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

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

Go to page 21 to learn more.

PAYING SUBSCRIBERS EARN CONTINUING EDUCATION

CREDITS PER YEAR!

24

Clear Performance.

More Control.

Actual Damon patients wearing Damon Clear.

Treated by Dr. Todd Bovenizer.

Offering the same crystal clear performance with more control, Damon Clear2 allows you to treat a wide variety of cases with outstanding results so your practice and your patients can put their best face forward.

100% CLEAR BRACKET BODY AND SLIDE for the supreme aesthetics patients demand SMOOTH, ROUNDED CORNERS for outstanding patient comfort

NEW!

Variable Torques*

INNOVATIVE SPINTEK™ SLIDE for easy and comfortable wire changes SELF-LIGATING BRACKET DESIGN eliminates the need for elastomerics which stain and collect bacteria

FOUR SOLID WALLS with improved precision slot for 2x the rotational control** for meticulous finishing and efficient treatment

Order your Damon Clear2 brackets today!

Visit ormco.com

*Variable torques for upper 3-3 brackets. **As compared to Damon Clear upper 3-3 brackets.

© 2016 Ormco Corporation

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

MedMark, LLC 15720 N. Greenway-Hayden Loop #9, Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 Web: www.orthopracticeus.com www.medmarkaz.com

Digital orthodontics: from good to great

D

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

6

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

10

Dr. Rohit Sachdeva discusses how the unique features of suresmile’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

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

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

The Ceramic Bracket Strong Enough to Rebond

Part Art. Part Science. All Orthodontics.™

800.645.5530 | www.dentsplygac.com

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)

35

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

M

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

A

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

Flexible.

Support for most scanners. Custom wear schedules.

Free retainers. Free online training. Shipped up front or in phases.

From simple to advanced cases, ClearCorrect works on your terms.

The most affordable, doctor-friendly alternative in clear aligners.

FREE LIMITED 6 CASE

Sign up for free at clearcorrect.com/doctors and use promo code OPRAC1 Paid Advertising. Offer expires May 1, 2016.

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

THE DIGITAL ADVANTAGE with TRIOS digital color impressions ®

®

3Shape TRIOS Orthodontics • improved patient experience with fast and accurate full-arch color scanning • seamless integrations with leading orthodontic treatment solutions • step-by-step digital workflows for patient diagnosis, treatment planning and model archiving

Meet 3Shape at AAO and discover hands-on, the benefits of digital orthodontics. www.3shape.com/discover/orthodontist

3Shape.com

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

A

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.

Call to see how to make your bonding process more efficient.

Call (800) 423-4588 3MUnitek.com/ADVANCED

* “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

L

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

POWERING PROVEN TECHNOLOGY

DISCOVER THE

EXCELLERATOR PT ÂŽ

The Excellerator PT (Power Tip) is the latest addition to Propel’s award winning series of Excelleration Drivers. Powering the PT is the cordless Orthonia driver with a contra-angle head, allowing easy access to all areas of the mouth including lingual, posterior and palatal surfaces.

- Ergonomic design for comfortable use over multiple applications - Optimal torque and speed making procedures fast and easy - Surgical stainless steel ensures tip strength and integrity - Patented thread design creates perforations with ease - Facilitates cases using braces or clear plastic aligners

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

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

What’s your game plan?

Ever started treatment of a case and come across unexpected challenges? Of course, everyone has.

Using the latest in suresmile’s digital diagnostics to plan cases minimizes the unexpected and provides a dependable clinical support network throughout treatment. The suresmile Comprehensive Treatment Management System gives you the tools you need to plan and manage every case to its desired finish.

Great finishes start with a great game plan.

October 2014 Frontal initial

November 2014 Planned result

“You don’t need the luck of the Irish when you have the predictability of suresmile treatment planning!”

J. Peter Kierl, DDS, MS Edmond, OK

September 2015 Final result

suresmile, it’s your game plan for success.

To learn more call 877.787.7645.

suresmile.com

to be sure.

© 2016 OraMetrix, Inc. All rights reserved. suresmile is a registered trademark of OraMetrix. elemetrix is a trademark of OraMetrix.

That’s exactly what suresmile gives you.

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 StratasysŽ (Stratasys, 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

Precisely what you’ve been waiting for.

The iTero® Element™ intraoral scanner is engineered to deliver everything doctors love about iTero scanners in a compact footprint design with even bigger capabilities. Designed to be portable, powerful, and intuitive, it demonstrates our continued investment in clinical precision and patient satisfaction.

Now is the perfect time to add intraoral scanning to your practice.

Schedule a demo or learn more at www.iTero.com

© 2016 Align Technology, Inc. All rights reserved.

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 doctor’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

Confidence without Limits.

With esthetic braces from Opal, your patients can smile with confidence.

To purchase Avex CX2, call 888.863.5883 or visit opalorthodontics.com to learn more.

Zara Guinard Professional Triathlete, Coach, and Model

opalorthodontics.com | 888.863.5883 Š 2016 Ultradent Products, Inc. All rights reserved.

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 patient’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 — such as archform or occlusal plane — 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

A Simple & Aesthetic Alternative to Class II Correction “The MARA has been a simple, trustworthy, patient-friendly way to not only correct a Class II, but also frequently to improve the chin.”

Dr. James Eckhart, Torrance, CA.

• Its compact design allows for bracketing upper and lower 5-5, potentially reducing treatment time.

• It’s conveniently available as either a customized appliance or a 13 patient kit.

Submit your MARAs and all your cases to AOA using your scanner.

Due to our commitment to quality and craftsmanship, our preferred method is Stereo Lithography (SLA), and is highly regarded as the premier method of rapid prototyping.

Send to us and experience the difference!

Learn more about the MARA at 800.262.5221 or visit us at aoalab.com.

Orthodontic Laboratory

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

Winner: PAtient CHAirs & stooLs

When You Learn hoW affordabLe our Chairs are, You Might have to sit doWn. Every Boyd chair is meticulously manufactured of the

finest materials by skilled craftsmen in our own factory here in the U.S. We know, this sounds expensive.

And every piece is engineered for extreme durability and advanced ergonomics, for far greater productivity.

Plus, Boyd is renowned for product customization, to match your specific practice, décor and taste.

By now, you’re seeing many dollar signs.

But, surprise! Boyd chairs cost the same or less than brands whose quality doesn’t come close to ours.

Because we do everything ourselves, from sourcing to manufacturing, we’re saved from layers of vendors and their costs — and we pass on those savings to you.

All of which means that the most important element we hand craft into Boyd products is this: Our value.

Built to last.

Built for you.

Built by Boyd.

Exam and Treatment Chairs, Delivery Systems, Doctor and Assistant Seating, LED Exam Lights, Custom Sterilization Centers and Video Game Consoles.

800-255-2693 727-561-9292 Fax: 727-561-9393

www.boydindustries.com

Boyd Industries 12900 44th Street N, Clearwater, FL 33762 © Boyd industries 2016

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

T

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 “Airway Centric� 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 Children’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.

REFERENCES

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

1.

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

2.

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.

3.

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.

5.

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.

6.

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.

7.

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.

8.

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.

9.

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.

4.

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.

Volume 7 Number 2

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

REF: OP V7.2 OLMOS REF: OP V7.2 STOCKSTILL

CONTINUING EDUCATION BROUGHT TO YOU BY

FULL NAME

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

AGD REGISTRATION NUMBER

LICENSE NUMBER

ADDRESS

CITY, STATE, AND ZIP CODE

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

EMAIL

TELEPHONE/FAX

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

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

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

OLMOS

STOCKSTILL

1.

2.

3.

4.

5.

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

7.

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

8.

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

9.

___ 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

1.

2.

3.

4.

5.

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

6.

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

7.

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

8.

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

9.

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

CONTINUING EDUCATION

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

CONTINUING EDUCATION

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

Benefits clearly outweigh harms

When oral appliance therapy is prescribed by a sleep physician for an adult patient with obstructive sleep apnea, we suggest that a qualified dentist use a custom, titratable appliance over non-custom oral devices.

Guideline

Low

Benefits clearly outweigh harms

We recommend that sleep physicians consider prescription of oral appliances, rather than no treatment, for adult patients with obstructive sleep apnea who are intolerant of CPAP therapy or prefer alternate therapy.

Standard

Moderate

Benefits clearly outweigh harms

We suggest that qualified dentists provide oversight — rather than no follow-up — of oral appliance therapy in adult patients with obstructive sleep apnea, to survey for dentalrelated side effects or occlusal changes and reduce their incidence.

Guideline

Low

Benefits clearly outweigh harms

We suggest that sleep physicians conduct follow-up sleep testing to improve or confirm treatment efficacy, rather than conduct follow-up without sleep testing, for patients fitted with oral appliances.

Guideline

Low

Benefits clearly outweigh harms

We suggest that sleep physicians and qualified dentists instruct adult patients treated with oral appliances for obstructive sleep apnea to return for periodic office visits — as opposed to no follow-up — with a qualified dentist and a sleep physician.

Guideline

Low

Benefits clearly outweigh harms

Use of OAs for treatment of primary snoring in adults We recommend that sleep physicians prescribe oral appliances, rather than no therapy, for adult patients who request treatment of primary snoring (without obstructive sleep apnea).

Use of OAs for treatment of OSA in adults

placed upon the limitations of these appliances and the specifications for their fabrication and use.

1. OAs are fabricated to protrude and help stabilize the mandible in order to maintain a patent upper airway during sleep.

2. An OA is custom fabricated using digital or physical impressions and models of an individual patient’s oral structures.

3. An effective OA is NOT a prefabricated item that is trimmed, bent, relined, or otherwise modified.

4. An OA is made of biocompatible materials and engages BOTH the maxillary and mandibular arches.

5. OAs allow the mandible to be advanced in increments of < 1 mm with protrusive adjustment range of 5 mm.

6. Any reversal of the mandibular advancement must be possible.

7. OAs are suitable for placement and removal by the patient or caregiver.

8. OAs maintain a stable retentive relationship to the teeth, implants, or edentulous ridge and retain the prescribed setting during use 9. OAs maintain their structural integrity over a minimum of 3 years.

These expectations and limitations were developed as a means of establishing some sense of evidence-based uniformity in the fabrication and use of oral appliances with 46 Orthodontic practice

OSA patients for dental generalists and specialists.

Conclusion Orthodontic diagnosis is a three-dimensional exercise in data collection including advanced CBCT imaging and digitally scanned models that help provide the orthodontist with cutting edge information about their patients. In the past, orthodontic diagnosis consisted of data specific for dental, skeletal, and soft tissue structures and relationships. However, current standards for diagnosis and treatment may now include airway architecture analysis, diagnosis of sleep-disordered breathing and management strategies for OSA diagnosed in pediatric and adult patient populations alike. Orthodontics is recognized as being a key player in the multidisciplinary, evidence-based approach to diagnosis and management of sleep-disordered breathing problems and how these problems relate to the growth, development, health, and wellbeing of our orthodontic patients. OP

5. Ivanhoe, JR, Lefebvre CA, Stockstill JW. Sleep disordered breathing in infants and children: a review of the literature.

Pediatr Dent. 2007;29(3):193-200.

6. Proffit WR, Fields HW, Sarver DM. Contemporary Orthodontics. 5th edition. St. Louis, MO:Mosby, 2012.

7. Standring S (ed.). Gray’s Anatomy: The Anatomical Basis of Clinical Practice. 40th ed. London:Churchill Livingstone;2008.

8. Guilleminault C, Akhtar F. Pediatric sleep-disordered breathing: New evidence on its development. Sleep Med Rev. 2015;24:46-56.

9. Athanasiou AE. Orthodontic cephalometry. London: Mosby-Wolfe;1997:241–292.

10. Nalçaci R, Oztürk F, Sökücü O. A comparison of twodimensional radiography and three-dimensional computed tomography in angular cephalometric measurements.

Dentomaxillofac Radiol. 2010;39(2):100–106.

11. Karatas OH, Toy E. Three-dimensional imaging techniques: A literature review. Eur J Dent. 2014;8(1):132-140.

12. Johnson JM, Moonis G, Green GE, Carmody R, Burbank HN. Syndromes of the first and second branchial arches, part 1: embryology and characteristic defects. AJNR. 2011;32(1):14-19.

13. Johnson JM, Moonis G, Green GE, Carmody R, Burbank HN. Syndromes of the first and second branchial arches, part 2: syndromes. AJNR. 2011;32(2):230-237.

14. Graber L, Vanarsdall R, Vig K. Orthodontics, 5th Edition.

Philadelphia, PA:Mosby, 2012.

15. National Institutes of Health – National Heart, Lung and Blood Institute – 2012.

16. Epstein LJ, Kristo D, Strollo PJ Jr, Friedman N, Malhotra A, Patil SP, Ramar K, Rogers R, Schwab RJ, Weaver EM, Weinstein MD; Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009;5(3):263-276.

17. Division of Sleep Medicine – Harvard Medical School, 2011.

REFERENCES: 1. Neidle E. On the brink — will dental education be ready for the future? J Dent Educ. 1990;54(9):564-566.

2. Klasser, G and Balasubramaniam, R. Sleep Bruxism: What Orthodontists Need to Know? In Kandasamy S, Greene, CS, Rinchuse DJ, Stockstill JW, eds. TMD and Orthodontics – A Clinical Guide for the Orthodontist.

Switzerland:Springer International Publishing;2015:63-79.

18. Lazard DS, Blumen M, Lévy P, Chauvin P, Fragny D, Buchet I, Chabolle F. The tongue-retaining device: efficacy and side effects in obstructive sleep apnea syndrome. J Clin Sleep Med. 2009;5(5):431-438.

19. Journal of Clinical Sleep Medicine 5(3), 2009

3. McNicholas WT. Diagnosis of Obstructive Sleep Apnea in Adults. Proc Am Thorac Soc. 2008;5(2):154-160.

20. Ramar K, Dort LC, Katz SG, Lettieri CJ, Harrod CG, Thomas SM, Chervin RD. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep Med. 2015;11(7):773-827.

4. Lumeng JC, Chervin RD. Epidemiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc. 2008;5(2):242-252.

21. Punjabi NM. The epidemiology of adult obstructive sleep apnea. Proc Am Thorac Soc. 2008;5(2):136-143.

Volume 7 Number 2

And CLEAR may be the least extraordinary thing about it.

Whether it’s the simplicity of use, the sleek patient-friendly design, or the remarkable speed and predictability of how it works, the Carriere ® Motion™ Class II Appliance is truly extraordinary.

The Carriere Motion Clear Class II Appliance is currently undergoing 510(k) premarket review by the FDA for orthodontic movement and alignment of teeth during orthodontic treatment.

888.851.0533 or HenryScheinOrtho.com © 2016 Ortho Organizers, Inc. All rights reserved. PN M928 03/16.

U.S. Patent No. 7,621,743, and foreign patent numbers.

AAO

AAO PREVIEW

American Orthodontics Empower® 2 Self Ligating Brackets

A

merican Orthodontics has taken its Empower® line of self ligating brackets, the industry’s most complete self ligating bracket system, and made it even better.

Empower’s metal brackets and molar tubes will now be known as Empower 2 and will feature upgrades designed to enhance the bracket’s strength and dependability.

Empower 2 metal brackets and molar tubes include new micro-etched Maximum Retention™ bonding pads, which increase bond strength 15%-30% over non-microetched pads. A new modified clip shape also helps seat wire into the slot during clip closure. This enhanced clip is 20% thicker and stronger than the previous generation,

and increases wire seating force while reducing clip deformation. A chamfered slot entrance also reduces friction from wire binding.

Empower brings you choice like you’ve never had before. The Empower family includes bracket and system options that put control back in your hands by allowing you to treat your patients your way. You get the most features, prescription choices, and treatment

possibilities all in one quality, unified system.

Multiple bracket options include metal, clear, and molar tubes; and system choices include a fully interactive system, a fully passive system, or the innovative Dual Activation™ system. This combines interactive brackets on the anterior teeth with passive brackets on the posterior teeth in one unified system.

Learn more about Empower 2 and the entire Empower family by visiting www. americanortho.com/Empower.

Visit American Orthodontics at Booth No. 1341

AOA customizing the MARA™ since 1994

A

OA released the first generation of the MARA™ back in 1994 and has since worked with many doctors, introducing multiple enhancements, all designed to make sure we’re delivering one of the best Class II appliances for doctors and patients. Today’s version, the MARA 3.0, offers a sleek, forged lower arm designed to withstand natural mastication forces and provide a smaller profile than that of previous designs.

AOA currently produces more than 10,000 MARAs annually!

“As the orthodontist becomes comfortable in the performance of the appliance, the

48 Orthodontic practice

simplicity of design becomes more appreciated since there is little to master,” says Jerry Engelbart, AOA’s lead MARA technician since the MARA first made its debut.

The basic MARA consists of: • • • •

Four crowns or bands Upper and lower archwire tubes Lower arms soldered to the crowns Upper elbow tubes soldered to the crowns • Upper elbows shimmed to support the desired advancement. Ball end hooks for ligation • Lower lingual archwire soldered to lower crowns/bands The MARA can also easily be combined with a variety of different expansion screws to incorporate both transverse correction and mandibular advancement into one simple design. Another benefit of this appliance is the option for placement at various stages of patient treatment. It can be just as easily placed in a mixed dentition as it can in a

permanent dentition due to its compact size and ease of delivery. Its ability to combine with upper and lower brackets, 5-5, can have an influence on reducing overall patient treatment time.

To hear more, visit AOA at the Ormco Booth No. 1021, or contact our Customer Care Team at 800-262-5221. To learn more, connect to www.aoalab.com.

Visit AOA at Booth No. 1021 Volume 7 Number 2

Boyd Industries, Inc.

B

uilt to Last. Built for You. Built by Boyd is more than a tagline — it signifies the commitment that everyone at Boyd makes to each and every one of our customers.

Best known for the durability and reliability of our award-winning products, we combine decades of design and manufacturing expertise to create personalized cabinetry and upholstered products to match your imagination. The Boyd team, from product designers to product installers, takes great pride in the craftsmanship of the products we build at our Clearwater, Florida, facility.

Among our uniquely Boyd products are our award-winning M3010 series drop-toe exam chairs. These chairs are great for an operatory where space may be a constraint or in consultation rooms. All chairs are manufactured using a durable steel frame, quiet low-voltage DC motors, ergonomic winged back, and choice of headrests.

The chairs are offered in three different base configurations — fixed, lift column, or cantilever — to suit your preferences.

The cantilever version comes standard with a membrane switch programmable hand control mounted on both sides of the chair back for easy access. Complemented by our award-winning stools, the M3010 series has received much praise for its styling and functionality.

Boyd’s custom cabinetry products are designed and fabricated to the highest quality standards. The design process is a collaboration between you and our team to create your vision for your office while balancing design elements to assure the highest staff efficiency and safety. We offer a wide variety of cabinet products to include sterilization centers, records room, laboratories, toothbrushing stations, and other storage solutions. Like our chairs, our cabinetry will stand up to the rigors of an active orthodontic office to provide many years of service.

To learn more about our products, contact your Boyd sales representative, or visit us at Visit Boyd Industries at Booth No. 841 www.boydindustries.com.

New CS 3600 intraoral scanner makes digital impression workflow fast and easy for orthodontists

C

arestream Dental puts easier, faster, more open scanning in orthodontists’ hands with the new CS 3600 intraoral scanner. Featuring a dedicated orthodontic workflow, the scanner makes capturing digital impressions easier than ever.

With the CS 3600, users can quickly and easily create digital models for study and record keeping or for use in appliance fabrication.

Bite registration is easy to acquire with little to no manipulation. Sophisticated CS Model software automatically creates model bases and trims, so doctors can view the model from every possible angle when developing a treatment plan.

Continuous scanning allows users to scan in a smooth, uninterrupted pattern and negates the impact of unsteady hands or fidgeting young patients on successive views. This also makes full and dual arches

Volume 7 Number 2

the scanner comes with two rounded, interchangeable tips in different orientations — normal for anterior and occlusal and side-oriented for highquality buccal surface scans.

The CS 3600 is part of an open system and doesn’t require a proprietary computer system, making it easy to carry from operatory to operatory.

Once scans are acquired, they can be sent to any lab that accepts digital impressions.

With the CS 3600, orthodontists can eliminate the mess associated with traditional impressions; save money on shipping and impression materials; and achieve faster turnaround between impression and appliance. Learn more about the CS 3600 in Booth No. 1801 at the AAO Annual Meeting.

easier to acquire. The CS 3600’s Intelligent Matching System lets users jump to any position in the mouth to fill in missing information for any area in the data set at any time. Additionally, the broad scanning range of the CS 3600 means users can either hover or briefly rest the scanner on a tooth and still achieve optimal scans. To capture Visit Carestream Dental at Booth No. 1801 scans in difficult-to-reach places,

Orthodontic practice 49

AAO PREVIEW

PREVIEW

AAO

AAO PREVIEW

Sani-Soak Ultra from Enzyme Industries

S

ani-Soak Ultra is an anti-corrosive enzymatic cleaner that can be used as an ultrasonic cleaner and/or an evacuation system cleaner. Sani-Soak Ultra is designed to brighten and extend the life of instruments, is nontoxic, and is safe to use on burs and instruments. It is available in Cool Mint or Lemongrass Lavender scent. SaniSoak Ultra is available in a quart or gallon bottle or a 64-count box of 0.5 oz uni-dose packets. The quart bottle has a built-in “tip

and measure” cup, and it yields 64 gallons of cleaner.

The following are excerpts from a September 2015 Research Report performed

by John A. Molinari, PhD, and Peri Nelson, BS, on behalf of THE DENTAL ADVISOR Microbiology Research Center, Dental Consultants Inc., Ann Arbor, Michigan.

Read the entire Research Report at www.enzymeindustries.com/sanisoakultra/

Cleaning efficiency of Sani-Soak Ultra Enzymatic Cleaner System Results Excellent cleaning of contaminated instruments was noted after processing with Sani-Soak Ultra Enzymatic Cleaner System.

The overwhelming majority (149/150) of soiled instruments showed no evidence of debris after a 10-minute ultrasonic cycle.

Summary In the present investigation, dental scalers

and probes were heavily contaminated with organic soil prior to undergoing processing in an ultrasonic cleaner. The amount of challenge debris on instruments was far greater than what would be expected in clinical settings. After contaminated instruments were processed in an ultrasonic unit for 10 minutes, rinsed, and subsequently visually observed, it was found that Sani-Soak Ultra Enzymatic Cleaner System effectively removed the extensive dried material in >99% of soiled test samples.

Visit Enzyme Industries at www.enzymeindustries.com

Henry Schein® Orthodontics™

H

enry Schein Orthodontics (HSO) is a Specialty Division of Henry Schein.

Placing Henry Schein’s orthodontic-focused operations under the Henry Schein umbrella enhances the business prospects for the Company and helps enable it to serve the orthodontic professional with innovative product offerings and practice solutions, which include forward-thinking educational offerings.

Changing the industry Demonstrating Henry Schein Orthodontics’ strong commitment to partnering with orthodontists in the growth of their practice, we have come to market with the Carriere® SLX™ Self-Ligating Bracket System. In just a few short months after its release, this passive system established a new standard in performance within the industry with 10-clinician inspired improvements. Complementing the SLX Appliance System is one of the most popular Class II correction appliances on the market today, the Carriere Motion™ Class II Appliance. In 50 Orthodontic practice

addition, the system offers the Motion Class III Appliance, which has gained overwhelming popularity in a short amount of time.

Excellence in orthodontics Our commitment to partnering with the orthodontist doesn’t stop at manufacturing.

We are devoted to providing complete solutions, including ground-breaking educational courses that will make you stand out within your community by offering total health solutions in your practice. Over the last 3 years, we have introduced industry-leading courses with overwhelming success, including Airway-Friendly Orthodontics™ taught by

Drs. Lou Chmura and Dave Paquette, CBCT in Orthodontics™ presented by Drs. Sean Carlson and Juan-Carlos Quintero, as well as Soft Tissue in Orthodontics™ taught by Dr. Scott Frey. Henry Schein Orthodontics has also held two first-of-their-kind Orthodontic Excellence and Technology™ Symposiums, selling out their second annual symposium.

In addition, HSO will be hosting a European Carriere Symposium, September 22-24, 2016, in Barcelona, Spain.

Visit Henry Schein Orthodontics at Booth No. 901 Volume 7 Number 2

Exclusive seminars to precede AAO Annual Session

D

iscover the most sophisticated software available for evaluating your patients more thoroughly, accurately, and quickly — with better results. This first-ever Joint Orthodontic Conference sponsored by Motion View Software, LLC, the Andrews Foundation, and Henry Schein® Orthodontics is at The Point Orlando Resort at 7389 Universal Boulevard in Orlando on April 27, 28, and 29.

Dr. Larry Andrews presents his Six Elements Orthodontic Philosophy™, and other speakers discuss the WALA Ridge and Jaw Surgery Considerations. This event debuts the automated Six Elements module developed by Motion View and demonstrates the benefits of using Ortho Insight 3D™ diagnosis and treatment planning software with other Motion View products for a complete in-your-own-office solution for automating 3D data capture, digitization, analysis, storage, sharing, and printing.

Ortho Insight 3D™ provides unmatched abilities to create and visualize multiple treatment plans quickly, clearly communicate

plans to patients/dentists, and reduce time from initial exam to treatment start and finish.

• Scan then integrate 3D facial scans with 3D study models for accurate evaluation of the occlusal plane in all three planes of space.

• Duplicate/modify the patient’s natural arch form, test anchorage requirements in different treatment scenarios, evaluate arch length deficiencies/excesses, and create user-definable ceph, facial, and model analyses.

• Create model series for active

aligners with motion handles. Aligners made from setups created in Ortho Insight 3D™ are so accurate they just snap into place.

• Create indirect bonding setups and transfer trays with required bracket positions precisely calculated.

• Create precisely positioned surgical guides for implants in complex restorativeorthodontic cases that once required multiple wax setups.

• Export STL files to print trays/guides on your in-office iPrint 3D® printer at a fraction of the cost of outside labs.

Register by using the registration form at www.MotionView3D.com or by calling (423) 475-6914. Walk-ins welcome if space available. Standard registration for Orthodontists is $395 per person; a group discount is available. Rate for Residents/Staff is $195 per person.

Visit Motion View Software at The Point

Don’t READ your notes — SEE your notes using Oral4D Ortho

W

e live in an interactive, 3D world, and orthodontics is a field that relies heavily on visuals. Despite this, most patient records still exist in the form of text-based notes.

Oral4D Ortho was created by an orthodontist frustrated with flat 2D images and having to read through pages of text notes in treatment records and finding inconsistencies and errors in the notes, common pain points in the orthodontic industry.

Dr. Hisham Badawi of Smile Elements in Calgary, Alberta, recognized that while the introduction of Electronic Health Records

Volume 7 Number 2

(EHR) made it easier to enter and track patient treatment notes, he was still having to read his notes as opposed to seeing the actions of his patients’ treatments. In 2013, he went on to take the EHR industry to the next level and founded Oral4D Systems Ltd., an orthodontic software program that creates innovative 3D patient treatment cards to provide orthodontists and assistants with visual communications to accompany their patient treatment notes. By championing the 3D visualization of patient treatment notes, Oral4D Ortho has revolutionized the way orthodontists create, review, and trust their clinical notes.

Using Oral4D Systems patented 3D visual communications for your patients’ treatment notes, know exactly which brackets, wires, springs, attachments, and elastics your patients have with a quick glance at the computer screen. This allows the doctor and assistant to go through the patient visit quickly and efficiently, eliminating the chance of errors or miscommunication.

Without typing, assistants can capture complete notes. You no longer have to decipher your assistants’ unique treatment notation, and you quickly see accurate information you need to make your clinical decisions without guesswork.

Our software is suitable for solo practices, multiple locations, corporate, and multi-specialty and can be installed at your location or as a hosted solution (cloud).

Be sure to see us at Booth No. 1759 at the AAO conference in Orlando for a live demo of our software solution! Or visit us at www.oral4d.com.

Visit Oral4D at Booth No. 1759 Orthodontic practice 51

AAO PREVIEW

PREVIEW

AAO PREVIEW

Ormco™ Corporation

AAO

Offering a variety of esthetic fixed appliances and practice growth support

O

rmco supports the orthodontists’ ability to cater to the esthetically-minded patient with a variety of discreet solutions and practice growth support.

With a completely clear body and door resistant to staining, Damon™ Clear2 brackets, now available in variable torques (U3-3), provide the control and performance needed to treat a wide range of cases. Eliminating the need for elastomerics, the Damon Clear selfligating bracket design with SpinTek™ slide ensures quick and comfortable wire changes.

Damon Clear is also available with Insignia™, providing patients with a customized and even more efficient treatment experience.

For orthodontists seeking an esthetic twin appliance, Inspire ICE™ brackets are crystal clear and virtually invisible regardless of the tooth color. With a low profile, yet ample tie-wing undercuts, Inspire ICE provides a smooth surface and rounded facial contours to enhance patient comfort.

Ormco’s array of esthetic solutions include Damon™ Clear2, the new Alias™ Lingual System, and Inspire ICE™

The Alias™ Lingual Bracket System is the first self-ligating, square slot, lingual appliance. Alias combines the efficiency of straight-wire mechanics with a patented square slot to simplify treatment and improve torque and rotational control. With an easier to bond bracket, Alias is designed to make lingual orthodontics easier and more efficient.

Ormco’s online Doctor Locators are designed to drive consumers of all ages to doctors treating with Damon Clear, Insignia, and Inspire ICE. Additionally, Ormco provides a range of online practice

marketing assets and staff training tools on www.marketing.ormco.com and educates patients on the benefits of orthodontics and the Damon System via its online consultation tool, My Smile Consult™.

Visit Ormco Booth No. 1021 at the AAO Annual Session for more information. Plus, meet with industry experts and get handson demonstrations of My Smile Consult and Insignia!

Visit Ormco at Booth No. 1021

AcceleDent® is leading the category of Accelerated Orthodontics

N

ow available in more than 3,000 locations in North America, AcceleDent® is leading the category of accelerated orthodontics. AcceleDent is a noninvasive, FDAcleared, Class II medical device that speeds up orthodontic treatment by as much as 50% and relieves pain often associated with orthodontic treatment. Using patented SoftPulse Technology®, it works at a cellular level to accelerate bone modeling and remodeling in the craniofacial region.

AcceleDent is recommended by many of the industry’s leading orthodontists as the only fast, safe, and gentle solution to accelerate orthodontic treatment. According to the Journal of Clinical Orthodontics, AcceleDent is the most common accelerated treatment technique used by orthodontists.

Recently published randomized clinical trials also add to the growing body of clinical evidence supporting AcceleDent’s safety and effectiveness. In September 2015, Seminars in Orthodontics published results demonstrating that pulsatile forces, as used in AcceleDent, 52 Orthodontic practice

significantly accelerate tooth movement. A prospective, double-blind, randomized, shamcontrolled trial further demonstrates that gentle, noninvasive satisfaction with their AcceleDent experivibration increases the rate of tooth movement ence,” says Michael K. Lowe, president and when applied as an adjunct to orthodontic CEO of OrthoAccel® Technologies, Inc., the treatment. Additionally, the peer-reviewed manufacturer of AcceleDent. “It’s rewarding journal The Angle Orthodontist published and exciting to hear from patients about “Pain Control in Orthodontics Using a Microhow AcceleDent accelerated their journey pulse Vibration Device: A Randomized Clinto healthy, beautiful smiles.” ical Trial.” Participants in this study reported Underscoring the company’s leadership that they experienced less pain when using in accelerated orthodontics, OrthoAccel was AcceleDent, and the authors concluded that ranked on the prestigious 2015 Deloitte Fast micropulse vibration devices, such as Accele500 list of the fastest-growing companies Dent, significantly lower orthodontic treatment in North America. OrthoAccel was ranked pain scores for overall pain and biting pain.

No. 69 on the Deloitte list and was the only These studies, in conjunction with the posiorthodontic company on the list. tive patient and provider feedback, illustrate To learn more, visit AcceleDent.com/ why AcceleDent is the preferred accelerated orthodontists, or call 866-866-4919. orthodontic treatment technology.

“Tens of thousands of AcceleDent patients across Visit OrthoAccel Technologies at Booth No. 1141 the globe report their Volume 7 Number 2

AAO PREVIEW

PREVIEW Increase revenue @full power with Propel

F

or orthodontic providers seeking to delight their patients and achieve superior practice growth, Propel has expanded its award-winning series of Excellerator® Drivers with the all new Excellerator PT (Power Tip).

Propel’s Excellerator Drivers earned the Pride Institute’s “Best of Class” honor in 2014 and 2015, and also received acclaim as one of Dentistry Today’s Top 50 Technology Products in 2014 and 2015.

Powering the PT is the cordless Orthonia driver, which combines optimal torque and

speed, making procedures fast and easy.

“The PT delivers easy and comfortable handling with the added advantage of facilitating access to difficult to treat areas such as the posterior and palatal anatomy” said Jonathan Nicozisis, DMD, MS. To learn more about the Excellerator Series Drivers, as well as other exciting new Propel products, please contact either your Territory Manager, or Propel Customer Support by calling 855-377-6735 or emailing info@propelortho.com.

Attend one of our AAO in-booth lectures for the chance to win a free power driver.

Visit Propel at Booth No. 451

New M.A.R.A. Class II corrector from Specialty Appliances

S

pecialty Appliances recently announced the release of their new M.A.R.A. (Mandibular Anterior Repositioning Appliance). The M.A.R.A. is a great addition to the orthodontic lab’s full service list of over 250 appliances and industry leading digital services. Similar to Specialty’s other popular Class II appliance, the M4 Herbst, the M.A.R.A. is constructed from their own custom manufactured parts. This improves appliance customization for a better fit, while also making Specialty’s M.A.R.A. more affordable than versions from other labs.

The M.A.R.A. is a dependable fixed appliance for Class II correction. It utilizes lower mandibular stops and upper extension elbows to advance the mandible.

The M.A.R.A. is generally secured to teeth with crowns or Specialty’s custom “ROC” Removed Occlusal Crowns for strength and easy removal. The compact design makes this device strong, comfortable, and esthetic for orthodontic patients.

Volume 7 Number 2

Quality craftsmanship and expert techCustomization of Specialty’s M.A.R.A. gives doctors more control of their Class nical support differentiates Specialty AppliII patients. The appliance is designed with ances from other orthodontic laboratories. removable elbows, allowing clinicians to Their Quality First Warranty guarantees control skeletal midline asymmetry by proper fit and function of every appliance. making bilateral or unilateral advancement Specialty will repair or replace any defecadjustments. These adjustments are easily tive appliance or part within 9 months of it being shipped to your practice. Please visit managed by crimping shims ranging from the Specialty Appliances team in Booth No. 1 mm to 4 mm in length. A lower lingual arch and upper trans-palatal arch come standard 2131 at the Orlando AAO, call them at 1-800to ensure arch stability during treatment.

522-4636 (LAB-INFO), or visit www.specialty Doctors can add rest to any teeth at no appliances.com for more information. extra charge. Expansion devices for both arches are also available Visit Specialty Appliances at Booth No. 2131 upon request.

Orthodontic practice 53

AAO

AAO PREVIEW

Get into digital

suresmile® fusion … finally, lingual treatment that is both precise and predictable

T

he latest in digital technology. Precise indirect bonding techniques. The efficiency of self-ligating appliances. Clinical assistance throughout treatment. suresmile fusion is the lingual treatment system that gives clinicians the ideal combination of esthetics, function, and comprehensive control. fusion brings together the precision of suresmile treatment planning software, robotically bent archwires, along with the laboratory expertise of Specialty Appliances and the efficiency of GC Orthodontics’ self-ligating, low-profile bracket system … all supported by the clinical expertise of lingual orthodontists.

Why should you prescribe fusion?

• Expert start-to-finish assistance from lingual orthodontists • Self-ligating, low-profile design brackets from GC Orthodontics • Advanced treatment planning using the suresmile system • Computer-aided digital bracket placement • The precision of suresmile robotically bent archwires to deliver precise and predictable finishes • Indirect bonding trays • Modifications available at any time throughout treatment • Starting a fusion case is easy — all you need is upper and lower scans in STL format and treatment instructions. We’ll take it from there.

To place an order for your first fusion case, visit the fusion North America doctor portal at www.fusionnorthamerica.com

Before

After

To learn more about this revolutionary approach to lingual treatment, call us at 855-281-0966 (toll-free) or 972-728-5901.

You can also reach us via email at fusion@ orametrix.com.

Visit suresmile at Booth No. 531

Orthodontic Practice US

PRO

an • m

M

OT

vice

ent ad

agem

les

al artic

clinic

E ING

L XCE

data pts in l once quentia e ent c Curr re for s py captuer thera alignavid Penn

LEN

IN CE

ORT

DO

HO

NTI

clinical

articles

• mana geme

nt advic

ires iTi w on N ection ns ends l corr g V-b surgica locclusiohouri in s U a on .K for n lass III mr. Suhail A D of C

e • pr actic

e profile

PROM

Dr. D

OTIN

G EX CELL

3D orth for pedi opedic deve sleep atric obstru lopment apnea ct Dr. Stev (OSA) ive en R. Ol

ENCE

s • tec hnology reviews March/A pril 2016 – Vol 7

IN O RTH

ODO

NTIC

mos

Receive your free 1-year digital subscription at our booth If you are unable to stop by our booth, you can take advantage of this offer by visiting http://ortho-us.link/2016AAO and entering the following code: 2016AAO

CS

Sleepdisord in orth e p lansered br ea ncodon ins bartlaI y Robbtic patient thing hpa s: Cas Dr. Jo Ton Zgainer hnTo Stmocks and till

Living choice with the file s pro ills Tony Ro wetic eB c meak bbins an an Tom Zg Pra Ddr. D

ntics , hodo bota o Ku l Ort Taka i igita deva, ash BioD 19 Sach uo Hay . rt .L a p Rohit C d Kaz

ainer

an Drs. oward, H Eric

BioDig ital Orthodo ntics: Dr. Rohit C.

part 20

L. Sach

deva

AAO pr eview Sp ecial se

ction

RN S EA ION IBER DUCAT E SCR !

SUB INUINGR YEAR ING T PAY CON DITS PE E CR

No 2

A A C C H H I I E EV VIIN NG GY YO OU UR RC CLL I I N N I I C C A ALL G GO OA ALLS S..

At Orthodontic Practice US, we are dedicated to bringing our readers the most relevant information in the orthodontic space.

We want to spread the word — and now you can have the opportunity to read all about it — free for a year. Sign up for our weekly eNewsletter and get access to 12 months of free CE credits and a digital subscription to Orthodontic Practice US.

s review o1 logy l7 N chno – Vo • te 2016 ofiles ruary pr b e Fe ary/ actic Janu • pr

24

S

PAYING

SUBS CONT CRIBERS 24 CR INUI EA EDIT NG EDUC RN S PER

GamePla

n_Cover

Visit Orthodontic Practice US at Booth No. 2263 54 Orthodontic practice

_OPUS_

F.indd

1

AT YEAR! ION

Go to pa to lear ge 21 n mor e.

3/9/16

12:32

PM

Volume 7 Number 2

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

INTERACTIVE

ease of self ligation plus the best of both interactive and passive systems.

• Interactive anterior brackets

PASSIVE

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

NOW AVAILABLE WITH EMPOWER CLEAR!

Visit americanortho.com/DualActivation to see Dr. Dan Bills’ video testimonial on Dual Activation ©2016 AMERICAN ORTHODONTICS CORPORATION | +1 920 457 5051 | AMERICANORTHO.COM

PROPELLING ORTHODONTICS

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

“Y

ou miss 100% of the shots you don’t take.” — Wayne Gretzky Over the past 2 years, I have had the opportunity to progressively incorporate micro-osteoperforations (MOPs) using the Propel® System into my practice. During the course of this integration, I have used both the initial Excellerator and the secondgeneration Excellerator RT (replaceable tip) (Figure1) with a significant degree of success both in clinical efficiency and outcome. With the introduction of Propel’s new power driver, the Excellerator PT (power tip) (Figure 2), my capacity to conduct MOPs has been elevated to a remarkably new level of clinical experience.

As previously described,1 I was initially reluctant to even consider adopting this treatment modality. While acknowledging and respecting the science supporting MOPs,2-4 I nevertheless considered the procedure invasive and obtrusive and assumed that my patients would mirror my concerns. I could not have been more mistaken.

While I continued to follow the clinical success and impressive clinical outcomes of early adopters of MOPs,5-8 I was simultaneously confronted with an increasing demand from my own patients to meet their esthetic and functional needs with less time in treatment. Accordingly, I set aside my questions and embraced the modality, starting with the Excellerator and graduating to the Excellerator RT, which increased efficiency and patient comfort.

As with the aforementioned early adopters, I began to immediately witness both successful clinical outcomes and remarkably increased patient satisfaction with the integration of MOPs.

Figure 1: (left) Excellerator fully disposable device. (right) Excellerator RT — reusable handle

Figure 2: Propel’s newly launched Excellerator PT (power tip)

An Excellerator that accelerates MOPs Several months ago, I was afforded the opportunity to try Propel’s new power driver, the Excellerator PT. Until then, I had been pleased with my progress with the technique and use of the Excellerator RT. For example, I learned that it is ergonomically more efficient and effective to stand chairside when using the hand driver. However, I still recognized the benefits of integrating the new power driver into the MOPs protocol immediately.

First, the power driver is fast, fluid, and with its push button delivery both in forward and reverse modes, is exceptionally easy to control while completing the MOP’s application in less time than with the Excellerator RT. The power driver offered by Propel for use with the PT tips operates at higher RPMs than most battery-operated torque drivers

Gary Brigham, DDS, MSD, earned his doctorate at Case Western Reserve University, where he also received his certificate in orthodontics and a master’s degree in Immunology. He was awarded the Harry Sicher Award from the AAO for his graduate research and served as an Assistant Professor of Pediatric Medicine at the Center for Craniofacial Anomalies at the University of Illinois at the Medical Center in Chicago. He has lectured throughout the United States for Align Technology since 2004 and is the recipient of Align’s first award for service to the orthodontic profession. Dr. Brigham currently serves as an Adjunct Professor of Orthodontics in the orthodontic graduate program at the A.T. Still School of Dentistry and Oral Health, where he is the dedicated Invisalign® instructor. He maintains a full-time practice in Scottsdale, Arizona.

56 Orthodontic practice

Figure 3: Contra-angle head attachment

currently available. The higher operating speed and adjustable torque settings are optimal for the micro-osteoperforation procedure. A standard torque driver would be slow and inefficient when making multiple perforations. So the power driver offered by Propel provides the right combination of control and efficiency.

Second, the increased patient comfort with the entire procedure was immediately evident. For example, in using the handdriven accelerators, I found that it was occasionally necessary to supplement the topical anesthetic gel BTT (lidocaine 12.5%, tetracaine 12.5%, prilocaine 3%, phenylephrine 3%, Woodland Hills Pharmacy, Woodland Hills, California) with local infiltration anesthesia using Septocaine® (articaine HCL 4% and epinephrine 1:100,000). I attribute this to my exacting some degree of torque to the interdental bone when performing MOPs with the hand/wrist delivery application of the Excellerator RT. It has been speculated that incorporating operator-induced torque to the alveolar bone creates micro-stresses. These micro-stresses radiate from the perforations to the nerve endings of the periodontal ligaments of adjacent teeth and are likely responsible for the sensitivity. Since using Volume 7 Number 2

Propel, Invisalign®, and smile-driven orthodontics Any clinician with significant experience with clear plastic aligners will likely agree that, the more cases that are completed using Invisalign, the more complicated the treatment of new cases (as well as their ClinCheck®) becomes. The reason for this phenomenon

is that, with increased skill in the use of Invisalign, most clinicians will necessarily expand his/her treatment goals. Whereas alignment of malposed teeth was once the principal goal (and sometimes the only objective) of treatment, the experienced clinician often strives to create ideal occlusions that require the least amount of neuromuscular adaptation to function, as well as esthetic smile arcs with idealized tooth axial inclinations. Along with the increase in detail delivered by ClinCheck® Pro, there has been a natural increase in the number of attachments to effect these additional changes. Clinicians have to only review the excellent clinical outcomes display in the education section of Invisalign’s doctor website to appreciate the evolution in both treatment objectives and results that have occurred over the past decade.

However, this expansion in treatment objectives has created a clinical conundrum for many clinicians. For example, where a patient was once regarded as a case that could readily be treated with Invisalign Express (maximum of 10 aligners), the nature of the case changes significantly when incorporation of a smile arc to maximize smile-driven esthetics is considered.

The application of the Nicozisis Extrusion Protocol9 to extrude the maxillary incisors necessarily adds a considerable number of aligners to achieve the desired results, specifically because purely vertical extrusive

movements using Invisalign are not practical. Although patients expect impressive clinical results, they are normally not willing to accept the additional treatment time required to realize those results.

Incorporating the use of Propel addresses this problem directly. Following the procedure, when patients are directed to exchange their aligners every 3, 5, or 7 days according to aligner tracking, the number of aligners required to complete treatment becomes inconsequential.

Case No. 1 illustrates this point. The patient had previously been treated with fixed appliances. However, the arches had since constricted, and the mandibular incisors had collapsed labially. The proclined incisors resulted in heavy palatal contacts to the maxillary central incisors that resulted in their anterior displacement with spacing that created an esthetic concern for the patient. In addition, the distal aspects of the maxillary lateral incisors had rotated palatally, reinforcing the illusion of a “two-tooth smile” when viewed frontally. Finally, an unesthetic reverse smile arc was evident.

The patient expressed a desire for a broader and more esthetic smile with straight teeth. A total of 24 aligners were required to achieve the treatment objectives, which under traditional aligner exchanges of every 2 weeks, would result in 12 months of treatment. However, 2 months after the

Figure 4: Case No. 1 pretreatment photos

Figure 5: Case No. 1 ClinCheck at Stage 24 (note the extensive use of attachments) Volume 7 Number 2

Figure 6: Case No. 1 posttreatment photos Orthodontic practice 57

PROPELLING ORTHODONTICS

the Excellerator PT, it has not been necessary to use any supplemental local infiltration anesthesia. Moreover, for patients who underwent an initial Propel procedure using the Excellerator RT and then underwent a second procedure using the Excellerator PT, the response was unanimously in favor of the Excellerator PT as the driver that produced the greatest level of patient comfort.

Third, by virtue of the contra-angle latch type driver holder assembly of the Excellerator PT (Figure 3), access to previously difficult areas, such as the molar regions, is no longer challenging. This is particularly beneficial where MOPs, applied to the maxillary buccal segments in high angle/anterior open bite cases, is critical to facilitating the intrusion of these posterior teeth. Finally, ensuring sterile technique is effortless. The single-use contra-angle perforation screws are individually packaged and sterilized with gamma radiation, and the contra-angle driver holder easily detaches from the motorized hand piece for autoclaving.

PROPELLING ORTHODONTICS

Figure 7: Case No. 2 pretreatment photos

Figure 8: Case No. 2 ClinCheck at Stage 41 (note extensive use of attachments)

Figure 9: Case No. 2 posttreatment photos

Figure 10: Case No. 3 pretreatment photos

Figure 11: Case No. 3 ClinCheck at Stage 34 (note extensive use of attachments)

Figure 12: Case No. 3 posttreatment photos

aligners were delivered, all attachments were placed, and interproximal reduction (IPR) was completed, the patient underwent Propel to both arches and initiated the 3/5/7 day exchange protocol. Treatment was completed in 5 months and 2 weeks.

Case No. 2 presented with a Class I malocclusion characterized by an excessive 60%-70% overbite, 3 mm overjet, an occlusal cant to the patient’s left, a maxillary midline discrepancy to the patient’s right of 2 mm, a right Class II canine relationship, and a significant Bolton discrepancy in the maxillary arch. Both arches were constricted, with procumbent and crowded mandibular incisors. The patient expressed concern for the midline discrepancy, the overbite, and the unesthetic appearance of her smile.

A total of 41 aligners were required to achieve the treatment objectives, which under the 2-week aligner exchange format, would result in almost 21 months of treatment. The patient initially rejected Propel as a treatment option at the treatment plan presentation.

However, after 8 months of treatment at an aligner exchange of every 2 weeks (total of 16 aligners), the patient requested a review of the Propel procedure and subsequently accepted treatment. Accordingly, Propel was initiated, and the patient was placed on the 3/5/7 day 58 Orthodontic practice

aligner exchange protocol. Treatment was completed in 10 months and 3 weeks.

Case No. 3 presented with a Class I malocclusion characterized by 20% overbite, 2 mm overjet, severe bimaxillary arch constriction/ collapse, severe mandibular anterior tooth crowding, the absence of four first bicuspids from previous fixed appliance treatment, and a paucity of free gingiva labial to the mandibular anteriors. The patient’s principal concern was the unesthetic appearance of her smile. The treatment ClinCheck® required a total of 34 aligners. Propel was initiated at the beginning of treatment, and the patient was placed on the 3/5/7 day aligner exchange protocol. Treatment was completed in 6 months.

Epilogue Micro-osteoperforation has already proven to stimulate a cytokine cascade response in interdental bone that results in an increase in the rate of orthodontic tooth movement. Propel has been a leader in delivering patented medical devices that truncate orthodontic treatment time regardless of the type of appliance used. Incorporating the use of Propel into our practice has resulted in consistently improved treatment efficiency, productivity, and remarkable patient satisfaction without compromising clinical outcomes.

After using all three Propel devices, I much prefer the Excellerator PT. Having witnessed the reaction of patients who have experienced both the Excellerator PT and one of the other hand-driven devices, I am convinced that the powered device is more efficient, productive, and patient friendly. I would at least encourage clinicians to evaluate it for their own Propel procedures. OP REFERENCES 1. Brigham G. The Propel® System: the next generation orthodontic disruptor. Orthodontic Practice US. 2015;6(5):36-38.

2. Garlet TP, Coelho U, Silva JS, Garlet GP. Cytokine expression pattern in compression and tension sides of the periodontal ligament during orthodontic tooth movement in humans. Eur J Oral Sci. 2007; 115(5):355-362.

3. Alikhani M, Raptis M, Zoldan B, Sangsuwon C, Lee YB, Alyami B, Corpodian C, Barrera LM, Alansari S, Khoo E, Teixeira C. Effect of micro-osteoperforations on the rate of tooth movement. Am J Orthod Dentofacial Orthop.

2013;144(5):639-648.

4. Teixeira CC, Khoo E, Tran J, Chartres I, Liu Y, Thant LM, Khabensky I, Gart LP, Cisneros G, Alikhani M.. Cytokine expression and accelerated tooth movement. J Dent Res. 2010; 89(10):1135-1141.

5. Nicozisis J. Accelerated orthodontics through micro-osteoperforation. Orthodontic Practice US. 2013; 4(3):56-57.

6. Nicozisis J. Topical anesthesia and patient messaging.

Orthodontic Practice US. 2015;6(1):24-25.

7. Shipley TS. The use of Propel to increase the rate of aligner progression. Orthodontic Practice US. 2014;5(2):52-56.

8. Boschken DR. Increasing case acceptance and practice differentiation with Propel. Orthodontic Practice US. 2015;6(4):46-47.

9. Nicozisis J. Clinical Report. Clinical Reports & Techniques.

2006; 2(1) 9-15.

This information is sponsored and provided by Propel Orthodontics.

Volume 7 Number 2

One name. One design. One goal.

Unparalleled esthetics.

&

fascinatingly natural.

Small and brilliant.

discovery速 brackets have a well-established tradition of success. The highly esthetic ceramic bracket discovery速 pearl and the small and

brilliant metal bracket discovery速 smart are the perfect addition to this successful bracket line, each on its own with optimally aligned characteristics. Put together, they lead the way to an efficient and esthetic treatment allowing all possible therapy designs.

E T A D E H T E SAV 速 onferenc tomas TAD C um ur ta en D e Th

es 2016

Phoenix, AZ th - 29th , 2016 I 28 er m Octob ca Raton, FL th - 5th , 2016 I Bo 4 r be em m Nov

Dentaurum Inc. I 2050 Cabot Boulevard West, Suite 100 I Langhorne, PA 19047 I USA I Phone + 1 - 800 - 523 - 3946 Fax + 1 - 800 - 553 - 6389 I www.dentaurum.com I info@dentaurum-us.com

LABORATORY LINK

Retention â&#x20AC;&#x201D; esthetics, delivery, and long-term success James Bonham highlights recent advancements in posttreatment retention appliances

O

rthodontic product development is growing from recent technology advancements like digital scanning, computer-aided design (CAD) software, milling machines, and 3D printing. These innovations generate exciting possibilities and ignite the creative minds of many orthodontists and orthodontic companies.

Dental material development has also evolved in recent years. Todayâ&#x20AC;&#x2122;s materials are stronger and more esthetic than ever before.

The purpose of this article is to highlight recent advancements in posttreatment retention appliances, their delivery, and new approaches for long-term success.

Same-day delivery The combination of intraoral scanning, CAD software, and 3D printing has changed many doctorsâ&#x20AC;&#x2122; retainer-delivery protocol.

Patients are scanned at their final check appointment with braces still on the teeth.

That scan is sent to a digital laboratory like Specialty Appliances where the brackets are digitally removed using sophisticated software. Skilled technicians can also digitally repair flaws in the model, block out undercuts, and even manipulate teeth prior to printing the 3D model. These models are now ready for fabrication of appliances such as positioners, aligners, and fixed or removable retainers. Orthodontists receive these appliances before the bracket-removal appointment. Finishing and retention appliances are delivered immediately before or after the brackets are removed, eliminating an additional appointment for both patients and orthodontic offices.

Fixed lingual retainers (FLR) Laboratories report a steady increase in the use of bonded lingual retainers. Many

James Bonham is a partner at Specialty Appliances and manages sales and marketing.

He has spent the past 12 years in orthodontics with a strong focus on the integration of digital technology into orthodontic practices.

60 Orthodontic practice

Digital bracket removal enables same-day delivery of post braces appliances

Fixed lingual retainers are accurately delivered in minutes with IDB trays

patients simply demand a retention solution that is esthetic and requires little to no compliance. FLRs are available in a wide range of wire stiffness and shapes, including round, rectangular, and braided wire. They bond to selected teeth using either metal mesh pads or the more popular custom composite pads. In addition, the wire can also be scalloped below the papilla to help avoid plaque buildup for challenging hygiene patients.

Guardian FLR Volume 7 Number 2

OUR SPECIALTY…

Digital Laboratory Efficiency

Experience Digital Laboratory Efficiency

Specialty Appliances works with innovative orthodontists and technology companies to improve appliance quality and workflow. Our goal is on time delivery of the most accurate fitting appliances for your patients and practice.

Digital Bracket Removal

Digital Band Fitting

3DiB Bracket Placement

nce Digital Laboratory Efficiency

t Removal

SAVE TIME WITH SPECIALTY APPLIANCES’ DIGITAL WORKFLOW

Digital Band Fitting We digitally remove braces and build your appliance. Eliminate appointments with same day delivery of post braces appliances.

Our technology enables us to digitally remove braces before building your appliance. Your practice can eliminate unnecessary patient appointments with same-day delivery of post braces appliances.

3DiB Bracket Placement

No need to inventory and fit Save treatment time with 3DiB. nooffice. longer need and optimizes fit bands in your office. Specialty bands You in your We size your to inventory Digital placement your bands and build your appliance staightwire brackets. Easy web Appliances will size your interface bands gives and you build your appliance from a digital from a digital records impression. full control.

records impression.

Appliances is a full service e braces andSpecialtyNo need to inventory and fitorthodontic Savelaboratory, treatment time with 3DiB. manufacturing more We than 250 premierDigital products. ce. Eliminate bands in your office. size your placement optimizes your th same day bands and build your appliance staightwire brackets. Easy web ces appliances. (800)522-4636 | www.specialtyappliances.com from a digital records impression. interface gives you full control.

Specialty Appliances is a full service orthodontic laboratory, manufacturing more than 250 premier products. ull service orthodontic laboratory,

e than 250 premier products.

ww.specialtyappliances.com

800.522.4636 • SpecialtyAppliances.com

4905 Hammond Industrial Drive, Suite J Cumming, Georgia 30041

LABORATORY LINK Same-day delivery is the normal for bonded retainers, but it can take up valuable chair time when making them inside the office. Specialty Appliances’ laboratory can custom fabricate these wires and composite pads, then deliver the FLR in an indirect bonding (IDB) tray. Chairside assistants can seat the FLR in less than 2 minutes, just prior to bracket removal. No doctor time is required for this simple and consistent retention delivery method.

Esthetic Hawleys and wraps New materials have greatly improved the esthetics of removable Hawley and wraparound retainers. The new ClearBow™ labial bow is an excellent replacement of metal labial bow wires. Patients are more likely to wear this invisible Hawley retainer, but there are other benefits besides esthetics. Using a heat gun, the material is formed to hug the tooth’s labial surface, providing excellent retention. ClearBow™ retainers also cover little to no biting surfaces, allowing the teeth to settle into occlusion.

ClearBow™ retainers provide superior durability compared to other clear labial bows. We rigorously tested the ClearBow™

ClearBow™ retainers are custom formed for ideal retention and esthetics

in our lab for 8 months before confidently recommending it to our doctors. The transparent BPA-free material proved to be highly resistant to stains and unaffected by sunlight. We are most impressed with its virtually unbreakable material. The labial bow’s custom anatomical shape does not deform or break when exposed to higher than normal stress and temperatures. We confidently guarantee ClearBow™ Hawleys and wraparound retainers under Specialty Appliances’ Quality First Warranty.

Long-term retention plan Posttreatment retention patients will inevitably lose or break their removable retainers. Teeth often shift when patients do not promptly visit their orthodontist. The best way to insure against relapse is to provide

backup retainers, and today’s technology makes it affordable.

The new Guardian retention system delivers multiple invisible retainers along with the patient’s printed model. As long as there is no major dental change, a lifetime of retainers, without new impressions, can be formed from this printed model. Digital bracket removal is also included for all digital impressions submitted with braces. Other enhancements include minor anterior refinement and integrated pontic teeth. Guardian retainers are frequently designed to fit over fixed lingual retainers, both delivered at the brace removal appointment.

For more information about laboratory technology, retention, or other lab appliances, contact Specialty Appliances at 678-5134408, or visit specialtyappliances.com. OP

ClearBow™ versus standard metal labial bow

Guardian retainers come with a backup plan 62 Orthodontic practice

This article was provided by Specialty Appliances.

Volume 7 Number 2

2nd Annual

OC PINNACLE Embassy Suites Portland - Downtown

September 22 - 24, 2016 I N D U S T R Y L E A D I N G E D U C AT O R S Dr. Tom Pitts

Dr. Duncan Brown

Dr. Tomas Castellanos

Dr. Patricia Vergara

Dr. David Herman

• World Renowned Speakers

• Affordable Pricing

• Dynamic & Innovative Presentations

• Fun Relaxed Atmosphere

• 12 CE Credits

• Fun Educational Orthodontic Event

Dr. Rael Bernstein

Dr. Nimet Guiga

Register By August 31st & Receive a H4 5-Case Starter Kit* *Limit One Per Doctor

Dr. Jim Morrish

Dr. Michael McLaughlin

LeeAnn Peniche

$999.00 VALUE!

R E G I S T E R ON L I N E TO DAY

w w w . o c p i n n a c l e . c o m This activity has been planned and implemented in accordance with the standards of the academy of General Dentistry Program Approval for Continuing Education (PACE) through the provider approval of Ortho Classic. Ortho Classic is approved for awarding FAGD/MAGD credit. AGD ID# (Ortho Classic AGD ID#334767)

TREATS 5 PATIENTS!

RESEARCH

A survey of orthodontic practitioners regarding centric bite registrations A study by Drs. Nancy Proano Wise, Donald Rinchuse, and Daniel Rinchuse Abstract Objective The aim of this study was to survey orthodontic clinicians on the topic of centric bite registrations. Specifically, this study surveyed 1) who is/are the person(s) taking the bite registrations in United States orthodontic practices, 2) the methods being used to record the bite, 3) whether or not the same method is being used for facial photographs and lateral cephalograms, and 4) whether or not the person taking the bite registration is the same person taking the facial photos and lateral cepahologram.

Methods An email invitation from the American Association of Orthodontists (AAO) Partners in Education was sent to a random sample of the members of the AAO (n = 2,300), requesting participation in a 10-question online survey (SurveyMonkey®) regarding centric bite registrations. A total of 166 orthodontists participated in the survey.

Results According to the survey, the majority of the orthodontists (92%) said they do take a bite registration as part of their orthodontic records. However, there seems to be little consistency among orthodontists in

regards to the method used or who actually takes the bite registration. Most of the respondents (39%) said when they take a bite registration, they simply tell the patient to bite down on their back teeth, and the orthodontic assistant is usually the person in charge of recording the bite. The majority of the respondents (about 64%) said that the same bite method that is used for the bite registration is also used for the facial photographs and the cephalogram. When asked if the same person that records the bite is also the same person who takes the rest of the records, 45% said that only sometimes the same person takes all the records, and 42% said that they always have the same person taking all the records.

Conclusion Uses and methodologies for bite registrations vary among orthodontic practitioners.

Persons taking the bite registration differ (orthodontist versus assistant versus other) as well as whether or not the same bite registration is used for photos and lateral cephalograms. Inconsistencies were also found as to who takes all records.

Introduction Over the past century, the definition of centric relation (CR) has changed multiple

Nancy Proano Wise, DMD, was born and raised in Miami, Florida, and attended Florida International University for her undergraduate degree. She graduated from Nova Southeastern University dental school and completed her orthodontic residency at Seton Hill University,

Donald J. Rinchuse, DMD, MS, MDS, PhD, graduated from the University of Pittsburgh School of Dental Medicine in 1974 with degrees in Dentistry (DMD) and Pharmacology/Physiology (MS). He received his certificate and MDS degree in orthodontics in 1976 and a PhD in Higher Education in 1985 from the University of Pittsburgh. He is a Diplomate of the American Board of Orthodontics. In addition, Dr. Rinchuse is on the editorial review board of many professional journals, including the American Journal of Orthodontics and Dentofacial Orthopedics. He has published over 120 articles, several book chapters, and two books and has made many presentations.

Daniel Rinchuse, DMD, MS, MDS, PhD, has enjoyed a career in orthodontic in academics, research, and private practice for almost 40 years. He received his Doctorate of Dental Medicine (1974), MS (1974) in Pharmacology/ Physiology, MDS (1976) in Orthodontics, and PhD (1985) in Higher Education from the University of Pittsburgh. He has authored over 90 articles in peer-reviewed journals. In 2012, he co-authored a book, Evidence-based Clinical Orthodontics. In addition, he is a Diplomate of the American Board of Orthodontics and editorial consultant for various journals such as the American Journal of Orthodontics and Dentofacial Orthopedics, The Angle Orthodontist, and the European Journal of Orthodontics. Currently, he is Professor and Program Director of Orthodontics at Seton Hill University Center for Orthodontics, Post Graduate Program in Orthodontics.

64 Orthodontic practice

times, and several philosophies have developed regarding the “proper” definition and “correct” recording technique. The inconsistency among the different schools of thought seems to make the topic of CR a continuous debate. The American Board of Orthodontics is equivocal and does not currently provide any guidelines regarding what is the correct method to take a bite registration, who should be taking it, and whether or not that same bite relationship should be used for patient photos and lateral cephalogram.

Orthodontic records are taken for the purpose of diagnosis and treatment planning orthodontic patients. Most commonly these records include a clinical exam, diagnostic study models, intraoral and extraoral photographs, a panoramic radiograph, and a lateral cephalogram.1 Another diagnostic tool, not mentioned in the list above, is the bite registration. The bite registration is an optional orthodontic record. Some practitioners do not use the bite registration because they do not feel it provides unique information for diagnosis and treatment planning. Some practitioners view the bite registrations to be one of the most important tools in orthodontic diagnosis.

There are at least six occlusal philosophies in dentistry: 1) classic gnathology, 2) bioesthetic dentistry, 3) Dawson/Pankey, 4) the neuromuscular school (LVI), 5) the Roth orthodontic gnathologic view, and 6) the nongnathologic view. The main difference among the above schools of thought is how CR is recorded. There are also various philosophies concerning manipulation techniques to record CR, deprogramming, and whether to use a facebow or an earbow transfer.

Most CR records are dentist-manipulated, and there are differences in findings from manipulated an unmanipulated CR recordings. Dentist-manipulated CR records are considered to be more reliable but less valid and physiological than patient-manipulated records.2-11 A contemporary thought is that recording a retruded CR would make sense for only denture fabrication when no interocclusal reference is possible.

Volume 7 Number 2

RESEARCH Contemporary gnathologic orthodontists recommend articulator-mounted dental casts mounted in anterior-superior CR in order to establish coincidence of MI (maximum intercuspation)-CR.3-4 They believe that the only way to recognize MI-CR discrepancies is via articulator-mounted casts, not via hand-held casts.5 Orthodontic gnathologists believe it is possible to assess a threedimensional condylar position through the use of the Roth power centric bite registration with articulator-mounted dental casts.615,18,20-21 The belief is that it is possible to locate a particular position of the condyle precisely in the glenoid fossa via CR recordings and that the power centric will seat the condyles in the optimal, anterior-superior CR position. This approach also advocates using the terminal hinge axis position, the need for pretreatment MI-CR converted lateral cephalograms, and placing a gnathologic positioner immediately after orthodontic appliances are removed.6 On the other hand, nongnathologic orthodontists tend to use hand-held dental casts and non-instrument-oriented techniques. Their focus is on achieving the best occlusal relationship within the framework of optimal dentofacial esthetics, function, and stability. They also believe that MI-CR does not have to be coincident, and that there is a tolerance for slides up to 2 mm-4 mm in the horizontal plane with little or no attention given to the relevance of the vertical and transverse planes.7,8 Parenthetically, the gnathologists believe that the tolerance for MI-CR discrepancies is 1.5 mm in the horizontal and vertical planes and 0.5 mm in the transverse plane.

The purpose of this study is to survey orthodontists throughout the United States to assess 1) who is the person taking the bite registrations in their practices, 2) the exact method being used to record the bite, 3) whether or not the same method is being used for facial photographs and lateral cephalogram, and 4) whether or not the person taking the bite registration is also the same person taking the facial photos and lateral cepahologram.

Table 1: Results of a 10-question survey of orthodontists on the topic of centric bite registrations Topic 1. Gender

Male

85.54%

Female

14.46%

5 years or less

16.87%

6 to 10 years

12.65%

11 to 15 years

6.63%

16 to 20 years

10.84%

21 to 25 years

23.49%

26 years or more

30.12%

Yes

45.78%

No

37.95%

I was previously certified but did not re-certify

11.45%

I am in the process of getting certified

4.82%

4. Do you, or does someone else in your office, routinely take impressions for diagnostic casts as part of your pretreatment records?

Yes

86.75%

No

14.46%

5. Who is the person responsible for taking the bite registration in your practice?

The orthodontists

35.54%

The orthodontic assistant

51.81%

The lab technician

2.41%

I do not take bite registrations

7.83%

Other

6.63%

Bimanual manipulation

22.89%

Tell patient to bite down on their back teeth

39.16%

2. Number of years practicing orthodontics

3. ABO certified

6. Centric bite registration method

Tell patient to touch the roof of their mouth with the tip of their tongue and bite down

7. Is the same bite that is used for the bite registration also used when taking the facial photographs?

8. Is the same bite that is used for the bite registration also used when taking the cephalogram?

9. Does the same person take all the orthodontics records (i.e., bite registration, cephalogram, photographs, etc.)?

Materials and methods A 10-question survey was sent to a randomized sample of orthodontists across the United States via three email blasts through the AAO. Orthodontic residents and faculty at a university program worked concomitantly to develop this 10-question survey. The survey consisted of seven questions pertaining to orthodontic records and bite registrations and three demographic questions.

66 Orthodontic practice

Results of 166 respondents

28.31%

Roth power bite

4.82%

N/A I do not take bite registrations

7.83%

Other

6.63%

Yes

63.25%

No

17.47%

Sometimes

12.05%

N/A

7.83%

Yes

65.06%

No

13.86%

Sometimes

12.65%

N/A

8.43%

Yes

41.57%

No

45.18%

Sometimes

13.86%

N/A 10. Occlusal philosophy

Classic gnathology

43.98%

Bioesthetic dentistry

6.02%

Dawson/Pankey

14.46%

Neuromuscular school

5.42%

Roth orthodontic gnathologic view

8.43%

Nongnatholigic view

30.72%

Volume 7 Number 2

Don’t READ your notes, SEE your notes with Oral4D Systems

At-a-glance, orthodontists and assistants have the ability to visually review and verify patient treatments, discuss future treatments and effectively explain outcomes to patients without having to scroll through pages of text notes.

“The instant I saw Oral4D Ortho, I knew that I had to have this software program in my practice. The ability to treatment plan, chart and track treatments in 3D is unreal! Imagine standardizing charting with team members, never missing a chart entry and having the ability to go back quickly in time to visually review notes from previous visits. And lets face it, being more efficient is every office’s goal and Oral4D Ortho is a dream when it comes to tracking our cases and treatments. This software is going to blow up the orthodontic community!”

- Dr. Stuart Frost of Frost Orthodontics

“Oral4D Ortho is the ‘Game Changer’ I have been searching for in my practice. Accessing the visual power of 3D treatment planning and charting has dramatically increased our efficiency level and profitability. Oral4D Ortho will move your practice to the next level regardless of size, philosophy or treatment modality.”

- Dr. Mark Coreil of Le Centre Orthodontics

1-844-4-Oral4D | 1-844-467-2543 | info@Oral4D | www.Oral4D.com

RESEARCH A finalized copy of the 10-question survey was generated using SurveyMonkey. The survey was then forwarded to the AAO for approval. A finalized survey tool was created using SurveyMonkey. The AAO then sent out an email, including a link to the survey, to a random sample of 2,300 of its members. A letter was distributed with the survey asking for participation as well as an agreement to participate.

The survey link was first sent out on January 12, 2015. Then to increase participation, a second and third email was sent on February 23, 2015, and April 22, 2015, to the surveyed population. After data collection, the survey instrument was utilized to compile responses into useful figures and charts.

Results Of the 2,300 emails sent out to a random sample of orthodontists who are members of the AAO, 166 participated in the survey, amounting to a response rate of approximately 7.2%. The survey was completely anonymous. The important findings from the survey are shown in Table 1.

As far as the different philosophies on occlusion, there was little consistency among the respondents as to which philosophy they believe in. Most respondents (44%) said they follow classic gnathology; 31% said they follow the nongnathologic philosophy; 14% said they follow the Dawson/Pankey philosophy; 9% said they follow the Roth gnathologic view; 6% said they follow bioesthetic dentistry, and 6% said they follow the neuromuscular school of thought.

The majority of the respondents (92%) said they do take a bite registration as part of their orthodontic records. There was a small number (8%) of orthodontists who said they do not take a bite registration as part of their orthodontic records. However, there seems to be little consistency among orthodontists in regard to the method used or to who actually takes the bite registration. The majority of the respondents (39%) said, when taking a bite registration, they simply tell the patients to bite down on their back teeth. About 28% said they tell the patients to touch the roof of their mouth with the tip of their tongue and bite down; 23% said they use the bimanual manipulation technique; 5% said they use the Roth power bite technique; 7% said they use some other technique that was not listed in the answer choices, and 8% said that do not take a bite registration as part of their orthodontic records.

The majority of the respondents (52%) said their assistant(s) is/are the person(s) 68 Orthodontic practice

responsible for recording the bite registration, whereas 36% said they themselves (the orthodontists) record the bite. However, when asked if the same person that records the bite is also the same person who takes the rest of the records, 45% said that only sometimes the same person takes all the records, and 42% said that they always have the same person taking all the records.

That being said, the majority of the respondents (63%-65%) said that the same bite that is used for the bite registration is also used for the facial photographs and the cephalogram.

Discussion The results of this survey demonstrate that the majority of orthodontists are using bite registrations as part of their orthodontic records. However, as has been in the past, there remain inconsistencies in agreement among one occlusal philosophy and on the methodologies used by orthodontists to determine a patient’s “true” bite. The topic of centric relation, therefore, will continue to be debatable.

The majority of the respondents (51.81%) said their assistant(s) is/are the person(s) responsible for recording the bite registration, whereas 35.54% said they themselves (the orthodontists) record the bite. However, when asked if the same person that records the bite is also the same person who takes the rest of the records, 45.18% said that only sometimes the same person takes all the records, and 41.57 % said that they always have the same person taking all the records.

This could be misleading to an orthodontist who is looking at a set of records in which, for example, one assistant took a bite registration a certain way but another assistant took the cephalometric radiograph with the patient biting differently. That being said, the majority of the respondents (63%-65%) said that the same bite that is used for the bite registration is also used for the facial photographs and the cephalogram. To assure that the same bite is being used across the board, when multiple people are responsible for the records, it seems there would need to be a calibrated standard method for capturing the bite for any person in the office who is responsible for taking orthodontic records.

Does it matter if a bite registration is taken for initial records? Does it matter how it’s taken or who takes it? Does the information gained by taking a bite registration make any clinically significant impact on the final results of orthodontic treatment?

Maybe, maybe not. One would think that

since the majority of orthodontists are taking bite registrations as part of their orthodontic records, it must be a necessary diagnostic tool to plan a certain outcome. With all the debate still surrounding the topic of CR, no wonder the AAO is equivocal and does not currently provide any guidelines in regard to what is the “correct” method to take a bite registration, who should be taking it, and whether or not the bite relationship should be used for the patient photos and lateral or PA cephalogram.

Assuming that the small percentage of orthodontists who do not take bite registrations are getting acceptable orthodontic results, then maybe taking a bite registration is not a necessary step in orthodontic record taking. It would be interesting to know how many orthodontists actually look at and study their bite registrations when treatment planning a case versus how many just take them as a routine measure and never go back and look at them. In the latter of these two circumstances, it seems as though orthodontists could be spending excess money on overhead material and chairtime.

This survey has limitations. In the hierarchy of evidence, a survey typically falls on the lower end of the spectrum. Although a randomized clinical trial (RCT) appears to be the gold standard for obtaining information, the construction of an RCT may not always be feasible or appropriate for the type of research at hand. The information we are seeking in this particular study was best obtained via a survey. Another limiting factor of this survey is the low response rate. However, by surveying all orthodontic practitioners who are members of the AAO in the U.S., we were able to gain more information than if we had surveyed only a small sample of local/regional clinicians.

Conclusions Based on a survey of 166 AAO member orthodontists on the topic of centric bite registration, the following conclusions have been reached.

• The major school of thought being followed by orthodontists is classic gnathology.

• Generally, the orthodontic assistant is the person taking the bite registration.

• The most common method for recording a bite registration was to tell the patient to bite down on their back teeth.

• Generally, the same bite that is used for the bite registration is also being Volume 7 Number 2

Acknowledgments The authors of this article extend a special thank you to the surveyed members of the AAO who participated in this research topic.

retruded position of the mandible with application of varying external pressure to the lower jaw in man. Arch Oral Biol. 1971;16(10):1165-1171.

appliance. In: Graber TM, Swain BF, eds. Orthodontics, current principles and techniques. St. Louis: Mosby; 1985;665-716.

5. Kantor ME, Silverman SI, Garfinkel L. Centric-relation recording techniques — a comparative investigation. J Prosthet Dent. 1972;28(6):593-600.

19. Roth RH. Functional occlusion for the orthodontist. Part III. J Clin Orthod. 1981;15(3):174-9, 182-198.

6. Smith HF Jr. A comparison of empirical centric relation records with location of terminal hinge axis and apex of the gothic arch tracing. J Prosthet Dent. 1975;33(5):511-520.

7. Shafagh I, Yoder JL, Thayer KE. Diurnal variance of centric relation position. J Prosthet Dent. 1975;34(5):574-582.

8.

Strohaver RA. A comparison of articulator mountings made with centric relation and myocentric position records. J Prosthet Dent. 1972;28(4):379-390.

9. Long JH Jr. Location of the terminal hinge axis by intraoral means. J Prosthet Dent. 1970;23(1):11-24.

10. Lundeen HC. Centric relation records: the effect of muscular action. J Prosthet Dent. 1974;31(3):244-253.

11. Celenza FV. The centric position: replacement and character. J Prosthet Dent. 1973;30(4 Pt 2):591-598.

12. Kulbersh R, Kaczynski R, Freeland T. Orthodontics and gnathology: introduction. Semin Orthod. 2003;9(2):93-95.

REFERENCES 1.

2.

Dykhouse VJ, Moffitt AH, Grubb JE, Greco PM, English JD, Briss BS, Jamieson SA, Kastrop MC, Owens SE Jr. A revision of the adult intraoral radiograph protocol for ABO clinical examinations. Am J Orthod Dentofacial Orthop.

2007; 131(3):303-304.

Helkimo M, Ingervall B, Carlsson GE. Comparison of different methods in active and passive recording of the retruded position of the mandible. Scand J Dent Res. 1973;81(4):265-271.

3. Helkimo M, Ingervall B, Carlsson GE. Variation of retruded and muscular position of mandible under different recording conditions. Acta Odontol Scand. 1971;29(4):423-437.

4. Helkimo M, Ingervall B, Carlsson GE. Recording of the

Volume 7 Number 2

13. Cordray FE. Centric relation treatment and articulator mountings in orthodontics. Angle Orthod. 1996;66(2):153-158.

14. Klar NA, Kulbersh R, Freeland T, Kaczynski R. Maximum intercuspation-centric relation disharmony in 200 consecutively finished cases in a gnathologically oriented practice.

Semin Orthod. 2003;9(2):109-116.

15. Roth RH. Temporomandibular pain-dysfunction and occlusal relationships. Angle Orthod. 1973;43(2):136-153.

16. Roth RH. The maintenance system and occlusal dynamics.

Dent Clin North Am. 1976;20(4):761-788.

17. Roth RH. Functional occlusion for the orthodontist. J Clin Orthod. 1981;15(1):32-51.

18. Roth RH. Treatment mechanics for the straight-wire

20. Hoffman PJ, Silverman SI, Garfinkel L. Comparison of condylar position in centric relation and in centric occlusion in dentulous subjects. J Prosthet Dent. 1973;30(4 Pt 2):582-588.

21. Kulbersh R, Dhuta M, Navarro M, Kaczynski R. Condylar distraction effects of standard edgewise therapy versus gnathologically based edgewise therapy. Semin Orthod.

2003;9(2):117-127.

22. Crawford SD. Condylar axis position, as determined by the occlusion and measured by the CPI instrument, and signs and symptoms of temporomandibular dysfunction. Angle Orthod. 1999;69(2):103-115.

23. Utt TW, Meyers CE Jr, Wierzba TF, Hondrum SO. A three dimensional comparison of condylar position changes between centric relation and centric occlusion using the mandibular position indicator. Am J Orthod Dentofacial Orthop. 1995;107(3):298-308.

24. Schmitt ME, Kulbersh R, Freeland T, Bever K, Pink FE. Reproducibility of the Roth power centric in determining centric relation. Semin Orthod. 2003;9(2):102-108.

25. Lavine D, Kulbersh R, Bonner P, Pink FE. Reproducibility of the condylar position indicator. Semin Orthod.

2003;9(2):96-101.

26. Rinchuse DJ. A three-dimensional comparison of condylar change between centric relation and centric occlusion using the mandibular position indicator. Am J Orthod Dentofacial Orthop. 1995;107(3):319-328 27. Johnston LE Jr. Fear and loathing in orthodontics: notes on the death of theory. In: Carlson DS, Ferrara AM, eds.

Craniofacial growth theory and orthodontic treatment. Ann Arbor, Mich.: Center for Human Growth and Development, University of Michigan; 1990:75-91.

Orthodontic practice 69

RESEARCH

used when taking the patient’s facial photographs and cephalogram.

• Of the orthodontists surveyed, 42% of them have the same person take all of the orthodontic records, and 45% of them said that only sometimes does the same person take all the records. OP

PRACTICE MANAGEMENT

Three tips for boosting practice growth and leveraging esthetic treatment options Dr. Christopher Cosse offers advice for a streamlined and profitable year Introduction March 20 marks the first day of spring, a season that is metaphorically synonymous with some level of cleaning or organizing. In the business world, the season can serve as an excuse to pump new life into an organization, transferring the springtime cleanup routine to the workplace. For the orthodontic community, spring is also an optimal time to elevate the practice and take a step back to see what areas can be improved for a more streamlined and profitable year.

Over the last 15 years, the consumer demand for esthetically pleasing orthodontic treatment options has climbed at a rapid pace, and doctors are increasingly eager to offer esthetic appliances as a way to attract new patients and grow their practices.

Although the move to offer more discreet appliances can be viewed as a natural evolution, many practices are eager to better understand how to further capitalize on the esthetic appliance market and use this as a strategy for catapulting growth. It is important that we don’t get caught up in trying to offer the clearest option if it will not meet both your and your patients’ goals. That being said, one of your patient’s goals may be to reach the best outcome with the least visible appliance, and the doctor is caught in a balancing act. As an early adopter of virtually clear bracket systems, I’ve had the opportunity to witness firsthand how discreet treatment options, combined with simple business strategies, can truly transform and grow a practice. It all comes down to three core concepts that involve embracing patient

demand, securing business through the power of digital referrals, and taking advantage of online patient education tools.

Understand the patient esthetic demand — and embrace it There’s a reason the selfie hashtag has more than 250 million posts on Instagram alone. Consumers crave to put their best face forward 24/7 as part of their social media-infused lifestyle. Gone are the days of wanting only to look good for school picture day, a date, wedding, or special event. Case in point: just last fall, a story about college students taking selfies at a MLB baseball game quickly went viral as these fans were much more interested in snapping selfies than watching the matchup between the Colorado Rockies and Arizona Diamondbacks. If you haven’t seen the video, it’s worth watching on mlb.com for a quick laugh. Humor aside, it goes without saying that today, the patients we treat take extra pride in their smile and the confidence that goes along with it. This pride also holds true during their orthodontic treatment — patients want to look good not just after treatment, but throughout the entire process.

At my office, there has been a noticeable shift in patients’ desire for discreet treatment, which is why I began to search for the best esthetic option. The appliance I was looking for had to meet some strict criteria: 1) It had to readily be accepted by patients and virtually disappear on the teeth. 2) It had to be self-ligating, so there were no “O’s” that were going to stain or decrease my office efficiency.

Christopher C. Cosse, DDS, is a graduate of Louisiana State University-Baton Rouge. He was accepted into the dental program at Louisiana State University School of New Orleans (LSUSD). He received certification in Orthodontics and Dentofacial Orthopedics from Oregon Health Sciences University in Portland, Oregon. He studied the differences in orthodontics between the United States and Europe for a term at the University of Freiberg, Germany in 1997. Dr. Cosse was awarded the Pierre Fauchard Award for Academic Achievement while at LSUSD. Since joining his father’s practice in 2000, he has sought to further his orthodontic knowledge and training. He has 11 orthodontic patents and two orthodontics apps, and is the founder of Braces Academy.

He continues to push the field of orthodontics. In 2006, Dr. Cosse was presented with the Louisiana Dental Association New Dentist Award, an award presented to a Louisiana Dental Association member who has distinguished himself by giving his time and talents to his community and shown an unselfish devotion to the dental profession.

Dr. Cosse practices with Dr. Jeffrey Silmon in Shreveport and Bossier City, Louisiana. When he is not having fun at work, Dr. Cosse enjoys spending time with his wife, Stacy, and their four children — Athan, Michael, Kalli, and Stefan.

70 Orthodontic practice

Actual Damon™ patients wearing Damon™ Clear brackets

3) It could not have any visible metal, like a clip holding the wire in place. 4) I wanted to retain complete control of the case and have the power of a bracket. I use Ormco’s Damon™ Clear brackets because they fit all of the preceding criteria. Before Damon Clear, my patients were hesitant to jump into treatment because the esthetic options available had various limitations. Additionally, I had to turn down many cases because I wasn’t comfortable treating them with the existing esthetic options. Patients to whom I couldn’t ethically offer esthetic treatment in the past are now happy patients, thanks to improvements in the quality of these clear brackets.

Now, when patients come to the office and realize that they have an esthetic bracket choice — that is proven to provide exceptional results — the inclination to start treatment is much greater. Understanding and embracing this reality and industry evolution is the first step toward growing your practice to be more profitable with esthetic solutions.

In this same vein, it’s essential to understand your patients and their demand for esthetic options. Many adults and teens prefer Damon Clear to other options because they know they will look good during treatment and get the beautiful smile and facial results that I can provide using face-driven Damon™ System treatment protocols. At my practice, approximately one-third of patients are adults. If this is the case for you and your staff, I encourage your team to speak with prospective and current adult patients about the role esthetics plays in their decision to start treatment. This insight will not only keep you in touch with the demographics’ preferences, Volume 7 Number 2

but also help you to better understand what solutions they’re demanding most. In return, it also gives you the opportunity to play up the value-add of clear bracket systems.

Benefit from a digital referral program Another way to grow your practice is to develop and launch a referral channel through online resources that highlight various treatment solutions. The reality is, in today’s digital world, most referring methods are simply outdated. This is where a digital referral program is invaluable. In my practice, we’ve developed and incorporated a software system called Braces Academy where we’re able to arm general practitioners and referring specialists with educational tools and information to accurately and succinctly present treatment options. It also allows them to digitally refer the patient directly to our office. We then call the patient and schedule the new patient exam instead of waiting and hoping for the patient to call our office out of the three or more business cards they may have received from their general dentist.

As a part of this software, referring dentists can show subtle differences between a decent-looking smile and a truly beautiful smile. This not only is educational, but also motivates prospective patients to consider the most functional esthetic solutions. Similarly, there is an opportunity to increase referrals from your referring general dentists and hygienists by educating them — in addition to the patients — on what makes your practice and treatment solutions unique.

The Braces Academy practice development system allows the orthodontist and his/her staff to send prescriptive educational videos pertaining to a particular patient’s treatment, send quick messages to parents that might not have been at the appointment, Volume 7 Number 2

When Dr. Cosse gives a “lite” version of Braces Academy to his referring general dentists, they can refer patients directly to his practice with the click of a button. Dr. Cosse’s office can then call and schedule a new patient appointment

and send pictures of different configurations of how to hook up elastics or activate an appliance. It also provides plug-and-play advertising resources for Facebook and other social media outlets to establish you as the smile design expert in your area.

Don’t ignore online resources Keeping up with patients’ digital lifestyles can sound daunting, but orthodontists should take comfort in the fact that manufacturers are addressing consumers’ shifting habits head-on by arming us with patient education resources that live on the Web. As doctors, we can’t ignore the importance of incorporating online education and marketing tactics within a practice as this is where many, if not all, potential patients are doing their information gathering. Consider leveraging onlinebased consultation resources or educational tools such as Ormco’s My Smile Consult™.

Available to practices treating with the Damon System, My Smile Consult is a helpful online patient education tool that I was able to customize with my own practice branding and patient before-and-after photos. My practice actively uses this tool to help prospective patients better understand the benefits of orthodontics and the treatment that I can provide using the Damon System and Damon Clear. In my practice, we’ve seen that patients appreciate when the information they are viewing is catered to their needs.

We do this by asking the patient a series of questions to gather information about the type of person that our digital content speaks to. Without doing that due diligence, you are just dumping loads of information in hopes of answering their questions. My Smile Consult provides the patient with targeted information that specifically answers the questions for which most parents or patients are looking.

An interactive, online tool, My Smile Consult is designed to help educate your patient prospects on the benefits of orthodontics and the Damon™ System including Damon™ Clear

Conclusion Whether it’s incorporating the latest clear bracket like Damon Clear or leveraging nextgen software systems like Braces Academy or My Smile Consult to generate leads, making practice enhancements during a spring cleanup or anytime during the year can be the key differentiator for an orthodontist.

Esthetic treatment offerings and beautiful results present a unique and tangible way to stand out, especially when you take into consideration the growing number of adults and image-conscious consumers considering treatment. By embracing and understanding consumer demand, developing a targeted referral system, and using digital resources to your advantage, you’ll be able to better present the value and opportunity of esthetic options and the positive impacts it will have not only during treatment, but also on the final result. Because at the end of the day, an amazing smile and a happy patient will always be the best practice builder. OP Orthodontic practice 71

PRACTICE MANAGEMENT

A screenshot from the smile survey portion of Braces Academy. Dr. Cosse uses this survey to educate his patients about the subtle characteristics of a beautiful smile and to differentiate it from an average smile

INDUSTRY NEWS

Second annual Orthodontic World Congress engages capacity crowd For the second time in as many years, the upstart Orthodontic World Congress (OWC) engaged and inspired a sizable crowd with an eclectic collection of speakers, topics, and unique experiences. Running from January 27 to the 29, the DENTSPLY GAC 2016 OWC played host to a sold-out crowd at the Diplomat Resort & Spa in Hollywood, Florida.

This year’s roster of 16 speakers included a trio of keynote speakers. Having worked with companies such as Starbucks®, Lexus, Nordstrom, and The Ritz-Carlton, entrepreneur and author John DiJulius was first up. His presentation drew upon his considerable expertise to show practices how to craft a world-class customer experience. The next speaker, stockbroker-turned-author and consultant Mark Jeffries, engaged the crowd with an insightful presentation on improving conversation and communication within the orthodontic setting. Former Major League Baseball player Jim Abbott rounded out the roster of keynote speakers in a rousing presentation about his own life story, and how the lessons he’s collected over the course of his life can be embraced by anyone.

The clinical and business elements of orthodontics were also well represented at the conference, with an additional 13 speakers covering these two topics. The business-focused presentations included a “how to” on bulletproofing personal and professional assets, protecting your practice’s online reputation, and the keys to successfully managing multiple locations. The clinical topic touched upon a wide variety of subjects, including managing compliance with Class II cases, embracing clinical advancements in treatment mechanics, and transverse dimension and long-term stability, among others.

“The Orthodontic World Congress continues to bring together today’s top business leaders, industry advisors, and clinical experts to create a one-of-a-kind experience that provides practical insights designed to challenge the way we look at our business, our customers, and our lives,” said Brad Clatt, Vice President Commercial Operations DENTSPLY GAC. The conference concluded with an evening of dining, dancing, and celebrating on the infield at Marlins Park, home of Major League Baseball’s Miami Marlins. The unique evening included a meet and greet with two of the team’s rising stars as well as a retired player. Everyone shared in a behind-the-scenes tour of the facility. Planners from this year’s conference are now investigating ideas for the 2017 OWC.

OrthoEssentials adds new Spore Test Kit OrthoEssentials has added a new Spore Test Kit to its product offering. You can use the test in dry heat sterilizers, EO gas, and chemical vapor sterilizers. The test kit also includes third-party legal documentation from the largest sterilizer testing lab in North America. Get a 7-day turnaround on test results. Results can be viewed online. 52 weeks per kit. Contact us at 866-517-3257 or 215-396-3803, info@orthoessentials.net to receive an introductory offer.

72 Orthodontic practice

The iPrint 3D® Printer from Motion View Software enables accurate, economical, and quick 3D printing of transfer trays and other orthodontic appliances in your own office Motion View Software, LLC announced its SLA-based iPrint 3D® printers for use by orthodontists in their own offices and on their own schedules. Motion View’s in-office iPrint 3D® printer eliminates delays and reduces costs compared to contracting out to a lab for 3D printing services. Instead, appliances for indirect bonding and other purposes are made onsite and quickly available to use. Results are extremely accurate, high resolution, and fast. The iPrint 3D® software accepts .STL files for printing models at user-selectable layer thicknesses of 25, 50, or 100 microns. The iPrint 3D® printer is SLA-based, using a laser to cure the printing material in a build area of 7 x 7 x 8 inches.

The iPrint 3D® printer can print approximately 15 mm per hour vertically (in Z-axis) or more in some circumstances.

For more information, call 423-475-6914, or visit www.

MotionView3D.com, or write to Sales@MotionView3D.com.

Volume 7 Number 2