anterior segments. 8. The impression is inspected carefully, particularly on the axial walls where attachments may be placed. A minimum of 2 mm gingiva should be captured and as much data recorded in light body as possible. 9. The one-stage technique is not suitable for full-arch orthodontic recordings as the hydraulic forces created by the simultaneous loading of putty and light body drives the light body away from the critical areas to be captured. Typically, when this technique is employed, the operator will see the sulcular areas captured in light body and too much critical data recorded in the less accurate putty base. (Figure 5)

CONTINUING EDUCATION

Figure 7: Munchies device being positioned, seated, and deforming to engage the aligner to optimize intimacy of fit

also reported pain relief during all stages of orthodontic treatment by inducing the “bite wafer” effect.12

Conclusion The demand for sequential aligner therapy continues to grow. In order to achieve optimal outcomes and shortest treatment times, the accurate recording of initial data is paramount. This paper examined the variable nature of the results from traditional and digital impression techniques. Traditional impression techniques, employing superior materials and approved protocols produce the most accurate initial data. OP

34 Orthodontic practice

REFERENCES 1. Phulari BS. History of Invisalign. In: History of Orthodontics. New Delhi, India: JayPee Brothers Medical Publishers; 2013: 226-237. 2. Aligner Technology, Inc. website. Invisalign Corporate Fact Sheet. website. aligntech.com/documents/Align Technology Corp Fact Sheet 2015 Q1_F.pdf. Accessed December 14, 2015. 3. Kim SY, Lee SH, Cho SK, Jeong CM, Jeon YC, Yun MJ, Huh JB. Comparison of the accuracy of digitally fabricated polyurethane model and conventional gypsum model. J Adv Prosthodont. 2014;6(1):1-7. 4. Ender A, Attin T, Mehl A. In vivo precision of conventional and digital methods of obtaining complete-arch dental impressions. J Prosthet Dent. 2015;Nov 6. 5. Ender A, Mehl A. In-vitro evaluation of the accuracy of conventional and digital methods of obtaining full-arch dental impressions. Quintessence Int. 2015;46(1):9-17. 6. Ender A, Mehl A. Influence of scanning strategies on the accuracy of digital intraoral scanning systems. Int J Comput Dent. 2013;16(1):11-21.

7. German MJ, Carrick TE, McCabe JF. Surface detail reproduction of elastomeric impression materials related to rheological properties. Dent Mater. 2008; 24(7):951-956. 8. Dugal R, Railkar B, Musani S. Comparative evaluation of dimensional accuracy of different polyvinyl siloxane putty-wash impression techniques-in vitro study. J Int Oral Health. 2013;5(5):85-94. 9. DENTSPLY Raintree Essix website. Chewies™ Aligner Tray Seater. https://www.essix.com/orstore/downloads/DFU/ Chewies_DFU.pdf. Accessed December 10, 2015. 10. Ortho Munchies website. All about Munchies®. http:// www.orthomunchies.com/all-about-munchies/overview. Accessed December 10, 2015. 11. Sharp A, Dove E. Pilot study on aligner acceleration and seating device. Paper presented to: NSW Government Dept. of Innovation 2015. 12. Farzanegan F, Zebarjad SM, Alizadeh S, Ahrari F. Pain reduction after initial archwire placement in orthodontic patients: a randomized clinical trial. Am J Orthod Dentofacial Orthop. 2012;141(2):169-173.

Volume 7 Number 1

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

REF: OP V7.1 PENN

CONTINUING EDUCATION BROUGHT TO YOU BY

FULL NAME

AGD REGISTRATION NUMBER

LICENSE NUMBER

ADDRESS

CITY, STATE, AND ZIP CODE

TELEPHONE/FAX

Please allow 28 days for the issue of the certificates to be posted.

Current concepts in data capture for sequential aligner therapy PENN

1. Much of its (clear aligner therapy) success depends upon the __________ of the patient. a. understanding b. cooperation c. compliance d. all of the above 2.

Both options are _____________, and a broad range of clinical outcomes are produced that impact on aligner fit. a. very expensive b. highly material/device sensitive c. technique-employed sensitive d. both b and c Conventional impressions using __________ showed the highest precision, while those using the irreversible hydrocolloid showed the lowest precision. a. vinylsiloxanether material b. rubber base c. alginate replacement materials d. none of the above

4. The precision achieved across the complete arch scans _____________ among the various digital impression systems. a. showed absolutely no difference b. differed significantly c. did not differ significantly d. were extreme

Volume 7 Number 1

What are the clinical implications of a 25 to 40 micron difference in accuracy between a precision conventional impression and a quality digital scan? Given that sequential aligners generally program movements of between 125 to 250 microns per aligner over ______, this differential may have significant clinical impact. a. 1 week b. each 2-week period c. a 4-week period d. a 6-week period

6. While the use of PVSE and PVS impressions are still fraught with the drawbacks of drags, tears, voids, tray-to-tooth contact, temperature sensitivity, limited working time, and material shrinkage, this technique _______________ orthodontic practice. a. should only be used on certain patients in b. should not be readily discarded lightly from c. should be discarded before the inventory runs low in d. should have never been used 7.

The principal advantage of digital impressions would be that they are _______, and additionally, there is no need to select a tray, apply tray adhesive, clean impression trays, assemble impression guns and tips, or disinfect impressions. a. healthier for patients b. less stressful for many patients

c. less uncomfortable for many patients d. both b and c 8. (In the technique designed by the School of Aesthetic Orthodontics, Postgraduate School of Dentistry in Sydney, Australia) The putty material should be softer and exhibit flow characteristics that allow for capture of the sulcular regions _______ beyond the margins of the teeth (low viscosity). a. 1 mm-2 mm b. 3 mm c. 4 mm-5 mm d. 6 mm 9.

In a pilot study by Sharp A and Dove E in 2015, ____ of patients reported significantly improved seating of their aligners when Munchies were used immediately after reinsertion. a. 25% b. 50% c. 75% d. 100%

10. _____________ produce the most accurate initial data. a. Traditional impression techniques b. Employing superior materials c. Approved protocols d. all of the above

Orthodontic practice 35

CE CREDITS

ORTHODONTIC PRACTICE CE

LABORATORY LINK

Intraoral scanners â&#x20AC;&#x201D; an independent laboratory review James Bonham explores several aspects to consider when shopping for intraoral scanners

he adoption rate of intraoral scanners in orthodontics has been quite impressive. Scanners have been around for several years, but recent upgrades have pushed the technology past early adoption and into the early majority stage. Our laboratory (Specialty Appliances) has witnessed this rapid growth of scanners into our customersâ&#x20AC;&#x2122; hands. We currently receive thousands of digital model files each month, including scans from all U.S.-sold intraoral scanner machines. Every type of orthodontic appliance can be fabricated from these digital impressions. This article expresses our independent experience and opinion of the digital scanner market in orthodontics. Intraoral scanners capture highly accurate digital impressions, eliminating the need for physical impressions in most situations. The data is saved and can be exported as a generic stereolithography (STL) file to be digitally stored or shared with others. All scanners include 3D-image viewing software, allowing the doctor to instantly review the image for patient consultation. STL files can be sent to a 3D printer or milling machine for fabrication of a physical dental model or a digitally designed appliance. Digital orthodontic laboratories like Specialty Appliances can receive these STL files and immediately print the models for appliance fabrication. Not only does this process greatly reduce turnaround time, but the consistent accuracy of scans will yield appliances with an improved fit. Not all intraoral scanners are the same. Features that are important to some offices are not as important to others. It is very crucial to understand the differences that will help you find the best fit for your practice. We highly recommend experiencing a live intraoral scanner demonstration in a real mouth, not a stone model, before making the final decision to incorporate this technology into

your practice. Several features to consider when shopping for intraoral scanners follow.

Scan quality Most digital impressions we receive are high quality, but we also receive some with minor issues. These issues include holes (areas of missing data), flat areas (lacking accurate anatomy), noise (data that is not present in the mouth), double images (two images overlapping each other), and scans from machines that do not interpret brackets very well. Issues like these can be caused by the operator or the scanner itself. Digital models can usually be repaired by one of our experienced digital technicians, but sometimes they must be rejected.

scan times (around 5 minutes or less) have pushed the technology into mainstream orthodontics. Digital impressions must be as fast as your current alginate process if your goal is to replace alginate. Successful scanner integration into your office will heavily

Scan time Accurate scans have been around for years, but recent improvements in full mouth

Specialtyâ&#x20AC;&#x2122;s digital technicians process hundreds of scans every day

Before and after bracket removal and scan cleanup

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

Example of double scan data 36 Orthodontic practice

Volume 7 Number 1

LABORATORY LINK depend on the staff’s ability to take quick and accurate digital impressions. Again, the best way to evaluate scan time is to witness a live demonstration in a person’s mouth.

Third-party integration If you plan on routinely using a third-party company that accepts digital impressions, it is important to verify which scanners the company can accept. We do not recommend purchasing a scanner based on the promise of future integration. Specialty Appliances’ laboratory accepts STL data files from all scanner manufacturers.

Portability Intraoral scanners come in several shapes and sizes. Some have large monitors and computers attached to a rolling cart, while others are a small handpiece that plugs into a standard laptop. If you plan on using the scanner in multiple locations, inquire about the unit’s portability.

Cost of ownership There are two common pricing models that you will see. Some companies offer their scanner at a lower price but include monthly fees for services such as support

and unlimited scans. Other companies may charge a higher fee upfront, but all scans and support fees are included. It is important to compare the cost of ownership over a 4- to 5-year period before making your decision. Replacing alginate impressions with intraoral scanning technology will deliver tremendous benefits to your patients and practice. Before making your purchase, research the strengths of each scanner, have a hands-on demonstration, talk with other scanner users, and get feedback from an independent digital laboratory. This is one piece of technology you are sure to enjoy! OP

Replacing alginate impressions with intraoral scanning technology will deliver tremendous benefits to your patients and practice. Example of inaccurate occlusal anatomy

38 Orthodontic practice

Volume 7 Number 1

Dr. James Morris Reynolds offers some wise counsel on assembling an effective office team

ver the years, I have asked both the staff members and the doctors to complete the questionnaire that is shown in Figure 1. To many readers, this may look vaguely familiar, or at least the questions presented may represent any number of thoughts that have arisen when, on that rare occasion, the boss really pauses to wonder, How am I doing as an employer/leader in my office? Often what the staff member is thinking and what the doctor thinks he/she is thinking may be oceans apart. This may be compared to an interesting situation that I have encountered a number of times when I have asked members of my team to write, in their own words, their job description. Often two people whom I consider to have the same job have two very different pictures of positions, and I may have a third perception of basically the identical list of duties. One staff member will write briefly in perhaps two paragraphs his/her understanding of the job duties, and the other may take two-and-ahalf pages to describe in minute detail a job I didn’t know existed! So what has been the picture that has evolved from this interesting exercise? Over 8,000 staff personnel have been kind enough to participate along with far fewer orthodontists. After studying a few hundred entries, it became uncanny. I could look first at the area of their duties, and I could almost know the order of their concerns. Then for others, I would look at the age group they represented and could make a fairly accurate guess as to what their needs or desires were.

Figure 1

Orthodontic Personnel Survey

The following survey bas been used in industry to determine the attitudes and sometimes unspoken thoughts of personnel. We are asking that you rate the following factors in their importance to you as an orthodontic staff member. This is an attempt to survey over 1,200 offices and, hopefully, 10,000 staff people, to determine what is really important to you as an orthodontic employee. These results will be tabulated and released at a future date. At that time, you will have the opportunity to compare your own thoughts and ideas with those of other staffs. ln Column A, we have shown an example of how these might be rated. In Column B, we ask that you list them in their importance to you, placing opposite the one factor most important, the No. 1; No. 2 the next, and down to No. 10 as being the least important to you as a staff member, as well as an individual. We are asking that the doctors also fill out one of these, listing what he thinks is important to you. There may be quite a difference in opinion! A B Example Your Opinion 1 . Paid Insurance – Disability and Health

5. Fringe Benefits

3. Sympathetic Understanding of Personal Problems 4. Shorter Working Hours

6. Systematic Pay Increase

7. Appreciation of a Job Well Done 8. Higher Wages

2. Union or Professional Recognition

9. More Challenging Work Assignments 10. Voice in Office Policies

Please check the appropriate space:

3 7

10 2

AGE GROUP : Under 20_______ 20-‐25_______ 25-‐35_______ 45 and over_______ SEX: Female_______ Male_______

AREA OF PRINCIPAL STAFF DUTIES:

Chairside _______ Business_______ Reception_______ Laboratory_______ Doctor_______ LENGTH OF TIME EMPLOYED IN AN ORTHODONTIC OFFICE:

I Year or less______ 1-‐3 Years______ 3-‐7 Years______ 7-‐15 Years______ 15 Years or over______

SIZE OF COMMUNITY OR CITY IN WHICH YOU W ORK: _______________________________________

Thank you for your help; we hope this will make for a happier office relationship for you in the months to come.

In memoriam Dr. James Morris Reynolds, 97, of Lubbock, Texas, passed away on October 14, 2015, after a brief illness following a fall. A resident of Lubbock for almost 70 years, Dr. Reynolds was orthodontist to legions of young people in West Texas, a civic leader, devoted husband, and father. Dr. Reynolds practiced orthodontics in Lubbock, Texas, for more than 40 years. He was an ABO member, mentor to dozens of orthodontists, President of the American Association of Orthodontists, founder and CEO of Class One Orthodontic Company, and founder of Zulauf, Inc., and Element 34. He was the discoverer and developer of the ceramic bracket as well as an authority and active writer and speaker on practice management. His reliable and unpretentious personality made him a faithful and dependable source of support and sound advice, which continually nourished all who knew and depended on him. Orthodontist Dr. Larry White shared his thoughts about how Dr. Reynolds changed his life. “I first came to know Jim as an adolescent whose only dental experience heretofore had been the extraction of a tooth by a local dentist without benefit of anesthesia. I vowed never again to visit any dentist, but, of course, my mother had other ideas about that. She had heard good reports about a new dentist in Lubbock, and I was soon sitting in Jim’s treatment chair. The experience was so pleasant and enjoyable that on the way home I told my mother, ‘When I grow up, I want to be like that man.’ I still aspire to that goal.” The Orthodontic Practice US team extends condolences to the Reynolds family and is honored to publish some of his final words of advice to the orthodontic community.

Volume 7 Number 1

Orthodontic practice 39

PRACTICE MANAGEMENT

Orthodontic personnel principles

PRACTICE MANAGEMENT So let us examine the survey answers, and see if they help us better understand one another.

Business office personnel This group ordinarily consists of older (or more mature as they would categorize their elite status) team members, and they have mixed interests. In the past, the only way to learn this task was through experience. However, recently the development of computer software programs offer structured guidelines that make the learning of this job much easier. Business office personnel should reflect integrity, have a solid and sympathetic outlook, and an understanding of the parents’ dilemma of balancing the household budget. The concerns of business office personnel regardless of age turned out to be: • Appreciation of a job well done • Health coverage Almost all of these people 35 years and older cherished “a sympathetic understanding of personal problems.” Single parents make up a large percentage in this group and often have children to raise, a tight personal budget, or aging parents to care for. They need an employer to listen and help with special problems. If you hear, “Doctor, do you have a minute?” Believe me, doctor; you had better take the time. You have an opportunity to build loyalty and respect, so don’t blow it!

Laboratory personnel These people represent a neglected but important group. Often doctors will assign the laboratory task to an experienced staff member because they presume he/she understands the function and importance of all the products that come from this beehive of activity. Ordinarily introverts settle into this area comfortably, and they have pride in their production. You need to leave them and their work alone as far as feasible. Usually quieter, conservative, and more exacting people thrive in this position. A happy-golucky “people” person will go nuts in this job. How do you find a round peg for this round hole? First, these people must have good digital dexterity, and they will often have a high level of neatness and structure about them. Nevertheless, the survey gives us real clues to keeping these people happy 40 Orthodontic practice

Business office personnel should reflect integrity, have a solid and sympathetic outlook, and an understanding of the parents’ dilemma of balancing the household budget. and productive. Laboratory personnel often require or need: • More challenging assignments. This is always high on their list, and once they know their jobs and routinely achieve the near perfection they require, they may become bored. Combat this boredom by giving them other assignments or arranging professional learning opportunities outside of the office. • Lab technicians have a high need of the doctor’s appreciation for a job well done. • They usually like their jobs, and they look for security, stable work environments, and predictable, systematic pay increases. Please don’t expect the happy-go-lucky, extroverted “people” person to last long or be happy with this job.

Reception personnel We often find a variety of personalities that teem with contradictions in this area. But what kind of people should we look for? Certainly we want happy, warm people. They should give attention to detail, but the bubbly personality that thrives on people contact often lacks this trait. This job attracts people from every age group, so the task is not defined by age. The addition of good computer software has made this job much easier to teach and to learn, which allows people with little or no experience to perform adequately. Nevertheless, the tasks are not as easy as they may appear. A new receptionist will benefit greatly by having careful scripts that cover a myriad of situations that arrive by phone or in person. “But my child goes to school.” The receptionist must resist the temptation to respond, “Big deal! Your little dimpled darling is the only patient we have that goes to school.”

This position requires quick thinking as well as being a good listener. Carefully crafted scripts can help new receptionists overcome many obstacles. Should there be an overlap of tenure between the departing and the new receptionist, many questions and answers will naturally occur as situations arise. Nevertheless, we may sometimes face a crisis from an immediate departure due to illness, accident, elopement, or heaven knows what. These situations require scripts, so the new receptionist leaves nothing to chance. Develop a “cue card” for every imaginable situation and try to cover all possible situations that could arise such as: • The demanding patient or parent • The whiner who asks for special consideration • The chronic appointment no-show or frequent appointment changer • A demanding spouse who interrupts the appointment routine and requires unusual tact and diplomacy An office policy manual should offer enough clarity for every team member to understand and cover as many situations as possible. The most cited concern in the survey for these personnel was the doctor’s appreciation of a job well done, followed by having a voice in office policies. Policy decisions need the input of all of the staff — at least request input, and then consider it.

Chairside personnel This is the largest and most diverse group represented in the survey. Ages of these personnel range from 18-year-olds to grandparents. The entry-level remains fairly easy for the inexperienced since most doctors are willing to assume the challenge of training neophytes. All offices have examples of “on-the-job” training. Some show the results of thoughtful, thorough training while the sloppy, hurried Volume 7 Number 1

Survey exit One final question of the survey asks the size city in which the interviewee grew up. Generally speaking, people from smaller cities change jobs the least. One of the best chairside assistants I ever had came from a small town, and she lived on a ranch with four older brothers and two younger sisters. She played high school basketball and was a second-team all-state guard. In a nutshell, she had her share of chores to do on the ranch. She learned to share responsibilities with her siblings (teamwork), and she had good eye-hand coordination and quickness from her sports training. When I interviewed her after some testing, I asked her, “Do you think you have good hands?” She replied, “Yes, I think so.” I flipped a ballpoint pen at her. She never stopped looking at me in the eye, caught the pen, and flipped it back to me. I dropped it.

Age grouping What difference does the age of the staff make in how they respond to the questionnaire? First, let’s look at some of the common concerns of all ages: • Health coverage is now a must. • Appreciation of a job well done. • Understanding of personal problems. Surprisingly, some of the following seemed less important: Volume 7 Number 1

When an employee asks, “Doctor, do you have a minute?” Take the time. Be a good listener because it will pay dividends.

• • • •

Systematic pay increases. Union or professional recognition. Shorter working hours. Extra benefits were appreciated and were usually a welcome surprise, but they were seldom high on the list • Although union or professional recognition seldom ranked high, those with the longest tenure esteemed it the most. Those with the longest tenure had the most diversity in their responses. They understand the scale of compensation and know that the job pays what they receive, and it isn’t likely to change much. Compensation schedules should be spelled out. Clearly, this job will pay this much, and there will be no annual raises. One friend started automatic annual raises, and three employees were receiving salaries almost equal to the doctor after 20 years. Such a policy may guarantee experienced people, but they may be like the person who says, “I have 15 years of experience,” when she may have had only 1 year of experience 15 times. Quality assessment by a semiannual or annual evaluation should be the sole criterion for a salary increase with the possible exception of cost-of-living increases for the entire staff. Generally, common sense should prevail regarding compensations. Achieving a harmonious and successful orthodontic team requires an appreciation of one another’s needs, and compensation should be commensurate with the value of the contribution to team goals. The high ranking of “sympathetic understanding of personal problems” should not come as a surprise. Single parents, divorcees, aging or ill parents, and children in trouble require the understanding and occasional listening by the doctor to show sympathy, concern, and help. Ronald Shapiro, co-author of the fascinating book, The Power of Nice,

illustrates this point with a story, which I will paraphrase: A valued employee appeared at the door and asked her employer if he had a minute. She then said she needed a raise. He, rather surprised, responded with, “You just received a raise 3 months ago, and I’m afraid I can’t afford another right now.” She was crestfallen. He then asked, “Tell me, really, why are you here, and why do you need another salary increase?” Then the truth came out. Her daughter had been accepted to a prestigious school, and she couldn’t afford the tuition on her present salary. As a result of her asking, the employer took the time to make inquiries and found a scholarship that solved the problem. He, by caring and asking for the real reason, helped her with a personal problem that kept the employee happy, and the boss was able to keep the office budget under control. When an employee asks, “Doctor, do you have a minute?” Take the time. Be a good listener because it will pay dividends.

Summary This analysis of the survey contributions probably reflects many of my personal biases. Nevertheless, after practicing for many decades, I’ve had as many wonderful co-workers as anyone, and I feel qualified to have opinions based on virtually every conceivable office experience. Doctors must realize that not every employee intends to make a long-term career with the orthodontic team. Some come as temporary employees and then stay — loving the chance to work with delightful patients and congenial colleagues. Others have interests outside of orthodontics. Doctors should not resent change. Every change has its own advantages, and a good orthodontic team should be considered a journey rather than a destination. It is always a work in progress. OP Orthodontic practice 41

PRACTICE MANAGEMENT

offices will reflect attitudes of “watch, wait, and hope for the best.” Frequent turnover is a problem at this position, and the least experienced person will often list “a voice in office policy” as a concern. After all, doesn’t a college freshman know better how to run the university? Systematic training of chairside assistants must be constant and consistent. New chairside hires should be evaluated by every staff member after the first, second, and eighth week for characteristics such as: • Team cooperation • Empathy for patients • Promptness • Competence A questionnaire for the trainee for the “doctor’s eyes only” often provides an eyeopener for the doctor and a clue for possible incompatibility in the future. This private questionnaire should have inquiries such as: • Which of the staff is the most helpful? • Which of the staff gives the clearest instructions? • Which of the staff is the least helpful?

INDUSTRY NEWS

OrVance™ announces launch and distribution of OrthoDots™

Dr. David Paquette joins Henry Schein® Orthodontics as lead clinical advisor

OrVance™ has introduced OrthoDots™, a long-awaited solution to abrasions caused by braces and other orthodontic appliances. OrthoDots™ combine a biomedical grade silicone with a proprietary Moisture Activated Technology to produce an easier and more effective application that stays on much longer than competitive products. The silicone material used in OrthoDots™ is over 30 times more pliable than the leading brand of dental wax, preventing the crumbling associated with traditional wax products. OrthoDots™ also offer unsurpassed hygienic benefits, providing two packaging options specifically designed to comply with FDA guidelines for medical devices that are likely to be used across multiple patients. OrthoDots™ are now available from major suppliers, including Henry Schein® and Patterson Dental. Patients are also now able to purchase OrthoDots™ directly on amazon.com. Visit orvance. com for a current list of suppliers and to learn more.

Henry Schein® Orthodontics (HSO) announced that Dr. David Paquette has joined its company as lead clinical advisor who will be working with the HSO’s research and development teams and leading the HSO clinical advisory boards in evaluating new products and procedures that advance the state of orthodontic treatment. Paquette said he selected HSO as a working partner because of the high priority it places on clinicians’ feedback and the organization’s longstanding commitment to developing innovative solutions that represent significant breakthroughs in patient care. For information, visit www.henryscheinorthodontics.com/.

Planmeca imaging units now certified for use with OraMetrix’s suresmile® Roselle, Illinois-based Planmeca USA and OraMetrix announced that Planmeca imaging units are now compatible with suresmile®, a software program that allows orthodontists to visualize multiple diagnostic setups and design customized archwires for each patient. The announcement covers the Planmeca ProMax® 3D, the Planmeca ProMax® 3D Mid, the Planmeca ProMax®, and the Planmeca ProMax® 3D Max. For more information, visit www.planmeca.com.

Sirona announces 2016 CMW SIROWORLD party OrthoAccel®, makers of AcceleDent®, named to Deloitte’s 2015 Technology Fast 500 List of Fastest Growing Companies in North America OrthoAccel® Technologies, Inc., is ranked No. 2 in Texas and No. 69 nationally on Deloitte’s 2015 Technology Fast 500, a prestigious ranking that recognizes the fastest growing companies in North America. The only orthodontic company ranked among this year’s 500, OrthoAccel manufactures AcceleDent®, an FDAcleared, Class II medical device that speeds up orthodontic tooth movement by as much as 50%. AcceleDent is recommended by many of the industry’s leading orthodontists as the fast, safe, and gentle solution to accelerate orthodontic treatment. A prescription-only device, AcceleDent is available in more than 2,900 orthodontic locations across North America and 360 international locations. Orthodontic patients gently bite on AcceleDent’s mouthpiece for 20 minutes daily, and light pulsations employed by patented SoftPulse Technology® work at a cellular level to accelerate bone modeling and remodeling in the craniofacial region. Patients report that AcceleDent’s light pulsations relieve the pain often associated with orthodontic treatment. More information can be found at acceledent.com.

42 Orthodontic practice

Sirona Dental, Inc., is hosting a superhero-themed party at the House of Blues on February 26, 2016, in Chicago during the 2016 Chicago Dental Society Midwinter Meeting. This party is a membership benefit of SIROWORLD, Sirona’s new event-based community. All SIROWORLD members are invited to join in on this epic night of superhero action. Membership into SIROWORLD includes access to parties like this — along with SIROWORLD’s educational events held at major U.S. trade shows like the Greater New York dental meeting and the CDA South meeting in Anaheim, California. During these educational events, members can speak to leading experts in the field of digital dentistry and compare stories with fellow members about the technologies that have helped integrate their practice into the digital age. For more information on SIROWORLD membership and events, please visit www.SIROWORLD.com, or call 844-422-3226.

Subscribe to the Orthodontic Practice US newsletter Each week subscribers can look forward to receiving relevant and innovative information. Subscribe for free today: http://ortho-us.link/orthonewssignup

Volume 7 Number 1

3Shape TRIOS® Orthodontics integrates with Dental Monitoring

Instrumentarium Dental™, a member of KaVo Kerr Group and the Danaher dental platform, was awarded a Bronze prize in the 2015 Danaher Innovation Recognition Awards for its ORTHOPANTOMOGRAPH™ OP300 Maxio. The Danaher Innovation Recognition process was created to recognize and celebrate individuals and teams who bring innovation to life by contributing to the company’s most recent and important new products, services, and business models that have moved from concept to commercial success. OP300 Maxio received a Bronze award in part for these features: extended imaging areas, the option to reduce radiation dose, and patient-specific imaging parameters substantially increasing the efficiency and versatility of OP300 Maxio system. For more information, visit OP300 Maxio, visit http://www. instrumentariumdental.com.

3Shape TRIOS® Orthodontics has created a seamless integration with Dental Monitoring, enabling orthodontists who are using the TRIOS® intraoral scanner to send digital impressions directly to the Dental Monitoring platform with just a click. Dental Monitoring uses a digital impression to determine patient’s current baseline tooth position. The application then enables both the orthodontist and patient to monitor an orthodontic treatment by aligning photos taken regularly with the patient’s smartphone and comparing them with the original baseline tooth position as identified by the initial intraoral scan. Orthodontists using 3Shape TRIOS® can select Dental Monitoring from the list of integrated solution providers within the intraoral scanner’s software. From there, the orthodontist just needs to click to send the TRIOS® digital impression and case information directly to the Dental Monitoring platform. Because the digital impression becomes the first reference point in defining the baseline tooth position as well as a benchmark for all future calculations made by the application, it makes the accuracy of the initial intraoral scan paramount. For more information, visit www.3shape.com.

American Orthodontics wins three MarCom awards American Orthodontics’ (AO) creative marketing team has won three MarCom Awards, given by the Association of Marketing and Communication Professionals (AMCP) to honor the creativity, concept, writing, and design of print, visual, audio and web materials. AO won the Platinum Award in the Business-to-Business category for its Dual Activation Brochure (designer Eric Liebe, copywriter Matt Klitzke), the Gold Award in the Magazine category for its PowerScope Advertisement (designer Eric Liebe, copywriter Matt Klitzke), and the Gold Award in the Brochure category for its 2014 Ultimate CE Food and Wine Experience Brochure (designer Susan Bauman, copywriter Matt Klitzke). Out of more than 6,000 entries, only 16% of those earned Platinum status, and 23% earned Gold. For more information about the company, visit www.american ortho.com.

TAD Conference 2015 in Florida On November 6 and 7, 2015, Dentaurum USA celebrated the 10th anniversary of the market leading tomas® pin at the luxurious Boca Raton Resort & Club in Boca Raton, Florida. Over 70 participants, ranging from residents to orthodontic leaders, enjoyed a varied program featuring international lecturers. The conference program covered many subjects from the fundamentals of mini-implant design to studies on proper TAD placement to complicated cases solved in uncomplicated ways, as well as how to design appropriate biomechanics for a variety of situations. The response was so overwhelming that Dentaurum has already planned two events for 2016: one on October 28 and 29 in Scottsdale, Arizona, and another on November 4 and 5 returning to the popular Boca Resort & Club in Boca Raton, Florida. Dentaurum encourages all interested parties to save the dates and book early, as seats are expected to fill up quickly. For more information, call 1-800-523-3946, email info@ dentaurum.com, or visit the website www.dentaurum.com.

Volume 7 Number 1

New additions to the Ortho-Cast buccal tube series The Dentaurum Group is extending customer options with the new Ortho-Cast M-Series buccal tubes, double rectangular, non-convertible, which are available now in MBT* 18/22 and Roth 18/22, for the bonding and the banding technique. The new buccal tubes come with a sleek, low profile, and new features that make handling even easier. All Ortho-Cast M-Series buccal tubes are manufactured as true one-piece tubes using metal injection molding (MIM). The slim, pliable ball-end hooks and the base are molded in the same processing step as the body using very complex tools. This one-piece-design makes the tubes very biocompatible, as no additional material is used to connect different components. The buccal tubes were designed using the same modern CAD technology as all Ortho-Cast tubes. The base is contoured in three dimensions (mesio-distal and occlusal-gingival curvature), guaranteeing optimal fit. The pronounced funneled mesial opening allows for easy insertion of the archwire. The tubes are wedgeshaped, decreasing in profile on the distal side to enhance patient comfort. The anatomic contouring of the base fits into the buccal groove of the molar and makes positioning the tube more than easy. For more information, email DENTAURUM, info@dentaurum. com or visit the website at www.dentaurum.com. * The Dentaurum version of this prescription is not claimed to be a duplication of any other, nor does Dentaurum imply that it is endorsed in any way by Drs. McLaughlin, Bennett, and Trevisi.

Orthodontic practice 43

INDUSTRY NEWS

Instrumentarium Dental™ OP300 Maxio Receives 2015 Danaher Innovation Recognition Award

RESEARCH

Patient perceptions of speech, discomfort, and salivary flow while wearing Invisalign® aligners Drs. William J. Sweeney Jr., Daniel Rinchuse, Donald Rinchuse, Thomas Zullo, and Bryan King share insights into orthodontic patients’ perceptions Objective The aim of this study was to gain insight into the perceptions of orthodontic patients with regard to comfort, ease of speaking, salivary flow, and satisfaction while undergoing the initial stages of orthodontic treatment using Invisalign® aligners.

Methods Patients initiating orthodontic treatment using Invisalign aligners at a private orthodontic practice were surveyed using a visual analog scale (VAS) over the initial course of treatment. The first survey was completed when patients were given their initial aligners. They were surveyed again at each of their next two routine appointments.

Results Forty of the 72 patients who initially participated in the study completed surveys at all three time points. These patients indicated that they felt the aligners were moderately comfortable, and this changed little over the course of treatment. Patients reported they felt they could generally speak well while wearing the aligners, and this also changed little during treatment. On average, patients initially reported their mouths felt neither extremely dry nor extremely wet with only a minor increase in dryness over time. Finally, patient’s satisfaction began high and William Sweeney Jr., DDS, is currently a senior orthodontic resident, Seton Hill University Graduate Program in Orthodontics, Greensburg, Pennsylvania. Daniel Rinchuse, DDS, MS, MDS, PhD, is a Professor and Program Director, Seton Hill University Graduate Program in Orthodontics, Greensburg, Pennsylvania. Donald Rinchuse, DMD, MS, MDS, PhD, is in private orthodontic practice, Greensburg, Pennsylvania. Thomas Zullo, PhD, is Adjunct Professor of Biostatistics, Seton Hill University Graduate Program in Orthodontics, Greensburg, Pennsylvania. Bryan King, DMD, MSD, is Clinical Faculty, Seton Hill University Graduate Program in Orthodontics, Greensburg, Pennsylvania, and in private orthodontic practice, Pittsburgh, Pennsylvania.

44 Orthodontic practice

increased during the first time period and then remained constant through the final time point.

Conclusion Despite what patient’s may believe after searching the Internet or talking with friends, treatment using Invisalign aligners is a relatively positive one. Patients report the aligners are comfortable, do not interfere with speaking, and do not cause excessive dryness or salivation. Patients also report being satisfied with the experience during their initial phase of treatment.

Introduction “Perception is reality.” — Lee Atwater A positive experience using orthodontic aligners may lead to better acceptance and compliance, which may lead to enhanced results. Accurately anticipating patients’ experiences may improve practitioners’ ability to communicate with patients regarding what might be expected during treatment. Further, it may also be helpful to be able to advise patients if they can expect these feelings to change throughout treatment. Because various companies use different materials for aligner fabrication, this study used only Invisalign aligners from Align Technologies, Inc. A Google® search in April of 2013 using the phrase “Invisalign problems” revealed online testimonies of Invisalign aligners being associated with the sensation of a dry mouth, excessive salivation, impaired speech, and general discomfort. Further refining the Google query as “Invisalign Dry Mouth,” “Invisalign Excess Saliva,” “Invisalign Speech,” “Invisalign Pain,” and “Invisalign Discomfort” quickly revealed that there are numerous instances of patients proclaiming perceived adverse experiences while using Invisalign aligners. Although not an exhaustive review, a PubMed search was conducted to investigate publications regarding the use of Invisalign being associated with sensations of: dry mouth, excess salivation, impaired speech, or discomfort. Boolean

searches of PubMed were conducted using “Invisalign AND” in conjunction with the following terms; the number of associated results is in parenthesis: Xerostomia (1), Dry mouth (1), Salivation (0), Speech (2), Comfort (0), Discomfort (1), Satisfaction (6), Perception (1), and Experience (4).

Background Xerostomia The diagnosis of xerostomia can be through questioning the patient, salivary output studies, or imaging. Irrespective of whether scientific testing provides objective results, a patient’s report of xerostomia may indicate the need for palliative therapy to provide symptomatic relief.1 Thus, xerostomia, as the subjective condition relevant to this study, can only be ascertained through direct questioning of patients.2 In addition to objective clinical success, orthodontists would also like their patients to have a positive experience. Decreased salivary function could have an impact on the person’s quality of life.3 For the purposes of this study, the definition of xerostomia was taken from the American Dental Association as follows: “Xerostomia is defined as the subjective complaint of dry mouth that may result from a decrease in the production of saliva.”1 Though it could be argued that testing is required to determine if xerostomia is actually present, throughout the literature, xerostomia is considered the “subjective sensation of dry mouth.”4 It has been estimated that a 50% reduction in salivary secretion needs to occur before xerostomia becomes apparent,5 and xerostomia is estimated to affect one in every 10 dental patients.3 Symptoms may be due to a reduction in the quality of saliva produced, the actual composition of saliva, or both. Xerostomia, as defined by the American Dental Association is a subjectively perceived condition with no objective evidence of a change in salivary quantity or quality, is relevant for this study.1 Volume 7 Number 1

Hypersalivation Patients may also present with hypersalivation, also known as ptyalism or sialorrhea. Increased salivary flow may be due to a medical condition such as a neurologic disorder.8 The use of certain medications such as the antimuscarinic agent glycopyrrolate may also stimulate salivary flow.9 Medication such as Salvart Synthetic Saliva may also be used as a salivary substitute.10 Additionally, a relative feeling of excess salivary flow may be due to the patient’s inability to clear a normal amount of saliva, as is the case for patients with amyotrophic lateral sclerosis.11 Searches of PubMed to find articles pertaining to hypersalivation’s possible connection to Invisalign revealed publications relevant to the topic as follows: Hypersalivation (1480) alone as well as “Medication AND” the following: Hypersalivation (132), Increased Salivation (2165), Ptyalism (1220), Sialorrhea (1173), Sialorrhea drug therapy (277), Saliva substitutes (2568), Artificial saliva (2456). Further, PubMed was searched using “Invisalign AND” and the following was found: Saliva (4), Salivary (0), Salivation (0), Ptyalism (0), Sialorrhea (0), and Hypersalivation (0). Discomfort Discomfort associated with the use of Invisalign aligners may be due to the pressures applied to the teeth or physical irritation of soft intraoral tissues. Owen addressed soft tissue irritation in a case report of his own personal treatment experience.12 Tucany, et al., reported that teenage patients “seldom or never experienced discomfort.”13 A study Volume 7 Number 1

of 54 consecutive patients by Nedwed and Miethke found that patients “do not suffer much impairment” while using Invisalign aligners.14 Miller, et al., reported that “adults treated with Invisalign aligners experienced less pain and fewer negative impacts on their lives during the first week of orthodontic treatment than did those treated with fixed appliances.”15 Shalish, et al., compared the level of discomfort experienced by patients using labial brackets, lingual brackets, and Invisalign aligners. The results indicated that Invisalign aligners were better tolerated than both labial and lingual brackets.16 In the studies of both Miller, et al., and Fujiyama, et al., it was reported that the discomfort experienced by patients using Invisalign aligners to be less than those using traditional labial appliances.15,17 PubMed searches were performed for “Invisalign AND” with the following results: Pain (7), Comfort (0), and Discomfort (2). Speech Prospective Invisalign patients may fear potential difficulty speaking while wearing aligners. Owens mentions that he himself suffered compromised speech for a short time after beginning Invisalign therapy when reporting his own experience as a patient.12 Nedwed and Miethke’s investigation found

that patients “become accustomed to the aligners very quickly and do not suffer much impairment.”14 Results of a PubMed search for ”Invisalign AND” combined with the following are Speech (2), Speaking (1), and Talking (2). Satisfaction Nedwed and Miethke reported that “98% of patients were satisfied with the progress of therapy”14 in their study. Schaefer and Braumann reported that 84% of their subjects were “very satisfied” with the results of treatment and 16% were “satisfied.”18 The PubMed search criteria and number of results for “Invisalign AND” the following are Satisfaction (6), Satisfied (1), and Happy (0). Aim The aim of this study was to investigate the perceptions of patients with regard to comfort, ease of speaking, salivary flow, and satisfaction while undergoing the initial stages of orthodontic treatment using Invisalign aligners. Method Seventy-two consecutively treated patients beginning treatment in a private orthodontic practice, who met the inclusion criteria, began this pilot study by completing the initial survey (Figure 1) at time T1, their first appointment with the initial aligners. Of

How comfortable are the Invisalign aligners? I----------------------------------------------------------------------------I Extremely Comfortable

Extremely Uncomfortable

How would you rate your speech while wearing the Invisalign aligners? I----------------------------------------------------------------------------I Extremely Easy

Extremely Difficult

How does your mouth feel while wearing the Invisalign aligners? I----------------------------------------------------------------------------I Extremely Dry

Extremely Wet

How satisfied are you with your experience using Invisalign aligners? I----------------------------------------------------------------------------I Extremely Dissatisfied

Extremely Satisfied

Is there anything you would like us to know about your experience using your Invisalign aligners? _____________________________________________________________________________

Figure 1: Questions that were asked Invisalign users based on a visual analog scale (VAS) Orthodontic practice 45

RESEARCH

Historically, head-and-neck radiation therapy was considered the most common cause of xerostomia and salivary gland hypofunction. Systemic diseases such as Sjogren’s syndrome, HIV, and others are also associated with xerostomia. Currently, medications have emerged as the most common cause.3 According to Villa, et al., medication usage and age are highly significant risk factors for dental patients reporting xerostomia,6 and medications may be associated with a feeling of dry mouth despite normal saliva production.7 It is important to note that the association with age may simply be due to the increased likelihood that patients may be taking medications as they age. Specific PubMed searches using “Invisalign AND” with the following terms returned the subsequent results: Xerostomia (1), Dry mouth (1), and Salivation (0).

RESEARCH these 72 patients, 40 patients completed surveys at all three time points during the study. Patients were surveyed at the beginning of treatment after wearing their initial aligners for a few minutes (T1); again at their second routine follow-up appointment (T2); between 14-91 days, with a mean of 34.2 days; and finally, at their third routine followup appointment (T3) between 64-169 days, with a mean of 106.9 days. A relatively large number of patients who completed the survey at T1 did not complete surveys at either T2 or T3 or both. This was due to the clinical staff charged with collecting the surveys inadvertently forgetting to have the patients complete the survey at either T2 or T3. The time constraints of the private practice’s schedule also precluded the completion of some surveys. If all three time points were not complete for a particular patient, no surveys for that patient were included in the study. This resulted in the loss of 44% of the subjects who initially agreed to participate in the study. Each patient was asked to indicate his/ her level of perceived intraoral comfort, dryness/wetness, ability to speak, and satisfaction with his/her experience with the Invisalign aligners using a visual analog scale (VAS) during routine appointments at time points T1, T2, and T3. Patients were also given the opportunity to inform the doctor or staff of any other issues they felt were important. Those personnel administering the surveys were instructed to avoid giving any advice, opinions, or in any way influencing the patient’s perceived experience. Align Technologies has changed the material used in aligner fabrication over time, which may lead to different patient experiences currently when compared to years ago. “SmartTrack” is the third generation of material used to fabricate Invisalign aligners and was utilized for all patients in this study. Patients were excluded from the study if they were under 18 years of age or had had any predisposing conditions such as a history of radiation, chemotherapy, systemic disease, medication, or medical conditions that may increase the likelihood of xerostomia, ptyalism, speech impediments, or discomfort. The Multivariate and Univariate Tests, Pairwise Comparison and Mean Value Estimate were performed using IBM SPSS v.23 software. Results The overall Multivariate Test was performed to determine if there were overall 46 Orthodontic practice

Table 1: Results of the Pairwise Comparison

Measure

Comfort

(I) Time

(J) Time

2 3

1 3

1 2

Speech

2 3

1 3

1 2

Dry/Wet

2 3

1 3

1 2

Satisfaction

2 3

1 3

1 2

Mean Difference (I_J)

Std. Error

95% Confidence for Differenceb Sigb Lower Bound

Upper Bound

0.017

0.054

1.000

-0.119

0.153

0.092

0.050

0.223

-0.034

0.217

-0.017

0.054

1.000

-0.153

0.119

0.075

0.042

0.250

-0.031

0.180

-0.092

0.050

0.223

-0.217

0.034

-0.075

0.042

0.250

-0.180

0.031

0.010

0.049

1.000

-0.112

0.131

0.077

0.045

0.277

-0.035

0.190

-0.010

0.049

1.000

-0.131

0.112

0.068

0.034

0.153

-0.017

0.152

-0.077

0.031

0.277

-0.190

0.035

-0.068

0.030

0.153

-0.152

0.017

0.077

0.031

0.050

-7.143E-5

0.155

0.048

0.023

0.351

-0.027

0.123

-0.077

0.030

0.050

-0.155

7.143E-5

-0.030

0.023

0.602

-0.086

0.027

-0.048

0.030

0.351

-0.123

0.027

0.030

0.023

0.602

-0.027

0.086

-.119*

0.037

0.008

-0.212

-0.026

-0.130*

0.037

0.003

-0.222

-0.038

0.119*

0.037

0.008

0.026

0.212

-0.011

0.020

1.000

-0.062

0.040

0.130*

0.037

0.003

0.038

0.222

0.011

0.020

1.000

-0.040

0.062

Based on estimated marginal means * The mean difference is significant at the .05 level. b Adjustment for multiple comparisons: Bonferroni Volume 7 Number 1

95% Confidence Interval Measure

Time

Mean

Std. Error Lower Bound

Comfort

1 2 3

Speech

1 2 3

Dry/Wet

1 2 3

Satisfaction

1 2 3

0.334

0.039

0.255

0.413

0.317

0.044

0.227

0.407

0.242

0.033

0.175

0.310

0.349

0.036

0.275

0.422

0.339

0.036

0.265

0.413

0.271

0.034

0.202

0.340

0.513

0.023

0.467

0.560

0.436

0.019

0.398

0.474

0.465

0.018

0.430

0.501

0.659

0.034

0.590

0.728

0.778

0.025

0.728

0.828

0.789

0.025

0.739

0.839

differences (changes over time) for comfort, speech, salivary flow, and satisfaction with the experience of using aligners. The overall significance level (p-value) was 0.013 with an f-value of 3.019 leading clinicians to conclude that there were differences (changes over time). This is of statistical importance, but not of much practical importance since it does not provide information regarding which of the four measures changed over time. The Univariate Test was performed to determine which individual measures changed over time. The significance level (p-value) for comfort and speech, which were 0.145 and 0.150, respectively, are greater than 0.05 leading clinicians to conclude that there were no significant changes over time for these measures. Dry/wet and satisfaction do have significance levels (p-values) of 0.025 and 0.000, respectively, which are less than 0.05, indicating there are differences over time. Determining exactly where the changes over time occurred required the use of both a Pairwise Comparison (Table 1) and Mean Value Estimates (Table 2). Again, as would be expected from the Univariate Tests results, no significant differences (changes over time) Volume 7 Number 1

Upper Bound

were found for comfort and speech using the Pairwise Comparisons between any time points (T1-T2), (T1-T3), or (T2-T3). Looking at the comparisons for satisfaction, it can be seen that differences between T1-T2 and T1-T3 were statistically significant (p = 0.008 and p = 0.003, respectively) while the difference between T2-T3 is not significant. Since the mean differences are negative (meaning the second value is larger), it can be concluded that satisfaction increases significantly between T1-T2 and between T1-T3, but there is no significant increase between T2-T3. The findings for dry/wet are a little more statistically complex. The Univariate Tests for dry/wet show statistically significant differences across the time points. Also, the table for pairwise comparisons shows a significance value of 0.050 for the difference between T1-T2 for dry/wet. However, the Mean Difference value does not have an asterisk to indicate “The mean difference is significant at the 0.05 level.” It should be noted that, although the value printed out is 0.05, the actual value is 0.0503, which is very close. When controlling for Type II error,

in this case pairwise error rate, one must conclude that none of the pairwise comparisons (1 versus 2, 1 versus 3, or 2 versus 3) are significantly different from each other.

Discussion Patients with extreme or atypical experiences using Invisalign aligners may not be the norm and may be more likely to vocalize or post to the Internet their experiences and, thus, may be overrepresented. With more evidence, especially high-quality evidence, practitioners would be in a position to confidently inform Invisalign patients of realistic expectations and not anecdotal information found on the Internet. From the result of this study, patients can expect to be reasonably comfortable with little speech impairment. While statistically insignificant, patient’s initial slight discomfort and speech inhibition did technically improve slightly during the initial phases of treatment. Some patients have also indicated they feel the edges of the aligners were sharp when asked if they would like to report anything specific. Simply buffing the edges of the aligners or an improved manufacturing process may alleviate this issue. The results of the study show a dry- or wet-mouth feel is almost exactly in the middle of the visual analog scale. This may indicate that there is no difference from what patients perceive as normal. Further studies to isolate patients into subgroups of those experiencing xerostomia from those experiencing ptyalism may better indicate the experience and associated changes over time. Finally, patients undergoing orthodontic treatment using Invisalign aligners may expect that they will be satisfied with their experience. They will also feel an initial increase in the level of satisfaction that will continue through the initial phase of treatment. Schaefer and Braumann reported that, while patients could not be objectively shown to have dry mouths, their subjects did report the occasional feeling of dry mouth, particularly over the first 3 to 4 months.18 However, this subjective feeling of dry mouth was reported to have hardly influenced the patients’ quality of life and was thought to be attributable to the patients’ heightened awareness of their oral condition. Similarly, Schaefer and Braumann’s subjects initially reported difficulties with certain pronunciations and sensations of pain but with little impact on their lives. Finally, Schaefer and Braumann’s subjects reported being satisfied with their results. Likewise, Nedwed and Miethke reported that, while there may be Orthodontic practice 47

RESEARCH

Table 2: Mean Value Estimates

RESEARCH some mild transient pain or speech impairment, their subjects reported these issues quickly dissipated and were of little relevance leading to a high level of patient satisfaction with aligner therapy.14

ways that were not determined. Because the patients were aware their answers were being tracked, they may have experienced a Hawthorne effect, also referred to as the observer effect.

Limitations

Clinical implications

This pilot study had a relatively small sample size, and the length of the study could be extended. Patients were followed for the first three appointments, and patient experiences may change after long-term wear over the full course of treatment. Thirty-two of the initial 72 subjects who initially participated did not complete all three surveys, leaving only 40 subjects who completed all three surveys. This study also did not investigate the effects of wearing Invisalign aligners on patients under the age of 18 years of age. Patients under the age of 18 years old may have different responses to the aligners than adults. Subjects were not segregated into groups according to occlusal classification. This pilot study focused on publications found through searching PubMed as a preliminary investigation. A more exhaustive review of the literature would include MEDLINE®, Embase®, and the Cochrane Library, in addition to AAO resources and hand searching. These additional search methods may reveal additional research. A confounder may be that some patients with undiagnosed medical conditions or those taking medications may have inadvertently been included in this study. All patients in the study came from the same private practice and may have been influenced in

This pilot study and the literature cited in this paper may allow clinicians to be optimistic about the minor negative patient experiences with Invisalign therapy.

Conclusion This study followed patients using Align Technologies’ Invisalign brand aligners during their initial phase of treatment. The findings indicate there is little clinically significant effect on comfort, speaking, the level of dryness, or excess salivation perceived by the patient. Perhaps most importantly, the majority of patients were satisfied; only one patient reported being dissatisfied with the experience of using the Invisalign aligners. OP

REFERENCES 1. Guggenheimer J, Moore PA. Xerostomia: Etiology, recognition and treatment. J Am Dent Assoc. 2003;134(1):61-69. 2. Hopcraft, MS, Tan C. Xerostomia: an update for clinicians. Aust Dent J. 2010;55(3):238-244. 3. ADA Council on Scientific Affairs. Artificial salivas. Xerostomia. J Am Dent Assoc. 2001:132(2):1720-1721. 4. Furness S, Bryan G, McMillan R, Birchenough S, Worthington HV. Interventions for the management of dry mouth: nonpharmacological interventions. Cochrane Database Syst Rev. 2013;9. 5. Dawes C. Physiological factors affecting salivary flow rate, oral sugar clearance, and the sensation of dry mouth in man. J Dent Res. 1987;66:648-53. 6. Villa A, Polimeni A, Strohmenger L, Cicciù D, Gherlone E, Abati S. Dental patients’ self-reports of xerostomia and associated risk factors. J Am Dent Assoc. 2011;142(7):811-816. 7. Furness S, Worthington HV, Bryan G, Birchenough S, McMillan R. Intervention for the management of dry mouth: topical therapies. Cochrane Database Syst Rev. 2011;12. 8. Boyce HW, Bakheet MR. Sialorrhea: a review of a vexing, often unrecognized sign of oropharyngeal and esophageal disease. J Clin Gastroenterol. 2005;39(2):89-97. 9. Blissit KT, Tillery E, Latham C, Pacheco-Perez J. Glycopyrrolate for treatment of clozapine-induced sialorrhea in adults. Am J Health Syst Pharm. 2014;71(15):1282-1287. 10. Dental Product Spotlight. Artificial Salivas. J Am Dent Assoc. 2001;132(12):1720-1. 11. Young CA, Ellis C, Johnson J, Sathasivam S, Pih N. Treatment for sialorrhea (excessive saliva) in people with neuron disease/ amyotrophic lateral sclerosis. Cochrane Database Syst Rev. 2011; 5(pub2). 12. Owen AH 3rd. Accelerated Invisalign treatment. J Clin Orthod. 2001;35(6):381-385. 13. Tuncay O, Bowman SJ, Amy B, Nicozisis JT. Aligner Treatment in the teenage patient. J Clin Orthod. 2013;47(2):115-119. 14. Nedwed V, Miethke RR. Motivation, acceptance and problems of Invisalign patients. J Orofac Orthop. 2005;66(2):162-173. 15. Miller KB, McGorray SP, Womack R, Quintero JC, Perelmuter M, Gibson J, Dolan TA, Wheeler TT. A comparison of treatment impacts between Invisalign aligner and fixed appliance therapy during the first week of treatment. Am J Othod Dentofacial Orthop. 2007:131(3):302e1-9. 16. Shalish M, Cooper-Kazaz R, Ivgi I, Canetti L, Tsur B, Bachar E, Chaushu S. Adult patients’ adjustability to orthodontic appliances. Part I: a comparison between Labial, Lingual, and Invisalign. Eur J Orthod. 2012;34(6):724–730. 17. Fujiyama K, Honjo T, Suzuki M, Matsuoka S, Deguchi T. Analysis of pain level in cases treated with Invisalign aligner: comparison with fixed edgewise appliance therapy. Prog Orthod. 2014;22:15:64. 18. Schaefer I, Braumann B. Halitosis, oral health and quality of life during treatment with Invisalign® and the effect of low-dose chlorhexidine solution. J Orofac Orthop. 2010;71(6):430-441.

to the weekly Orthodontic Practice US newsletter! Each week subscribers can look forward to receiving relevant and innovative information including: • CE articles • Practice Profiles • Case Studies • Cutting-Edge Technology • and more

Subscribe for free today: http://ortho-us.link/orthonewssignup

48 Orthodontic practice

Volume 7 Number 1

NEW YEAR NEW RELEASE ANNOUNCING THE

EXCELLERATOR PT ÂŽ

The Excellerator PT (Power Tip) is the latest addition to Propelâ&#x20AC;&#x2122;s award winning series of Excelleration Drivers. Powering the PT is the cordless Orthonia driver with a contra-angle head, allowing easy access to all areas of the mouth including lingual, posterior and palatal surfaces. - Ergonomic design for comfortable use over multiple applications - Optimal torque and speed making procedures fast and easy - Surgical stainless steel assures tip strength and integrity - Patented thread design creates perforations with ease - Facilitates cases using braces or clear plastic aligners

Propel is an authorized reseller of the Orthonia Power Driver which is manufactured by Jeil Medical Co.

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