Orthodontic Practice US March/April 2016 Vol 7., No 2 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews

PROMOTING EXCELLENCE IN ORTHODONTICS 3D orthopedic development for pediatric obstructive sleep apnea (OSA) Dr. Steven R. Olmos

Sleep-disordered breathing in orthodontic patients: part I Dr. John Stockstill

Living with the choices we make Tony Robbins and Tom Zgainer

BioDigital Orthodontics: part 20 Dr. Rohit C.L. Sachdeva

AAO preview Special section

ACHIEVING YOUR YOUR CLINICAL CLINICAL GOALS. GOALS. ACHIEVING

March/April 2016 – Vol 7 No 2

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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 WEBSITE MANAGER | Anne Watson-Barber Email: anne@medmarkaz.com E-MEDIA PROJECT COORDINATOR | Michelle Kang Email: michellekang@medmarkaz.com FRONT OFFICE MANAGER | Theresa Jones Email: tjones@medmarkaz.com

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Digital orthodontics: from good to great

igital orthodontics is getting a lot of traction these days. Just look at orthodontic publications — they all address digital orthodontics in some way. So why incorporate it into our practices? Is it only for the younger orthodontist? How and when do I bring it into my practice? These are questions that we need to answer for ourselves individually. However, I am sure we all want our results to be great and our orthodontic care to be efficient. James Collins in his book, From Good to Great, sums it up best: “Greatness is not a function of circumstance. Greatness, it turns out, is largely a matter of conscious choice.” However, the one thing that rings true is that the digital world has improved every other industry and profession. For example, the automobile today can be produced more efficiently, more cheaply, and to higher standards than automobiles 20 years ago. Why shouldn’t orthodontic results and processes also be improved with digital applications? It is a conscious choice we have to make and make sooner rather than later. If we were to “wave the magic wand,” what would we orthodontists want to see in our orthodontic treatment and results? I think we would all agree that we want great smiles, with great occlusions in the shortest amount of treatment time. We would also want to be able to compare treatment modalities and results, so we can customize the treatment to our patients’ needs and desires. Digital orthodontics affords us the opportunity to do this with more accuracy than conventional orthodontics. Smile lines, smile arcs, cants, and interincisal angles can easily be addressed in most cases with the use of digital orthodontics, rather than by conventional estimation of bracket positions and wire bends. We are still bending wire, of course, but now with “robots” instead of by hand. Additionally, the robotically bent wire is more accurate and can address movements in all three planes of space simultaneously. Digital orthodontics aids in our treatment planning and in our application of our orthodontic knowledge. We must still remember that digital orthodontics is just a tool — one of great sophistication — but still a tool. We must still be orthodontists and continue to diagnose and treatment plan our patients. Digital orthodontics represents a paradigm shift in how we do it, but it is still the orthodontist who determines the course of treatment. Moving to digital takes an investment in time for learning, staff training, and equipment. The use of this digital “tool” does not allow just anyone to do excellent orthodontics any more than giving someone Jordan Speith’s golf clubs is going to make him/her a pro-caliber golfer. Because of this requirement of core professionalism, the fear of non-specialists incorporating digital technology may not be as real as we may fear. Given the shift toward digital technology, when is a good time to incorporate it into your practice? There is no time like the present. Technology is rapidly changing, and the “catchup” costs are increasing. The longer we wait, the harder and more expensive it will be to go digital. For the seasoned orthodontists, switching to digital systems may not seem like a good investment, particularly when they may be near transitioning their practice. To me, this is misguided thinking. Recent graduates have more than likely been trained using digital treatment methodologies and would be looking to purchase or associate with a technologically advanced practice. Orthodontics has changed and changed for the better. Digital orthodontics is here to stay. There are many opportunities to become engaged in this new way to practice, and there is certainly a program or process to meet every orthodontist’s requirements. Darwin’s concept of “survival of the fittest” is often thought to refer to being the biggest, fastest, or strongest. His truly revolutionary thinking, however, is that the fittest is the one who could adapt to change. Now is the time to elevate our orthodontics, our patient care, and our practices to the digital level. It’s our time to adapt and change for the better.

SUBSCRIPTION RATES 1 year (6 issues) $129 | 3 years (18 issues) $319 © FMC 2016. 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 2

Dr. William Crutchfield holds a BS in Biology from Virginia Tech and a DDS from the Medical College of Virginia. He also completed his orthodontic residency at the Medical College of Virginia and now practices in Chantilly, Virginia. Dr. Crutchfield is recognized as a Diplomate of the American Board of Orthodontics. He began offering suresmile® treatment in 2008. Since then, Orthodontics By Crutchfield is a 100% suresmile practice, completing 1,100 suresmile cases.

Orthodontic practice 1

INTRODUCTION

March/April 2016 - Volume 7 Number 2

TABLE OF CONTENTS

Financial focus Living with the choices we make Tony Robbins and Tom Zgainer discuss why you should understand how fees in your retirement plan investments will affect your future and that of your employees.................... 14

A conversation with ... The early days of nitinol wire

Case challenge The Propel Clinical Case Challenge: case results ........................................................16

Dr. Larry White interviews Dr. Patrick Brady

Orthodontic concepts Biodigital Orthodontics Design and use of suresmileÂŽ 3D-printed, customized indirect bonding trays: part 20

Case study

Dr. Rohit Sachdeva discusses how the unique features of suresmileâ&#x20AC;&#x2122;s IDB can lead to predictable bonding and treatment outcomes........................ 20

Utilizing CEREC scans with ClearCorrect for alignment Dr. James Alexander discusses a way to avoid traditional PVS impression

ON THE COVER Cover photo courtesy of Dr. Rohit Sachdeva. Article begins on page 20.

2 Orthodontic practice

Volume 7 Number 2

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TABLE OF CONTENTS

Continuing education Sleep-disordered breathing in orthodontic patients: part I — diagnostic and management guidelines

Preview ighlights

Dr. John Stockstill discusses how orthodontics is key to the multidisciplinary, evidence-based approach to diagnosis, and management of sleep-disordered breathing problems........................ 42

Continuing education 3D orthopedic development for pediatric obstructive sleep apnea (OSA)

Dr. Steven R. Olmos offers information to raise awareness about the signs and treatment of OSA

AAO preview 2016 Annual Session

......................................................48

Propelling orthodontics Increasing microosteoperforation efficiency with Propel’s new Excellerator PT Dr. Gary Brigham discusses his experience with an efficient, productive, and patient-friendly device ........................................................56

4 Orthodontic practice

Laboratory link

Practice management

Retention — esthetics, delivery, and long-term success

Three tips for boosting practice growth and leveraging esthetic treatment options

James Bonham highlights recent advancements in posttreatment retention appliances........................60

Research A survey of orthodontic practitioners regarding centric bite registrations

Dr. Christopher Cosse offers advice for a streamlined and profitable year ........................................................70

Industry news................72

A study by Drs. Nancy Proano Wise, Donald Rinchuse, and Daniel Rinchuse .......................................................64

Volume 7 Number 2

A CONVERSATION WITH ...

The early days of nitinol wire Dr. Larry White interviews Dr. Patrick Brady

odern orthodontics has experienced some significant developments over the past 75 years that have resulted in the current state of the art. The first was, of course, Dr. Edward Angle’s development of the edgewise bracket which has endured with only supplemental changes such as the twin-bracket design by Dr. Brainerd Swain, addition of rotation wings by Dr. Paul Lewis, and the Uni-Twin™ (3M Unitek) bracket developed by Dr. Tom Creekmore along with the self-ligation brackets of late. Certainly the change initiated by Rocky Mountain® Orthodontics from customized gold appliances to preformed stainless steel brackets, bands, and wires presented orthodontists and their patients with another large improvement in therapy. Perhaps nothing contributed more to patient comfort than the development of direct bonding begun by Dr. George Newman, which eliminated the fitting and cementing of multiple bands. Dr. Larry Andrews’ introduction of the Straight Wire Appliance™ captured the imagination and endorsement of the profession in the early 1970s. Simultaneously, Dr. George Andreason, Chairman of the Orthodontic Department at the University of Iowa Dental College, had begun to work with nitinol wire, whose eponymous name derived from its content — nickel and titanium (NiTi) and its development at the Naval Ordnance Laboratory (NOL). In this issue of Orthodontic Practice US, Dr. Larry White interviews Dr. Pat Brady

of Dallas, Texas, who, as an orthodontic resident at Iowa, worked closely with Dr. Andreason in those early investigations and published one of the first articles on nitinol wire. Dr. Brady will share some of his experiences in those early days with nickeltitanium wires.

By the time you arrived at Iowa, the chairman of the orthodontic department, Dr. George Andreason, had already established himself as a first-rate researcher and orthodontic scholar. What was it like to work with him? What was his style? George was a very humble and quiet person. He led by knowledge and patience. He treated all students equally. In my time as a resident, I never heard him raise his voice in anger to any resident or colleague. He was one of the most intelligent persons that I have ever known. He had an engineering degree and was also a Rhodes Scholar. He was extremely sensitive to peoples’ needs and helped as much as possible with clinical theses and with any personal problems of the residents. I found him to be very competitive, however. He and I played racquetball a lot, and he was relentless in his efforts to win. I worked on my thesis at his home in the garage, and this was great for both of us. We got to know each other well, and his great humor came through. It was actually fun working together and wasn’t a chore at all.

When, where, and how did you get the idea that nickel-titanium wire might be useful in orthodontics? I was discharged from the United States Air Force Dental Corps in June 1969 and had started my orthodontic residency at the University of Iowa Dental College. One day when I was in the orthodontic conference room, Dr. Andreason asked me to read an article in a national news magazine about a couple of men, William Buehler and Frederick Wang, at the Naval Ordnance Laboratory who were working with a wire alloy made of almost equal parts of nickel and titanium. Dr. Andreason thought that this wire, which had unusual superelasticity and shape memory, was being used by the Naval Ordnance Laboratory as antennae in space satellites and might have an orthodontic use. The wires that the Naval Ordnance Laboratory used were cooled, folded, and packaged in satellites. In space, the package heated and opened because of its shape memory, and the satellites functioned. We felt that perhaps a cooled nitinol wire might warm in the mouth and align the teeth. This idea evolved into my Master’s Thesis, A Use Hypotheses for 55 Nitinol for Orthodontics, which was published in the April 1972 issue of The Angle Orthodontist.

Even in 1969, many orthodontic residents were still doing theses based on cephalometric studies. Did it excite you for Dr. Andreason to ask that you work with him on the only nonferrous orthodontic metal since stainless steel became popular 30 years earlier? George definitely thought “outside of the box.” When he asked me to work on this project, I jumped at it. At the time, I had no idea that nitinol wire would be in the future of orthodontics. I always liked to do things off the beaten path — e.g., motocross racing, handball, playing the accordion. This project kind of fit my personality. I had so much confidence in George’s abilities as a thinker and clinician that I was completely taken with this challenge.

6 Orthodontic practice

Volume 7 Number 2

Intelligent design for maximum reliability and comfort. Value priced for practice profitability.

SMPP568Rev111815

A CONVERSATION WITH ...

George’s engineering degree, his vision, and creative genius in the clinic allowed us to have one of the most useful tools ever to straighten teeth.

What were the features that made nickel-titanium wires so inviting to you and Dr. Andreason? Nitinol wires have two closely related properties — shape memory and superelasticity. Shape memory is its ability to undergo deformation at one temperature and then recover its original shape upon heating above its transformation temperature range (TTR). Superelasticity refers to the wire’s enormous flexibility that is 10 to 30 times more than comparable stainless steel or twist flex wires. These unusual features derive from its reversible crystalline transformation between the high temperature austenite (parent phase) and the martensite (daughter phase) that occurs when the alloy cools. We were interested in the amount of force that occurred by the crystalline change during the transformation temperature range (TTR). We couldn’t come up with a simple plan to measure this force during leveling and alignment of teeth, but we realized that the wire would stretch about 8% of its length. This led us to measure the force of recovery after stretching and subsequently heating the wire, which then returned to its original length. This suggested the possibility of using it as a closing mechanism much like Alastik chains or stretched coil springs. This idea proved stillborn because we could not keep the wire cool enough while attaching it to the molars before it passed through its TTR. Even though the space closure idea didn’t work out, it provided a simple way of testing the shape memory force of the wire.

Since nickel-titanium wire comes in two forms, martensite and austenite, what type did you work with originally, and what size wire did you use? The Naval Ordnance Laboratory supplied us with two types of straight martensitic wires of .020" diameter. One wire had a TTR of 16°-27°C, and the other had a TTR of 32°-42°C. Both of these wires were 8 Orthodontic practice

cold-worked martensite, and they were almost like a wet noodle, so we didn’t feel that they would be very effective in leveling and alignment, and that caused us to consider it as a stretched closing mechanism.

One conclusion of your study was that the wire’s stiffness was too low to act as a leveling and alignment wire, and that it should not be used as a main archwire, but did it not, in fact, become exactly the main archwire and useful in leveling and alignment? Yes, it did, but that didn’t happen until a few years later after Dr. Andreason and Unitek began to collaborate on the manufacture of a clinically useful wire, but even those first nitinol wires displayed extreme brittleness and poor formability and often broke between the premolars and molars where the mastication force was greatest. Dr. Rohit Sachdeva noted that the early nitinol wire had a soft outer surface that would notch from the biting pressure and work-harden, making them susceptible to fracture. It was some time before nitinol wires achieved some formability and more fracture resistance. This was done by altering the processing temperatures and the alloys used in their manufacture.

How difficult was nickel-titanium wire to make when you first started with it? Apparently, it was quite difficult and expensive to manufacture and needed to pass through several companies before a useful clinical wire could be made. That was the reason the wires we finally got in the late 1970s and early 1980s were so expensive. They started by melting, combining, and processing large nickel-titanium ingots that kept being refined, heat treated, and drawn through ever finer dies. Fortunately, for doctors and patients, these improved nickeltitanium wires proved scalable, and the price has reduced dramatically.

Nickel is a known allergen and considered carcinogenic. What prevents leakage of nickel ions from the nickel-titanium wires? When nickel and titanium combine, a stable titanium oxide forms on the surface of the wire and prevents any leaching out or ion exchange. In fact, nitinol releases nickel more slowly than stainless steel, and this stability also prevents the wire from corroding.

With the development and ubiquitous use of nickel-titanium wires, Dr. Andreason must have greatly profited from his work. Did that happen? No, it did not. George was a generous and thoughtful person, and he assigned all financial proceeds from his arrangement with Unitek Corporation to the Iowa University College of Dentistry. I, of course, have no way of knowing how much that amounted to, but it had to have been a lot. Unfortunately, George died from a brain tumor soon after the development of these wires. He was a remarkable, highly intelligent person who had a passion for his work, and his death robbed orthodontics of a seminal intellectual force that we sorely miss.

Reflecting back, what did you learn from your experience, and how has it affected your professional life? This project taught me how unique our profession is. This research pointed out how important our history is to our profession. George’s engineering degree, his vision, and creative genius in the clinic allowed us to have one of the most useful tools ever to straighten teeth. I’m very fortunate to have known and worked with him. Because of this, I feel that because of his mentorship that I was lucky to have helped improve and be a part of orthodontic history. His vision of the shape-memory mechanism has also helped improve other fields in the health profession and engineering. Every time that I tie in a piece of nitinol wire, I have to admit that I’m proud to have been a part of its pioneering efforts and thankful for George’s unrelenting obsession with bringing this wire to orthodontic clinicians.

Orthodontic Practice US thanks you for taking the time to remind us how the nitinol age began for orthodontics and your participation in it. OP Volume 7 Number 2

SMPP574Rev111915

CASE STUDY

Utilizing CEREC scans with ClearCorrect for alignment Dr. James Alexander discusses a way to avoid traditional PVS impression

24-year-old Hispanic female visited my office for a comprehensive examination, radiographs, and prophylaxis. The patient’s complaint was her lower third molars. Her periodontium was stable, with the only pocketing occurring around tooth Nos. 17 and 32. There were multiple carious lesions, and tooth Nos. 17 and 32 were partially erupted, with tooth No. 17 mesially impacted. After her restorations and extractions were completed, the patient was placed on recall. At this time, the patient expressed interest in straightening her teeth. With her dentition and periodontium stable, the patient was deemed an excellent candidate for clear aligner therapy. Upon post-orthodontic relapse, the patient was ½ cusp Class III bilaterally, with 5% overbite and 1 mm overjet. Tooth Nos. 7 and 26 and tooth Nos. 10 and 23 were in edge-to-edge occlusion. The patient lacked anterior guidance in protrusion, and she had a bilateral group function with a balancing side interference when in left excursive (Figures 1-6). After obtaining consent for orthodontic treatment and discussing treatment options, we decided to move forward. Although I had previously submitted cases with standard PVS impression techniques, I had recently become aware that ClearCorrect was now accepting digital impressions through CEREC (Sirona). Full-arch scans and buccal bite were completed with the CEREC Omnicam and submitted to ClearCorrect, along with my prescription for treatment. After receiving ClearCorrect’s proposed treatment plan, called a treatment setup, the first sets of trays arrived and were

Figure 1

Figures 2-4

Figures 5-6

James Alexander, DMD, grew up just a few miles from Saint Augustine, Florida. As a child, he enjoyed a range of activities, including soccer, baseball, football, tennis, BMX racing, and music. Although he graduated near the top of his class, he joined the United States Marine Corps at a time when most of his friends were making plans for college. The Marine Corps helped mold Dr. Alexander into the man he is today. After serving, he attended Jacksonville University, graduating summa cum laude with a 4.0 and a bachelor’s degree in biology. Following that, he earned his DMD from the University of Florida College of Dentistry. In the years since, he has continued to learn, amassing 343 hours of continuing education in his first year after dental school alone. He has trained in endodontics, attended the Nash Institute, and completed the prestigious Implant MaxiCourse® in New York City. He is also diligently working toward Diplomate status with the American Academy of Dental Sleep Medicine. Today, Dr. Alexander lives in the community he serves with his beautiful wife and three wonderful kids. Dr. Alexander is also currently a member of the American Dental Association, Florida Dental Association, Academy of General Dentistry, and the American Academy of Dental Sleep Medicine.

10 Orthodontic practice

delivered to the patient. I then performed 0.3 mm interproximal reduction between tooth Nos. 25/26 and 26/27. The patient was given the second set of trays with instructions to switch to the new tray after 3 weeks. (Wear schedule preferences can be adjusted as the clinician sees fit.) The patient returned for the second visit in 6 weeks and reported excellent compliance, which was verified by the accurate Volume 7 Number 2

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CASE STUDY fit of the trays and closed space between tooth Nos. 26/27. The third set of trays called for engagers (also known as attachments), which were placed on tooth Nos. 8, 9, 10, 11, 23, 24, and 25. For easy placement, engager templates were provided by ClearCorrect. A thin layer of Vaseline® was placed inside both engager templates, followed by Filtek™ Supreme (3M) and TPH® flowable as the final layer. The patient was then isolated, the teeth were etched and bonded, and the templates were seated. I requested the patient return in 3 weeks, and at that time, I decided to replace the No. 25 engager that had previously chipped and veriFigure 7 fied that the fourth set of trays were seating normally. The patient returned after an additional 3 weeks, and we delivered sets five and six. I began noticing a discrepancy between the lower tray and the present engagers and decided to remove all lower engagers and replaced Nos. 23, 24, and 25 using the patient’s current aligner as the template. This resulted in a much more satisfactory fit. At the next 6-week visit, the case was tracking correctly, and the new set of trays was delivered. The patient returned in 3 weeks and reported pressure between Nos. 22/23. I performed IPR in this area with a lighting strip to allow easier movement. I then delivered the next trays, both of which had an excellent fit. At the following 6-week check, tooth No. 23 was still resisting movement and not tracking appropriately. This time, stripping was performed on both the mesial and distal to ensure that the tooth had no resistance to movement. The patient was checked after 1 week, at which time I noted that the previously made space was closed, yet rotation was not complete. Additional interproximal stripping was performed, and the patient continued wearing the current aligner for an additional week. After the week, I saw the alignment of tooth No. 23 improving, and I decided to allow additional time in the current tray (Figure 7). When I saw the patient 3 weeks later, the alignment had improved further, but there were slight open contacts on both sides. Therefore, I decided to rescan with CEREC and submit for a revision to ClearCorrect. When the revision arrived, I placed an engager on tooth No. 23 and delivered the newly received trays along with another set to be changed after 3 weeks. At the 6-week check, the case was tracking correctly; 12 Orthodontic practice

therefore, the final three sets of trays were given to the patient. At the completion of these trays, tooth No. 23 had rotated into place with contacts on both sides closed. Mild occlusal adjustment was necessary

on tooth No. 23, after which retainers were ordered from ClearCorrect (Figures 8-13). The patient was very happy with the final result and delighted she was able to receive orthodontic treatment without the need for traditional PVS impressions. In summary, clear aligner therapy was successfully provided to a patient with post-orthodontic relapse with the aid of the CEREC system to provide intraoral scanning. Treatment progression was various but not unusual for an adult patient. Close observation, judicious IPR, and treatment revision were key elements for an excellent result. OP

Figure 8

Figures 9-11

Figures 12-13 Volume 7 Number 2

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FINANCIAL FOCUS

Living with the choices we make Tony Robbins and Tom Zgainer discuss why you should understand how fees in your retirement plan investments will affect your future and that of your employees

s this article was written, the presidential campaign had officially started with the Iowa caucus now completed. In each of our states, we’ll soon enjoy the great individual privilege of choosing who we think will be the most suitable candidate in each party. When November 9 rolls around, and the results of the previous day’s election are confirmed, we’ll then have to live with the choices we made, or did not make, for the next 4 years. When it comes to our retirement planning, the choices we make today related to our investment options and their associated fees need to be made with a much longer time horizon in mind. Twenty to thirty years of life after active work has completed is now the norm. And if we intend to work another 10-25 years, the opportunity for the positive effects of compounding growth in your retirement savings will make all the difference in the quality of life we might enjoy in retirement. Different from what you might choose for yourself, be it a presidential candidate or a particular investment, if you are the sponsor of a retirement plan, your employees are counting on your decisions, and the ramifications of those choices good or bad. You are choosing for them, as they generally have no say so in the matter. And yet it’s their money, their future. It is a very significant responsibility often overlooked. We review hundreds of 401k plans per month, and while the employers are certainly well intentioned, so little is often understood regarding the effect of investment-related fees over time. A recent study found that the average total cost for a small business retirement plan declined to 1.46% over the past year, and that within this amount, the investment-related expenses typically borne by participants average 1.37%. This particular study defined small plans as those with 50 participants or $2.5 million in assets. However, if you own or work for a business that has fewer than 50 participants or Peak performance strategist Tony Robbins and Tom Zgainer, founder and CEO of America’s Best 401k, offer advice on growing retirement savings.

14 Orthodontic practice

less than $2.5 million in plan assets, odds are you’re paying a substantial amount more in 401k fees. Plans in this demographic are defined as “micro” plans. It is not uncommon for the underlying investments in these plans to have expense ratios averaging between 1.50% and 2.50%. This has a major impact on retirement savings over time that can be difficult to decipher. Why is this important to you? While 1.00% may sound insignificant, the costs of your investments can have a staggering effect on your retirement savings over time. According to the Department of Labor (DOL), paying just 1 percentage point more in expenses over the course of 35 years could reduce a worker’s retirement savings by nearly 28%. For example, Bob is a participant in a plan offered by his employer with a 401k balance of $25,000 that earns 7% over the next 35 years. If Bob paid 0.50% in fees, even if he stopped making new contributions, his account would grow to $227,000 at retirement. But if he paid fees totaling 1.5%, the savings would rise to only $163,000, or 28% less. A startling statistic is that in a recent survey by the AARP, nearly 70% of participants in 401k plans believe they are paying no investment-related expenses or that their employer absorbs these fees. Nearly 40% of plan sponsors, the business owners bearing the fiduciary liability of the plan, who have chosen the providers and investments in the plan, do not know the average expense

ratios of the funds in the plan. Both figures are truly astonishing. A review of your own 401k fees and investment options should be a near-term action item. Plan sponsors are required by the Department of Labor to compare their current plans against alternatives on a regular basis to be sure all fees are reasonable and prudent. With the proliferation of lawsuits that exist — many very high-profile — recently in the news brought on by plan participants and almost always related to excessive fees or the use of proprietary funds in the 401k plan, it makes all sense to have a documented process and report of your findings in case a DOL examiner knocks on your door. We’ve made it easy for you to get a quick check to see how your plan compares to industry averages here: http://americasbest 401k.com/medmark. A couple of pieces of information are all we’ll need to complete the analysis. You’ll know right away if the path your retirement plan is heading is a place you’ll want to end up — or if a change will do you, and your employees who are counting on you, a world of good. Nothing is more important regarding your money than knowing how much you have, where it is, and if it is invested, how the costs of those investments will affect your future. Consider taking these steps for you, your family, and those you employ, who most likely do not even understand how your choices affect their future. OP Volume 7 Number 2

Better, together. + At 3M Oral Care, we help you work smarter and more efficiently to improve lives and deliver better results. The incomparably aesthetic Clarity™ ADVANCED Ceramic Brackets are available with APC™ Flash-Free Adhesive — an adhesive pre-coated technology for brackets that does not require flash clean-up and reduces bonding time by up to 40%*. The APC™ Adhesive Coated Appliance System is the most efficient bonding system in orthodontics — proven worldwide**. No other system comes close.

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* “According to… early users, APC Flash-Free Adhesive has shown a 40% reduction in bonding time…”, S10659, 03/2013. Not yet verified by published, peer-reviewed research. ** Not yet verified by published, peer-reviewed research. © 3M 2016. All rights reserved. 3M, APC and Clarity are trademarks of 3M. Used under license in Canada.

CASE CHALLENGE

The Propel Clinical Case Challenge: case results

ast summer, Orthodontic Practice US and Propel Orthodontics partnered to publish results from The Propel Clinical Case Challenge — “Bring Us Your Most Challenging Cases, and We’ll Bring You the Solution.” The following participating doctors are representative of the dramatic results that orthodontists can achieve.

Jean Seibold McGill, DDS, MS, PC Easton, Pennsylvania Dr. McGill is a graduate of Northwestern University Dental School, completed her orthodontic residency at the University of Michigan, and is a Diplomate of the American Board of Orthodontics. She has been in private practice since 1995, is one of the top providers of Insignia in the United States, and lectures to other orthodontists on the Insignia System. She currently serves as a Clinical Assistant Professor, Department of Orthodontics, Rutgers School of Dental Medicine.

Weddings and Propel — An excellent treatment option Propel is an excellent tool to meet wedding date goals without compromising treatment outcomes. Patient diagnosis and treatment goals Kerry, a 25-year-old female, presented in July 2014 with Class I moderate crowding, narrow arches, and anterior open-bite tendency with a high mandibular plane angle. Treatment plan included non-extraction, upper clear Damon® brackets, and Damon Insignia brackets on the lower arch. In addition, posterior bite turbos were placed along with daily squeeze exercises to assist bite closing. Initial treatment time was estimated at 22-24 months without Propel. Brackets were placed. December 2014: Kerry’s wedding was planned for September 2015. She requested to reduce the 22-24 month treatment to 15 months. March 2, 2015: As a wedding gift, our office offered to add complimentary Propel procedures. I performed interproximal single Propel perforations from the first molar to the first molar in both the upper and lower arches. The posterior perforations were 5 mm, and the anterior perforations were 3 mm. May 27, 2015: A second Propel procedure was performed at 12 weeks with the same molar-to-molar interproximal single perforations in both arches. September 10, 2015: Treatment was successfully completed in 15 months with 16 Orthodontic practice

Figure 1: Initial treatment records

Figure 2: Patient 12 weeks after initial Propel procedure

Figure 3: Final treatment records after 15 months of treatment with Propel. The original treatment time without Propel was estimated at 22 months

Figure 4: Pretreatment (top) and 15-month posttreatment (bottom) photos treated successfully using Propel

the assistance of Propel. Retention included a clear Essix retainer with full-time wear for the first month, followed by nighttime wear for lifetime. We also placed an upper 2-2 bonded retainer and lower 3-3 bonded retainer. Minimal incisal edge bonding was also added. Dr. McGill shared her thoughts: “We choose to use Propel proactively and offer it in our consultations with adults and teens who are not on anti-steroidal medications. It is also a great option to use in midtreatment to help progression of stubborn tooth movements.”

Figure 5 Volume 7 Number 2

CASE CHALLENGE

Randall L. Shaw, DDS, MS Livonia, Michigan Dr. Shaw received his DDS degree from the University of Michigan. He completed an Orthodontic Residency at Washington University in St. Louis. He serves as faculty and a Clinical Advisory Board member for suresmile® and is in full-time private practice in Livonia at Drs. Shaw & Jane Orthodontics.

A case in progress Read about the progression of Dr. Shaw’s challenging case. Patient diagnosis and treatment goals Jeremiah is a 21-year-old male concerned with severe crowding and overbite. He presented with a Class II Division 2 malocclusion, severe crowding, and a 100% overbite. The incisors were very linguoverted due to an extreme curve of Spee in the lower arch. Treatment was planned non-extraction to flare the upper and lower incisors, intrude the lower incisors to open the bite, and utilize Class II elastics to correct the overjet. With compliance, treatment was anticipated to take 22 months. April 2, 2015: Full upper and lower SPEED brackets were placed 7-7. Archwires were fully engaged in all the brackets with an additional open coil to make space for the lower right central incisor. Bite turbos were placed on the lingual of the upper centrals to protect the lower braces and help intrude the lower incisors. June 18, 2015: Jeremiah came in to continue opening space for the lower central. Because of the extensive amount of movement remaining, we made Jeremiah our first unplanned Propel patient. Perforations were made with the Propel Excellerator interproximally from the distal of the cuspids forward according to the standard protocol of two to three vertical perforations. In hindsight, I probably should have gone at least to the distal of the second bicuspids. Post Propel, Jeremiah experienced some short-term numbness and tenderness but felt fine after a few hours. July 16, 2015: There was great progress in the alignment and rotations and significant leveling of the lower arch. The open coil was compressed to help rotate the lower right central incisor. August 3, 2015: Jeremiah returned to have a bracket rebounded, and we were actually able to reengage the central incisor into the archwire. Typically, we’d need 6-8 weeks to get enough movement to engage this tooth, but it was ready 18 days after activating the coil spring. September 22, 2015: All the rotations were fully corrected, and overbite was reduced to 40% during these 3 months! We inserted 19 x 25 finishing wires with all brackets easily engaged. Class II elastics were started on these wires to begin reducing the overjet that Volume 7 Number 2

Figure 1: Initial records

Figure 2: Jeremiah after first Propel procedure (Microosteoperforations (MOP) in photo

Figure 3: Jeremiah almost 1 month after Propel procedure

Figure 4: Jeremiah 3 months after Propel procedure.

Figure 5: Pretreatment photos (Left), and 7.5 month posttreatment progress photos (right) after initiating Propel approximately 6 weeks into treatment

had developed from flaring the upper incisors. November 12, 2015: (7 months after treatment initiated) A 19 x 25 TMA was placed in the lower arch. Overbite is ideal; lower arch is level. We engaged these finishing wires 5 months after accelerating with Propel. Originally, we had hoped to be able to insert these after 1 year. January 21, 2016: We removed his bite turbos since the overbite was completely corrected, and the incisal edges were cosmetically recontoured. We continued Class II

Figure 6: Bite turbos removed and final detailing to correct midlines approximately 9 months after treatment started and only one Propel procedure

elastics on the right side only to coordinate the midlines. Final detailing was started. His treatment progress continues to be exceptional! Dr. Shaw shared his thoughts about the progress results: “I wasn’t sure what to expect even after extensive research. I was astonished by the incredible tooth movement we achieved in a short period of time.” Orthodontic practice 17

CASE CHALLENGE Marc Yarascavitch, DDS Huntsville, Ontario Dr. Yarascavitch completed his dental degree at the University of Toronto in 2008 and his master’s degree in 2010 in the Graduate Orthodontics Program. He has successfully completed his orthodontic specialty examination and practices orthodontics in Muskoka, Ontario.

Missing bicuspid site closure? Closing large extraction sites (or in this case congenitally missing teeth) can present extended treatment times and difficult mechanics. Dr. Yarascavitch initiated Propel and mini-screw anchorage with amazing results. Patient diagnosis and treatment goals Virginia’s consultation and treatment started in March 2014 at age 14. She had a Class II Division 1 malocclusion with a retrognathic facial type and long lower face height, mild upper and lower crowding, minimal overbite and overjet, multiple retained primary teeth, including primary second molars, missing adult second premolars, lingually ectopic lower adult canines, and an upper-right crossbite. My initial plan was full fixed orthodontics, trimming the lower primary molars to smaller proportions and keeping them as long as possible eventually replacing with implants. Early in treatment, the primary molars were creating difficulty in establishing a good occlusion. Virginia did not want implants and wished to close spaces. After much deliberation with Virginia and her primary dentist, lower second primary molars were removed December 2014. January 7, 2015: Virginia had the lower second primary retained molars recently removed. After 10 months, I was losing upper and lower incisor torque using conventional mechanics and Class III elastics. I planned to place lower TADs to help protract molars, correct incisor torque, and re-establish normal overjet. October 1, 2015: Virginia expressed frustration regarding treatment time, and I told her we’d try Propel. There had been some slow space closure with mini-screws. I placed a single perforation mesial and distal to the lower first molars on the buccal alveolus. Space-closing coils were placed from the indirectly screw-anchored lower premolars to the first molars, and light Class III elastics were used to support movement along a rounded 17 x 25 SS archwire.

October 28, 2015: Four weeks after Propel, the lower-right first molar moved 2 mm mesial. The lower-left first molar moved 1.5 mm mesial; the lower-right second molar moved 2 mm; and the lower-left second molar moved 1.5 mm. Gingiva was healthy, and no abnormal discomfort was noted. December 1, 2015: Eight weeks after the first Propel procedure, the space mesial to the lower-left first molar was eliminated, and the lower-right and left second molars protracted a large distance. The lower-right first molar moved an additional 1 mm; and the lower-left first molar moved 1.5 mm. Lower second molars

Figure 1: Patient initial records taken July 2013

Figure 3: First Propel treatment initiated October 1, 2015

Figure 5: December 1, 2015: 8 weeks post-Propel treatment, space closure was successfully achieved. A second Propel procedure was initiated mesial to the lower second molars. (Procedure site can be seen in photo on right) 18 Orthodontic practice

continued to move mesially (1 mm right; 1.5 mm left). The panoramic shows bone remodeling distal to the lower first molars, and gingival attachment was healthy. A second Propel procedure was performed just mesial to the lower 7’s. January 2016 Update: The lower first molars were protracted successfully, and the lower second molars were simultaneously protracted more than 4 mm over the course of 12 weeks. Only minor spaces remain, and I expect that in February 2015, all lower spaces will be closed. Virginia’s case will only require minor finishing/settling, and she’s delighted to be done ahead of schedule. Dr. Yarascavitch noted, “I have done more cases for ‘problem teeth,’ but I hope to start some full Propel Micro-osteoperforation (MOP) cases for accelerated overall treatment from the start as a general protocol.” OP

Figure 2: January 7, 2015: Progress photos before TAD placement after 10 months of conventional anchorage and mechanics

Figure 4: 4-week progress from first Propel procedure. The lower-right molar had moved mesially by 1.5 mm in 1 month

Figure 6: December 1, 2015: Panorex shows bone remodeling distal to the lower first molars

Figure 7: January 4, 2016: Progress shows healthy tissues and most of the molar space closed Volume 7 Number 2

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ORTHODONTIC CONCEPTS

Biodigital Orthodontics Design and use of suresmile® 3D-printed, customized indirect bonding trays: part 20 Dr. Rohit Sachdeva discusses how the unique features of suresmile’s IDB can lead to predictable bonding and treatment outcomes Introduction In its goal to better patient care, the profession of orthodontics is cautiously transforming conventional care delivery from an analog, reactive, and standardized approach to a digital, proactive, and customized approach. This digital care platform is enabled by technologies such as 3D imaging, computer-aided design software, and robotic and 3D printing. Recently, suresmile® has expanded its technology repertoire from prescriptive, customized archwires for finishing — commonly used in the latter half of treatment — to include indirect bonding (IDB) trays. IDB trays facilitate a more accurate, precise, and efficient placement of brackets at the start of treatment.1 In addition to the proper use of suresmile technology, I must emphasize that a robust plan and the appropriate management of the patient are the driving forces for any successful treatment outcome. This is the

central tenet of my philosophy and practice of biodigital orthodontics and is discussed in my previous articles.2-5 This article will discuss the design principles for and chairside technique of bonding with the suresmile IDB tray, explaining how the unique design features of the suresmile design software and IDB tray allow for more predictable bonding and treatment outcomes.

Designing the suresmile IDB tray The suresmile IDB tray is designed on the virtual dental working model, also known as the virtual diagnostic model. (Note from author: I prefer the phrase “virtual dental working model” as it better describes the use case of the model. And when I use it for diagnostics, I call it the virtual diagnostic model.) The dentition may be imaged in two ways in order to create the virtual dental working model. Direct in vivo optical scanning Direct in vivo optical scanning is the optimal approach to obtain an accurate digital representation of the malocclusion6-7 (Figure 1); suresmile recommends this method. A number of suresmile-certified,

light-based scanners may be used for image capture (Table 1). Prior to scanning the patient, it is best to smooth jagged tooth edges or surface aberrations to allow for better fitting trays. Indirect in vitro optical scanning Indirect in vitro optical scanning involves scanning the plaster model of the malocclusion; any of the suresmile-certified, lightbased scanners may be used for imaging. This approach to image capture is not recommended by suresmile due to the loss of accuracy that occurs when taking impressions and pouring the model in plaster. If the clinician opts for indirect in vitro optical scanning, he/she should take a PVS impression and pour the model in hard stone (Figure 2). As a word of caution, the processing of such models faces a high-rejection rate from the suresmile laboratory, delaying the delivery of the tray.

Types of suresmile IDB trays The suresmile laboratory processes the 3D virtual dental working model within 2 business days of receiving the raw scan data from the practice. I classify the IDB trays into three types — namely types 1, 2, and 3.

Table 1: Imaging devices certified by suresmile Optical scanners

CBCT machines

3M™ True Definition

i-CAT® Classic, Next Generation, and FLX

TRIOS 3, TRIOS

Carestream® CS9300, CS9300 Select and 9500

Figure 1: An in vivo preprocessed scan taken with the orascanner 2 and virtual dental working model

orascanner® 2

Planmeca® ProMax® 3D Max, ProMax® 3D Mid, ProMax® 3D Classic

iTero® for Orthodontics and IOC

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.

20 Orthodontic practice

Volume 7 Number 2

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October 2014 Frontal initial

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September 2015 Final result

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to be sure.

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ORTHODONTIC CONCEPTS

Figure 2: Typical patient suited for Type I IDB. Images of the dentition, 2D, and 3D intraoral (in vivo optical scan)

Figures 3A-3C: IDB Design. 3A. Bracket type and height selection and workflow checklist. 3B. Initial virtual auto bonding on the working dental model. 3C. Initial virtual bracket correction prior to simulation. Note the exaggerated distal crown tip angulation on the upper right molar bracket. It is highlighted, and the navigational tools are used to correct its position

Figure 4: Type 1 IDB. Intrarch setup. Archform selection and simulation

Type 1 IDB tray Type 1 is the most common tray used. The design of the type 1 tray is based upon an intrarch setup and follows the straight archwire paradigm.8 Each arch is treated independently, and the only variables considered in this setup are crown morphology, relative spatial position of the teeth, archform, and bracket prescription. The type 1 arch is indicated in patients who require first- and second-order tooth corrections with a minimal need for third-order movements to coordinate the upper and lower dental arches (Figure 2). Local third-order corrections are managed by choosing the appropriate bracket prescription from the bracket library or by preferentially placing the brackets (i.e., inverting the brackets). 22 Orthodontic practice

The design sequence for the tray replicates the clinical procedures a clinician follows when he/she directly bonds a patient; this process consists of four steps, which are described below in the following stepwise guide. Step 1: virtual pre-bonding phase (Figures 3 and 4) a. Bracket system selection i. The clinician selects the bracket system of his/her choice from the electronic bracket library. (The library has over 30,000 bracket systems or types to choose from.) If the bracket type is unavailable, suresmile will scan the type into the library upon receiving a request from the doctor or manufacturer.

b. Bracket height selection i. Bracket heights may be customized to suit individual preferences or may be based on measures guided by the doctor’s treatment philosophy. c. Archform selection i. The treatment archform is selected from the menu. The necessary parameters need to be only input once and are stored in the system under the doctor’s preferences. At any point in time, this list may be modified to include different bracket systems, heights, etc. Step 2: virtual initial bonding phase (Figure 3) a. Automatic bracket placement i. The software automatically populates the dentition with the selected brackets at the selected heights. b. Bracket position evaluation and correction i. Bracket positions are quickly evaluated. A bracket that appears misplaced may be readily corrected using the software’s navigational tools. Step 3: virtual target setup (Figure 5) a. Automatic virtual target setup i. Based upon the selected bracket heights and archform, the software automatically generates a 3D virtual intrarch target setup. Volume 7 Number 2

automatically synchronized with bracket position adjustments on the working model. Step 4: virtual IDB tray design and order (Figure 6) a. Automatic IDB tray design and order i. The IDB tray is designed automatically. If the clinician needs sectional trays, appropriate segments are selected in the

menu, and the software automatically generates the trays for sectional use. The trays are ordered following this step. The entire process of designing the type 1 IDB tray typically takes less than 5 minutes of operator time. The IDB tray is produced using additive 3D printing technology and is fabricated from MED610, a biocompatible polymer manufactured by StratasysÂŽ (Stratasys,Â Eden Prairie, Minnesota). The tray is shipped within 5 business days of receiving the virtual IDB prescription from the practice.

Clinical technique for bonding with the suresmile IDB tray

Figures 5A-5F: Bracket position correction post simulation. 5A. Mesio-lingual rotation of upper right second molar. 5B. Bracket activated and moved mesially to correct rotation. 5C. Rotation corrected automatically in response to new bracket location. 5D. Bracket position adjusted on the working dental virtual model. 5E. Initial virtual simulation model. 5F. Final virtual target model

Figure 6: Virtual suresmile indirect bonding tray. It is automatically designed

Figures 7A-7B: 7A. suresmile indirect bonding tray showing design features. 7B. Close up external view of bracket receptacle (cap)

Figures 8A-8B: suresmile IDB trays in their original packing and the bonding preparation kit. 8B. Checking design of the suresmile IDB tray against its virtual counterpart on the computer screen Volume 7 Number 2

The following section summarizes the technique for bonding with the suresmile IDB tray (Figures 6A and 6B). Emphasis is placed on the procedures specific to the use of the suresmile IDB tray. Step 1: IDB tray check and preparation (Figures 8A and 8B) a. Tray integrity and design is first verified against the virtual tray image on the computer. b. Since the tray is not produced in a sterile environment, it should always be wiped down with isopropyl alcohol prior to use. Acetone reacts with the tray material and will damage the tray; therefore, acetone should never come into contact with the tray. c. The patient ID tag should be snipped off with scissors prior to use (Figure 9).

Figure 9: Clipping the patient identification tab off the suresmile IDB tray Orthodontic practice 23

ORTHODONTIC CONCEPTS

b. Virtual target setup evaluation i. The target setup is evaluated for any incorrect tooth positions. Again, corrections are easily performed using the navigational tools, and radiographs may be used to estimate root position and make appropriate corrections to the setup. Bracket position corrections in the virtual target setup are

ORTHODONTIC CONCEPTS

Figures 10A-10E: Loading the brackets in the tray. 10A-10B.This is easily accomplished with finger pressure. 10C. Or the use of an instrument 10D-10E. The bracket is guided into its receptacle by the proximal walls

d. The tray material is biocompatible and is certified to be in contact with the oral mucosa for up to 24 hours. Step 2: loading brackets in the trays and application of the adhesive (Figures 10A-10D and 11A-11C) a. The prescribed brackets should be loaded. Prior to loading self-ligating brackets, the doctor should make sure that the bracket doors are firmly shut. b. The bracket is seated using gentle finger pressure aided with a scalar. Molar brackets are best seated by pushing them against the receptacle wall in a downward direction. c. Each bracket base is wiped clean with alcohol and allowed to dry. d. The adhesive is applied in clean strokes in a mesial-to-distal direction (e.g., Transbond™ XT Light, 3M Unitek, Monrovia, California). Vertically guided strokes may dislodge the bracket from its receptacle. e. A primer or sealant (e.g., Opal® Seal™, Opal® Orthodontics, South Jordan, Utah) is applied to an applicator and is used to gently press the adhesive into the pad mesh. Step 3: tooth preparation and bonding (Figures 12A and 12B) a. The techniques of standard Isolation with cheek retractors, etching, and priming are used to prepare the teeth for bonding.8-12 b. The tray is seated by applying firm pressure on the occlusal surface and firmly pushing against the labial and buccal surfaces of the teeth. c. It is preferable to use a curing light with a small tip to cure the adhesive (e.g., American Orthodontics’ Blue Ray 3 microflash LED curing light (American Orthodontics, Sheboygan, Wisconsin). 24 Orthodontic practice

Figures 11A-11C: Preparing the brackets in the suresmile IDB tray for bonding. 11A. Applying primer to the bracket base. 11B. Applying adhesive. 11C. Pressing adhesive into the bracket pad mesh

Figures 12A-12B: Sectioned suresmile IDB inserted into the mouth. 12B. Brackets are being light cured

Figure 13: suresmile IDB tray removal. Note the lingual spline is clipped before removal. A sectional tray was used in the lower arch

The light should travel over the buccal and labial surfaces of the teeth as well as the gingival margins. It is best to exceed the light manufacturer’s recommendations for curing time. Step 4: IDB tray removal (Figure 13) a. Once cured, the lingual spline is snipped away from the tray by cutting the supporting connector arm for each bracket receptacle with ligature cutters.

b. The lug on the occlusal surface of the bracket receptacle is used as a lever to gently lift and peel the receptacle away from the tooth. c. The tray or tray segment is then pulled away occlusally. Step 5: bonding check a. The bonded brackets’ positions are checked against their positions on the virtual dental working model. Volume 7 Number 2

Vi sit Bo us a ot t th h# eA

19 AO 21

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ORTHODONTIC CONCEPTS b. A discussion of clinical indications and design characteristics of the types 2 and 3 IDB trays follow. Type 2 IDB tray The design of the type 2 IDB tray is based upon a 3D interarch virtual target setup of the dentition. The type 2 arch is indicated

in patients (a) whose treatment will involve a significant amount of interarch corrections through facial orthopedics or surgery, (b) who need a significant amount of interarch form coordination through precise archwidth and torque control, (c) who have skewed and canted upper and lower arches and present with substantial variations in tooth

morphology, (d) in whom dento-alveolar compensations need to be maintained, and (e) who require lingual orthodontic treatment (Figures 14-16). Two factors need to be considered in the design and use of type 2 IDB trays. First, type 2 trays are best designed by the suresmile laboratory rather than by the

Figure 15: Typical type 2 IDB patient. Virtual target setup created by the suresmile digital laboratory based upon the doctorâ&#x20AC;&#x2122;s input

Figure 14: Typical patient suited for type 2 IDB. Images of the dentition, 2D, and 3D Intraoral (in vivo optical scan). Note the significant interarch discrepancy

Figure 16: Typical type 2 IDB patient. Comparison of initial working dental model (blue) against the final virtual target setup (white). Note the significant interarch discrepancies planned to be corrected

Figure 18: Typical type 2 IDB patient. Virtual target setup. Both the suresmile IDB tray (see later) and the 3D precision archwire are designed for such patients

Figures 17A-17D:Typical type 2 IDB patient. 17A. Note the significant amount of mandibular A-P movement planned. 17B. And the arch width changes that will need to occur in the mandibular arch to accommodate for the new mandibular position. Not shown are the changes in the maxillary archwidth in the virtual target setup. 17C-17D. Also, the occlusal plane level and cant both in the saggital and frontal and transverse plane need to be accounted for in patients with significant interarch discrepancies 26 Orthodontic practice

Figure 19: Typical type 2 IDB patient. Shows design of 3D precision suresmile archwire Volume 7 Number 2

Type 3 IDB tray The type 3 IDB tray is indicated in “highrisk” patients. This patient is commonly an adult female whose dentition is severely periodontally compromised and who seeks an uncompromised treatment result. Successful treatment for such a patient requires a comprehensive care plan developed from a thorough assessment of the 3D crown and root positions with respect to (1) their location in the alveolar bone and (2) their relationship to the soft tissues (lips, gingiva). In addition, the therapeutic management of such a patient demands 3D control of tooth movement through the entire care cycle. The 3D virtual dentofacial working model representing the dentofacial complex is constructed from an amalgamation of different images. These images include a 3D CBCT image of the dentofacial complex, an optical scan of the dentition, and a 2D frontal photograph of the patient. Note: Only suresmile-certified CBCT machines and optical scanners may be used for imaging; these are shown in Figure 21. Optical scans are necessary because the models processed from CBCT scans do not accurately represent the incisal edges of the anterior teeth, making it difficult to print wellfitting IDB trays. To overcome this limitation, Volume 7 Number 2

ORTHODONTIC CONCEPTS

orthodontic practice since the creation of the virtual setup requires a substantial time commitment from the orthodontist and care team. Second, many variables impact final tooth position, such as variation in tooth morphology, the force-system dissonance between the ideal bracket height and desired torque and bracket archwire play,13-19 etc. Unfortunately, such issues cannot be solely managed by IDB or the use of customized bracket prescriptions. To overcome these limitations, the clinician needs to pair IDB with the use of robotically bent, 3D precision archwires to achieve reliable treatment outcomes (Figures 17-20). The suresmile software provides the clinician the tools to design both the IDB tray and customized archwires in tandem (if he/she so chooses). However, as previously mentioned, the creation of the virtual target setup is best managed by the suresmile laboratory in concert with the clinician’s input. Design considerations for the virtual target setup and suresmile robotically bent prescriptive archwires have been described in previous articles.2-5 The setup services and the archwire production provided by suresmile come at an extra cost to the doctor and add a minimum of 10 business days to the delivery of the type 2 IDB tray.

Figure 20: Typical type 2 IDB patient. suresmile IDB tray design. Note for the lower arch, sectional IDB trays have been designed to allow an unobstructed path for insertion. The doctor can section the tray at level by choosing the appropriate segments. Also the software warns the doctor about conflicts in tray design

Figures 21A-21D: The virtual working craniofacial model used in the design of the Type 3 IDB. 21A. Optical in-vivo scan of the dentition. 21B. CBCT scan of the patient showing bone, crowns, and roots. 21C. Fused image of A and B. 21D. 2D-facial image superimposed over C

a supplemental in vivo scan of the patient’s dentition needs to be taken with a suresmilecertified optical scanner. This scan is then fused with the CBCT image to create a model that accurately represents the crown and root morphology and position with respect to the alveolar bone. In addition, a 2D planar frontal facial image (if provided) is superimposed on this 3D dental-skeletal model to create a virtual integrated working model. This virtual dentofacial working model is used to design an interarch “3D biologically driven” setup (Figures 22 and 23). As a clinician might expect, it is impossible to achieve “3D biologically driven” optimal tooth positions solely based upon the notion of idealized bracket positions and/ or bracket prescriptions. Predictable tooth movement necessitates the use of the type 3 IDB tray complemented with robotically bent

Figure 22: Typical type 3 IDB patient.Virtual craniofacial working model. Besides crown positioning, esthetic, and accurate 3D root position planning is possible with this model Orthodontic practice 27

ORTHODONTIC CONCEPTS

Figure 24: Typical type 3 IDB patient. suresmile Precision 3D archwire design (note IDB tray is not shown)

Figure 23: Typical type 3 IDB patient. Virtual craniofacial working model. Planning for the position of the roots in bone is also possible with this model. 23A. Note the dehiscence on the lower anterior teeth. 23B.The roots are moved in a lingual direction in an attempt to get maximum bone coverage on the labial aspects of the lower anteriors. 23C. Bracket location on the virtual target model

3D prescription archwires and auxiliary appliances that generate consistent force systems (Figure 24). Again, it should be recognized that these additional services are cost additive and increase the delivery time of the tray. The clinical technique for bonding with types 2 and 3 suresmile IDB trays is similar to the Type 1, as described earlier. There are many features of suresmile technology that provide the clinician the ability to design IDB trays that aid in accurate, precise, and efficient bonding. A discussion of these features follow: (1) software capabilities that allow the doctor to make better judgments on bracket position and (2) the physical attributes delivered by the suresmile IDB tray (i.e., how the suresmile IDB tray facilitates targeted indirect bonding in an efficient and effective manner in the clinical setting).

3D virtual dental and dentofacial working models 3D model accuracy is an important consideration in the accurate design of an IDB tray. suresmile 3D optical-scanned models have been shown to be the most accurate in the industry.20 The 3D model overcomes the limitations of and errors associated with the 2D planar view. The 3D model provides the doctor with unrestricted multiplanar views of the dentition simultaneously. These views allow for a better understanding of the impact of tooth morphology on bracket position — and subsequently tooth displacement (Figure 28 Orthodontic practice

Figure 25: Benefits of 3D multi-planar views. The brackets on both the lower second premolars have been placed at the same heights. However, their torque expressions are different as a result of variation in the labial surface contour. These differences cannot be detected easily at the chairside or casual viewing of the physical model or 3D model. The doctor has to spend the time to understand the impact of the morphological differences between the teeth on the expression of the bracket prescription and account for such anomalies in planning for care for patients

Figures 26A-26E: Benefits of 3D multi-planar views. 26A. Occlusal view of The lower left central with a distolabial rotation and the current bracket position. 26B. Apical-occlusal view of the lower left central with a distolabial rotation current bracket position as shown in Figure A. 26C. The bracket is moved distally to augment to overcorrect the rotation. 26D. If this is done, the distal flange of the pad no longer conforms to the third surface. This “ void” may result in a number of possibilities — premature bond failure due to increased adhesive interface or if not filled, plaque retention followed by decalcification. 26E. In this patient, the nonconformity of the bracket pad with the labial tooth surface of the lower right central incisor may lead to both first and third order spatial discrepancies . Multi-planar views of the brackets afford the orthodontist the ability to gauge the possible effects of the point of location of a bracket on tooth movement and institute proactive measures to prevent unwanted tooth movements

25). In addition, multiplanar views can be effectively used to view the conformance of the bracket pad to the tooth surface (Figure 26). This impacts adhesive thickness, which impacts bond strength and, as a result, bracket failure.21 With such information, the doctor can place the brackets more strategically to avoid bracket failure. Furthermore, the virtual dentofacial working model gives the orthodontist a fresh pair of eyes to better appreciate the complex interrelationships that exist among the various dental, skeletal, and soft tissue components of the dentofacial complex. This perspective allows the doctor to consider a “biologically driven” approach to bracket placement (Figures 27 and 28).2-5 The virtual dentofacial working model enhances the doctor’s ability to design bracket placement on the basis of esthetic considerations (Figure 22).22-23

Since the virtual dental and dentofacial working models reside in the cloud, the doctor and his/her care team can remotely access the model and work synchronously or asynchronously to design the IDB tray. A virtual model is in no danger of destruction, which is a concern with physical models.

Universal electronic bracket library As previously stated, the suresmile electronic bracket library houses over 30,000 bracket types or sets. This library allows the orthodontist various options in terms of selecting the appropriate bracket prescription for the patient (Figure 29).

Automated bracket placement tools and checklists While the automatic virtual bracket placement is not 100% accurate, it is based on a Volume 7 Number 2

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ORTHODONTIC CONCEPTS

Figure 28: It would be impossible to recognize the possible collision between the roots of the upper-right second molar with those of the upper-right first molar as a result of its extrusion. As a result, the mechanics and the bracket position based upon just crown position would help not the doctor plan for such contingencies and put the patient at risk

Figures 27A-27F: Example of the benefit of 3D images and multi -planar views. 27A. 2D Panorex view of upper right second molar. Its exact root position is difficult to ascertain. 27B. In-vivo optical scan does not show root position of the upper right second molar. 27C. CBCT image with bone coverage. The upper second molar root position is hidden, and therefore, difficult to evaluate. 27D. CBCT image showing only root images. Note upper second molar root appears to be trapped between the roots of the upper first molar. 27E. Apical occlusal view clearly demonstrates the problem with the root position of the upper right second molar. 27F. A sectional view of the roots at the apical third level demonstrates the complexity of the root proximity problem between the upper first and second molars

Figure 30: Evaluation and reference tools for bracket positioning. The ability to orient the patientâ&#x20AC;&#x2122;s dentition to global (external) references such as the maxillary bone, the cephalometric x-ray, the occlusal plane, and internal references such as marginal ridges and slot axis provides the clinician the unique ability to plan for superior bracket location

consistent approach to applying brackets. This approach rests on operational definitions and references that are hard coded in the software, enhancing both the efficiency and efficacy of the design process (Figure 30). Furthermore, this approach allows every member of the care team to follow a consistent protocol, minimizing variability in the design process. 30 Orthodontic practice

Simulations The ability to simulate and evaluate the effect of bracket position or boundary conditions â&#x20AC;&#x201D; such as archform or occlusal plane â&#x20AC;&#x201D; on the target tooth position in real time is impossible in the physical world (Figures 4 and 5). In vivo, the doctor would have to wait for tooth movement to occur over time in order to recognize

Figures 29A-29C: Bracket prescription selection. 29A. The upper lateral incisors are palatally displaced. During alignment, the tooth will inevitably tip, causing the incisor root to tip further palatally. An undesirable effect. 29B. the standard palatal root torque prescription often rate limits the desired correction, namely, labial root movement. 29C. This effect has been counteracted by selecting the bracket of the lateral incisor and bonding it inverted

his/her errors in bracket placement or bracket prescription. suresmile software enables orthodontists to compare the targeted movement to the original model, providing doctors with a reference point in terms of understanding whether or not they have exceeded the boundaries of tooth movement in their target setups (Figure 4). Currently, methods do not exist in the clinic or laboratory setting to accomplish such an assessment. In addition, the real-time simulations generated by suresmile software allow for self-paced learning via subtle principles of gamification. When each member of the care team uses such tools, the team is able to calibrate the skills sets across the team. Realtime interactive simulations minimize errors in the design process. These simulations also Volume 7 Number 2

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ORTHODONTIC CONCEPTS provide a visual communication tool for the doctor and his/her patients in the blue space.

Virtual target setup evaluation tools An automatic grading tool based on the ABO OGS evaluation scheme24 allows the doctor to rapidly assess the fidelity of his/ her setup and make appropriate changes through setup redesign or the modification of the bracket prescription and/or placement (Figure 31). Collision detection tools allow the doctor to evaluate interocclusal interferences (Figure 32). Dynamic evaluation tools such as the virtual articulator can be used to simulate limited mandibular movements, allowing for the evaluation of potential premature occlusal interferences and the design of a “functional” occlusion (Figure 33).25-26 Bracket interferences can also be detected and appropriate action can be taken.

suresmile IDB tray (Figures 6, 7, 10, 34, and 35) Following is a list of the unique design features of the suresmile IDB tray that promote (1) accurate and precise bonding and (2) ease of clinical use: 1. The tray is fabricated with 3D stereolithographic printing technology; this manufacturing approach has an accuracy of up to 0.1 mm. 2. The tray has a patient ID tag for ease of identification. 3. The “correctness” of the physical tray design can be easily verified against its virtual analog on the computer.

4. The tray’s material and its dual-rail track tubular splines provide the “right” flexure stiffness to the appliance, which minimizes distortion and micromovement of the tray during bonding. 5. Each bracket receptacle allows for three-wall support of the bracket, giving a snug fit to the bracket and, therefore, minimizing any chance of bracket movement. 6. The tray covers a substantial part of the tooth, providing reliable docking and stability of the device. This feature also allows for accurate and precise bracket transfer.

Blended therapeutics Proponents of the straight archwire philosophy suggest that successful treatment outcomes may be achieved with accurate bracket prescription and placement. However, numerous authors13-19 have challenged this notion, recognizing that archwire bends are required to overcome the multitude of variables that determine final tooth position. suresmile offers the clinician a blended approach to achieve the target outcome; this blended approach includes (1) accurate bracket placement with the help of indirect bonding, (2) the ability to select and use the appropriate bracket prescription, and (3) the use of a robotically bent, 3D precision archwire. Most importantly, the clinician may select any of these approaches singularly or in concert as he/she deems necessary for the patient.

Figures 31A-31B: Evaluation and reference tools. The quality of the virtual target setup can be evaluated using automated graded tools calibrated to the American Board of Orthodontics’ OGS standards. The auto-evaluation tool allows the orthodontist to recognize where his/her virtual target setup may be deficient. The orthodontist may then take corrective actions in the target setup to achieve the desired result. 31A. Shows that the bucco-lingual inclination of the lower right second molar needs correction and carries with a 2 point loss according to the ABO OGS guidelines. 31B. The corrected tooth position is shown. The feasibility of such correction is based upon the doctor’s assessment of the biological boundaries, limitations of the appliances considered for use, the patient’s care preferences, and not the doctor’s personal skills

Figures 32A-32B: Collision detection: 32A. Virtual target setup. 32B. Interocclusal interferences detected on the lower central incisors (red indicator)

Figures 33A-33C: Typical type 3 IDB patient. Virtual craniofacial working model being used in the dynamic mode. 33A. Articular eminence slope angle is established on the cephalometric image. 33B. Lower right canine is moved into alveolar bone through to maximize its bony support. (Biologically driven target setup) 33C. Functional movement in right lateral mandibular excursion is simulated to evaluate canine-guided occlusion based upon the target position of the lower right canine. Note no interferences are seen in the buccal segments. (Functionally driven target setup) 32 Orthodontic practice

Figures 34A-34E: Suresmile IDB features that are designed for stability. 34A. The buccal and lingual splines provide for flexural and torsional rigidity in all planes of space. 34B. The three-wall support for the bracket provides for lateral and vertical stability. Against the tooth, the lingual wall of the receptacle and the buccal surface of the tooth prevent movement buccolingually. 34C-34E. The inner surface of the cap is an accurate negative representation of the occlusal surface of the teeth (positive). This allows almost perfect indexing and locking of the inner occlusal surface of the tray to the occlusal surface of the teeth for accurate tray location and bracket transfer during bonding and keeps the tray stable during the installation process Volume 7 Number 2

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ORTHODONTIC CONCEPTS 7. It is reasonably easy to dock the bracket into its individual receptacle since the tray has mesial and distal channels to guide the bracket into its resting position. 8. The tray can be designed modularly to accommodate for the severity of the malocclusion and avoid conflicts. This allows for the optimal, obstruction-free “fit” of the sectioned trays. 9. The tray is not bulky and therefore is well tolerated by the patient and easily guided into the oral cavity. 10. The tray material is translucent; therefore, the curing light can be transmitted through the body of the tray. This allows for a substantial part of the bracket to be exposed to the light. 11. There are enough cutaways around the bracket receptacle to allow for the UV light to be guided around the gingival margins of the bracket in order to achieve a high cure. 12. The abilities to disengage the splines after bonding and also apply leverage against the lugs on the bracket receptacle facilitate the peeling of the tray, which ultimately minimizes the potential of bracket delamination. 13. Each receptacle is marked by the appropriate tooth number and can be easily cut out as a single jig to rebond the bracket if the bracket were to fail in the future. In case a replacement tray is needed, a “digital fingerprint” of the tray is accessible in the patient record, which can be used to print a replacement tray. 14. The tray material is biocompatible, durable, and has a long shelf life. 15. The results of preliminary studies on the accuracy of bracket transfer as a result of the suresmile IDB tray are encouraging and suggest the following: The bracket transfer is accurate to within 1 degree for angular and 0.2 of a millimeter of the planned bracket location on the virtual dental working model (Figure 35).

Figure 35: suresmile IDB transfer accuracy. Very preliminary results on the accuracy of sure smile IDB tray appear to show bonding angular accuracies of within 1 degree and translational of about 0.2 mm or less

tools, will result in error-prone bracket locations, diminishing the value of the technology and patient care. An incorrect virtual target setup results in merely a dispensing tray for brackets; these brackets may be efficiently, yet ineffectively, bonded on a patient, reflecting a cafeteria approach to care. We belong to an era of celebrity- and media-driven orthodontics, an era that sponsors the claim of breakthrough technologies that accelerate orthodontic care, operate autonomously, and promote a culture of “effortless orthodontics.” Currently, no such “smart technology” exists; therefore, cognitive effort must be applied by the ortho-

REFERENCES 1. Kalange JT. Indirect bonding: A comprehensive review of the advantages. World J Orthod. 2004;5(4):301-307. 2. Sachdeva R. BioDigital Orthodontics: Diagnopeutics with suresmile technology (Part 3) Orthodontic Practice US. 2013;4(3):22-30. 3. Sachdeva R. BioDigital Orthodontics: Outcome evaluation with Suresmile technology: part 4. Orthodontic Practice US. 2013;4(4):28-33 4. Sachdeva R. BioDigital orthodontics: Planning care with Suresmile technology: part 1. Orthodontic Practice US. 2013;4(1):18-23. 5. Sachdeva R. BioDigital orthodontics: Designing customized therapeutics and managing patient treatment with Suresmile technology: part 2. Orthodontic Practice US. 2013;4(2):18-26. 6. Akyalcin S, Cozad BE, English JD, Colville CD, Laman S. Diagnostic accuracy of impression-free digital models. Am J Orthod Dentofacial Orthop. 2013;144(6):916-922. 7. Andrews LF: Straight-wire — The Concept and Appliance. San Diego, CA: L.A. Wells Co., 1989.

Discussion and conclusions

8. Miles PG. Indirect bonding with a flowable light-cured adhesive. J Clin Orthod. 2002;36(11):646-647.

suresmile’s simulation-guided indirect bonding and IDB tools enable the orthodontist to more accurately and precisely bond brackets while considering the biological, functional, and esthetic needs of the patient. The suresmile digital technology and its output — the IDB tray — are only useful tools when driven by a fully developed, realistic design and plan — the inputs to the virtual target setup. A pathological virtual target setup, which is based on incorrect inputs and overreliance of the automation

9. Sondhi A. Efficient and effective indirect bonding. Am J Orthod Dentofacial Orthop. 1999;115(4):352-359.

34 Orthodontic practice

10. Kalange JT. Ideal appliance placement with APC brackets and indirect bonding. J Clin Orthod. 1999;33(9):516-526. 11. Gange P. Paul Gange on the present state of bonding. Interview by Homer W. Phillips. J Clin Orthod. 1995;29(7):429-436. 12. Specialty Appliances. Indirect Bonding: Reference manual. https://www.specialtyappliances.com/files/pdfs/indirect_ bonding_reference_manual.pdf. Accessed February 10, 2016. 13. Miethke RR, Melsen B. Effect of variation in tooth morphology and bracket position on first and third order correction with preadjusted appliances. Am J Orthod Dentofacial Orthop. 1999;116(3):329–335. 14. Dellinger EL. A scientific assessment of the straight-wire appliance. Am J Orthod. 1978;73(3):290–299. 15. Miethke RR. Third order tooth movements with straight wire appliances. Influence of vestibular tooth crown morphology

dontist in order to appropriately use technology. The orthodontist must incessantly cultivate, cherish, and celebrate the cognitive and professional skills necessary to use technology effectively. Technology, in and of itself, offers limited benefits to the patient and the practice. Technology, processes, and skills must work in concert to ensure effective treatment. As such, it behooves the orthodontist to separate the wheat — the practice of professionalism — from the chaff — market-driven orthodontics. OP

Acknowledgment Dr. Sachdeva sincerely thanks Nikita Sachdeva for her editorial assistance and Dr. Ed Lin for sharing the clinical images of the in vivo IDB technique.

in the vertical plane. J Orofac Orthop. 1997;58(4):186–197. 16. Streva AM, Cotrim-Ferreira FA, Garib DG, Carvalho PE. Are torque values of preadjusted brackets precise? J Appl Oral Sci. 2011;19(4): 313–317. 17. Morrow JB. The angular variability of the facial surfaces of the human dentition: an evaluation of the morphological assumptions implicit in the various “straight-wire techniques” [master’s thesis]. St. Louis: St. Louis University; 1978. 18. Meling TR, Ødegaard J. On the variability of cross-sectional dimensions and torsional properties of rectangular nickeltitanium arch wires. Am J Orthod Dentofacial Orthop. 1998;113(5):546–557. 19. Cash AC, Good SA, Curtis RV, McDonald F. An evaluation of slot size in orthodontic brackets — are standards as expected? Angle Orthod. 2004;74(4):450-453. 20. Grünheid T, Patel N, De Felippe NL, Wey A, Gaillard PR, Larson BE. Accuracy, reproducibility, and time efficiency of dental measurements using different technologies. Am J Orthod Dentofacial Orthop. 2014;145(2):157-164. 21. Jost-Brinkmann PG, Schiffer A , Miethke RR. The effect of adhesive-layer thickness on bond strength. J Clin Orthod. 1992;26(11):718–720. 22. Pitts T. Begin with the end in mind: bracket placement and early elastics protocols for smile arc protection. Clin Impressions. 2009;17(1):1-11. 23. Sarver DM. The importance of incisor positioning in the esthetic smile: the smile arc. Am J Orthod Dentofacial Orthop. 2001;120(2):98-111. 24. Casko JS, Vaden JL, Kokich VG, Damone J, James RD, Cangialosi TJ, Riolo ML, Owens SE Jr, Bills ED. Objective grading system for dental casts and panoramic radiographs. American Board of Orthodontics. Am J Orthod Dentofacial Orthop. 1998;114(5):589-599. 25. Roth RH. Functional occlusion for the orthodontist. J Clin Orthod. 1981;15(1):32-40,44-51. 26. Roth RH. Functional occlusion for the orthodontist, Part III. J Clin Orthod. 1981;15(3):174-179, 182-198. 27. Stratasys. Objet 30 Pro [Machine Spec Sheet]. http:// usglobalimages.stratasys.com/Main/Files/Machine_Spec_ Sheets/PSS_PJ_Objet30Pro.pdf?v=6357843104346449 01. Accessed February 10, 2016.

Volume 7 Number 2

Dr. Steven R. Olmos offers information to raise awareness about the signs and treatment of OSA

his article seeks to evaluate the 3D volumetric changes that are necessary to treat pediatric obstructive sleep apnea (OSA). Adult static therapies are not indicated for children. Children require dynamic therapies to encourage and correct skeletal development to improve sleepbreathing disorders. Formulas for arch width expansion are currently based on dental space and skeletal calculations and are not applicable nor are they validated in the treatment of pediatric OSA. Treating children with OSA requires a new formula of skeletal development for both maxilla and mandible based on correction of the immediate medical problem evaluated by overnight sleep testing called polysomnography (PSG) (attended) or home sleep testing (HST) (unattended). The awareness and treatment for OSA is the fastest growing segment of dentistry. The Council on Dental Accreditation now requires a course in sleep pathology. The education of sleep-breathing disorders in the undergraduate dental curriculum in the United States is less than 1 hour per year.1 All of the education currently provided in dental school curriculums and most postgraduate education is based on the treatment for adults. Successful treatment for adults includes positive pressure devices, oral appliances, oral soft tissue implants or surgery, nasal surgery, bi-maxillary advancement surgery, hypoglossal nerve stimulation, myofunctional therapy, diet, exercise, or a hybrid of any of the above. Unfortunately for most adults, OSA can only be managed for the rest of their lives. In children, orthodontists have the ability to make significant improvement and, in some cases, cure the condition.2-3 This is significant, as children with OSA have a sevenfold risk of mortality and had greater morbidity at least 3 years before their

Steven R. Olmos, DDS, is an Adjunct Associate Professor in the Department of Bioscience Research at the College of Dentistry, University of Tennessee Health Science Center, Memphis, Tennessee. He practices at the TMJ & Sleep Therapy Centre in La Mesa, California.

Volume 7 Number 2

Educational aims and objectives

This article aims to raise awareness about the signs and treatment of obstructive sleep apnea (OSA).

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 41 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Recognize the risks of OSA in children. • Recognize some of the symptoms of OSA in children. • Identify some orthodontic treatment options for children with OSA. • Realize some of the symptoms and treatments for OSA in adults.

diagnosis. After diagnosis, OSA has been associated with incidences of endocrine, nutritional, and metabolic diseases (OR 1.78, 95% CI 1.29 to 2.45), nervous conditions (OR 3.16, 95% CI 2.58 to 3.89), ENT diseases (OR 1.45, 95% CI 1.14 to 1.84), respiratory system diseases (OR 1.94, 95% CI 1.70 to 2.22), skin conditions (OR 1.42, 95% CI 1.06 to 1.89), musculoskeletal diseases (OR 1.29, 95% CI 1.01 to 1.64), congenital malformations (OR 1.83, 95% CI 1.51 to 2.22), abnormal clinical or laboratory findings.4 Children with OSA suffer from immune suppression, attention deficit hyperactivity disorders (ADHD), heart rate/ blood pressure variability, neurocognitive, and endothelial inflammation.5-8 Prevalence rates for pediatric OSA range between 1.2% and 5.7%.9-11 These figures are likely low as screening for pediatric OSA is not common in most medical or dental practices. The American Academy of Pediatrics since 2012 has made the following recommendations: 1. All children/adolescents should be screened for snoring. 2. Polysomnography should be performed in children/adolescents with snoring and symptoms/signs of OSAS.12

3D orthopedic treatment for pediatric OSA Treating children with OSA requires immediate and effective therapy throughout its course to ensure proper management for this serious medical problem. Static

therapies used for adults to treat OSA prevent proper skeletal development such as CPAP (headgear effect) and static oral appliances. Adult surgeries such as uvulopalatopharyngoplasty (UPPP), nasal corrective surgery, and tongue reduction are contraindicated in children. Tonsil and adenoid surgery is effective for children for a short time; however, studies show that there is a high relapse after 6 months.13-16 Dento-facial development in snoring children is not changed by adenotonsillar surgery regardless of symptom relief as stated in otorhinolaryngology literature. It is recommended that “If snoring persists or relapses, that orthodontic maxillary widening and/or functional training should be considered. Collaboration between otorhinolaryngologist, orthodontists, and speech language pathologists is strongly recommended.”17 Enlargement of the lymphatic tissue may be a consequence of sleep-disordered breathing (SDB).18 Palatal expansion has been shown to reduce apnea, increase nasal volume, correct skeletal deformities related to breathing dysfunction, improve sleep-related symptoms such as fatigue, nocturnal enuresis, conductive hearing loss, restore proper functional nasal breathing, and uprighting head posture.19-25 Efficacy of orthodontic therapy for pediatric OSA is increased when treated at earliest onset of symptoms.26 Benefits of palatal expansion for OSA symptoms have been demonstrated to be long-standing in 12-year follow-up utilizing PSG and Epworth Sleepiness Scale (ESS).27 Orthodontic practice 35

CONTINUING EDUCATION

3D orthopedic development for pediatric obstructive sleep apnea (OSA)

CONTINUING EDUCATION

Figure 2

Figure 1: 2.36% volumetric increase for each mm of expansion (Reprinted with permission of Dr. Melih Motro)

Palatal expansion can be accomplished with expansion devices and myofunctional exercise therapies to increase nasal volume and restore proper functional nasal breathing. A recent study quantified the three-dimensional increase of volume of the nose with palatal expansion. It was found that there is a 2.36% volume increase with each millimeter of transverse expansion (Figure 1). Another important finding is that this ratio was constant in the population base from 9- to 22-year-old patients.28 This challenges the belief that expansion is not possible in adults. Optimal outcome is accomplished with combined therapies. Palatal expansion has been performed for many years prior to the discovery of sleep-breathing disorders. Expansion traditionally has been based on space necessary for dentition and dental alveolar bone aligned with opposing arch width, without evaluation of nasal or sleep-breathing pathology. A historical review of expansion measurement guides has been dependent on space for teeth. Various arch width determination methods are: • Pont’s analysis (1909), which has been disproven long ago, determined the premolar width by multiplying the sum of the four maxillary incisors length (SI) by 100 divided by 80. The molar width is determined by SI x 100 divided by 64. • Linder Harth Index uses the same calculations with slightly different numbers in his equation: SI x 100 divided by 85 for the premolar width and SI x 100 divided by 64 for the molar width (Figure 2). • Korkhaus Analysis uses Linder Harth’s formula and adds the 36 Orthodontic practice

Figure 3

Figure 4

length of a line that bisects the maxillary centrals (Figure 3). • The Bolton Analysis states that the sum of the mesiodistal widths of the 12 mandibular teeth should be 91.3% of the mesiodistal widths of the 12 maxillary teeth, and it is permissible to extract teeth to accomplish this ratio (Figure 4). This may be the beginning of the thought process for extraction for the space provided, without regard to the underdevelopment of the arches and their relative skeletal position in regard to upper airway obstruction. Proper functional breathing is through the nose. Air is warmed, moistened, filtered, and mixed with nitric oxide (NO) gas, which is drawn from the maxillary sinuses where it is concentrated up to 40 times. NO is important in mucociliary flow of the sinuses to ensure clearing of inhaled materials and irritants, antimicrobial effect on the lungs to prevent

Figure 5: Four points of obstruction

respiratory function, and cardiac and peripheral vasodilation that can reduce blood pressure.29-38 It has been recommended that the final endpoint in treating OSA is restoration of nasal breathing.39 Establishing/developing patency of the four points of obstruction (Figure 5) is necessary to prevent orthodontic relapse, (anterior or posterior open bite). This is most evident in Volume 7 Number 2

Increasing oral volume and preventing airway collapse (vertical and phonetic bite)

movements are not linear and are best described as pitch (AP cant), roll (lateral cant), and yaw (rotational cant). The coined term â&#x20AC;&#x153;Airway Centricâ&#x20AC;? is a physiological 3D positioning that prevents airway muscle collapse and increases oral volume, while improving orthopedic positioning and function of the TM joints.42 This technique is known as the Sibliant Phoneme Registration, which has been shown to prevent airway collapse in adults and currently is being researched for pediatric OSA patients.43 Preventing airway collapse is key in the treatment of obstructive apnea.44 Using the Sibilant Phoneme position as a starting point for vertical stabilization corrects medio-lateral cant asymmetries, so it is an ideal technique for appliances or materials added to teeth to increase vertical (Planas Tracks or development/expansion appliances, Figures 12-14).45 The increased

Figure 6: Anterior open bite with wire fixation

In situations where the patient has decreased lower face height and or deep overbite, they suffer from a reduced oral volume. These patients often present with canted plane of occlusion, which can predispose the patient to unilateral TM joint pathology (Figure 11). These conditions require increasing the oral volume in a three-dimensional way. Understanding that increases in volume can require small 3D changes rather than the traditional linear techniques of opening (vertical), protrusive, and lateral movements. In reality, these

Figure 9: Orthognathic fixation with posterior open bite

Figures 12-14 (Used with permission of Dr. German Ramirez) Volume 7 Number 2

vertical is beneficial for inflammatory conditions of the TM joints, which is often comorbid with sleep-breathing disorders in children. Uneven loading of the TM joints in these asymmetric conditions may lead to craniofacial deformity. One in six children and adolescents have clinical signs of TMJ disorders.

Figure 7: CBCT of same patient

Figure 8: Middle and inferior soft tissue hypertrophy blocking nasal airway on same patient

Figure 10: Same patient

Figure 11: Cant of plane of occlusion in patient with AHI 118

Figure 15: Screw linear transverse expander Orthodontic practice 37

CONTINUING EDUCATION

cases that have been retained with bonded anterior archwires and even orthognathic surgery with fixation plates (Figures 6-10).40 Harvold, in his work with primates, was the first to demonstrate craniofacial deformations and skeletal open bite with silicon obstruction of their noses.41 A new paradigm is proposed that the determination of expansion of the maxilla and mandible in pediatric patients with OSA be the optimal individual reduction of Apnea Hypopnea Index (AHI) and respiratory effortrelated arousals (RERA), rather than the traditional space for dentition. (According to the American Academy of Sleep Medicine, AHI is an average that represents the combined number of apneas and hypopneas that occur per hour of sleep.)

CONTINUING EDUCATION

Figure 16: ALF (Applied Lightwire Force)

Figure 17: Coiled NiTi spring expander

Myofunctional therapy for maxillary arch development Exercises for the tongue and skeletal muscles has been shown to be effective in the treatment of OSA.46 The tongue must have the ability for proper movement in swallowing, breathing, chewing, and speech. Evaluation for tongue tie is an important step and should be identified as early as possible. Tongue tie can result in pathology as early as breast feeding and lead to craniofacial deformities and sleep-breathing disorders as it fails to develop the palate normally.47 In a normal swallow, the dorsum of the tongue presses against the palate to develop the maxilla. Myofunctional therapy includes exercises that are specific for developing the palate, improving lip seal, and nasal breathing.48-50

Figure 18: Quadhelix expander

When myofunctional exercises and therapy from certified therapists are combined with oral appliance therapy for OSA, temporomandibular dysfunction (TMD), arch development, fixed vertical increase in oral volume (Planas Tracts), and orthodontic therapy, the net effect is maximized.51

Dynamic oral appliances (mandibular advancement) are effective treatment for pedo OSA Static oral appliances have been shown to be effective in treating pediatric OSA; however, continued use would prevent skeletal development.52 These would include transverse expansive appliances in a linear fashion: screw, coiled NiTi springs. Examples of three dimensional expansive techniques

Figure 1

Figure 3 38 Orthodontic practice

Figure 19: NiTi palatal expander

would be NiTi wires, applied light wire force (ALF), NiTi palatal expander, quadhelix).

Case study Seji, an 11-year-old boy, presented for orthodontic treatment (Figure 1). Expansion therapy was provided (Figure 2). By all evaluations, it would seem that the development was more than sufficient for proper arch development and dental occlusion (Figures 3-5); however, an overnight sleep study (MediByte by Braebon) read by a Board Certified Sleep Physician demonstrates that he has an AHI (apnea-hypopnea index) of 7.5. A child is diagnosed with OSA (obstructive sleep apnea) if the AHI is greater than 1. This young man has a moderate form of OSA.

Figure 2

Figure 4 Volume 7 Number 2

Figure 6

Figure 7

Figure 8: Phonetic positioning

The TM joints and nasal skeletal relationships are normal after expansion (Figures 6 and 7). Treating pediatric OSA requires a 3D development process with re-evaluations of breathing in order to properly treat. This requires a 3D mandibular correction to open the airway and prevent collapse (Figure 8). This is the position from which to determine orthopedic cephalometric evaluations (Figures 9 and 10). Crowding of dentition is the result of retrognathia both maxilla and mandible. Maxillary retrognathia is comorbid with deviated septum and nasal obstruction. Nasal obstruction results in mouth breathing and anterior open bite (malocclusion). It is recommended that all children undergoing orthodontic therapy for underdeveloped maxilla, dental crowding, malocclusion, and open bite be evaluated for sleep-breathing disorders. The hallmark symptom is snoring as recommended by the American Academy of Pediatrics. The BEARS pediatric screening for sleep-breathing disorders is an excellent tool for this purpose. It has a range that is inclusive of toddlers, children, and adolescents.56 This tool was developed by Dr. Judith Owens, professor at Harvard and Director for Pediatric Sleep Disorders at Boston Childrenâ&#x20AC;&#x2122;s Hospital. OP Volume 7 Number 2

CONTINUING EDUCATION

Figure 5

Figures 9-10

Recommend screening of all orthodontic patients for sleep-breathing disorders, including snoring, utilizing the BEARS screening. Orthodontic practice 39

CONTINUING EDUCATION 27. Pirelli P, Saponara M, Guilleminault C. Rapid maxillary expansion (RME) for pediatric obstructive sleep apnea: a 12-year follow-up. Sleep Med. 2015;16(8):933–935. 28. Motro M, Schauseil M, Ludwig B, Zorkun B, Mainusch S, Ateş M, Küçükkeleş N, Korbmacher-Steiner H. Rapid-maxillary expansion induced rhinological effects: a retrospective multicenter study. Eur Arch Otorhinolaryngol. 2015;Apr 3 [epub ahead of print]. 29. Maniscalco M, Sofia M, Pelaia G. Nitric oxide in upper airways inflammatory diseases. Inflamm Res. 2007;56(2):58-69. 30. Mancinelli RL, McKay CP. Effects of nitric oxide and nitrogen dioxide on bacterial growth. Applied Environ Microbiol. 1983;46(1):198-202. 31. Nathan CF, Hibbs JB Jr. Role of nitric oxide synthesis in macrophage antimicrobial activity. Curr Opin Immunol. 1991;3(1):65-70. 32. Fang FC. Perspectives series: host/pathogen interactions. Mechanisms of nitric oxide-related antimicrobial activity. J Clin Invest. 1997;99(12):2818-2825. 33. Sanders SP, Proud D, Permutt S, Siekierski ES, Yachechko R, Liu MC. Role of nasal nitric oxide in the resolution of experimental rhinovirus infection. J Allergy Clin Immunol. 2004;113(4):697-702. 34. Sanders SP, Siekierski ES, Porter JD, Richards SM, Proud D. Nitric oxide inhibits rhinovirus-induced cytokine production and viral replication in a human respiratory epithelial cell line. J Virol. 1998;72(2):934-942. 35. Jorissen M, Lefevere L, Willems T. Nasal nitric oxide. Allergy. 2001;56(11):1026-1033. 36. Runer T, Cervin A, Lindberg S, Uddman R. Nitric oxide is a regulator of mucocillary activity in the upper respiratory tract. Otolaryngol Head Neck Surg. 1998;119(3):278-287. 37. Jain B, Rubinstein I, Robbins RA, Leise KL, Sisson JH. Modulation of airway epitheial cell ciliary beat frequency by nitric oxide. Biochem Biophys Res Comm. 1993;191(1):83-88. 38. Lindberg S, Cervin A, Runer T. Low levels of nasal nitric oxide (NO) correlate to impaired mucocillary function in the upper airways. Acta Otolaryngol. 1997;117(5)728-734. 39. Guilleminault C, Sullivan SS. Towards Restoration of Continuous Nasal Breathing as The Ultimate Treatment Goal in Pediatric Obstructive Sleep Apnea. Pediatr Neonatol Biol. 2014;1(1). http:// enlivenarchive.org/pediatrics-neonatal-biology-001.pdf. Accessed February 19, 2016. 40. Olmos S. CBCT in the evaluation of airway-minimizing orthodontic relapse. Orthodontic Practice US. 2015;6(2):46-49. 41. Harvold EP, Tomer BS, Vargervik K, Chierici G. Primate experiments on oral respiration. Am J Orthod. 1981;79(4):359-372. 42. Moeller JL, Paskay LC. Gelb M. Myofunctional Therapy: A Novel Treatment of Pediatric Sleep-Disordered Breathing. Sleep Medicine Clinics. 2014;9(2). http://www.sleep.theclinics.com/article/ S1556-407X%2814%2900025-3/references. Accessed February 19, 2016.

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school-aged children with sleep disordered breathing. Sleep Med. 2013;14(5):440-448.

Simmons MS, Pullinger A. Education in sleep disorders in US dental schools DDS programs. Sleep Breath. 2012;16(2):383-392.

Pirelli P, Saponara M, Guilleminault C. Rapid maxillary expansion in children with obstructive sleep apnea syndrome. Sleep. 2004;27(4):761-766.

14. Biggs SN, Vlahandonis A, Anderson V, Bourke R, Nixon GM, Davey MJ, Horne RS. Long-term changes in neurocognition and behavior following treatment of sleep disordered breathing in school-aged children. Sleep. 2014;37(1):77-84.

Villa MP, Malagola C, Pagani J, Montesano M, Rizzoli A, Guilleminault C, Ronchetti R. Rapid maxillary expansion in children with obstructive sleep apnea syndrome: 12-month follow-up. Sleep Med. 2007;8(2):128-134.

15. Bonuck KA, Chervin RD, Cole TJ, Emond A, Henderson J, Xu L, Freeman K. Prevalence and persistence of sleep disordered breathing symptoms in young children: a 6-year population-based cohort study. Sleep. 2011;34(7):875-884.

Jennum P, Ibsen R, Kjellberg J. Morbidity and mortality in children with obstructive sleep apnoea: a controlled national study. Thorax. 2013;68(10):949-954.

16. Bonuck K, Freeman K, Chervin RD, Xu L. Sleep-disordered breathing in a population-based cohort: behavioral outcomes at 4 and 7 years. Pediatrics. 2012;129(4):e857-865.

Kim J, Hakim F, Kheirandish-Gozal L, Gozal D. Inflammatory pathways in children with insufficient or disordered sleep. Respir Physiol Neurobiol. 2011;178(3):465-474.

Spruyt K, Gozal D. Sleep disturbances in children with attention-deficit/hyperactivity disorder. Expert Rev Neurother. 2011;11(4):565-577.

17. Löfstrand-Tideström B, Hultcrantz E. Development of craniofacial and dental arch morphology in relation to sleep disordered breathing from 4 to 12 years. Effects of adenotonsillar surgery. Int J Pediatr Otorhinolaryngol. 2010;74(2):137-143. 18. Guilleminault C, Akhtar F. Pediatric sleep-disordered breathing: New evidence on its development. Sleep Med Rev. 2015;24:46-56.

Nisbet LC, Yiallourou SR, Walter LM, Horne RS. Blood pressure regulation, autonomic control and sleep disordered breathing in children. Sleep Medicine Rev. 2014;18(2):179-189.

19. Pirelli P, Saponara M, Guilleminault C. Rapid maxillary expansion in children with obstructive sleep apnea syndrome. Sleep. 2004;27(4):761-766.

Gozal D, Kheirandish-Gozal L, Bhattacharjee R, Spruyt K. Neurocognitive and endothelial dysfunction in children with obstructive sleep apnea. Pediatrics. 2010;126(5):e1161-1167.

20. Marino A, Ranieri R, Chiarotti F, Villa MP, Malagola C. Rapid maxillary expansion in children with Obstructive Sleep Apnoea Syndrome (OSAS). Eur J Paediatr Dent. 2012;13(1):57-63.

Bixler EO, Vgontzas AN, Lin HM, Liao D, Calhoun S, Vela-Bueno A, Fedok F, Vlasic V, Graff G. Sleep disordered breathing in children in a general population sample: prevalence and risk factors. Sleep. 2009;32(6):731–736.

21. Usumez S, Işeri H, Orhan M, Basciftci FA. Effect of rapid maxillary expansion on nocturnal enuresis. Angle Orthod. 2003;73(5):532-8.

10. Li AM, So HK, Au CT, Ho C, Lau J, Ng SK, Abdullah VJ, Fok TF, Wing YK. Epidemiology of obstructive sleep apnoea syndrome in Chinese children: a two-phase community study. Thorax. 2010;65(11):991–997. 11. O’Brien LM, Holbrook CR, Mervis CB, Klaus CJ, Bruner JL, Raffield TJ, Rutherford J, Mehl RC, Wang M, Tuell A, Hume BC, Gozal D. Sleep and neurobehavioral characteristics of 5- to 7-yearold children with parentally reported symptoms of attention-deficit/ hyperactivity disorder. Pediatrics. 2003; 111(3):554–563. 12. Marcus CL, Brooks LJ, Draper KA, Gozal D, Halbower AC, Jones J, Schechter MS, Ward SD, Sheldon SH, Shiffman RN, Lehmann C, Spruyt K. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130(3):e714-755. 13. Vlahandonis A, Nixon GM, Davey MJ, Walter LM, Horne RS. A four year follow-up of sleep and respiratory measures in elementary

40 Orthodontic practice

43. Singh GD, Olmos S. Use of the sibilant phoneme registration protocol to prevent upper airway collapse in patients with TMD. Sleep Breath. 2007;11(4):209-216. 44. Ng AT, Qian J, Cistulli PA. Orophayrngeal collapse predicts treatment response with oral appliance therapy in obstructive sleep apnea. Sleep. 2006;29(5):666-671. 45. Rivera-Morales WC, Mohl ND. Anteroposterior and mediolateral variability of the closest speaking space. Int J Prosthodont. 1990;3(2):179-184. 46. Guimarães KC, Drager LF, Genta PR, Marcondes BF, Lorenzi-Filho G. Effects of oropharyngeal exercises on patients with moderate obstructive sleep apnea syndrome. Am J Respir Crit Care Med. 2009;179(10):962-966. 47. Olivi G, Signore A, Olivi M, Genovese MD. Lingual frenectomy: Functional evaluation and new therapeutical approach. Eur J Paediatr Dent. 2012;13(2):101-106. 48. Rogers AP. Exercises for the development of muscles of face with view to increasing their functional activity. Dental Cosmos LX. 1918;59:857-876. 49. Guimaraes KC. [Soft tissue changes of the oropharynx in patients with obstructive sleep apnea]. J Bras Fonoaudiol. 1999;1(1):69-75. 50. Guilleminault C, Huang YS, Monteyrol PJ, Sato R, Quo S, Lin CH. Critical role of myofascial reeducation in pediatric sleepdisordered breathing. Sleep Med. 2013;14(6):518-525. 51. Cunali PA, Almeida FR, Santos CD, Valdrichi NY, Nascimento LS, Dal-Fabbro C, Tufik S, Bittencourt LR. Mandibular exercises improve mandibular advancement device therapy for obstructive sleep apnea. Sleep Breath. 2011;15(4):717-727.

22. Schütz-Fransson U; Kurol J. Rapid maxillary expansion effects on nocturnal enuresis in children: a follow-up study. Angle Orthod. 2008;78(2):201-208.

52. Nazarali N, Altalibi M, Nazarali S, Major MP, Flores-Mir C, Major PW. Mandibular advancement appliances for the treatment of paediatric obstructive sleep apnea: a systematic review. Eur J Orthod. 2015;37(6):618-626.

23. Eichenberger M, Baumgartner S. The impact of rapid palatal expansion on children’s general health: a literature review. Eur J Paediatr Dent. 2014;15(1):67-71.

53. Gerbino G, Bianchi FA, Verzé L, Ramieri G. Soft tissue changes after maxillo-mandibular advancement in OSAS patients: A threedimensional study. J Craniomaxillofac Surg. 2014;42(1):66–72.

24. Cerruto C, Di Vece L, Doldo T, Giovannetti A, Polimeni A, Goracci C. A computerized photographic method to evaluate changes in head posture and scapular position following rapid palatal expansion: a pilot study. J Clin Pediatr Dent. 2012;37(2):213-218.

54. Lal C, White DR, Joseph JE, van Bakergem K, LaRosa A. Sleep-disordered breathing in down syndrome. Chest. 2015;147(2):570-579.

25. McGuinness NJ, McDonald JP. Changes in natural head position observed immediately and one year after rapid maxillary expansion. Eur J Orthod. 2006;28(2):126-134. 26. Villa MP, Rizzoli A, Rabasco J, Vitelli O, Pietropaoli N, Cecili M, Marino A, Malagola C. Rapid maxillary expansion outcomes in treatment of obstructive sleep apnea in children. Sleep Med. 2015;16(6):709-716.

55. Peanchitlertkajorn S. RPE and Orthodontic Protraction Facemask As An Alternative Therapy for Severe Obstructive Sleep Apnea Associated with Maxillary Hypoplasia. Journal of Dental Sleep Medicine. 2016;3(1)1. http://www.jdsm.org/ViewArticle. aspx?pid=30401. Accessed February 19, 2016. 56. Owens JA, Dalzell V. Use of the ‘BEARS’ sleep screening tool in a pediatric residents’ continuity clinic: a pilot study. Sleep Med. 2005;6(1):63-69.

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3D orthopedic development for pediatric obstructive sleep apnea (OSA)

Sleep-disordered breathing in orthodontic patients: part I – diagnostic strategies

OLMOS

STOCKSTILL

In children, orthodontists have the ability to make significant improvement and, in some cases, cure the condition. This is significant, as children with OSA have _____ risk of mortality and had greater morbidity at least 3 years before their diagnosis. a. double the b. triple the c. a fourfold d. a sevenfold The American Academy of Pediatrics since 2012 has made the following recommendations: ____ children/adolescents should be screened for snoring. a. All b. Only a select few c. Already medically compromised d. Only mouth-breathing Palatal expansion can be accomplished with ____ to increase nasal volume and restore proper functional nasal breathing. a. expansion devices b. myofunctional exercise therapies c. tongue reduction d. both a and b Proper functional breathing is through the nose. Air is warmed, moistened, filtered, and mixed with nitric oxide (NO) gas, which is drawn from the maxillary sinuses where it is concentrated up to ____ times. a. 10 b. 20 c. 40 d. 60 Establishing/developing patency of the ____ is/ are necessary to prevent orthodontic relapse, (anterior or posterior open bite). a. two points of obstruction b. four points of obstruction

Volume 7 Number 2

c. adenoids only d. uvula only 6.

In reality, this/these movement(s) are not linear and is/are best described as _____. a. pitch (AP cant) b. roll (lateral cant) c. yaw (rotational cant) d. all of the above

Using the ____ as a starting point for vertical stabilization corrects medio-lateral cant asymmetries, so it is an ideal technique for appliances or materials added to teeth to increase vertical (Planas Tracks or development/expansion appliances). a. Sibilant Phoneme position b. Apnea Hypopnea Index c. Bolton Analysis d. Pont’s Analysis

____ children and adolescents have clinical signs of TMJ disorders. a. One in six b. One-fourth of all c. Most d. 75% of all

___ can result in pathology as early as breastfeeding and lead to craniofacial deformities and sleep-breathing disorders as it fails to develop the palate normally. a. Slow swallowing b. Nasal breathing c. Tongue-tie d. Respiratory effort-related arousals

10. It is recommended that all children undergoing orthodontic therapy for ____, and open bite be evaluated for sleep-breathing disorders. a. underdeveloped maxilla b. dental crowding c. malocclusion d. all of the above

OSA is “… a highly prevalent disorder characterized by instability of the upper airway during sleep, which results in markedly _____ at the nose/mouth.” a. reduced (hypopnea) airflow b. absent (apnea) airflow c. increased airflow (hypernea) d. both a and b This significant three-dimensional growth and development of the ______ of the cranium chiefly occurs during childhood and puberty, and represents a significant change in facial proportionality during this period. a. upper third b. middle-to-lower half c. coronal suture d. lower half only To briefly review, normal development of the airway from embryo to newborn is dependent upon appropriate and timely first and second branchial arch influences along with other factors, including those having to do with _____ and other external influences. a. genetic penetrance b. maternal health c. maternal diet d. all of the above Examples of first and second branchial arch origin syndromes include _____ and Pierre Robin Sequence and, in some instances, cleft lip and palate. a. Glossodynia b. Down syndrome c. Treacher-Collins syndrome d. both b and c It is within the context of appropriate orthodontic diagnosis that this particular component (children with first and second branchial arch origin syndromes) airway obstruction, be addressed by __________ when these patients are being evaluated. a. a board-certified orthodontist only b. a sleep physician only

c. d.

a multidisciplinary team of dental and medical specialists an oral surgeon only

On projecting and converting 3D objects to a reduced two-dimensional image, structures ______in proportion to their distance from the film. a. displace vertically b. displace horizontally c. expand d. both a and b

Errors in cephalometric measurements may be associated with uncertainties in locating anatomical landmarks due to the deficiency of _____ as well as patient position, and due to operator error, especially in the absence of acceptable intrarater and, when utilized, interrater reliability. a. well-defined outlines b. hard edges c. shadows d. all of the above

Thus a ______ allows the orthodontist to more accurately diagnose dental, skeletal, soft tissue, AND upper airway dimensions as needed. a. truly digital 2D X-ray b. true 3 x 3 dimensional analysis c. transilluminated image d. hand-traced cephalometric image

With the advent of interest in sleep-disordered breathing and its diagnosis and management, more attention is being given to _____ when collecting clinically useful data for orthodontic diagnosis. a. those with a wide palate b. breathing and respiration integrity c. lowered Mallampati score d. underweight children

10.

A ____ is defined as a reduction in airflow that is followed by an arousal from sleep or a decrease in oxyhemoglobin saturation.

a. b. c. d.

Hypopnea Bohr effect Betaoxyhemoglobin Syndrome none of the above

Orthodontic practice 41

CE CREDITS

ORTHODONTIC PRACTICE CE

CONTINUING EDUCATION

Sleep-disordered breathing in orthodontic patients: part I — diagnostic and management guidelines Dr. John Stockstill discusses how orthodontics is key to the multidisciplinary, evidence-based approach to diagnosis, and management of sleep-disordered breathing problems

“T

o learn how to treat disease, one must first learn how to diagnose. The diagnosis is the best trump in the scheme of treatment.” — Charcot It is no wonder that practicing dentists will adopt a method based on the testimonials of a colleague or on unpublished anecdotes and truly believe that they have made an informed decision based on professional judgment. — Dr. Enid Neidle1 Evidence-based (EB) diagnostic and classification strategies for any medically and/or dentally related disorders are intended to weigh the impact of reliability, validity, sensitivity, and specificity derived from the scientific method for techniques and modalities being utilized. The intent of this article is to convey EB diagnostic and classification schemes for obstructive sleep apnea (OSA) in pediatric, pre-adolescent, adolescent, and adult patients seen in the orthodontic office. Additionally, while it is not the intent of this article to comprehensively explore the global neurophysiological nature of sleep disorders, an excellent source of information on this particular subject is available regarding the epidemiology and pathophysiology of sleep disorders, sleep bruxism, and parasomnias often encountered in dental patients.2

What is the role of orthodontics in obstructive sleep apnea (OSA)? Orthodontics is the art and science of three-dimensional diagnosis and management of 1) dental, 2) skeletal, and/or 3) soft tissue structures of the craniofacial system. Components of diagnosis include documentation of dental, skeletal, and soft tissue relationships relative to one another and to the chief complaint of the patient. Included in this diagnostic work-up is the documentation of posterior airway architecture, including transverse and vertical dimensions of the palatal John W. Stockstill, DDS, MS, is a Professor — Orthodontics Temporomandibular Disorders/Orofacial Pain at Seton Hill University Center for Orthodontics in Greensburg, Pennsylvania. He is also a Diplomate of the American Board of Orthodontics.

42 Orthodontic practice

Educational aims and objectives

This article aims to explore the multidisciplinary, evidence-based approach to diagnosis, and management of sleep-disordered breathing problems.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 41 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify the role of orthodontics in obstructive sleep apnea (OSA). • Define the role of orthodontics in the diagnosis of OSA. • Recognize the role of orthodontics in airway imaging relative to OSA. • Identifying extraoral and intraoral characteristics of patients with suspected OSA. • Recognize the role of oral appliances in the treatment of OSA.

vault and oropharyngeal areas. This inclusive diagnostic protocol is intended to use orthodontic “gold standards of diagnosis” and to appropriately identify how dentoskeletal and soft tissue findings may correlate with other systemic disorders such as OSA, often overlooked in initial examinations. OSA is “… a highly prevalent disorder characterized by instability of the upper airway during sleep, which results in markedly reduced (hypopnea) or absent (apnea) airflow at the nose/mouth. Episodes are typically accompanied by oxyhemoglobin desaturation and terminated by brief micro arousals that result in sleep fragmentation and diminished amounts of slow wave and REM sleep.”3 For example, the prevalence of OSA in pediatric patients is the following: • prevalence of OSA in pediatric population — ~ 2% (NOTE: prevalence in non-syndromic patients) • parent reported “always snoring” child — 1.5% to 6% • parent reported apneic events during sleep — 0.2% to 4% • peak onset between ages 2-8 • “global” sleep-disordered breathing re: parent reported symptoms on questionnaire — 4% to 11% • prevalence of parent reported snoring by any definition in meta-analysis — 7.45% (95% confidence interval having a range of 5.75-9.8%)4,5 For adults, the prevalence of OSA associated with accompanying daytime sleepiness

is approximately 3% to 7% for adult men and 2% to 5% for adult women in the general population.21 OSA or any pulmonary problem is routinely diagnosed and managed by a team of medical personnel including pulmonologists, otorhinolaryngologists, pediatricians, and internists/family physicians. With the evolution of evidence-based OSA diagnostic and management information, it has become commonplace for the medical profession to work closely with their dental colleagues in providing care for these patients. This cooperative or multidisciplinary approach involves not only the appropriate referral of these patients (dentist to physician), but also the proper management of OSA when oral appliances are identified as being potential treatment modalities (physician to dentist). In light of this shared responsibility for our patients, it is imperative that we as clinicians identify key points of clinical protocol for the triage and management of OSA patients. Questions to ask regarding how we as orthodontists should be managing these patients include: • What is the role of orthodontics in the diagnosis of OSA? • What is the role of orthodontics in airway imaging relative to OSA? • What are identifying characteristics of patients with suspected OSA? • How are treatment decisions made regarding OSA? Volume 7 Number 2

CONTINUING EDUCATION

• What is the role of oral appliances in the treatment of OSA? Have guidelines been established regarding the use of oral appliances, and is there evidence for their efficacy in general?

What is the role of orthodontics in the diagnosis of OSA? An appropriate starting point in understanding the characteristics of OSA in our pediatric and adult patients “begins at the beginning.” In craniofacial growth and development, the majority of the cephalocaudal gradient of growth is manifested in the middle-to-lower half of the cranium (nasion/ occipitus to menton).6 This significant three-dimensional growth and development of the middle-to-lower half of the cranium chiefly occurs during childhood and puberty, and represents a significant change in facial proportionality during this period.7 In conjunction with the three-dimensional craniofacial development, and in tandem with the development of the mid-face, is the growth and development of the upper airway (most notably, the nasopharyngeal and oropharyngeal components).8 To briefly review, normal development of the airway from embryo to newborn is dependent upon appropriate and timely first and second branchial arch influences along with other factors, including those having to do with genetic penetrance, maternal health and diet, and other external influences. Disturbances in proper growth and development can result in craniofacial syndromes accompanied by airway obstruction or deficiencies in airway architecture. Examples of first and second branchial arch origin syndromes include Down syndrome, Treacher-Collins syndrome, and Pierre Robin Sequence, and, in some instances, cleft lip and palate. All exhibit some degree of airway obstruction as part of their clinical profile. It is within the context of appropriate orthodontic diagnosis that this particular component, airway obstruction, be addressed by a multidisciplinary team of dental and medical specialists when these patients are being evaluated.12-13

What is the role of orthodontics in airway imaging relative to OSA? In the past, two-dimensional analysis of the craniofacial region was the “gold standard” for assessing upper airway in orthodontic patients. While somewhat accurate anterior-posterior measurements could be made of the airway using a cephalometric X-ray, no precise analysis could be made Volume 7 Number 2

Figure 1: Two-dimensional orthodontic analysis

since the anatomy of the airway could not be defined in a three-dimensional manner (Figure 1.) Regarding volumetric analysis of the airway using a two-dimensional image, other limitations exist, including: 1. On projecting and converting 3D objects to a reduced two-dimensional image, structures displace vertically and horizontally in proportion to their distance from the film.9,10 2. Cephalometric analyses are based on superimposition of the left and right sides at mid-sagittal plane, but precise superimposition is difficult to achieve since facial symmetry is infrequent. 3. Manual data collection and processing (manual and digital representation of physical landmarks) in cephalometric analysis have been shown to be less precise than threedimensional imaging techniques. 4. Errors in cephalometric measurements may be associated with uncertainties in locating anatomical landmarks due to the deficiency of well-defined outlines, hard edges, and shadows as well as patient position, and due to operator error, especially in the absence of acceptable intrarater and, when utilized, interrater reliability.11 The greatest limitation of a two-dimensional technique is the inability of the cephalometric X-ray to adequately address volumetric analysis of the airway. That is, the transverse dimension of the airway cannot

Figure 2: 3 x 3 dimensional planes in orthodontic/OSA diagnosis

be seen in the field of imaging, and thus, any assessment of the airway volume using twodimensional imaging would be inadequate and incomplete. With the advent of threedimensional imaging capability observed in cone beam computerized tomography (CBCT), a true three-dimensional volumetric analysis of the upper airway is possible and is now used as an adjunctive diagnostic modality in the comprehensive orthodontic evaluation of suspected OSA cases.9-11 As a result of this imaging improvement, the orthodontist is now able to evaluate not only dental, skeletal and soft tissue structures in a three-dimensional (x – y – z) dimension, but also capable of evaluating the integrity of these structures relative to their pitch (coronal or anterior-posterior dimension), yaw (transverse or horizontal dimension), and roll (vertical or sagittal dimension) (Figure 2). Thus a “true 3 x 3 dimensional analysis” allows the orthodontist to more accurately Orthodontic practice 43

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Figure 3A: CBCT for imaging airway — adjunctive for three-dimensional diagnosis

diagnose dental, skeletal, soft tissue, AND upper airway dimensions as needed (Figures 3A-3B).

What are identifying extraoral and intraoral characteristics of patients with suspected OSA? A comprehensive orthodontic examination includes the observation, measurement, and documentation of dental, skeletal, and soft tissue components of the craniofacial region. With the advent of interest in sleepdisordered breathing and its diagnosis and management, more attention is being given to breathing and respiration integrity when collecting clinically useful data for orthodontic diagnosis. Specifically, documentation of the anatomical architecture and integrity of the oropharyngeal area, including the tonsils and tonsillar crypts, base of tongue, and tongue position should be a part of a comprehensive orthodontic records appointment. Other physical characteristics routinely observed during an appointment and exhibited by suspected OSA patients include: 1. Neck girth (circumference) > 17 inches (physical assessment by physician) 2. Retropositioned mandible (Class II skeletal profile) 3. Retropositioned maxilla 4. Vaulted or narrowed palate — transverse palatal constriction 5. Enlarged tongue relative to arch forms with scalloping of the lateral surfaces of the tongue suggestive of tongue thrust behavior 6. Inferiorly positioned hyoid bone relative to the mandibular border 7. Chronic mouth breathing 44 Orthodontic practice

Figure 3B: Advanced CBCT orthodontic imaging — anterior-posterior and transverse airway imaging. 3D airway evaluation

8. Elevated Mallampati score (3-4) 9. Subjective report of the following: a. Daytime sleepiness b. Difficulty concentrating upon everyday tasks, including attention deficit hyperactivity (ADHD) c. Waking up “feeling tired” d. History of upper respiratory disorders, including eustachian tube problems (“tubes in ears”), asthma, respiratory allergies e. Diagnosed obesity f. Generalized parasomnias comorbid with sleep bruxism, including restless leg syndrome, sleep walking, enuresis, and gastroesophageal reflux (GERD)2,14 The most frequent physical findings on examination of suspected OSA or sleepdisordered breathing patients are: 1. Narrow maxilla (reduced transverse palatal width) 2. Posterior cross bite (bilateral more severe than unilateral re: OSA patients) 3. Forward tongue posture during rest and during swallowing (“lick your lips, and let your jaw relax”) 4. Juvenile tongue thrust in swallowing (anteriorly projected rather than against palatal rugae) 5. Hypertrophied tonsillar crypt areas 6. Subjective parental report of “snoring” and “interrupted breathing during sleep” — report of suspected apneic episodes by parent or “bedroom report” Given the physical signs and subjective symptomatology common to OSA, it is apparent that a very thorough extraoral

and intraoral craniofacial examination be conducted as part of the orthodontist’s diagnostic due diligence to their patients.

How are treatment decisions made regarding OSA? Management of OSA is a multidisciplinary effort utilizing a number of treatment modalities such as CPAP (continuous positive airway pressure – nasal or oral); behavior modification (dietary modifications, smoking cessation, weight loss, and exercise, for example); MME (maxillomandibular surgical expansion/advancement); and oral appliances. The “gold standard” for reliably and accurately diagnosing OSA is polysomnography (sleep study – PSG) conducted either in medical facilities such as “Sleep Centers” or a home study utilizing a portable polysomnography unit. Data collection includes electroencephalogram (EEG) activity to measure and record brain wave activity, electromyography (EMG) to record muscle movements associated with restless leg movements and sleep bruxing, electrooculogram (EOG) to record eye movements during REM-NonREM transitions during sleep, electrocardiogram (ECG) to record heart rate, nasal air flow sensors, and audio microphones to record frequency and duration of snoring.15 The physician ordering the PSG interprets the data collected, and treatment recommendations are made according to the severity of the problem, most often using the “gold standard” of Apnea-Hypopnea Index (AHI) and blood oxygen saturation. Sometimes, Respiratory Disturbance Index (RDI) is used to classify OSA, but this may be somewhat confusing since it includes data other than AHI, resulting in the RDI being greater Volume 7 Number 2

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than the standard AHI. By definition, apnea is the complete cessation of airflow for at least 10 seconds, and these can be classified as obstructive, central, or mixed based on whether effort to breathe is present during the event. Hypopnea is defined as a reduction in airflow that is followed by an arousal from sleep or a decrease in oxy-hemoglobin saturation21. Using AHI findings for treatment recommendations, the severity of OSA is classified as: • None/Minimal: AHI < 5 per hour • Mild: AHI ≥ 5, but < 15 per hour • Moderate: AHI ≥ 15, but < 30 per hour • Severe: AHI ≥ 30 per hour

What is the role of oral appliances in the treatment of OSA? Have guidelines been established regarding the use of oral appliances, and is their evidence for their efficacy in general? It has been reported that oral appliances are more efficacious in treating patients having AHI scores of < 5 per hour (none/minimal) to AHI scores of > 15 but < 30 per hour.16,17 Oral appliances to be used during sleep are usually designed to have full arch coverage in the maxilla and mandible for mandibular repositioning. With this design, the maxilla acts as an anchor to the protrusive repositioning of the mandible, and the mandible and tongue are held forward (protrusively) to improve posterior airway patency with the patient in a supine sleeping position. Tongue retention appliances are designed for both arches (discussed previously) if tongue retention is desired while protrusively repositioning the mandible.18 In patients exhibiting more severe OSA, the use of the CPAP or MME is recommended. CPAP is considered reversible therapy as are the oral appliances, but patients using the CPAP or oral appliances must be periodically monitored for any changes in dental occlusal relationships and/or temporomandibular joint integrity. MME is an irreversible surgical correction protrusively repositioning both the maxilla and mandible in order to improve nasal and oral airway patency (to be discussed in "Orthodontic diagnosis and management of OSA: part 2 — case presentations"). An algorithm and flow chart for recommended treatments and referrals can be seen in Figure 4.9 Guidelines for and definition of effective oral appliances for the treatment of obstructive sleep apnea and snoring of the American Academy of Dental Sleep Medicine (AADSM) Volume 7 Number 2

Figure 4:Initiation, management, and follow-up of oral appliances

Orthodontics is recognized as being a key player in the multidisciplinary, evidence-based approach to diagnosis and management of sleep-disordered breathing problems .... (2014) are listed in Table 1. This generalized description of the “what, how, and why” of oral appliance therapy was an attempt to lay the groundwork for establishing an evidencebased “gold standard” for appliance use in treating OSA. To summarize this attempt at standardization of treatment, it was agreed that oral appliances: 1. treat OSA, primary snoring, and associated symptoms 2. decrease the frequency and/or duration of apneas, hypopneas, respiratory effort-related arousals (RERAs), and/or snoring events 3. improve nocturnal oxygenation as well as the adverse health and social consequences of OSA and snoring 4. are indicated for patients with mild to moderate OSA and primary snoring 5. should be used in treatment of patients with severe OSA who do not respond to or are unable or unwilling to tolerate positive airway pressure (PAP) therapies 6. are an adjunct to PAP therapy and/ or other treatment modalities for the management of OSA

7. mandibular advancement devices are the most effective and widely used in clinical practice Recently, a collaboration between the American Academy of Sleep Medicine and the American Academy of Dental Sleep Medicine resulted in the publication of Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015 - An American Academy of Sleep Medicine and American Academy of Dental Sleep Medicine Clinical Practice Guideline. These guidelines include recommendations for the use of oral appliance therapy in the treatment of OSA and snoring, and are internally graded as to their strength of recommendation, quality of evidence and benefits versus harms/burdens assessment. These guidelines represent the best effort to date to identify for whom and how these appliances should be implemented for the treatment of OSA and snoring. As a supplement to the listed guidelines and recommendations, the AADSM published a list of Functional Expectations of Oral Appliances in 2014 with emphasis Orthodontic practice 45

CONTINUING EDUCATION Table 1: Summary of recommendation statements Recommendation statement

Strength of recommendation

Quality of evidence

Benefits vs. harms/ burdens assessment

Standard

High