Orthodontic Practice May-June 2016 vol 7 no 3 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews

Orthodontic and surgical diagnosis and management of OSA — case presentations: part 2 Drs. John W. Stockstill, Joseph E. Cillo, and Stevan H. Thompson

Airway orthodontics the new paradigm: part 1, addressing the airway Dr. Barry D. Raphael

Being creative with 401k planning Tony Robbins

BioDigital Orthodontics: part 21 Drs. Rohit C.L. Sachdeva and Takao Kubota

Practice profile Dr. Barry D. Raphael

Learn from Dr. Barry Raphael at the Raphael Center for Integrative Education how orthodontics could – and should – be leading the way in the new wellness-care paradigm

PROMOTING EXCELLENCE IN ORTHODONTICS

Presenting Airway Orthodontics for the Orthodontic Specialist

May/June 2016 – Vol 7 No 3

Read more about Dr. Raphael on page 8

Corporate profile OSA University

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INTRODUCTION

Taking the lead in sleep dentistry

May/June 2016 - Volume 7 Number 3 EDITORIAL ADVISORS Lisa Alvetro, DDS, MSD

hree years ago, while corporate consulting for a number of companies, including SomnoMed, I met and befriended the incredibly talented publisher of all four MedMark journals, Lisa Moler. At that time, as we discussed a variety of orthodontic topics, she asked me about my role at SomnoMed. I shared with her the personal impact consulting for that company had on me, as well as the fact that I had just finished a presentation at the annual Benco sales meeting on sleep apnea — discussing everything from signs to treatment options. In my presentation, I talked about a salesman at Saks Fifth Avenue who helped me to buy a suit. He was maybe 5'3" tall, thin, and very talkative. When he heard about my involvement with SomnoMed and sleep apnea, his whole persona changed, and he became very pensive. He told me that his Dad had died very young, and what everyone remembered the most in the family was his snoring and that he would wake up routinely through the night gasping for air. He became very tired constantly throughout the day and had major mood swings. He never received a firm diagnosis, but unfortunately, one day he had a heart attack and passed away. His family felt that all of the symptoms that he had shared with me played a role, but they weren’t ever sure. I sat there in shock as he walked me through this very personal and upsetting story. He then said, “Funny, my wife tells me I do the same thing.” I immediately asked him if he had been seen by any medical professional for this, and he said no. I sent him to a dental sleep specialist whom I knew locally and told him to keep in touch. Weeks later, upon returning to pick up my suit, when he saw me, he immediately ran over and embraced me. He started to cry, saying, “Thank you for saving my life!” He ended up having an AHI score of 70! (Any score greater than 30 is classified as severe sleep apnea.) Now, he was going through the steps needed to manage his disease. This whole series of events had a real impact on me as well. Maybe we, as dental professionals, could be part of the answer. Upon hearing the story, Lisa stated that she was having some similar sleep issues; she was exhausted during the day and just wasn’t herself either! Well, off she went to a colleague for whom I had great respect, and it was a huge revelation as she followed the needed steps through the process of diagnosis and treatment of her own sleep-related symptoms, which brought her back to being the Lisa I know and love today. As she began to feel the benefits of treating the condition, she became an evangelist. She said, “Lou, you are right! How can we make a difference?” That discussion led to her launching Dental Sleep Practice magazine after fortunately hiring Dr. Steve Carstensen as the Editor-in-Chief. The journal has quickly grown to a circulation of 30,000 and is considered THE RESOURCE in the field. My mission as Managing Editor of Dental Sleep Practice has been simple and straightforward from the start, and it is the same message that I leave with you here. My goal is for every dental practitioner and, in this case, every one of us, to make the effort to gain enough knowledge to be able to screen for sleep apnea — and to help save lives as a result. As orthodontists, especially with our comfort level and expertise around the use of appliances, we have the ability to take it even further. As my first communication as the managing editor of Orthodontic Practice US and a fellow orthodontist, I ask that we, as a specialty, take the lead as the example for the rest of dentistry to follow, to acquire what’s necessary to be able to screen every patient that sits in our chair. May this issue, dedicated to sleep dentistry, be the motivator to accomplishing that goal. Lou Shuman, DMD, CAGS Lou Shuman, DMD, CAGS is the President and CEO of Cellerant Consulting Group and is personally known for his expertise in Internet strategy, emerging technologies, e-learning applications, and digital marketing methods. Highly respected in the dental corporate and education community, he is an executive consultant for KaVo Kerr Group (KKG), WEO Media, ZQuiet, DEXIS, i-CAT, Pelton & Crane, HR for Health, SFP Capital, and Vanguard Dental Partners among others. He is the Chairman of the Technology Advisory Board at WEO Media, is a Venturer in Residence at Harvard’s Innovation Lab, and is on the Clinical Advisory and Editorial Boards at Dentistry Today, Inside Dentistry, Dental Products Report, Dental Practice Report, The Progressive Dentist, and Seattle Sleep Education LLC. He is the Managing Editor of Dental Sleep Practice journal and Orthodontic Practice US. Dr. Shuman served as President of Pride Institute for 6 years and Vice President of Clinical Education and Strategic Relations at Align Technology for 7 years. He is the past owner of a 10-doctor multispecialty group practice where he specialized in Adult Orthodontics. He received his Certificate in Advanced Graduate Studies in Orthodontics from Dr. Anthony Gianelly at the Henry M. Goldman Boston University School of Dental Medicine.

2 Orthodontic practice

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-inchief 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

© 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 3

Better, together.

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TABLE OF CONTENTS

Financial focus Being creative with 401k planning Tony Robbins addresses the question, “Is the 401k game still winnable for the average person?”............................ 16

Practice profile Barry Raphael, DMD

Achieving a new equilibrium

Case study Pediatric severe apnea/obesity/ TMD/headache — Class III Dr. Steven Olmos illustrates the need to identify the clinical signs and screen for sleep-breathing disorder symptoms in children and adolescents.............20

Orthodontic concepts BioDigital orthodontics suresmile® aligners: part 21

Corporate profile OSA University

Drs. Rohit C.L. Sachdeva and Takao Kubota discuss how suresmile works within the aligner production process ....................................................... 26

Start-to-finish dental sleep education and implementation

4 Orthodontic practice

Volume 7 Number 3

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TABLE OF CONTENTS

Continuing education Airway orthodontics the new paradigm: part 1, addressing the airway

Dr. Barry D. Raphael discusses some ways to mitigate predisposing risk factors to airway resistance

Continuing education Orthodontic and surgical diagnosis and management of OSA — case presentations: part 2 Drs. John W. Stockstill, Joseph E. Cillo, and Stevan H. Thompson review some diagnostic and treatment strategies for obstructive sleep apnea (OSA) in adolescent and adult patients ....................................................... 38

Practice management Unlocking the code to medical insurance for oral appliances for OSA

PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com

Rose Nierman, founder and CEO of Nierman Practice Management, offers advice to facilitate insurance reimbursement................................ 54

MANAGING EDITOR | Lou Shuman, DMD, CAGS Email: lou@medmarkaz.com

Propelling orthodontics Laboratory link Self-ligation and accelerated orthodontics — applications and new opportunities Dr. Stuart L. Frost discusses how he integrated accelerated treatment into his practice...................................... 48

Digital Positioners

James Bonham discusses how new Digital Positioners have improved orthodontic treatment and work-flow ....................................................... 56

Materials & Education exploration equipment.........................58 Reflections on Ormco’s Forum 2016 Q&A with Drs. Michael Hess and Toby VanLandschoot............................... 52

6 Orthodontic practice

Industry news/ meeting news................62

EDITOR IN CHIEF | Mali Schantz-Feld, MA Email: mali@medmarkaz.com | Tel: (727) 515-5118

ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkaz.com NATIONAL ACCOUNT MANAGER | Adrienne Good Email: agood@medmarkaz.com CREATIVE DIRECTOR/PROD. MGR. | 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 Fax: (480) 629-4002 Tel: (480) 621-8955 Toll-free: (866) 579-9496 www.orthopracticeus.com | www.medmarkaz.com

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PRACTICE PROFILE

Barry Raphael, DMD Achieving a new equilibrium What can you tell us about your background? JWM, age 64, spent my summers “down the shore” in New Jersey. Oh, you mean in ortho? Penn Dental. Fairleigh-Dickinson Ortho. Had 14 instructors and 14 different techniques. Came out using a combination bracket so I could use any technique that suited the case. I called it “thinking-man’s ortho.” I kept up with the times, using functionals, self-ligating, lingual, aligners, etc., until I learned that orthodontics was not just about moving teeth. Then things changed. I own the Raphael Center for Integrative Orthodontics and the Raphael Center for Integrative Education in Clifton, New Jersey, and teach myofunctional orthodontics at the Mount Sinai School of Medicine in New York City and for the Myofunctional Research Company (no financial interest). I lecture in and out of the U.S. on Airway Orthodontics and wrote every word of my website at www.alignmine.com. Ever active in organized dentistry, I started my turn as President of the New Jersey Association of Orthodontists in April 2016.

Gotta have laughs at the chair

Why did you decide to focus on orthodontics? The truth? Because trying to make money in a band was no fun — and my dad was getting tired of waiting for me. But that’s only part of the story. Once my residency started, I was hooked. I became the best student I’d ever been and haven’t stopped learning since. In fact, orthodontics is now more exciting to me than ever. Now I can help patients with more than a smile. I can help them grow and be healthier, too. In fact, I believe orthodontics is (or can be) on the forefront of something very important for the health and welfare of coming generations.

Is your practice limited solely to orthodontics, or do you practice other types of dentistry? My passion is for “airway orthodontics” — that is, how we get a child to grow up with the best possible airway at the earliest possible age. For the past 8 years, I’ve been changing my thinking about the definition of malocclusion. Since malocclusion is really a 8 Orthodontic practice

New Jersey in the fall

modern disease — not identifiable in anthropological records to any great degree before just a few hundred years ago — its etiology must be more epigenetic than genetic and, therefore, based on things we, as humans, do. And like the other myriad chronic diseases we deal with today (e.g., obesity, diabetes, heart disease, etc.), there are things we can do to mitigate malocclusion as well. And believe it or not, there are LOTS of ways in which we can change the course of growth and development for every child with malocclusion.

What do you think is unique about your practice? We take care of the child attached to the teeth as well as the teeth attached to the child. Orthodontics is not just about straightening teeth anymore. It’s about helping the child achieve a new equilibrium where the teeth are in balance with the rest of the body. We help each child deal with the habits that create imbalances and replace them with habits that will maintain balance. We do our best to “peel the onion” of root causes Volume 7 Number 3

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

SMPP568Rev042916

PRACTICE PROFILE until the teeth can find their way straight. Yes, often I have to undo the damage that’s been caused by years of bad habits, but then we still have to replace the old habits with new. And, no, I can’t do that alone. We work with physicians, health educators, body therapists, and all manner of collaborators, including parents. But what we try not to do is force teeth into a further compromise against other imbalances. I will also say that nothing I do is mine alone. If our practice is unique, it’s because we’ve taken the brilliant work of others and put it into a package that works. Furthermore, I don’t want it to be unique. I want it to serve as a model for others to copy. We are here to be in service to the profession as well as our patients.

How long have you been practicing orthodontics, and what systems do you use?

Right, I thought. But it slowly began to sink in, and now I know it’s correct. Almost every malocclusion (except for extra, missing, or decayed teeth) is the result of the muscles (active or at rest) having their way. And once I began to see this in my patients’ faces, there was no turning back. We use systems that were designed by the Myofunctional Research Company specifically to educate patients and parents — custom lightwire expanders like Advanced Lightwire Functionals (ALF) and Farrell Bent Wire System (BWS); functional appliances like Biobloc™ and MARA; and yes, Damon for light-force, low-friction mechanics. I also help adults with breathingdisordered sleep back away from needing CPAP and mandibular advancement devices (MADs), but that’s another story.

What training have you undertaken? For years, I loved CE courses. But it began to get boring — same old stuff over and over. When I learned that crooked teeth are just a symptom of another imbalance and not just the “problem” to be solved, I had to start “re-learning,” and it got really exciting again. First, I learned myofunctional orthodontics and myofunctional therapy, then Orthotropics®. Then cranial osteopathy and lightwire osteogenesis. I learned about breathing and posture, nutrition and sleep. Some of what I learned has been around for many, many years. Perhaps we weren’t ready for this knowledge before. But now, with our children becoming sicker with allergies, asthma, chronic inflammatory and immune issues, neurocognitive and attention problems, we really need to pay attention.

I have been practicing for 33 years total. The first 27 were about moving teeth. I was up to using Damon® Q™ and the mandibular anterior repositioning appliance (MARA) with expansion when I sat down to lunch one day and read an article that changed everything for me. I had been struggling with some open-bite cases that I couldn’t close no matter what I threw at them. Everyone knows about tongue thrust, sure, but this article by German Ramirez said, “Soft tissue dysfunction is THE etiology of malocclusion.”

Teaching airway ortho

We take care of the child attached to the teeth as well as the teeth attached to the child. First look is the best

Award-winning office design 10 Orthodontic practice

Nose. Lips. Tongue. Swallow. Repeat Volume 7 Number 3

SMPP574Rev042916

PRACTICE PROFILE Who has inspired you? At first it was my dad, Jerry, who gave me the treatment planning and a retirement date from day one. Then it was Jim McNamara, who got me to look beyond brackets and wires. In the last 8 years, though, the list has become very, very long. I now stand on the shoulders of forward thinkers who took a chance to do something new and make things better despite what others thought. Here’s the short list: John Mew, Chris Farrell, John Flutter, Roger Price, Joy Moeller, Kevin Boyd, Mark Cruz, Brian Palmer, Bill Hang, Gavin James, Christian Guilleminault, and a Philadelphia lawyer from the 19th century named George Catlin, who wrote a book in 1879 that was recommended by Edward Angle in 1925 called Shut Your Mouth and Save Your Life. A must-read even now.

What is the most satisfying aspect of your practice?

ortho faster, cheaper, and on a bigger scale based on providing a great smile. I say the future of orthodontics lies in giving a more thorough service based on providing better health with a great smile as icing on the cake. Face it; we have a population that is getting sicker, more often, and at younger ages. We have a responsibility to help our children grow up in a world where they don’t have to suffer disfigurement and chronic disease. We must reestablish ourselves as physicians of the face. That may sound pie-in-the-sky to many, but there is so much we can do — so much that is already being done — that we just have to stand up and do it.

What are your tips for maintaining a successful specialty practice? Did I say I was successful? If you’re looking for enrollment percentages, dollars/ visit, or patients-per-day, don’t ask me that question. If you’re looking for how I make a

To the best of my ability, I am fighting daily for the health and welfare of my patients, well beyond their smiles. But to be honest, it is also the most challenging thing I’ve ever done. While my profession continues to search for ways to do things faster, more predictably, without compliance, I have moved toward changing behavior, requiring the daily cooperation of the child and family. I work hard to improve the protocols every day. I figure if someone else can get kids to excel at soccer, piano, dance, and gymnastics, which they do to an amazing degree, the least I can do is figure out how to get kids to breathe through their nose, close their lips, and keep their tongue on their palate, right? And when they do, the trajectory of their lives changes. That is very satisfying.

difference in people’s lives, well, that’s what I’m talking about.

What advice would you give to a budding orthodontist? First, there is a long and important thread of thinking in your profession that you are not learning about in your program. Really read Angle. Read about Al Rogers who corrected Class II malocclusions with exercise alone. Read what Tweed thought about early treatment (he predicted it would be the future of orthodontics). Read Graber’s chapters on the etiology of malocclusion (it’s been in front of our face all along). Read what Ricketts said about the relevance of the rest of the body to malocclusion. Figure out why Harvold’s work has fallen on deaf ears. Second, don’t be a “Barker” (someone who stands so close they don’t even see the tree let alone the forest). It’s not about “finishing” that 2-degree rotation on the lower lateral or accelerating your treatment (especially if you’re going in the wrong direction in the first place). And don’t think that “plaster on the table” is what makes you a wo/man. There is a precious child attached to those teeth. Stand back and look at the big picture. You’ll be amazed at what you see (good and bad).

What are your hobbies, and what do you do in your spare time? I still play bass. My grown kids love me, but they do laugh at me when they say, “It’s all about Barry and the World of Mouth Breathing.” OP

Professionally, what are you most proud of? Despite the challenges, I journey on. I figure I’m doing it for my great-grandchildren (yet to come).

Adjusting a lightwire expander

Do your patients come through referrals? I used to have a typical 50/50 mix of patient/GP referral pattern. Now I have people traveling distances because I offer services that others don’t. They may pass 50 offices to get to me. I shake my head in bewilderment because any well-trained orthodontists can do what I do. It’s simple. (But it’s not easy.)

What is the future of orthodontics and dentistry? My professional organization is afraid that the future lies in the hands of those who do 12 Orthodontic practice

Promoting the Big Picture is a daily task

Airway Orthodontics for the Orthodontic Specialist courses available: • July 22-23, 2016 • November 18-19, 2016 at the Raphael Center for Integrative Education in the NYC metro area. Visit learnairwayortho.com to register or for more information.

Volume 7 Number 3

CORPORATE PROFILE

OSA University Start-to-finish dental sleep education and implementation

SA (Obstructive Sleep Airway) University is an online education program that administers extensive dental sleep medicine training and dedicated implementation support. OSA University members have exclusive access to eight online courses, platinum diagnostic referral support, Medicare Durable Medical Equipment credentialing, a virtual study club led by clinical director, Dr. John Tucker, and ongoing CE offerings (up to 36 per year). OSA University has trained thousands, and the OSA University team has supported dental and orthodontic offices with the integration of dental sleep medicine. Founder, Elias Kalantzis, commented, “The growth has surpassed our organizational goals, and we are extremely grateful for this and the phenomenal level of commitment from practices, especially orthodontic offices.” Orthodontic practices have been especially successful with the education and the implementation process. This is particularly due to the nature of orthodontic practices being 95% team driven. Additionally, team members in orthodontic practices are already comfortable with a total health approach, making the inclusion of obstructive sleep apnea treatment an easy transition into the practice’s philosophy and treatment offering. For years prior to OSA University’s opening, the founder worked passionately to stress the importance of treatment for airway and sleep-breathing sufferers. Sadly, his dedication came with a price, as his connection to airway and sleep health emerged after a personal family tragedy in January of 2010. Since then, Mr. Kalantzis continues to push forth the message of airway and sleep health prioritization in both public and professional circles. OSA University evolved from a vision of seeing a much larger scale of obstructive sleep apnea treatment availability for patients and a greater public awareness of this alarming health threat. Within a short time, a need of education and training on sleep-breathing fundamentals and practice protocols was identified as a channel toward both a greater outreach of public 14 Orthodontic practice

OSA University executive team: Jay Kelsall, Operations Manager; Anna Gordon, VP of Marketing and Strategic Planning; Rob Suter, VP of Sales; and Elias Kalantzis, Founder

awareness and patient treatment availability. The OSA University concept originated from a profound desire to educate others on the critical nature and importance of sleep and airway health. The OSA University brand was built on the foundation of integrity and resourcefulness. Exceptional educational experience was set as the goal — fueled by inspiration for team members to expand the awareness of airway and sleep health to patients and their communities. OSA University embraced an organizational philosophy to become a non-biased information provider of the latest and most current industry data. To best deliver Dental Sleep Medicine education to orthodontists, dentists, and

their team members, OSA University organized and developed an online academic platform that is available to each student on an on-demand basis. Students are able to take courses on any computer, any time, and at a pace that suits each student. Eight courses were developed from specific areas of concern and education needed for orthodontists and team members to succeed. The information is delivered on a learning gradient, whereas each course is taught from the foundation of the previous one. Each course contains the following elements: a course handout that can be downloaded and printed; an instructional video with pop quizzes and chapter points; and a final exam each student must pass Volume 7 Number 3

CORPORATE PROFILE

Foundation for Airway Health Launch NYC 2015

with a 70% grade or higher to continue onto the next class. Implementation and orientation meetings are scheduled in advance of starting courses to assure success. Upon completion, each student receives a CE verification form. According to OSA University VP Sales, Rob Suter, “Our education is more than the online classes. We deem success based on our practices treating more patients — and we take success very seriously. We personally do everything within our ability to assist with the implementation needs of each practice, including the introduction to a diagnostic channel.” Mr. Suter has been working in the industry for more than 15 years and has been involved with several industry studies and OSA white papers. In addition to the curriculum and diagnostic referral assistance, each practice receives an office launch kit, which includes marketing pieces to initiate patient conversations and treatment launch awareness. The marketing materials include: • StopBang Questionnaire • Framed OSA University Office Diploma • Do you Snore Brochures • Oral Appliances Brochures • Sleep Apnea Quick Reference Sheet • Sleep Apna Office DVD • Team Buttons The purpose of these items is to provide inspiration to the team and to assist in connecting with patients on airway health and Oral Appliance Therapy. The launch of OSA University has been warmly welcomed and endorsed among industry leaders. In 2014, OSA University Volume 7 Number 3

The OSA University brand was built on the foundation of integrity and resourcefulness.

partnered with Henry Schein® for their Sleep Complete™ Program and became their educational arm for dental sleep medicine training. Since OSA University joined the Sleep Complete Program, the number of seminar offerings has doubled. According to Henry Schein, the program has never been more successful. In 2015, OSA University became a benefactor to The Foundation for Airway Health, taking on the Foundation as a philanthropic partnership. The foundation was launched in March of 2015 as a public awareness organization, working to shed light on the critical issues of suboptimal airway and sleep-breathing health. Currently, 100% of OSA University webinar proceeds go to the Foundation of Airway Health. Recently, in 2016, OSA University partnered with Planmeca, a global leader in dental 3D imaging and CAD/CAM technology, including the first ultra-low dose CBCT. Planmeca has provided high-quality 3D scans for orthodontic offices for years and united with OSA University to develop a sleep-training program for their clients’

practices. Orthodontists find using Planmeca technology easy and safe to plan maxillary expansion cases to expand airway volume from pediatrics to adults. Also in 2016, new webinar series became a valuable offering from OSA University. Specifically, three different types of OSA University webinar schedules were organized in efforts to continue to support and increase the awareness of sleep and airway health. The first series is available to the general public, with a recommended donation to the Foundation of Airway Health. This series includes presentations from industry leaders. The second webinar series is available through the OSA University Virtual Study, led by the clinical director, Dr. John Tucker. These webinars for OSA University members only include current industry topics and report summaries. The third series is offered for Sleep Complete seminar attendees, 10 days after the completion of the seminar. This is to allow for course attendees to ask questions, talk with the clinical director, and review material that was taught during the seminar. CE offerings are available for each webinar, and OSA University members can obtain up to 36 additional CE credits per year for attendance. As OSA University continues to educate members and train orthodontic practices, a greater number of patients are being treated and helped. If you’d like more information on the university, visit www.osauniversity.org, or call (844) OSA-UNIV. OP

This information was provided by OSA University.

Orthodontic practice 15

FINANCIAL FOCUS

TONY ROBBINS

Being creative with 401k planning Tony Robbins addresses the question, “Is the 401k game still winnable for the average person?”

e can all remember a time during our formative years when a bully used his/her position, power, or sheer physical presence to push around someone who seemed like an easy target. At 5'1" my sophomore year of high school, I was the short fat kid who wanted to “change the world” — not a popular thought at that stage of life. Although wrapped in a temporarily small package (I am now 6'7"), I was fiercely protective of anyone who was suffering under the tyranny of these kinds of kids. The nose guard of our football team was one such buffoon. He was 6'2" and almost 300 pounds. During lunch one afternoon, I witnessed him pouring chocolate milk over the head of my helpless friend while he laughed to the applause of his band of letterman-jacket cronies. Without missing a beat, I got in his face. After a barrage of colorful language that caught him by surprise, I threw the hardest punch I could and ran like hell. Unfortunately, I wasn’t very fast! Peak performance strategist Tony Robbins is a partner and board member of America’s Best 401k and a board member and Chief of Investor Psychology for Creative Planning. To learn more, visit http://americasbest401k. com/medmark Legal Disclosure: Tony Robbins is a board member and Chief of Investor Psychology at Creative Planning, Inc., an SEC Registered Investment Advisor (RIA) with wealth managers serving all 50 states. Mr. Robbins receives compensation for serving in this capacity based on increased business derived by Creative Planning from his services. Accordingly, Mr. Robbins has a financial incentive to refer investors to Creative Planning.

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Decades later, I still do not tolerate bullies. The bullies of the financial services industry are those who extract as much value for themselves to the detriment of others. I don’t think there is an educated person in America who doesn’t think that the system feels set up for those in the know. The rest are left out in the cold. In 2008, while watching many of my friends and clients lose half of their nest egg to the market crash and real estate crises, it struck a deep chord. Having grown up with very little, I was reminded of the pain. These weren’t just statistics to me. I was reminded of nights where my own family went with little or no food. That fearless high school kid in me was kicked into gear. I knew I had to take action.

For decades now, I have been blessed with the incredible gift of “access” — access to some of the most brilliant minds and peak performers in their own fields. I’ve had the privilege of coaching Paul Tudor Jones, one of the top 10 traders in financial history, for 22 straight years now. He hasn’t lost money in any of those 22 years. As his coach, I have been inside the ropes, and what I have learned from him has been invaluable to my own situation. In early 2009, I thought, what if I sit down

and get 50 of the top financial minds, from Carl Icahn to Ray Dalio to Warren Buffett to Vanguard founder Jack Bogle, and more? I wanted them to share their own perspectives. And I asked them, “Is the game still winnable for the average person?” — even in a world where 70% of the daily trades are made in microseconds by supercomputers. The good news is that the answer is yes! And I was able to extract the specific strategies and tools in my No. 1 The New York Times bestseller, MONEY Master the Game, which we released in paperback in April. The foundation of winning the game of money is that you MUST know the rules of the game before you blindly throw your money at a bunch of mutual funds your brother-in-law wants to sell you, or before you trust your 401k to get you through your golden years. For example, 67% of investors think they pay no fees in their 401k, when in fact, it’s a gravy train for the brokers, plan providers, and mutual funds that are on your plan menu. Heck, the 401k industry didn’t have to disclose their fees for over 30 years! Now they offer you 30- to 50-page disclosures that you, and 99.9% of people, have never seen nor read. They are opaque at best, predatory at worst. Volume 7 Number 3

One of the foundational lessons to becoming the chess player is to find a highly qualified advisor who doesn’t have conflicts of interest. It’s common sense that’s not so common. You wouldn’t believe the level of abuse and the lengths the major firms go to in order to mask these conflicts in the multitrillion industry of wealth management. I have educated millions of people now on the difference between a fiduciary, also called a registered investment advisor (RIA), and a broker. A broker sells and receives compensation for products or funds, while a fiduciary is required by law to put your interests first. I am a firm believer that the advice you receive should be separated from the products or funds you buy. Would you go to a doctor who manufactured and sold his own medicine? Of course, not! But the vast majority of the financial industry isn’t legally obligated to put your interests first like a doctor. You heard me right. Well over 90% of financial advisors in this industry are brokers. They don’t call themselves brokers, of course. Their titles are financial advisors, wealth managers, etc. The vast majority of people I meet, both the sophisticated and the unsophisticated, are still unaware of the difference, or they wrongfully assume their advisor is a fiduciary. (Hint: Nearly all name-brand firms are brokers in disguise.) If your financial advisor is with a firm that has its name on a sports stadium, blimp, or race car, there is a high probability that he/she is a broker. They are master marketers, and they make it feel or sound as though they are giving unbiased advice, but we would be naïve to think that their own pockets aren’t the priority.

Volume 7 Number 3

To be sure, many advisors are wonderful and committed people who truly believe they are doing what’s best. This is by no means an assault on their character or good intentions. But one can be sincere and sincerely wrong. Most advisors are trained by and work in a system that is hard-wired to make money for the “house” and reward those who produce sales. Compensation drives behavior, so they certainly don’t wake up each day seeing the conflicts as an issue.

by my standards. He is, by all accounts, the epitome of excellence in the wealth management world. Peter and his firm, Creative Planning, manage nearly $20 billion in assets and carry a number of prestigious accolades — including being the only wealth manager in history to have been ranked No. 1 Independent Financial Advisor in America by Barron’s 3 years in a row. And they are also now ranked the No. 1 Wealth Management Firm in America by CNBC for the second

If your financial advisor is with a firm that has its name on a sports stadium, blimp, or race car, there is a high probability that he/she is a broker. As Upton Sinclair famously said, “It’s hard to get a man to understand something when his salary depends on him not understanding it.” Over the past couple of years, I went on countless talk shows and radio shows, wrote articles, and created videos — all with the intent of educating Americans on the damage caused by this broken model where the person you trust with your financial future is rewarded for selling highcommission products and proprietary funds, while layers of hidden fees go unnoticed.

And although we’ve come a long way in sharing the truth, I’ve recently learned we have a new problem. And it’s even worse! Nearly a year after the first edition of my book was released, I was introduced to Peter Mallouk — an impressive guy, even

consecutive year. It’s great to see a true fiduciary topping the charts. Creative Planning’s typical client is the millionaire next door, but they also have an elite group that works the ultra-wealthy ($10 million or more). Peter and his team, with a little arm twisting from me, recently went from serving only higher net worth folks to opening up a new division to accept smaller accounts. His team will provide a complimentary second opinion to anyone and help them uncover the layers of conflicts, hidden fees, and proprietary funds in their current scenario. A free second opinion from the No. 1-ranked firm is a no-brainer (www.TheNumberOneFirm.com). Peter had asked for a meeting with me, knowing my passion for protecting clients and my commitment to real and absolute transparency in the personal financial sector. What he shared with me left me completely disheartened. After years of trying to educate millions of people on the difference between a broker and a fiduciary and stressing the need for a fiduciary standard, Peter showed me a mountain of evidence that many “fiduciaries” were exploiting a legal loophole to make additional revenue off unsuspecting clients. How so? It turns out that fiduciaries can moonlight as a broker when it suits their pocket book. You heard me right. Somehow, regulators will allow advisors to be both a fiduciary and a broker through a process called “dual registration.” One foot in both camps. Talk about a wolf in sheep’s clothing. That’s like sitting in your doctor’s office and after diagnosing you, the doctor prescribes you a medication that he/she mixes up in Orthodontic practice 17

FINANCIAL FOCUS

I had one singular outcome when I set out to write the book — to help people become the chess player, and stop being the chess piece.

FINANCIAL FOCUS the backroom and sells at a profit! We would never accept such a conflict! “It gets worse, Tony!” Peter carried on … “Some fiduciary advisors are actually receiving additional fees and kickbacks for directing people to specific funds under the guise of ‘shareholder services fees’ or ‘consulting fees.’ Or, in some cases, they have been so brazen as to sell proprietary products under different names where they made more money for recommending an inferior product! And although disclosed in fine print, the client is unsuspecting.”

I was dumbfounded and disheartened, but I also know that we must empower people with knowledge they need to avoid these land mines. There are lots of high-quality firms out there, so I asked Peter to give people the criteria they need to first discover if they are working with a broker or not, and then how to make sure the fiduciary they select is operating solely in their best interests. 1. Aside from making sure that the firm is registered with the SEC as a registered investment advisor, the most important criterion is to make sure that that person/firm is not affiliated with a broker dealer (and ask for it in writing.) This is the “dual registration” I explained above. (Tip: If the advisors website or email says “Securities offered through […],” you are dealing with a broker.)

to expect that the advisor is selling you investments as well. 3. Make sure the registered investment advisor is compensated based on a percentage of your assets under management — and never more than 1.25% in annual advisory fees for comprehensive financial planning. Preferably this number should be 1% or even less if you have substantial assets to invest. Be sure there are no “12b-1” fees, shareholder service fees, consulting fees, or other “payto-play” fees. 4. Make sure the registered investment advisor is not compensated for trading stocks or bonds. If you are a

After all, we aren’t really after “money” per se. We are after the emotion that money gives us. Freedom, security, comfort, contentment, or whatever it is for you. 2. Make sure your advisor does not offer any proprietary funds. Some firms create their own products/ funds to increase revenues and then put those products in their clients’ portfolios. In other words, you may be paying a firm to advise you to buy its own products! If you are paying for investment advice, you deserve

bond investor, the most flagrant fouls in this industry are the “markups” charged by the broker and the firm. (Tip: If your advisor says you pay no fees on your bond portfolio, beware! Ask specifically if any bonds are “marked up.”) 5. Don’t just give an advisor your funds directly. You want to make sure that

your money is held with a reputable third-party custodian, such as Schwab, TD Ameritrade, or Fidelity, which offers you 24/7 online account access and sends monthly statements directly to you. (Note: A fiduciary using a firm like ones named above to custody your investments is NOT the same as the retail branch of these firms.) 6. When looking at an advisory firm, be sure the firm has educated and credentialed advisors on board. When you go to a doctor, you want to make sure they have the MD credentials to back it up. The Certified Financial Planner designation, CPAs, and attorneys are all good qualifications to have on your financial team. Since penning this article, I have decided to align myself with Creative Planning by becoming a board member and Chief of Investor Psychology. My mission is to help people from making poor emotional decisions during volatile times and help them connect to their core purpose so that they will take control of this area of life. After all, we aren’t really after “money” per se. We are after the emotion that money gives us. Freedom, security, comfort, contentment, or whatever it is for you. But what if we could tap into the emotion we really want, so that we enjoy the journey to financial freedom and not wait “until” before we give ourselves permission to have an extraordinary life. Live strong, and live with passion! OP This article originally appeared as a post by Tony Robbins on LinkedIn.

Check to see how your 401k plan compares to industry averages here: http://americasbest401k.com/medmark. 18 Orthodontic practice

Volume 7 Number 3

THE WORLD’S MOST COMPLETE SELF LIGATING BRACKET SYSTEM JUST GOT EVEN BETTER. Micro etched Maximum Retention™ bonding pads Increases bond strength 15-30%* Modified clip shape Helps seat wire during clip closure Thicker and stronger clip Increases wire seating force and reduces clip deformation Chamfered slot entrance Reduces friction from wire binding

Experience Empower 2 for yourself. Contact your American Orthodontics representative to learn more. * Not yet verified by published, peer-reviewed research

CASE STUDY

Pediatric severe apnea/obesity/TMD/headache — Class III Dr. Steven Olmos illustrates the need to identify the clinical signs and screen for sleep-breathing disorder symptoms in children and adolescents

he purpose of this case study is to demonstrate the relationship between obstructive sleep apnea (OSA), obesity, TMD, and headache in the pediatric population. It is possible to resolve OSA in children whereas we most often only manage it in the adult population. This demonstrates the need to identify the clinical signs and screen for sleep-breathing disorder symptoms in children and adolescents. Treatment for children with OSA can be accomplished by dynamic orthopedic development. This case demonstrates that elimination of OSA can be accomplished within a 3-month period. This now gives the physician an effective alternative to positive pressure, which has been shown to magnify the condition by increasing the midface deficiency — the result of the headgear effect with CPAP.1 OSA occurs in all ages, including infants. The preponderance of evidence suggests a prevalence of OSA in the range of 1%-5%. When defined by parent-reported symptoms, the prevalence of OSA is between 4%-11%. OSA results from an anatomically or functionally narrowed upper airway. This usually is a combination of a decreased upper airway patency (upper airway obstruction such as adenotonsillar hypertrophy or intraluminal fat deposits and/or decreased upper airway diameter), increased upper airway collapsibility (reduced pharyngeal muscle tone), and decreased drive to breathe.2 As overweight and obesity have become more prominent, the incidence of OSA in the pediatric population is increasing as it is for adults. Today, about one in three American children and teens is overweight or obese. The prevalence of obesity in children more than tripled from 1971 to 2011. With good Steven R. Olmos, DDS, is an Adjunct Associate Professor, 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. For more information on how to treat adult and pediatric OSA, visit www.tmjtherapycentre.com.

20 Orthodontic practice

reason, childhood obesity is now the No. 1 health concern among parents in the United States, topping drug abuse and smoking.3 The incidence of sleep-breathing disorders and chronic facial pain is increasing throughout the world. One in six children and adolescents has clinical signs of TMJ disorders.4 Headache is common among children and adolescents. Up to 82% of adolescents report having a headache before the age of 15. Migraines experienced in the pediatric population are just as disabling as those experienced by adults.5 A review of the literature worldwide found that there is a global high prevalence of headache and migraine in children and adolescents.6 Migraine is the most common headache with TMJ disorders.7 Children diagnosed with migraine are 8.25 times more likely to have a sleep-breathing disorder, and children diagnosed with chronic tension-type headaches are 15.23 times more likely to have a sleepbreathing disorder.8 Patients of all ages who have OSA are 6.52 times more likely to have a TMJ disorder.9

Case study: Emily Emily was 10 years old when she was referred to me at the University of Tennessee (UT) College of Dentistry Pediatric Department by Robert Shoumacher, MD, (Professor of Otolaryngology-Head-Neck Surgery) a pediatric sleep specialist from Le Bonheur Children’s Hospital Memphis. She was referred due to ineffective positive pressure therapy and worsening of symptoms. Emily was first diagnosed at age 5 with severe OSA. The results of her polysomnography (PSG) sleep study, evaluated on October 1, 2010, were an apnea-hypopnea

index (AHI) of 118. A child with an AHI equal to or greater than 1.5 is diagnosed with OSA and requires therapy. Her nadir (lowest level) blood oxygenation was 65%, when normally at sea level it should be around 98%-100%. At 65% that is equivalent to oxygen levels at an altitude of 26,240 feet. (Mount Everest is 29,029 feet.) Emily was placed on CPAP and attempted to use for 5 years prior to referral to our clinic at UT. Children have the same cardiovascular pathophysiology as adults secondary to OSA. She first presented for examination at our clinic on November 15, 2015. She was 5'4" and weighed 240 pounds with a body mass index (BMI) of 42.9. A BMI over 22 for children is considered obese. She had hypertension with a blood pressure of 130/112 and was being treated with Lisinopril (ACE inhibitor). She was taking metformin/ Glucophage® for her Type 2 diabetes. She was taking Singular® (antihistamine) for her severe environmental and food allergies. She was taking Tylenol® for her chronic headaches/face and body pain throughout the day, every day. Her chief complaints were frequent snoring, dry mouth, sinus congestion, and headache. Palpation of the TM joints revealed moderate pain. Joint vibrational analysis was used to evaluate the hard and soft tissue with mandibular movement. This is the only dynamic quantitative equipment available as all other techniques such as MRI and X-ray imaging is static/positional. Vibrations less than 300 Hz are consistent with soft tissue movement (disc), and vibrations greater than 300 Hz are consistent with bone-on-bone osseous pathology (Figure 6), which demonstrates bilateral disc perforation. This was confirmed by CBCT imaging (Figure 7). Volume 7 Number 3

Figures 1-2: Evaluation and quantification of the patientâ&#x20AC;&#x2122;s posture

Figure 3: Facial asymmetry

Figures 4-5: Evaluation of skeletal, oral, and dental relationships

Figure 6 Volume 7 Number 3

Figure 7 Orthodontic practice 21

CASE STUDY

This case demonstrates that a dynamic skeletal development of children with severe apnea can be helped in a nonsurgical way with dramatic results.

CASE STUDY Patients of all ages who are diagnosed with OSA have a collapse of the oropharyngeal airway. Children younger than 10 years of age have a relatively larger tongue in the oropharynx than the adult’s, and the narrowest portion of the airway is below the glottis at the level of the cricoid cartilage.10 Starting the orthopedic development from a position of larger volume and, more importantly, reduced collapse is vital. The sibilant phoneme registration has been proven to reduce airway collapse in adults, and we are currently performing studies on children with similar findings.11 Compare the volume changes from baseline to phonetic position on Emily in Figure 9. Positioning is necessary not only to increase the oropharyngeal airway, but also to increase the oral volume. From this position, all skeletal and dental landmarks can be assessed (Figures 10 and 11). The maxilla was deficient in all dimensions as well as being posteriorly positioned in relation to the cranial base. The treatment plan for this case was the following: • Maxillary and mandibular transverse development for increased nasal and oral volume. • Reverse-pull mechanics to advance the maxilla while holding the threedimensional mandibular position that will decompress the TM joints and reduce airway collapse. • I decided to use a Tandem appliance to lever against the temporal bones (fossa) to advance the maxilla instead of a reverse pull headgear that would place forces on the frontal bone. A case study was published recently in the Journal of Dental Sleep Medicine using a protraction facemask for a less severe case.12 See Figures 12-15 for design. The lower appliance was worn 24 hours per day, Figure 10 including meals, the tandem

Figure 12 22 Orthodontic practice

Figure 8: The resting baseline volume of the oropharyngeal airway

Figure 9: Baseline airway (left) and starting orthopedic development airway (right)

Figure 11

Figure 13

Figure 14 Volume 7 Number 3

done with both. Due to the extreme reduction in AHI, she did not need to use the positive pressure device. Dr. Schoumacher decided to stop the NCPAP therapy and use only the orthopedic therapy at this point. At 12 weeks of treatment (not wearing the NCPAP for 4 weeks), she reported that her chief complaints of snoring were 100% resolved, dry mouth 100% resolved, sinus congestion 50% reduced, and headaches 100% resolved. Her posture had continued to improve (see Figure 19) as did her maxillary advancement compared to baseline (Figure 20). In addition to resolution of her sleeprelated breathing condition, we were able to heal the perforations in her TM discs as demonstrated in the JVA analysis of March

10, 2016 (12 weeks) (Figure 21). The scanning shows no osseous vibrations greater than 300 Hz bilaterally. This is confirmed on the TM joint imaging using the CBCT (Figure 22). Joint spaces are now present bilaterally,

Figure 15

Figure 16

Figure 18: Maxillary advancement at 8 weeks

Figure 21 Volume 7 Number 3

Figure 17

Figure 19

Figure 20

Figure 22 Orthodontic practice 23

CASE STUDY

bow was inserted, and elastics were used at night for 10 hours in combination with NCPAP (nasal delivery positive pressure). After 4 weeks of treatment, her frequent snoring was resolved 100%, dry mouth 50% reduced, sinus congestion 20% reduced (still using NCPAP), and headaches resolved 100%. Uprighting of posture was dramatic (Figures 16 and 17). This is due to the reduction of TM joint inflammation and increase in nasal breathing.13,14,15 Maxillary advancement at 8 weeks is demonstrated in Figure 18. At this point, a new PSG was performed, and her AHI had reduced from 118 to 3.1. The test was scheduled for a split night study, the first half with only the orthopedic devices and no NCPAP, and then the second half would be

CASE STUDY

Figure 23

and cortical bone on the superior surface of both condyles is observed. In order to quantitatively measure the skeletal and dental position changes, we superimposed the 3D CBCT images from start and at 12 weeks. Skeletal suture points were used to orient the two images for accuracy. The blue areas are the origin skeletal position, and the bone-colored areas are the new relationships. Even though we levered against the mandible to pull the maxilla forward, it was the mandible that advanced the most, and the maxilla grew from the base of the orbit while maxillary anterior teeth assumed a more proper torque (Figure 23). Notice that the frontal bone advanced, and the temporal bones changed, left greater than right. The sagittal projections demonstrate that the mandible rotated up and the maxilla down as seen in Figure 24. In both Figures 24 and 25, notice the dramatic changes to the cervical spine. This is consistent with the visible changes observed. This case demonstrates that a dynamic skeletal development of children with severe apnea can be helped in a nonsurgical way with dramatic results. This treatment is an orthopedic development for a medical condition and is not an orthodontic therapy. It is billed to medical insurance as an alternative therapy to positive pressure with superior and life-long results. Now that the patient has been treated and has stabilized her sleepbreathing disorder and TM pathology, she can now be assessed for orthodontic therapy, which is dental and billed accordingly. OP

Figure 24

Figure 25

REFERENCES 1. Roberts SD, Kapadia H, Greenlee G, Chen ML. Midfacial and dental changes associated with nasal positive airway pressure in children with obstructive sleep apnea and craniofacial conditions. J Clin Sleep Med. 2016;12(4):469–475. 2. Mindell JA, Owens JA. A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems. 2nd ed. Philadelphia, Pennsylvania: Lippincott Williams & Wilkins; 2010. 3. American Heart Association. Understanding childhood obesity. https://www.heart.org/idc/groups/heart-public/@ wcm/@fc/documents/downloadable/ucm_304175.pdf. Accessed April 18, 2016. 4. da Silva CG, Pachêco-Pereira C, Porporatti AL, Savi MG, Peres MA, Flores-Mir C, Canto Gde L. Prevalence of clinical signs of intra-articular temporomandibular disorders in children and adolescents: a systematic review and metaanalysis. J Am Dent Assoc. 2016;147(1):10-18. 5. Winner P. Pediatric and adolescent migraine. American Headache Society. http://www.americanheadachesociety. org/assets/1/7/Paul_Winner_-_pediatric_and_Adolescent_ Migraine.pdf. Accessed April 18, 2016. 6. Abu-Arafeh I, Razak S, Sivaraman B, Graham C. Prevalence of headache and migraine in children and adolescents: a systematic review of population-based studies. Dev Med Child Neurol. 2010;52(12):1088-1097. 7. Franco AL, Gonçalves DA, Castanharo SM, Speciali JG, Bigal ME, Camparis CM. Migraine is the most prevalent primary headache in individuals with temporomandibular disorders. J Orofac Pain. 2010;24(3):287-292.

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8. Carotenuto M, Guidetti V, Ruju F, Galli F, Tagliente FR, Pascotto A. Headache disorders as risk factors for sleep disturbances in school aged children. J Headache Pain. 2005;6(4):268-270. 9. Sanders AE, Essick GK, Fillingim R, Knott C, Ohrbach R, Greenspan JD, Diatchenko L, Maixner W, Dubner R, Bair E, Miller VE, Slade GD. Sleep apnea symptoms and risk of temporomandibular disorder: OPPERA Cohort. J Dent Res. 92(7Suppl):70S-77S. 10. Department of Pediatrics University of Wisconsin School of Medicine and Public Health. Sedation program. https:// www.pediatrics.wisc.edu/education/sedation-program/ sedation-education/pediatric-airway.html. Updated January 4, 2016. Accessed April 18, 2016. 11. Singh D, Olmos S. Use of a sibilant phoneme registration protocol to prevent upper airway collapse in patients with TMD. Sleep Breath. 2007 Dec;11(4):209-216. 12. Peanchitlertkajorn S. RPE and Orthodontic protraction facemask as an alternative therapy for severe obstructive sleep apnea associated with maxillary hypoplasia. J Dent Sleep Med. 2016;3(2). http://www.jdsm.org/ViewArticle. aspx?pid=30401. Accessed April 18, 2016. 13. Olmos SR, Kritz-Silverstein D, Halligan W, Silverstein ST. The effect of condyle fossa relationships on head posture. Cranio. 2005;Jan;23(1):48-52. 14. Tecco S, Festa F, Tete S, Longhi V, D’Attilio M. Changes in head posture after rapid maxillary expansion in mouthbreathing girls: a controlled study. Angle Orthod. 2005 Mar;75(2):171-176. 15. 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.

Volume 7 Number 3

T&S Therapy Centre I N T E R N ATI O N AL

TMJ & Sleep Therapy Research & Education

NOT A PREREQUISITE TO TAKE IN SEQUENCE

ORTHODONTIC CONCEPTS

BioDigital orthodontics suresmile® aligners: part 21 Drs. Rohit C.L. Sachdeva and Takao Kubota discuss how suresmile works within the aligner production process Introduction Today, aligners are broadly accepted by the orthodontic community for use in orthodontic treatment. Treatment with aligners is generally restricted to a select group of patients. Factors affecting the use of aligners include: 1. the patient’s desire 2. the doctor’s skills in managing the appliance 3. the nature of planned tooth movement 4. the affordability 5. the length of care Historically, suresmile® technology has focused on providing customized therapeutic solutions for labial- and lingual-fixed appliance treatment.1,2 In recent years, suresmile has extended the functional range of its technology to enable the doctor to design aligners. As a result, the clinician may design a combined therapeutic solution comprising the use of both fixed and removable appliances (when indicated). Furthermore, the

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.

Dr. Takao Kubota is in private practice in Yours Orthodontic Clinic, 378-6 Motomura Yame City, Fukuoka 834-0063 Japan. He is also the co-founder of the Institute of Orthodontic Care Improvement in Japan.

26 Orthodontic practice

advantage of using a “unified” computeraided design workstation provides the practice with superior ergonomics and costeffectiveness and minimizes the burden of additional training in another system. In this article, I discuss how suresmile facilitates the design of aligners, the process of producing the aligners, and a handful of use cases with patient histories. It is important to recognize that suresmile does not fabricate aligners. The following section briefly outlines the steps involved in designing and manufacturing aligners.

Step 1: Imaging suresmile recommends an in vivo optical scanned image as input. The in vivo image of the dentition should be scanned to include the surrounding gingival tissue (a minimum of 5 mm in height on the labial/lingual surfaces of the teeth). A scanned image of the bite for interarch model registration is required. Also, current standard intraoral images — cephalometric and panoramic X-rays of the patient — are requested (Figure 1). Intraoral scans with brackets are acceptable; the suresmile laboratory can remove the brackets using digital erasers and condition the hidden surfaces of the tooth to approximate the original tooth anatomy (Figures 2A-2B).

Figure 1: Records needed for suresmile aligners

Figures 2A-2B: 2A. Therapeutic intraoral scan showing brackets 2B. Tooth surfaces have been digitally “conditioned” to prepare them for the design and fabrication of aligners

A list of the certified scanners is provided in Table 1. The aligners may be designed at any stage in treatment — from the start of treatment, midtreatment, or the finishing and retention phases — to suit the doctor’s therapeutic protocol.

Table 1: Optical scanners certified for use with suresmile

3M™ True Definition TRIOS® 3, TRIOS® orascanner® 2 iTero® for Orthodontics and IOC

Volume 7 Number 3

The processed 3D image is used to design the target setup. The doctor has the ability to move the teeth on the virtual working model in all three planes of space, measure tooth displacement, and also plan for interproximal reduction (Figure 3). Tools for measuring the quality of the target setup based on both the ABO and suresmile guidelines are available (Figure 4). Once the target setup is completed, the doctor may apply attachments to the teeth to aid in better control of tooth

movement (Figure 5). Next, the doctor applies her preferences to stage incremental tooth movements. (Note: These are preset by the doctor and applied in default mode.) See Figure 6A. The process of serially staging the models is automatic and driven by the preset values (Figure 6B). The operator can always override the default settings for the entire series of incremental tooth movements or for any single stage to affect the magnitude and nature of tooth displacement. In addition, the doctor has the choice to select the hardness of the aligner material and

calibrate it to the nature and amount of the staged tooth movements. Staged movements may be observed both in a cumulative or incremental mode. The cumulative mode represents the aggregate of the tooth displacements for all the stages of tooth movement achieved up to the current stage. The incremental mode shows the amount of movement achieved between the previous stage and the current stage (Figure 7). For an additional fee, suresmile will design the target setup based on the doctorâ&#x20AC;&#x2122;s prescription (Figure 8).

Figure 4: Automatic quality check tools for the target setup

Figures 3A-3C: Designing the target setup. 3A. The virtual working model. 3B. The target setup. 3C. Measures for IPR (red arrow) and tooth displacement (green arrow) are automatically updated as the teeth are moved

Figures 5A-5B: Attachment selection. 5A. Individual attachments for each tooth can be selected. 5B. The attachments can be positioned to create and manage the required tooth movement

Figure 7: The displacement of the teeth can be displaced in either cumulative or incremental mode

Figure 6A-6B: Selection of constraints. 6A. The doctor can select both the parameters for material stiffness (Soft, Standard, or Hard), and the Maximum/Minimum Translation and Rotation constraints change according to the material chosen. 6B. The staging of the setup/models can be automatically sequenced Volume 7 Number 3

Figure 8: Aligner prescription form for the suresmile laboratory Orthodontic practice 27

ORTHODONTIC CONCEPTS

Step 2: Planning and appliance design

ORTHODONTIC CONCEPTS Step 3: Staging Once the target setup is accepted, the sequence of the automatically designed staged models are reviewed. The doctor has the ability to override any of the stages to suit the patientâ&#x20AC;&#x2122;s needs (Figures 9-10). The software automatically creates STL files of the staged models that can be saved on the desktop in a zip file for later use.

Step 4: Order and fabrication The operator can choose and print any stage of treatment (Figures 11A-11B) and has the option to order 3D hard copies of the models from suresmile (Figure 12) or from other sources. (Note: The virtual models can be automatically downloaded in STL format and subsequently exported.) The operator can then fabricate the aligners in-office using commonly accepted thermo-vacuum-forming techniques and materials.2 Figures 9A-9B: Controlling staging. 9A. Stages of tooth movement can be actively deleted (green arrow) 9B. Or added (red arrow)

Figure 10: Sequential (multi-stage) tooth movements displayed. Displacement of any number of teeth, in any direction, for any given stage of tooth movement can be changed

Figures 11A-11B: Ordering staged models for printing. 11A. Models can be deselected for printing. 11B. Or if exporting to a remote site. This way, the practice shelf space can be better managed

Figure 12: Hard models printed by suresmile sent to the practice. Note each model is labeled by its sequence and carries a patient HRID 28 Orthodontic practice

Volume 7 Number 3

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.

That’s exactly what suresmile gives you.

ORTHODONTIC CONCEPTS Three common clinical situations in which we have used suresmile aligners are described below:

Type 1 The concept of just-in-time retainer delivery is exemplified by this patient history. Two weeks prior to the patient’s debonding, the virtual target setup that was initially used to fabricate the suresmile finishing archwires was also used to design an Essix®type retainer.3 The physical model (printed model) production was outsourced to an external laboratory, and the retainer was fabricated in-house and delivered on the day of debonding (i.e., just-in-time delivery) (Figure 13). This proactive approach to designing and fabricating the Essix-type retainer appliances has many advantages, including obviating the necessity of taking an additional scan or impression of the patient to design the appliance. This approach results in chairside time savings, which opens up chairside capacity and allows for more effective staff utilization and cost savings. Most importantly, this approach 1) adds to patient convenience by shortening the debonding visit and 2) minimizes the risk of immediate post-debonding minor rebound effects. Furthermore, the printed hard copy of the model is virtually indestructible, has a long shelf life, and may be used to fabricate additional replacement retainers.

In recent years, suresmile has extended the functional range of its technology to enable the doctor to design aligners.

Figure 13: Just-in-time Essix® retainer for the upper arch created from the patient’s therapeutic model. The aligner was fabricated in the practice, and the fabrication of the hard model was outsourced to a remote laboratory

Type 2 This patient was scheduled for debonding at her next visit. Unfortunately, the patient lost her lower anterior bracket, which resulted in rotational relapse of the lower left lateral incisor (Figure 14). Rather than rebond a bracket and add refinements to an archwire to correct the rotation (this would have added at least 6 to 8 weeks to treatment time), the initial virtual target setup was used to design active aligners to correct the relapse. To the patient’s delight, an earlier debonding appointment was scheduled (2 weeks later), and a series of aligners were delivered to facilitate the correction of the rotation (Figure 14). The approach toward this patient’s care had the obvious benefit of adding to her satisfaction and also minimized the additional care processes involved in managing fixed appliances, etc.

Type 3 Minor relapse was noted immediately posttreatment. The tooth positions were simulated on the virtual target setup to reflect the current tooth position. This model was then used as a reference model to stage the 30 Orthodontic practice

Figure 14: Note bracket loss on the lower left lateral incisor. The tooth rotation was corrected with an aligner rather than rebonding the bracket. Note the aligner was fabricated from the patient’s virtual target setup; therefore, no additional scans or setups were required Volume 7 Number 3

corrective tooth movements. Hard copies of the staged models were printed, and a series of aligners to correct the relapse were fabricated. Again, this approach to managing the patient obviated the necessity of taking an additional scan or impression of the patient (Figure 15). In situations in which a substantial amount of relapse has occurred or significant interproximal reduction has been performed during fixed appliance therapy, it is recommended that a new scan be taken. It is difficult to judge and replicate the exact 3D positions of the teeth on the virtual model. A significant amount of interproximal reduction can drastically impact the shape of a tooth, making it difficult to fabricate accurate models and, in turn, aligners. A partial scan representing only the affected teeth may be taken; suresmile can then paste this scan into the original model. This process

Volume 7 Number 3

eliminates the need for a full scan, saving a considerable amount of chairside time.

Conclusions It should be noted that no additional intraoral scans for the patients described above were taken, and the initial target setup was used to design and manufacture the aligners. For clinical situations in which the aligner is used as a removable retainer, or when no more than 10 aligners are required for correcting tooth position, suresmile provides a very viable, cost-effective solution. Additionally, suresmile provides the doctor with enabling technology — specifically, a broad range of bundled diagnostic, communication, and therapeutic tools for total patient management. This bundling of tools avoids the issues associated with using multiple products from different vendors.

Successful care outcomes are driven by the orthodontist’s knowledge, skills, and commitment to excel within a cultural framework that practices the tenets of BioDigital orthodontics: patient-centered care, patient safety, and clinical effectiveness.4 OP

Acknowledgment We very much appreciate Nikita Sachdeva’s invaluable assistance in the editing and preparation of this article.

REFERENCES 1. Sachdeva R. BioDigital orthodontics: Planning care with Suresmile technology: part 1. Orthodontic Practice US. 2013;4(1):18-23. 2. Sachdeva R. BioDigital orthodontics: Designing customized therapeutics and managing patient treatment with Suresmile technology: Part 2. Orthodontic Practice US. 2013;4(2):18-26. 3. Sheridan JJ, LeDoux W, McMinn R. Essix retainers: fabrication and supervision for permanent retention. J Clin Orthod. 1993;27(1):37-45. 4. Sachdeva R. Novus ordo seclorum: a manifesto for practicing quality care - part II. EJCO. 2015;3(1):2-14.

Orthodontic practice 31

ORTHODONTIC CONCEPTS

Figures 15A-15C: Managing minimal posttreatment relapse. 15A. Lower arch showing posttreatment relapse in the anterior region. 15B. A sequence of five aligners were designed to correct the relapse. 15C. Final result

CONTINUING EDUCATION

Airway orthodontics the new paradigm: part 1, addressing the airway Dr. Barry D. Raphael discusses some ways to mitigate predisposing risk factors to airway resistance

wo cardiac surgeons are sitting at lunch discussing the comparative benefits of bypass surgery versus stents for maintaining coronary artery patency when a PCP sitting at the next table rudely interrupts, “Wouldn’t it be better to prevent the obstruction in the first place?” Two sleep docs are sitting at another table discussing the comparative benefits of CPAP versus mandibular advancement devices when the same nosy-body again interrupts, “Wouldn’t it be better to prevent the obstruction in the first place?” The analogy is apt and significant. No one would deny that many of the factors that lead up to a coronary can be addressed by either therapeutic or behavioral interventions and that, certainly, prevention is a far better choice. But there has been an absence of such discussion regarding occlusion of the airway. The purpose of this article is to stimulate such a discussion and to paint, with fairly broad strokes, a picture of what a preventive approach to sleep-disordered breathing would look like.

The etiology and predisposition to breathing disorders during sleep It was once thought that obstructive sleep apnea was a disease of old, fat men. We have since learned that thin, athletic women can also fall victim to this problem. We have learned that while weight and age add to the susceptibility to obstructive sleep disorders, they are not the root causes. Difficulty breathing at night comes from resistance to airflow and there are many circumstances that can make breathing difficult. Efforts at pinpointing the source of resistance are important to determining proper remediation. Barry D. Raphael, DMD, is a practicing orthodontist in Clifton, New Jersey, for over 30 years. His transition to airway-thinking came 25 years into practice, so as he says, “I know what it takes to make the change.” He teaches these concepts at the Mt. Sinai School of Medicine in New York City. He is currently serving as the President of the New Jersey Association of Orthodontists. He is the owner of the Raphael Center for Integrative Orthodontics and the founder of the Raphael Center for Integrative Education.

32 Orthodontic practice

Educational aims and objectives

This article aims to discuss the therapeutic or behavioral interventions that lead to a preventive approach to sleep-disordered breathing.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 37 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify the main determinants of airway resistance. • Realize the importance of airway size. • Realize the resilience of the airway. • Recognize the involvement of the velocity and turbulence of the airflow. • Identify some possible changes in daytime breathing behaviors. • Learn about some airway-related craniofacial dysfunctions.

We have learned from flow physics and airway physiology that there are three main determinants of airway resistance:1 1. Size of the airway 2. Collapsibility of the airway 3. Velocity and turbulence of the airflow Delving into the physics of each is not the point of the article. Instead, the way that each of these factors can be addressed — well before the first apnea ever occurs with either therapeutic or behavioral interventions — will be the goal of this article. By defining opportunities to mitigate predisposing risk factors to airway resistance, we can begin to build a new paradigm in airway and sleep management. As such, the focus will be on prevention so that, just as we might prevent the heart attack, the end-stage disease of obstructive sleep apnea might never occur. From this discussion will emerge a new field of Airway Dentistry and Orthodontics that can define a possible future for the way orthodontics is practiced.

The size of the airway Yes, losing weight and reducing fat deposits in the neck are important, but we also know that craniofacial morphology is a primary risk factor for breathing problems as well.2,3,4,5 Orthodontics has long been concerned with the growth and development of the face with regard to facial profile and the correction of skeletal and dental malocclusion, but has only recently considered its relevance to the formation of the naso-oropharyngeal airway.6 Anatomically,

the maxilla (and the soft palate that hangs off the back of it) and the mandible (with the tongue attached to it) create the anterior boundaries of the airway. Studies have shown how retroposition of the bones relative to the face narrow the airway and create the risk for obstruction.7,8 This is true in both adults and children. Orthopedic treatments in children are now being explored to help enlarge — or at least prevent restriction of — the airway in a more natural and permanent way.9 Most of the focus in orthopedic research has been on palatal expansion, with the purpose of widening the nasal aperture and palate, with equivocal results.10,11 Additionally, studies show that bringing either or both jaws forward with advancement appliances or orthognathic surgery can be effective in opening the airway in the adult.12 We also know helping either jaw grow forward in the child may also be helpful.13 More recent work shows that changing maxillary growth in all three planes of space, including advancement, provide even more promising results.14 Playing off findings in the anthropology literature, the shape of the maxilla has changed dramatically in the modern human. This transformation is associated with a rapid change in the following environmental challenges, all of which have become rampant in today’s world:15 • dietary (high sugar and refined carbohydrate content) • metabolic (autonomic and digestive stressors) Volume 7 Number 3

• cultural (early feeding and weaning habits) • breathing (open mouth and low tongue postures) • postural (forward head and slumped shoulders) • sleep (artificial light and altered sleep cycles) • inflammatory (a changing gut biome) Given the rapidity of the environmental change, purely genetic variations must be ruled out. Epigenetic variations of the bone’s shape, however, indicate that it is changing in width, yes, but also slumping downward and failing to fill out sagitally as well, a condition being called Craniofacial Dystrophy.15 This near universal midface deficiency (no matter the Angle classification of the teeth) has formed a bone with a collapsing palate with insufficient room for the teeth, and that often restricts the forward growth of the mandible hampering proper positioning of the tongue — all of which limit the eventual size of the airway. Helping the jaws grow forward, not just wider, is the ultimate goal. Reversal of midface collapse presents numerous challenges to current orthodontic paradigms that often look to retract teeth and jaws distally, but it also empowers us as well. There has been a thread of thought throughout the historical orthodontic literature supporting the idea that a palate is not just congenitally narrow, but becomes narrow due to habits and practices that occur after conception.16 Altering these habits can begin to heal the dystrophy. If the modern lifestyle can create these changes to the modern face so rapidly (in the past 300-400 years), then human ingenuity can reverse them as well. Originally separately stated by leaders of thought like George Crozat17, Edward Angle, and Alfred Rogers18 in the early part of the last century, modern philosophies of treatment, Volume 7 Number 3

Dr. Raphael with a patient in the activity center

including Crozat, Advanced Lightwire Functionals, Postural Orthodontics, Biobloc Orthotropics, Cranial Osteopathy, and Myofunctional Orthodontics, all seek to reverse the conditions that lead to midface collapse. All these schools of thought have a common goal of reestablishing postural support of the growing maxilla by maintaining the resting tongue on the palate as a scaffold for the growing (and non-growing) bone. The protocols that encourage forward growth of the jaws have all found some measure of success in reducing sleepdisordered breathing.19,20,21 Furthermore, treatments that restrict forward growth or reduce the size of space for the tongue have been shown to reduce airway size and, for purposes of breathing, should be avoided.22 More research in this area is needed, but common sense says that any technique that widens the airway space will be helpful in combating breathing problems.

Resilience of the airway Even a fairly substantial airway can be closed off if the walls cannot withstand the turbulence created by the airflow within it. There are a number of points along the way from the nose to the lungs where soft tissue is apt to give way to the negative pressure. And there are a number of conditions that can decrease the resilience and increase the collapsibility of these tissues — all of which are reversible to some extent. 1. Swelling of lymphoid tissue is perhaps the most commonly recognized problem.23 Tonsils and adenoids are currently thought of as the predominant risk factor for sleep-disordered breathing in children. The American Academy of Pediatrics has recently stated that surgical removal of lymphoid tissue can be considered a first line of treatment in obstructive sleep apnea.24 But one question that is rarely asked is, Why do lymphoid tissues get so swollen as

to block the airway? While they are known to be more active in a young growing child, their enlargement, like the collapsed palate, is not a congenital given. Efforts to reduce the swelling can sometimes dramatically open the airway and may reduce the need for surgery. Some of the methods used to reduce lymphoid swelling include: 1. A transition from mouth breathing — which allows unfiltered air to irritate the tonsils — to nasal breathing — which filters and conditions the air before it gets to the lymph tissue — can reduce swelling within weeks; 2. Improvements in body posture and muscular movement, as with regular exercise, can also help lymph tissue drain adequately; 3. A transition from accessory muscle use to proper use of the diaphragm for breathing also helps lymphatic circulation; 4. Nasal lavage to keep sinuses open and airway walls clean can help; 5. Massage and bodywork can help lymphatic circulation; 6. Acupuncture and homeopathic remedies that encourage drainage of lymph tissue throughout the body; 7. The use of ozone and ozonated water injected into the swollen tissue has been shown to reduce lymph swelling; 8. Short-term use of nasal steroids and decongestions as a good head-start are helpful. Certainly, it’s better to try to shrink swollen lymph tissues as a preliminary approach. The frequent recurrences seen after surgical removal are probably linked to a failure to incorporate some of the above conservative measures post-surgically, especially continued oral breathing. This makes a conservative approach all the more important Orthodontic practice 33

CONTINUING EDUCATION

Myofunctional therapy

CONTINUING EDUCATION as a first line of defense as it has to be done even when the tissues are removed. 2. Poor muscle tone is also associated with blockage of the airway. Certainly the tongue falling back into the oral cavity at night is well recognized as a risk factor for sleep-disordered breathing. But welltoned extrinsic and intrinsic glossal muscles resist backward displacement. The use of myofunctional therapy, with specific exercises for creating better muscular balance of the pharyngeal musculature, has been shown to be helpful in reducing airway collapse at night and deserves more attention in this field.25 Even learning to play the Australian didgeridoo has been shown to be helpful in reducing pharyngeal collapse at night.26 3. Chronic inflammation of pharyngeal tissues makes them less able to resist negative pressure due to loss of elasticity. The constant trauma to the tissues of the flapping of snoring only serves to irritate, elongate, and soften pharyngeal tissues and the soft palate. Chronic assault by stomach acid from gastric or laryngeal reflux is another source of inflammation that needs to be addressed. The cause of reflux itself can be addressed by changes in breathing mode (i.e., nasal breathing) and posture, too, thereby reducing reliance on protein pump inhibitors that have their own side effects. Finally, honing in on foods — some natural, some not — that instigate inflammation or a disturb the natural flora in the gut and supplanting them with healthier choices can change the condition of the airway as well as the rest of the body.

Velocity and turbulence of the airflow Though the way air flows through the breathing space has been tested and studied, and recognition of air pressure changes within the pharynx and within the thoracic cavity has been given due consideration, little attention has been paid to the behaviors that actually create these negative pressure conditions. In fact, some theorize that it is not the nighttime breathing that creates the biggest problem, but the daytime habits of breathing that set up the circumstances for airway collapse at night.27 These conditions include habitual overbreathing in response to the many chronic stressors that we encounter each day. Our autonomic nervous system is constantly activated without a chance for recuperation, setting in motion a cascade of events that result in, among many other things, rapid 34 Orthodontic practice

Patient receiving trainer

Craniofacial therapy

shallow breathing with tidal volumes nearly three times what is necessary for efficient oxygenation — in other words: chronic hyperventilation. It is said that over-breathing is just as dangerous to health as overeating. Chronic hyperventilation, especially with the large portal of an open mouth, shifts the balance between oxygen and carbon dioxide in the lungs and in the blood. Chronic hypocapnia is a common condition in mouth breathers and can result in reduced oxygenation of tissues (the Bohr effect) and increased smooth muscle spasm (think vessels and organs). The symptoms from these two phenomena alone are quite diverse, affecting the vasculature (hypertension, venous pooling); organs (enuresis, digestive issues); tubes (asthma, reflux, xerostomia); and tissue perfusion (neurocognitive deficits such as attention, memory and learning, anxiety, and muscle fatigue and spasm). And, oh yes, apnea. Heavy breathing at night pulls air through the pharynx rapidly, creating increased turbulence and negative pressure. This can compromise an otherwise healthy system (e.g., snoring only when you get intoxicated). Combine that with small airway size and increased collapsibility, and you have the perfect internal storm — a hurricane in a box, if you will. Some think that central sleep apnea is nothing more than the body’s respiratory mechanism taking a pause to restore proper carbon dioxide levels and maintain homeostasis. While this thinking seems to be in direct opposition to the commonly held view that sleep-disordered breathing is a problem of hypoventilation and hypercapnia, a change in daytime breathing mode — again, from oral to light nasal breathing — can alter nighttime distress almost immediately in some patients.28 In fact, the relationship between daytime breathing habits and nighttime distress is so strong, the syndrome should be called breathing-disordered sleep instead of sleep-disordered breathing.

Adopting new changes in daytime breathing behaviors should be the first line of defense in the treatment of breathingdisordered sleep. Simple breathing training includes: 1. Nasal breathing primarily, even during activity if possible; 2. Reduction of tidal volume by reducing breathing rate and depth; 3. Use of the diaphragm for powering inspiration. Biofeedback techniques are especially helpful in retraining daytime breathing. Once the body can accommodate to this new breathing mode, there is often no longer such a struggle at night. And at very least, modalities like CPAP and MADs can become more tolerable.

Airway-related craniofacial dysfunctions: a change in paradigm Besides sleep apnea, there are a host of refractory conditions that dentistry has been struggling with that are now being looked upon as airway-related craniofacial dysfunctions (ACDs). They include: 1. Chronic naso-pharyngeal obstruction (physical or functional)29 2. Tethered oral tissues (lip-tie and tongue-tie)30 3. Open mouth rest posture (with the tongue off the palate)31 4. Myofunctional disorders (swallowing, chewing, etc.)32 5. Chronic hyperventilation and hypocapnia33 6. Breathing-disordered sleep (OSA, UARS, snoring)34 7. Bruxism, parafunctions, and dental deterioration35 8. TMD and facial pain components36 9. Cranial and postural issues37 10. Craniofacial dystrophy with malocclusion38 Each topic deserves its own discussion, but putting them under the umbrella of airway dysfunctions seems to have answered a lot Volume 7 Number 3

CONTINUING EDUCATION

of challenging questions for practitioners in all disciplines. In fact, once you see the relationship, it’s hard to see how we ever thought otherwise.

Airway orthodontics: a change in protocol Putting these concepts into practice will be the next great challenge of the 21st century for orthodontics. Developing the protocols that will engender an understanding of the need for behavior change in our patients and creating the settings in which to support these changes are what we need to begin to do now. There are five domains in which airway orthodontics must create innovative, and even disruptive (in the business sense), solutions: Dr. Raphael assessing a patient

1. Assessment Looking at how once unclear symptoms are related to the need to breathe and achieve homeostasis will allow us to catch a system that is headed off course much earlier than any other sleep screening currently does. 2. Prevention When should treatment begin? As soon as the habits that create poor facial growth are discovered. This may begin before birth, at birth, in infancy, or whenever any airway-related problem begins. Many ancient cultures were well aware to never let their young leave their lips apart at rest. Breastfeeding is best feeding since it creates mechanical stimulation of growing bones. Tongues must not be tethered. Children need to chew real food. Noses must be kept patent. And that is just the starting point. 3. Mitigation By the time a person gets to OSA, it may be too late to do much but treat symptoms. But whenever damage from bad habits has been discovered, all attempts to reverse this damage should be made, and certainly, nothing should be done that would worsen or even perpetuate the damage (e.g, reducing or maintaining inadequate tongue space).39 4. Habit training It’s not easy. I will never say it’s easy. Or quick. Or certain. But if nothing changes in a person’s actions, nothing will change in a person’s health. There are no pills, no shots, no surgeries, no compliance-free appliances, and no shortcuts. Breathe right. Eat right. Sleep right. Be right. Volume 7 Number 3

5. Interdisciplinary collaboration The need to collaborate can be seen as another obstacle for what is now a solo practice. No one practitioner can handle all the etiologies patients may bring with them. As the Chinese say, “One disease, a thousand treatments … one treatment, a thousand diseases.” Such is the lot when looking at the whole person. A specialist may be able to reduce a person into small segments with isolated diseases and treat just those. But to create wellness, a variety of approaches may be necessary, requiring input from a variety of practitioners. The health and wellness center of today may be the best mode of practicing airway orthodontics for the future. And, by the way, while corporations are gobbling up practices and practitioners, this may also be the way to maintain some autonomy in our profession. By returning to the concept of orthodontist as a physician of the face, we open a new realm of possibilities. The orthodontic practice of the future will include, in either one place or many: 1. The airway-aware orthodontist 2. Health educator (who knows myofunctional therapy, breathing and postural training, nutrition, lactation for the very young, and maybe some bodywork) 3. Sleep/ENT/pulmonologist/allergist MD 4. Cranial osteopath or physical therapist who manages the craniofacial skeleton 5. Other auxiliaries in child development and wellness care In this practice, there will be ample time set aside for talking with the patient/parent, for collaborative treatment planning, and

Activity window

for follow-up care. The environment will be conducive to learning as well as therapy. And finally, it will be a place where patients can get preventive, holistic, and allopathic care.

The goals of airway orthodontics Here it is, for young and old, in a nutshell: 1. Breathe gently through the nose, using the diaphragm at all times. 2. Keep the lips together when not talking or eating. 3. Keep the tongue on the palate at rest. 4. Swallow without using the facial or cervical muscles. 5. Balance yourself well against gravity. (Sit and stand straight!) 6. Eat to nourish (with foods your body appreciates). 7. Sleep to rejuvenate.

The future of orthodontics The current gold standard treatment — if gold is the appropriate color — for obstructive sleep apnea is to artificially pry open the airway at night with air, plastic, or scalpel. Perhaps someday we’ll have Swarovskistudded tracheostomy plugs for a more perfect (read: fashionable and quick) solution. But if you look at the progression leading up to obstruction, there are many, many opportunities to intervene, to change the trajectory of the disease, and to increase the quality of life. By helping the airway to grow Orthodontic practice 35

CONTINUING EDUCATION larger (size), keeping the airway physically fit (resilience), and optimizing the airway’s use (flow), the problem can be, at worst, delayed and, at best, avoided. While opportunities to mitigate the progression of airway dysfunction from birth to sleep apnea are plentiful, there are three large challenges to overcome — all of which are common to medicine and dentistry: 1. Preventive medicine lacks the urgency most people need to create the behavior changes that create optimal health. Symptomatic treatment engenders changes but only so long as the symptoms last. Education and understanding are the only way to get people to change. Look how much we changed once we understood how the tobacco industry was victimizing us. Perhaps the same will happen for sugar soon. And then for sleep. 2. While reducing treatment to its most simplistic outcome (i.e., prying the airway open or Class I occlusion) makes good business sense, this REFERENCES 1. Chandra RK, Patadia MO, Raviv J. Diagnosis of nasal airway obstruction. Otolaryngol Clin N Am. 2009;42(2): 207–225. 2. Aihara K, Oga T, Harada Y, Chihara Y, Handa T, Tanizawa K, Watanabe K, Hitomi T, Tsuboi T, Mishima M, Chin K. Analysis of anatomical and functional determinants of obstructive sleep apnea. Sleep Breath. 2012; Jun;16(2):473-481. 3. Dempsey JA, Skatrud JB, Jacques AJ, Ewanowski SJ, Woodson BT, Hanson PR, Goodman B. Anatomic determinants of sleep-disordered breathing across the spectrum of clinical and nonclinical male subjects. Chest. 2002;122(3):840-851. 4. Lowe AA, Santamaria JD, Fleetham JA, Price C. Facial morphology and obstructive sleep apnea. Am J Orthod Dentofacial Orthop. 1986;90(6): 484-491. 5. Ikävalko T, Tuomilehto H, Pahkala R, Tompuri T, Laitinen T, Myllykangas R, Vierola A, Lindi V, Närhi M, Lakka TA. Craniofacial morphology but not excess body fat is associated with risk of having sleep-disordered breathing—The PANIC Study (a questionnaire-based inquiry in 6–8-year olds). Eur J Pediatr. 2012;171(12):1747–1752. 6. Carlyle TD, Chmura L, Damon P, Diers N, Paquette D, Quintero JC, Redmond WR, Thomas B. Orthodontic strategies for sleep apnea. Orthodontic Products. April/May 2014;21(3): 92-101. http://www.orthodonticproductsonline.com/2014/04/orthodontic-strategies-sleep-apnea/. Accessed April 13, 2016. 7. Dempsey JA, Skatrud JB, Jacques AJ, Ewanowski SJ, Woodson BT, Hanson PR, Goodman B. Anatomic determinants of sleep-disordered breathing across the spectrum of clinical and nonclinical male subjects. Chest. 2002;122(3):840-851. 8. Katyal V, Pamula Y, Martin AJ, Daynes CN, Kennedy JD, Sampson WJ. Craniofacial and upper airway morphology in pediatric sleep-disordered breathing: Systematic review and meta-analysis. Am J Orthod Dentofacial Orthop. 2013;Jan;143(1):20-30. 9. Singh GD, Garcia-Motta AV, Hang WM. Evaluation of the posterior airway space following Biobloc therapy: geometric morphometrics. Cranio. 2007;25(2): 84-89. 10. Rose E, Schessl J. Orthodontic procedures in the treatment of OSA in children, J Orofac Orthop. 2006,67(1):58-67. 11. Ruoff CM, Guilleminault C. Orthodontics and sleep-disordered breathing. Sleep Breath. 2012;16(2)2:271-273. 12. Holty JE, Guilleminault C. Maxillomandibular advancement for the treatment of obstructive sleep apnea: a systematic review and meta-analysis. Sleep Med Rev. 2010;14(5):287–297. 13. Kaygisiz E, Tuncer BB, Yüksel S, Tuncer C, Yildiz C. Effects

36 Orthodontic practice

reductionist practice — as well as reductionist research that supports it — distracts us from dealing with the bigger picture.40 We must pay equal attention to “holistic” aspects of the human, with all its variables and vagaries. While this approach may require a change in thinking, in our education, and in our practice, we have to pay attention to the child attached to the teeth as much as the teeth attached to the child. 3. Results will necessarily be subject to a bell curve, as it is with any educational system. Though most

Braces-off celebration of maxillary protraction and fixed appliance therapy on the pharyngeal airway. Angle Orthod. 2009;79(4):660-667. 14. Singh GD, Garcia-Motta AV, Hang WM. Evaluation of the posterior airway space following Biobloc therapy: geometric morphometrics. Cranio. 2007;25(2): 84-89. 15. Boyd, K. Darwinian Dentistry: an evolutionary perspective on the etiology of malocclusion, part 1. Journal of the American Orthodontic Society. Nov/Dec 2011: 34-39. 16. Mew, M. Craniofacial dystrophy: a possible syndrome? Br Dent J. 2014;216(10):555-558. 17. Rogers, AP. Stimulating arch development by the exercise of the masseter-temporal group of muscles. Am J. Orthod Dentofacial Orthop. (originally in The International Journal of Orthodontia, Oral Surgery and Radiography.) 1922; 8(2):61-64. 18. Crozat, George. The Crozat Philosophy of Treatment, Monograph, New Orleans, 1-8. 19. Rogers, AP. Stimulating arch development by the exercise of the masseter-temporal group of muscles. Am J. Orthod Dentofacial Orthop. (originally in The International Journal of Orthodontia, Oral Surgery and Radiography.) 1922; 8(2):61-64. 20. Oktay H, Ulukaya E. Maxillary Protraction Appliance Effect on the Size of the Upper Airway Passage, Angle Orthod. 2008; 78(2):209-214. 21. Singh GD, Garcia-Motta AV, Hang WM. Evaluation of the posterior airway space following Biobloc therapy: geometric morphometrics. Cranio. 2007;25(2): 84-89. 22. Villa MP, Bernkopf E, Pagani J, Broia V, Montesano M, Ronchetti R. Randomized controlled study of an oral jawpositioning appliance for the treatment of obstructive sleep apnea in children with malocclusion. Am J Respir Crit Care Med. 2002;165(1):123-127. 23. Wang Q, Jia P, Anderson NK, Wang L, Lin J. Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of Class I bimaxillary protrusion, Angle Orthod. 2012;82(1):115-121. 24. Li AM, Wong E, Kew J, Hui S, Fok TF. Use of tonsil size in the evaluation of obstructive sleep apnea, Arch Dis Child. 2002;87(2):156-159. 25. 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):3714-755. 26. Pitta DBeS, Pessoa AF, Sampaio ALL, Rodrigues RN, Tavares MG, Tavares P, et al. Oral Myofunctional therapy applied on two cases of severe obstructive sleep apnea syndrome. Int Arch Otorhinolaryngol. 2007;11(3):350-354.

orthodontists are trained to strive for “perfect,” we will have to learn to settle for, as does medicine, and live with “better” as a standard of care. One might even argue that the health of the airway takes precedence over the occlusal schema, or, heaven forbid, esthetics, should a choice have to be made. This is a real shift in priorities. In recent years, the orthodontic profession has been arguing about the relative benefits of early orthodontic treatment asking, “Is the benefit worth the burden?”41 One could ask the same question about the effort needed to prevent heart disease. Yet, today, fitness centers and whole foods establishments are becoming mainstream in our society answering that question by popular demand. Perhaps in days soon to come, there will be similar outcry looking for better sleep and breathing as well. OP Part 2 of Dr. Raphael's article, “Airway orthodontics the new paradigm: part 2, addressing malocclusion and facial growth,” will be published in the July/August issue.

27. Puhan MA, Suarez A, Lo Cascio C, Zahn A, Heitz M, Braendli O. Didgeridoo playing as alternative treatment for obstructive sleep apnoea syndrome: randomized controlled trial. BMJ. 2006;332(7536):266-270. 28. Litchfield, PM. Respiratory fitness and acid-base regulation. Psychophysiology Today. 2010; 7(1): 6-12. http:// betterphysiology.com/download/softwareupdates/Respiratory%20Fitness%202010%20Litchfield2.pdf. Accessed April 13, 2016. 29. Birch M. Sleep apnoea: a survey of breathing retraining. Aust Nurs J. 2012;20(4):40-41. 30. Chandra RK, Patadia MO, Raviv J. Diagnosis of nasal airway obstruction. Otolaryngol Clin North Am.2009; 42(2):207–225. 31. Kotlow L. infant reflux and aerophagia associated with the maxillary lip-tie and ankyloglossia (tongue-tie). Clinical Lactation. 2011;2(4):25-29. 32. Mew, M. Craniofacial dystrophy: a possible syndrome? Br Dent J. 2014;216(10):555-558. 33. 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. 34. Ritz T, Meuret AE, Wilhelm FH, Roth WT. Changes in pCO2, symptoms, and lung function of asthma patients during capnometry-assisted breathing training. Appl Psychophysiol Biofeedback. 2009;34(1):1–6. 35. Litchfield, PM. Respiratory fitness and acid-base regulation. Psychophysiology Today. 2010; 7(1): 6-12. http:// betterphysiology.com/download/softwareupdates/Respiratory%20Fitness%202010%20Litchfield2.pdf. Accessed April 13, 2016. 36. Hosoya H, Kitaura H, Hashimoto T, Ito M, Kinbara M, Deguchi T, Irokawa T, Ohisa N, Ogawa H, Takano-Yamamoto T. Relationship between sleep bruxism and sleep respiratory events in patients with obstructive sleep apnea syndrome. Sleep Breathe. 2014;18(4):837-844. 37. Gelb ML. Airway centric TMJ philosophy. J Calif Dent Assoc. 2014;4(8): 551- 562. 38. James GA, Strokon D . an introduction to cranial movement and orthodontics. Int J Orthod Milwaukee. 2005;16(1):23-26. 39. Mew, M. Craniofacial dystrophy: a possible syndrome? Br Dent J. 2014;216(10):555-558. 40. Huang YS, Guilleminault C. Pediatric obstructive sleep apnea and the critical role of oral-facial growth: evidences. Front Neurol. 2013;Jan 22(3):184. 41. Campbell C, Jacobson H. Whole: Rethinking the Science of Nutrition. Dallas, Texas: BenBella Books; 2013. 42. McNamara J, ed. Early orthodontic treatment: is the benefit worth the burden? U. Michigan Press, 2007.

Volume 7 Number 3

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Airway orthodontics the new paradigm: part 1, addressing the airway RAPHAEL

1. Losing weight and reducing fat deposits in the neck are important, but we also know that ___________ is a primary risk factor for breathing problems as well. a. nasal breathing b. craniofacial morphology c. diaphragmatic breathing d. use of ozonated water 2. Orthodontics has long been concerned with the growth and development of the face with regard to facial profile and the correction of skeletal and dental malocclusion, but has only recently considered its relevance to the formation of the _________. a. naso-oropharyngeal airway b. larynx c. sinus cavity d. tongue position 3. Orthopedic treatments in children are now being explored to help enlarge — or at least

Volume 7 Number 3

prevent restriction of — the airway in a _____ way. a. more natural b. more permanent c. more surgical d. both a and b 4. Epigenetic variations of the bone’s shape, however, indicate that it is changing in width, yes, but also slumping downward and failing to fill out sagitally as well, a condition being called _________. a. Myasthenia Gravis b. Craniofacial Dystrophy c. Hypoglossal Dystrophy d. Myotonic Dystrophy 5. The American Academy of Pediatrics has recently stated that surgical removal of lymphoid tissue can be considered a(n) ______ obstructive sleep apnea. a. first line of treatment in b. last resort of treatment in c. outdated treatment for d. overused diagnosis for

6. The use of __________, with specific exercises for creating better muscular balance of the pharyngeal musculature, has been shown to be helpful in reducing airway collapse at night and deserves more attention in this field. a. CPAP machines b. maxillomandibular expansion/advancement c. myofunctional therapy d. Lefort advancement 7. The constant trauma to the tissues of the flapping of snoring only serves to _____ pharyngeal tissues and the soft palate. a. irritate b. elongate c. soften d. all of the above 8. ______, especially with the large portal of an open mouth, shifts the balance between oxygen and carbon dioxide in the lungs and in the blood.

a. Snoring b. Laryngeal reflux c. Chronic hyperventilation d. Sore throat 9. In fact, the relationship between ______ and nighttime distress is so strong, the syndrome should be called breathing-disordered sleep instead of sleep-disordered breathing. a. CPAP b. tongue thrust c. daytime breathing habits d. tonsillar inflammation 10. By _________, the problem can be, at worst, delayed and, at best, avoided. a. helping the airway to grow larger (size) b. keeping the airway physically fit (resilience) c. optimizing the airway’s use (flow) d. all of the above

Orthodontic practice 37

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ORTHODONTIC PRACTICE CE

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Orthodontic and surgical diagnosis and management of OSA — case presentations: part 2 Drs. John W. Stockstill, Joseph E. Cillo, and Stevan H. Thompson review some diagnostic and treatment strategies for obstructive sleep apnea (OSA) in adolescent and adult patients Introduction 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.1 The same is true for treatment strategies, especially when utilizing reversible techniques such as oral appliances (OA) and irreversible techniques, including orthognathic surgery and MME (maxillomandibular advancement/expansion) for OSA-related problems. The intent of this article is to review EB diagnostic and treatment strategies in cases requiring treatment other than OAs for obstructive sleep apnea (OSA) in adolescent and adult patients seen in the orthodontic office and to present appropriate patient cases illustrating some of these treatment options.

How is OSA best diagnosed? Management of OSA is a multidisciplinary effort utilizing a number of treatment modalities such as: • Continuous positive airway pressure — nasal or oral (CPAP) • Behavior modification (dietary modifications, smoking cessation, weight loss, and exercise, for example) • Maxillomandibular surgical expansion/advancement (MME) • Oral appliances (OA) 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. Joseph E. Cillo, Jr., DMD, MPH, PhD, is Assistant Professor and Program Director — Division of Oral & Maxillofacial Surgery at Allegheny General Hospital in Pittsburgh, Pennsylvania. Stevan H. Thompson, DDS, is Clinical Assistant Professor, Division Director — Oral-Maxillofacial Surgery at East Carolina University School of Dental Medicine in Greenville, North Carolina. He is board certified by the American Board of Oral and Maxillofacial Surgery and the American Board of Oral and Maxillofacial Pathology.

38 Orthodontic practice

Educational aims and objectives

This article aims to discuss diagnostic and treatment strategies for obstructive sleep apnea (OSA) in adolescent and adult patients.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 45 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify a number of treatment modalities for the diagnosis and management of OSA. • Recognize some evidence-based guidelines used in the classification of airway problems. • Realize some types of treatment used to stabilize and manage OSA. • Identify some orthognathic procedures for the resolution of skeletal/dental and obstructive sleep apnea conditions.

• Polysomnography (sleep study — PSG), conducted either in medical facilities such as “sleep centers” or a home study utilizing a portable polysomnography unit, is the “gold standard” for reliably and accurately diagnosing OSA. A number of physical measurements are made during polysomnography, including indices for apnea (the complete cessation of airflow for at least 10 seconds — classified as obstructive, central, or mixed based on whether effort to breathe is present during the event) and hypopnea (a reduction in airflow that is followed by an arousal from sleep or a decrease in oxyhemoglobin saturation).2 This Apnea/Hypopnea Index (AHI) is commonly used to help identify which modality of treatment may be best for each patient. (See Section 2.) Furthermore, appropriate imaging of the oropharyngeal and nasopharyngeal areas in patients reporting sleep-related breathing disorders is used to assist the clinician in making the most appropriate and evidencebased decision for that patient’s treatment. In the past, two-dimensional imaging was used to assist the clinician in documenting airway architecture. With the advent of three-dimensional imaging, such as cone beam computerized tomography (CBCT), a more appropriate three-dimensional volumetric analysis can be made, yielding a more precise description of airway architecture.3-5 As part of the diagnostic work-up involving patients reporting with OSA as a chief or secondary complaint, the orthodontic

comprehensive records protocol is followed as a means of closely identifying dental, skeletal, and soft tissue relationships that may be involved in any combination orthodontic/ surgical treatment. That is, when patients are identified as being in need of orthodontic/ orthognathic management of their complaint, a very comprehensive records work-up is carried out. This records appointment consists of evaluation of the temporomandibular joints and related orofacial and cervical musculature, photos, intraoral and extraoral head and neck evaluation, dental models (either poured in plaster or digitized), and appropriate imaging. While CBCT imaging is not recommended for all orthodontic patients during their records appointment, patients designated as possibly being in need of orthodontic and surgical correction of their chief complaint (including those who may undergo MME or bilateral sagittal split osteotomy of the mandible [BSSO] procedures) should have CBCT imaging done in order to assist the orthodontist and surgeon in making the most appropriate treatment decisions. Additionally, the CBCT will assist the maxillofacial surgeon in carrying out model surgery prior to the actual surgery, thus allowing the orthodontist and surgeon to more clearly and appropriately plan the phases and timing of treatment. In other words, “The advent of the cone beam computed tomography (CBCT) allows the acquisition of 3D images of the patient’s craniofacial complex and eliminates the ambiguity that can occur with two-dimensional (2D) images.”6 Volume 7 Number 3

Guidelines and recommendations for the implementation of each of these treatment options have been published and are reviewed in part 1 of this publication.1 To review, 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.7,8 Based upon the objective assessment of the patient’s sleep studies and imaging, other modalities of treatment are recommended based upon the severity of the problem. For example, CPAP is recommended for those patients having moderate (> 15 but < 30 episodes/ hour) to severe (> 30 episodes per hour) AHI scores. If patients are unable to tolerate CPAP use or if their AHI scores have not been decreased to acceptable levels on follow-up sleep studies, surgical procedures may be recommended. These include mandibular advancement alone or maxillomandibular expansion/advancement (MME). These procedures are often used in severe skeletal problems encountered by the orthodontist, including severe mandibular retrognathia, severe maxillomandibular retrognathia, and midface discrepancy problems as a result of syndromic involvement. As in any skeletal advancement, surgical procedures are carried out in conjunction with orthodontic management of the patient since a surgical skeletal advancement in the absence of orthodontic involvement would result in instability of the case and, likely, relapse of any correction.

It is important to note that the fabrication and delivery of oral appliances should follow the referring physician’s assessment of the PSG sleep study. These same OAs may be used to treat self-reported snoring, but they are not intended to treat undiagnosed or undocumented OSA. For OSA, “fabrication follows diagnosis and documentation.”7,8 Guidelines for and definition of an effective oral appliance for the treatment of OSA and snoring are listed in Table 1.

Figure 1: Tongue-retaining appliance. (Lazard DS, Blumen M, Lévy P, Chauvin P, Fragny D, Buchet I, Chabolle F. The tongueretaining device: efficacy and side effects in obstructive sleep apnea syndrome. J Clin Sleep Med. 2009;5(5):431-438.)

Table 1: Guidelines for and definition of an effective oral appliance for the treatment of obstructive sleep apnea and snoring

1. Treat obstructive sleep apnea (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. Indicated for patients with mild to moderate OSA and primary snoring. 5. Treatment for patients with severe OSA who do not respond to or are unable or unwilling to tolerate positive airway pressure (PAP) therapies. 6. An adjunct to PAP therapy and/or other treatment modalities for the management of OSA. 7. OA mandibular advancement devices are the most effective and widely used in clinical practice.

Source: American Academy of Dental Sleep Medicine, 2014.

Figure 2: Mandibular Advancement Appliance — Custom-made oral appliances are proven to be more effective than overthe-counter devices, which are not recommended as a screening tool or as a therapeutic option. (AOA Specialty Laboratory)

What types of treatment are used to stabilize and manage OSA? Oral appliances 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. Tongueretention appliances are designed for both arches (discussed previously) if tongue retention is desired while protrusively repositioning the mandible.9 As previously mentioned, 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 (moderate). Volume 7 Number 3

Figure 3: Algorithm of oral appliance. (Adult obstructive sleep apnea task force for 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.) Orthodontic practice 39

CONTINUING EDUCATION

What evidence-based guidelines are used in the classification of airway problems?

CONTINUING EDUCATION Continuous positive airway pressure (CPAP) CPAP is a mechanical device that applies mild air pressure in order to keep the airways open. CPAP typically is used by patients who have breathing problems, such as sleep apnea, but may also be used in preterm infants whose lungs have not fully developed and are diagnosed with respiratory distress syndrome or bronchopulmonary dysplasia.10 It consists of a mask or other device that fits over the nose or nose and mouth with straps to keep the mask in place while it is being worn. A tube connects the oral or nasal mask to a positive air pressure pump. The CPAP mask is worn only during sleep. 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.7 Surgical procedures MME (maxillomandibular expansion/ advancement) is indicated for surgical treatment of patients with severe OSA who cannot tolerate or who are unwilling to adhere to positive airway pressure therapy, or for whom oral appliances, which are more often appropriate in mild and moderate OSA patients, have been considered and found ineffective or undesirable.1 Surgical procedures may include single jaw advancement (either bilateral sagittal split osteotomy advancement or Lefort I maxillary advancement) in combination with orthodontic treatment, two-jaw surgeries carried out in the threedimensional correction of skeletal/dental problems and OSA problems, and surgical augmentation (genioglossus advancement) to enhance and improve airway architecture and breathing. A number of different genioglossus advancement procedures are described in the surgical literature. Surgical treatment of sleep apnea is a key component of board certification for American oral and maxillofacial surgeons, and is therefore a core component of resident education throughout their training. Oral and maxillofacial surgeons are highly experienced in the diagnosis and surgical management of skeletal and soft tissue disproportion in the face and neck. These principles and surgical techniques have been demonstrated to be effective in modifying anatomic abnormalities that contribute to narrowing or obstruction of the airway at multiple levels.15-19 For example, maxillomandibular expansion/advancement (MME) surgery can address anatomic abnormalities in all the anatomic regions of the 40 Orthodontic practice

Figure 4: CPAP (continuous positive air pressure): oral, nasal, full face. (Cpaplus.com; Americarecpap.com; En.wikipedia.org; Ionmysleep.com)

Figure 5: Surgical algorithm. (Adult obstructive sleep apnea task force for 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.)

head and neck; only tracheostomy is more comprehensive. MME surgery and distraction osteogenesis can have a direct or indirect effect on the nasal valve, nasal septum, nasal turbinates, palate, tongue, tonsillar pillar region, hyoid bone, and pharynx. Maxillomandibular advancement as a primary or secondary treatment is a successful, safe, single-stage surgical intervention for clinically significant OSA with a therapeutic efficacy comparable to nasal CPAP and other surgical procedures.18,19 Oral and maxillofacial surgeons are uniquely qualified to provide this safe and effective option and should be a part of any comprehensive, multidisciplinary sleep disorder team.12 Following are orthodontic/oral-maxillofacial surgery case presentations demonstrating mandibular advancement procedures,

including distraction osteogenesis and MME in the treatment of skeletal deficiencies accompanied by airway problems.

Conclusion Orthodontics and oral/maxillofacial surgery play a key role in the appropriate and 3 x 3 dimensional diagnosis and management of obstructive sleep apnea and airway obstruction conditions. Advanced 3D imaging is the current â&#x20AC;&#x153;gold standardâ&#x20AC;? of imaging the posterior airway in the diagnosis of OSA, and is also utilized in the pre-surgical model planning for surgical correction of skeletal deficiencies contributing to airway problems. Evidence-based guidelines for the use of oral appliances, continuous positive airway pressure devices, and surgical procedures are presented within this text. Volume 7 Number 3

Case 1 A 15:6 year-old female presents with A 15:6 year-old female presented with a chief complaint of “I don’t like my smile and crooked teeth.” Clinical findings included Class II

Figure 6

Figure 7: 2D airway image

Figure 9: Treatment outcome Volume 7 Number 3

Division 1 dental relationship, excessive overjet exaggerated by missing mandibular lateral incisors, bilateral posterior crossbite, transverse constriction in palate, mandibular retrognathia, excessive dental crowding, and OSA “characteristics,” including upper airway constriction and medical history of chronic upper airway disorders. Comprehensive orthodontic records were initially taken, including maxillary and mandibular models, panoramic and cephalometric X-rays, periodontal probing and recordings, photos, and a comprehensive craniofacial intraoral and extraoral examination. Consultation was carried out with an oral and maxillofacial surgeon regarding the listed skeletal and dental problems — specifically, the patient’s significant mandibular retrognathia and maxillary transverse deficiency. Following a thorough review of her dental and medical records, a preliminary treatment

decision was made, including comprehensive orthodontic treatment in combination with a LeFort 1 maxillary procedure and bilateral sagittal split osteotomy to resolve her mandibular retrognathia and severe maxillary/mandibular disharmony. Comprehensive orthodontic treatment was initiated. Leveling and alignment and appropriate space management were carried out over an 18-month period in tandem with periodic OMS consults as to tooth positioning for appropriate surgical involvement. Following appropriate arch form development and creation of spaces for surgical access, the patient underwent a LeFort 1 maxillary procedure in combination with a bilateral sagittal split osteotomy (BSSO) procedure. Post-surgically, she was seen for routine orthodontic visits following her release from OMS care, and her case was completed after an additional 8 months of orthodontic treatment.

Figure 8: Pretreatment cephalometric values

Figure 10: Surgical Mandibular Advancement (following nonsurgical palatal expansion) Orthodontic practice 41

CONTINUING EDUCATION

Orthognathic procedures for the resolution of skeletal/dental and obstructive sleep apnea conditions — case presentations

CONTINUING EDUCATION Posttreatment outcomes Posttreatment orthodontic records revealed an improvement in her skeletal Class II condition and mandibular

Figure 11: Post-surgical ceph

Case 2 Surgical intervention â&#x20AC;&#x201D; distraction osteogenesis in OSA case Surgical interventions have been considered a last resort and reserved for patients who have not responded to nonsurgical therapies. Surgical therapies are more effective in those patients with severe problems when they are tailored to addressing the anatomic obstruction problems patients have with detailed specificity. Success is predicated on precisely locating the soft tissue airway obstruction. The nasal anatomy,

retrognathia with improvement in overjet and overbite, facial profile, resolution of palatal transverse constriction, resolution of dental crowding, and improvement in

facial esthetics. Subjective improvement in airway characteristics and related behavioral characteristics were also noted and reported.

Figure 12: Post-surgical cephalometric values

oropharynx-tonsillo-adenoid-lateral pharyngeal pillar region, and tongue base-retrolingual-hyoid complex region must be carefully evaluated. Maxillofacial surgery is recommended for patients that have hypopharyngeal collapse. Pretreatment clinical exam and imaging that allow analysis of the bony and soft tissue abnormalities at multiple sites is mandatory. The velo-oro-hypopharyngeal airway can be enlarged by advancing the pharyngeal tissues that are attached to the maxilla, mandible, and hyoid bone. Maxillomandibular advancement (MMA) has been

shown to produce consistent and significant reductions in the AHI. For severe AHI problems, MMA using distraction techniques can afford increased movement of the maxillomandibular complex and improvements in the volume of the velo-oro-hypopharyngeal airway. Distraction can result in detrimental alterations of the cranial and facial architectural balance depending on the degree of distraction. MMA surgery can affect the nasal valve, nasal septum, nasal turbinates, palate, tongue pillar region, hyoid bone, and pharynx.

Figure 13: Case 2. Notice the 2D airway A-P improvement 42 Orthodontic practice

Volume 7 Number 3

for the surgical correction of his severe OSA. A medical-grade CT scan was obtained according to the Medical Modeling protocol.14 The information from the CT scan was uploaded to the Medical Modeling website. Maxillary and mandibular occlusal models were obtained. These were set into the final desired occlusion and sent to Medical Modeling, and Virtual Surgical Planning (VSP) was conducted with this and the information from the CT scan. The VSP was utilized to precisely determine the anatomy that would be encountered during the MMA procedure. VSP was also utilized to determine the exact location of the genioglossus

muscle attachment on the lingual surface of the anterior mandible. An occlusal-based cutting guide was fabricated to facilitate optimal obtainment of the genioglossus muscle for advancement. The MMA and GA were performed under general anesthesia with rigid fixation and no complications. At the 1-year follow-up appointment, the patient reported no issues with resolution of facial paresthesia and no malocclusion. His occlusion was stable and reproducible with a maximum incisal opening of greater than 40 millimeters. Temporomandibular examination was unremarkable. The patientâ&#x20AC;&#x2122;s postoperative was AHI of 6 and an ESS of 1.

Figure 14: Virtual surgical planning of maxillomandibular and genioglossus advancement for the treatment of severe obstructive sleep apnea (facial view)

Figure 15: Virtual surgical planning of maxillomandibular and genioglossus advancement for the treatment of severe obstructive sleep apnea (profile view)

Figure 16: Preoperative lateral cephalometric radiograph of patient No. 3

Figure 17: One year status post maxillomandibular and genioglossus advancement lateral cephalometric radiograph of patient No. 1 with resolution of objective and subjective symptoms (Patient No. 3)

Volume 7 Number 3

Orthodontic practice 43

CONTINUING EDUCATION

Case 3 A 44-year-old white male with a polysomnogram-confirmed severe obstructive sleep apnea (OSA) with an apnea-hyponea index of 36 with an Epworth Sleepiness Score (ESS) of 14. His chief complaint consisted of excessive daytime sleepiness (EDS) and inability to wear nocturnal continuous positive airway pressure device. Cephalometric and nasopharyngoscopic evaluation revealed possible multi-level airway obstructions. After extensive discussion of his treatment options, he agreed to undergo maxillomandibular advancement (MMA) with genioglossus advancement (GA)

CONTINUING EDUCATION Case 4 A 36-year-old white male presented with a chief complaint of excessive daytime sleepiness and PSG-confirmed Moderate OSA. He had an AHI of 15 and an ESS (Epworth Sleepiness Score) of 16. Cephalometric and nasopharyngoscopic evaluation revealed possible obstruction at the base of the tongue. After extensive discussion of his treatment options, he agreed to undergo a genioglossus advancement (GA) for the surgical correction of his moderate OSA. A cone beam CT (CBCT) scan was obtained according to the Medical Modeling protocol.1 The information from the CBCT scan was uploaded to the Medical Modeling website. Virtual Surgical Planning (VSP) was utilized to determine the exact location of the genioglossus muscle attachment on the

lingual surface of the anterior mandible. A tooth-borne osteotomy cutting guide was fabricated to facilitate capture of the genial tubercle for optimal obtainment of the genioglossus muscle for advancement and avoidance of the apices of the mandibular anterior teeth and bilateral mental nerves. An intraoral genioglossus advancement of 10 millimeters with the aid of the tooth-borne osteotomy cutting guide was performed under general anesthesia with rigid fixation and no complications. At the 1-year follow-up appointment, the patient reported no issues with resolution of his lower lip paresthesia. He reported resolution of his ESS, increased sleep efficiency, and improved quality of life. The patient’s postoperative AHI was 1, and he had an ESS of 2. OP

Figure 19: Virtual surgical planning for genioglossus advancement showing tooth-supported osteotomy cutting guide

Figure 20: Virtual surgical planning for genioglossus advancement showing lingual portion of osteotomy verifying entire capture of genioglossus tubercle for genioglossus muscle advancement

REFERENCES

9. 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 .

1. Stockstill J. Sleep-disordered breathing in orthodontic patients: part I — diagnostic and management guidelines. Orthodontic Practice US. 2016;7(2):42-46. 2. Punjabi NM. The epidemiology of adult obstructive sleep apnea. Proc Am Thorac Soc. 2008;5(2):136-143. 3. Athanasiou AE. Orthodontic cephalometry. London: Mosby-Wolfe;1997:241–292. 4. Nalçaci R, Oztürk F, Sökücü O. A comparison of two- dimensional radiography and three-dimensional computed tomography in angular cephalometric measurements. Dentomaxillofac Radiol. 2010;39(2):100–106. 5. Karatas OH, Toy E. Three-dimensional imaging techniques: A literature review. Eur J Dent. 2014;8(1):132-140. 6. Becker OE, Scolari N, Melo MFS, Haas Junior OL, Avelar RL, De Menezes LM, De Oliveira RB. Three-dimensional Planning in Orthognathic Surgery using Cone-beam Computed Tomography and Computer Software. J Comput Sci Syst Biol. 2013;6: 311-316. 7. 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. 8. Ngiam J, Balasubramaniam R, Darendeliler MA, Cheng AT, Waters K, Sullivan CE. Clinical guidelines for oral appliance therapy in the treatment of snoring and obstructive sleep apnoea. Aust Dent J. 2013;58(4):408-419. .

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10. National Institutes of Health – National Heart, Lung and Blood Institute. What is CPAP? https://www.nhlbi.nih.gov/ health/health-topics/topics/cpap. Updated December 13, 2011. Accessed April 19, 2016. 11. Aurora RN, Casey KR, Kristo D, Auerbach S, Bista SR, Chowdhuri S, Karippot A, Lamm C, Ramar K, Zak R, Morgenthaler TI; American Academy of Sleep Medicine. Practice parameters for the surgical modifications of the upper airway for obstructive sleep apnea in adults. Sleep. 2010;33(10):1408-1413. 12. Golden, B. Surgical aspects of sleep medicine in dental school curriculum. In Sleep Medicine Education in US and Canadian Dental Schools: A Report of the Inaugural Dental Educators Conference at the University of North Carolina School of Dentistry, Sheats RD, Essick GK. (eds.). J Dent Sleep Med. 2016; 3(2). http://www.jdsm.org/ViewArticle. aspx?pid=29420. Accessed April 19, 2016. 13. Thompson SH, Quinn M, Helman JI, Baur DA. Maxillomandibular distraction osteogenesis advancement for the treatment of obstructive sleep apnea. J Oral Maxillofac Surg. 2007;65(7):1427-1429. 14. Xia JJ, Gateno J, Teichgraeber JF. New clinical protocol to evaluate craniomaxillofacial deformity and plan surgical correction. J Oral Maxillofac Surg. 2009;67(10):2093-2106. 15. Zaghi S, Holty JE, Certal V, Abdullatif J, Guilleminault C, Powell NB, Riley RW, Camacho M. Maxillomandibular

Figure 18: Preoperative lateral cephalometric radiograph of patient No. 4

Figure 21: One year postoperative lateral cephalometric radiograph following VSP-guided genioglossus advancement surgery for the surgical treatment of obstructive sleep apnea with resolution of objective and subjective symptoms (patient No. 4)

advancement for treatment of obstructive sleep apnea: a meta-analysis. JAMA Otolaryngol Head Neck Surg. 2016;142(1):58-66. 16. Goodday RH, Bourque SE, Edwards PB. Objective and subjective outcomes following maxillomandibular advancement surgery for treatment of patients with extremely severe obstructive sleep apnea (Apnea-Hypopnea Index >100). J Oral Maxillofac Surg. 2016;74(3):583-589. 17. Ubaldo ED, Greenlee GM, Moore J, Sommers E, Bollen AM. Cephalometric analysis and long-term outcomes of orthognathic surgical treatment for obstructive sleep apnoea. Int J Oral Maxillofac Surg. 2015;44(6):752-759. 18. Boyd SB, Walters AS, Song Y, Wang L. Comparative effectiveness of maxillomandibular advancement and uvulopalatopharyngoplasty for the treatment of moderate to severe obstructive sleep apnea. J Oral Maxillofac Surg. 2013;71(4):743-751. 19. Boyd SB, Walters AS, Waite P, Harding SM, Song Y. Long-term effectiveness and safety of maxillomandibular advancement for treatment of obstructive sleep apnea. J Clin Sleep Med. 2015;11(7):699-708. 20. Bettega G, Pépin JL, Veale D, Deschaux C, Raphaël B, Lévy P. Obstructive sleep apnea syndrome. Fifty-one consecutive patients treated by maxillofacial surgery. Am J Respir Crit Care Med. 2000;162 (2 Pt 1):641-649. 21. Caples SM, Rowley JA, Prinsell JR, Pallanch JF, Elamin MB, Katz SG, Harwick JD. Surgical modifications of the upper airway for obstructive sleep apnea in adults: a systematic review and meta-analysis. Sleep. 2010;33(10):13961407.

Volume 7 Number 3

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Orthodontic and surgical diagnosis and management of OSA — case presentations: part 2 STOCKSTILL, ET AL. 1. Evidence-based (EB) diagnostic and classification strategies for any medically and/or dentally related disorders are intended to weigh the impact of _____ and specificity derived from the scientific method for techniques and modalities being utilized. a. reliability b. validity c. sensitivity d. all of the above 2. A number of physical measurements are made during polysomnography, including indices for apnea (the complete cessation of airflow for at least ________ — classified as obstructive, central, or mixed based on whether effort to breathe is present during the event) and hypopnea (a reduction in airflow that is followed by an arousal from sleep or a decrease in oxyhemoglobin saturation. a. 10 seconds b. 15 seconds c. 20 seconds d. 30 seconds 3. Furthermore, appropriate imaging of the _______ in patients reporting

Volume 7 Number 3

sleep-related breathing disorders is used to assist the clinician in making the most appropriate and evidence-based decision for that patient’s treatment. a. oropharyngeal area b. nasopharyngeal area c. hypopharyngeal area d. both a and b 4. As part of the diagnostic workup involving patients reporting with OSA as a chief or secondary complaint, the orthodontic comprehensive records protocol is followed as a means of closely identifying _______ relationships that may be involved in any combination orthodontic/surgical treatment. a. dental b. skeletal c. soft tissue d. all of the above 5. Additionally, the ____ will assist the maxillofacial surgeon in carrying out model surgery prior to the actual surgery, thus allowing the orthodontist and surgeon to more clearly and appropriately plan the phases and timing of treatment.

a. intraoral photographs b. CBCT c. polysomnography d. 2D images 6. “The advent of the _________ allows the acquisition of 3D images of the patient’s craniofacial complex and eliminates the ambiguity that can occur with twodimensional (2D) image.” a. cephalogram b. cone beam computed tomography (CBCT) c. panoramic radiograph d. tomograph 7. Oral appliances to be used during sleep are usually designed to have ____ in the maxilla and mandible for mandibular repositioning. a. mandible coverage only b. coverage of the maxillary arch only c. full arch coverage d. partial arch coverage 8. 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 ___________. a. bodily movements during sleep b. dental occlusal relationships c. temporomandibular joint integrity d. both b and c 9. For example, _____ can address anatomic abnormalities in all the anatomic regions of the head and neck; only tracheostomy is more comprehensive. a. maxillomandibular expansion/ advancement (MME) surgery b. effectively wearing CPAP nightly c. oral appliances d. tongue retention 10. Advanced ______ is the current “gold standard” of imaging the posterior airway in the diagnosis of OSA and is also utilized in the pre-surgical model planning for surgical correction of skeletal deficiencies contributing to airway problems. a. 2D radiographs b. panoramic imaging c. cephalometric imaging d. 3D imaging

Orthodontic practice 45

CE CREDITS

ORTHODONTIC PRACTICE CE

PRODUCT PROFILE

AUTHOR GUIDELINES Orthodontic Practice US is a peer-reviewed, bimonthly publication containing articles by leading authors from around the world. Orthodontic Practice US is designed to be read by specialists in Orthodontics, Periodontics, Oral Surgery, and Prosthodontics.

Submitting articles Orthodontic Practice US requires original, unpublished article submissions on orthodontic topics, multidisciplinary dentistry, clinical cases, practice management, technology, clinical updates, literature reviews, and continuing education. Typically, clinical articles and case studies range between 1,500 and 3,000 words. Authors can include up to 15 illustrations. Manuscripts should be double-spaced, and all pages should be numbered. Orthodontic Practice US reserves the right to edit articles for clarity and style as well as for the limitations of space available. Articles are classified as either clinical, continuing education, technology, or research reports. Clinical articles and continuing education articles typically include case presentations, technique reports, or literature reviews on a clinical topic. Research reports state the problem and the objective, describe the materials and methods (so they can be duplicated and their validity judged), report the results accurately and concisely, provide discussion of the findings, and offer conclusions that can be drawn from the research. Under a separate heading, research reports provide a statement of the research’s clinical implications and relevance to implant dentistry. Clinical and continuing education articles include an abstract of up to 250 words. Continuing education articles also include three to four educational aims and objectives, a short “expected outcomes” paragraph, and a 10-question, multiple-choice quiz with the correct answers indicated. Questions and answers should be in the order of appearance in the text, and verbatim. Product trade names cited in the text must be accompanied by a generic term and include the manufacturer, city, and country in parentheses. Additional items to include: • Include full name, academic degrees, and institutional affiliations and locations • If presented as part of a meeting, please state the name, date, and location of the meeting • Sources of support in the form of grants, equipment, products, or drugs must be disclosed • Full contact details for the corresponding author must be included • Short author bio • Author headshot 46 Orthodontic practice

Pictures/images

Disclosure of financial interest

Illustrations should be clearly identified, numbered in sequential order, and accompanied by a caption. Digital images must be high resolution, 300 dpi minimum, and at least 90 mm wide. We can accept digital images in all image formats (preferring .tif or jpeg).

Authors must disclose any financial interest they (or family members) have in products mentioned in their articles. They must also disclose any developmental or research relationships with companies that manufacture products by signing a “Conflict of Interest Declaration” form after their article is accepted. Any commercial or financial interest will be acknowledged in the article.

Tables Ensure that each table is cited in the text. Number tables consecutively and provide a brief title and caption (if appropriate) for each.

References References must appear in the text as numbered superscripts (not footnotes) and should be listed at the end of the article in their order of appearance in the text. The majority of references should be less than 10 years old. Provide inclusive page numbers, volume and issue numbers, date of publication, and all authors’ names. References should be submitted in American Medical Association style. For example: Journals: (Print) Greenwall L. Combining bleaching techniques. Aesthetic & Implant Dentistry. 2000;1(1):92-96. (Online) Author(s). Article title. Journal Name. Year; vol(issue#):inclusive pages. URL. Accessed [date].

Manuscript review All clinical and continuing education manuscripts are peer-reviewed and accepted, accepted with modification, or rejected at the discretion of the editorial review board. Authors are responsible for meeting review board requirements for final approval and publication of manuscripts.

Proofing Page proofs will be supplied to authors for corrections and/or final sign off. Changes should be limited to those that are essential for correctness and clarity. Articles should be submitted to: Mali Schantz-Feld, editor-in-chief mali@medmarkaz.com

Reprints/Extra issues If reprints or additional issues are desired, they must be ordered from the publisher when the page proofs are reviewed by the authors. The publisher does not stock reprints; however, back issues can be purchased.

Or in the case of a book: Greenwall L. Bleaching techniques in Restorative Dentistry: An Illustrated Guide. London: Martin Dunitz; 2001. Website: Author or name of organization if no author is listed. Title or name of the organization if no title is provided. Name of website. URL. Accessed Month Day, Year. Example of Date: Accessed June 12, 2011. Author’s name: (Single) Doe JF

(Multiple) Doe JF, Roe JP

Permissions Written permission must be obtained by the author for material that has been published in copyrighted material; this includes tables, figures, pictures, and quoted text that exceeds 150 words. Signed release forms are required for photographs of identifiable persons.

Checklist for article submissions: 3 A copy of the manuscript and figures, captions, including all pictures (low res) necessary for reviewers 3 Manuscript: double-spaced including separate references, figure legends, and tables 3 Abstract, educational objectives, expected outcomes paragraph 3 References: double-spaced, alphabetical, American Medical Association style 3 Tables: titled and cited in the text 3 Mandatory submission form, signed by all authors Please contact Mali Schantz-Feld, editor-inchief, with any questions via email: Mali@medmarkaz.com

Volume 7 Number 3

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PROPELLING ORTHODONTICS

Self-ligation and accelerated orthodontics — applications and new opportunities Dr. Stuart L. Frost discusses how he integrated accelerated treatment into his practice

t has been exciting to practice orthodontics over the past 16 years and witness the technology advances in passive self-ligation mechanics, more specifically with the Damon® System. I believe that we are practicing in a Golden Age of orthodontics where the technology is rapidly changing, and patients are seeking treatment with orthodontists who embrace these new modalities. Accelerated treatment, in my opinion, is where I see most of the innovation in orthodontics over the next 10 years. Our profession will see tremendous impact from advances in accelerated treatment modalities such as vibration, light therapy, surgery first, low-level lasers, and bone repair/response procedures such as micro-osteoperforation (MOP) with Propel’s Excellerator Series drivers. I introduced accelerated orthodontics into my practice 5 years ago and already see a paradigm shift and monumental opportunity in what the next generation of orthodontics will encompass for my patients.

the same: Beautiful broad smiles in less time and comfortable safe treatment. For my Damon System cases, I am proactively performing a full-arch Propel procedure to accelerate therapy utilizing the full technology of the Damon Passive Self-Ligation System. Patients want to finish treatment faster, and they are willing to spend more money in treatment while achieving the beautiful outcomes that they are accustomed to seeing in my community with the Damon System.

Integrating accelerated treatment into your practice

Performing micro-osteoperforation (MOP) When I first tried Propel’s MOP a few years ago, I was hesitant because it seemed invasive. Propel as a company has greatly refined their system and has streamlined their technique. I find if the patient rinses for 1 minute with chlorhexidine, and then I numb the arch using a compounded topical (10% lidocaine, 10% prilocaine, 4% tetracaine, 2% phenylephrine), we have an easy procedure without much after-effect. If needed, I recommend Tylenol® post application for any discomfort, as I would with my typical orthodontic cases.

With any new technology, there is always an initial learning curve. That should not intimidate anyone from trying these new modalities. When using accelerated orthodontics, we need to remind ourselves that patient comfort and care is first and then use sound PSL mechanics that enhance tooth movement quickly and protect the periodontal membrane and alveolar bone during treatment. I will focus this article on my fixed orthodontic patients using the Damon® Q™ and Damon™ Clear2 bracket system with Propel. In any accelerated treatment modalities that I use in my practice, my outcome goals are

Mechanics, treatment sequencing, and protocols with Damon and Propel’s MOP I continue to use the same wire sequencing and sound Damon Principles of Passive Self-Ligation techniques. The treatment mechanics that change are the time interval between adjustments. On a patient that chooses accelerated treatment, I will see the patient back for routine adjustments every 4 weeks. My goals in treatment are to be at my pano reposition visit at 4 months of treatment. This allows me to be in my finishing wire at 5 months and gives me plenty of time to work on finishing

Stuart L. Frost, DDS, received his dental degree at the University of the Pacific School of Dentistry. Following a 1-year fellowship in temporomandibular joint dysfunction (TMJ), he completed a 2-year residency in orthodontics and dentofacial orthopedics at the University of Rochester. Dr. Frost practices in Mesa, Arizona. He is currently a part-time associate clinical professor at the University of the Pacific orthodontic program and has lectured on the Damon system at several Damon Forums and other Ormco-sponsored events, including the national American Association of Orthodontists Annual Session, component meetings, and his own Damon in-office seminars.

48 Orthodontic practice

mechanics. When I treatment plan for accelerated treatment with wires and brackets, I discuss with patients that we are going to save treatment time by 25%-30%. That being said, on a case where we I would normally treatment plan for 12-14 months in treatment, I now tell the patient that using Propel’s MOP, I can finish the case in 9-10 months. It is important to stress that I am still using the same mechanics in treatment that I normally use without acceleration. I will do a MOP application initially and then assess the need for additional MOP applications every 3 months as needed.

Clinical case application: the new frontier in my practice with accelerated orthodontics for adult patients using Propel’s MOP One thing I see consistently in adult patients with previous traditional or twin appliance treatment is that the bone is different from those that have never been treated. They appear to have a “bone-scarring” effect. This change of the bone physiology, in my opinion, demands more work in orthodontic mechanics, and the ability to let these patients go with lighter wires and longer periods of time between visits isn’t beneficial to their treatment. Sometimes it feels as though I am moving teeth through dense wet concrete. For this reason, I find MOP to be a great ally in releasing these movements, similar to turning on a “switch.” When over 50% of our practice has adults previously treated as teenagers, I find it a blessing to have techniques to expand our treatment plans and allow us to give them as many nonsurgical options with the same beautiful end results as we get with our younger patients. Propel, in my opinion, levels the playing field. The other benefit that Propel’s MOP gives us is speed in treatment. I have found that adults will accept treatment generally if it is less than 12 months start to finish. To accomplish these goals, and give patients what they want, there must be options for accelerating this process. The four main areas in which I use Propel’s MOP in my practice follow: 1. Opening implant sites where teeth Volume 7 Number 3

first bicuspid, but the space stopped opening with Damon brackets and wires and sound Damon Mechanics. We performed MOP at 8 months into treatment. MOP was performed on the distal of the upper-right 5 with three perforations spaced 3 mm-4 mm apart vertically and on the distal of the upper-right 3 in the same manner. Within 3 months, we had opened up 3 mm of space, and at 6 months after procedure, 6 mm of space after only one MOP application.

Case 1: space opening for implant procedure

Case 2: the reverse bicuspid extraction — opening the previous bicuspid spaces to help in the aging process

An adult male was previously treated in Vietnam over 20 years ago. We wanted to open a space for an implant on his upper-right

Julie, age 40, had a chief complaint of

severe TMJ, and she was also concerned with the collapse of her posterior arch width and narrow smile. She had previous four bicuspid extractions as a teenager. I proposed opening spaces up for missing bicuspids, enhancing arch-width facial midface, and then using TADs close to molars forward, preserving the new position of the anterior six front teeth. Spaces weren’t open until 12 months into treatment. TADS were placed with TPA and two Palatal Vector TADS to close space. At 14 months, the left side is closing normally, and the right is lagging behind. I used Propel on the upper-right 5 mesial and distal to increase the closure of the space. Space closed at 18 months into treatment.

Figure 1: Initial treatment photos — goal to open UR4 for implant

Figure 2: Post treatment/post-implant screws just 6 months after MOP

Figure 3: Initial treatment photos (left and center), and progress photo (right) initiating posterior segment mesialization to hold the anterior proclination

Figure 4: Post treatment photos with successful space closure 4 months after MOP. Patient achieved wide arches and proclination of the anterior segment Volume 7 Number 3

Orthodontic practice 49

PROPELLING ORTHODONTICS

have been extracted earlier in life (Case 1) 2. Opening space for missing teeth and closing the space forward (Case 2) 3. Closing stubborn spaces in treatment where MOP can enhance and speed up the process. (Case 3) 4. Prior orthodontics and posterior arch collapse and restoring upright beautiful broad smiles to fill the corridors of the smile. (Case 4)

PROPELLING ORTHODONTICS

Figure 5: Initial records (left and center) and (right) 6 weeks after initial MOP showing second application

Figure 6: (left) Initiation of MOP to assist the canine movement. (center) After 6 week progress and second application. (right) 3 months’ progress — two total Propel applications

Figure 7: Initial records (left and center) and (right) 4 months after MOP. Notice the uprighting of the posterior segment and widening of the arches

Case 3: addressing cases with stubborn movements I’ve had success using MOP applications moving stubborn teeth 2 mm-3 mm in order to bring them into alignment pretty easily. Marty was one of these patients with a severe tongue thrust, and we were able to close the space in 6 weeks after Propel. On a separate case, Propel’s MOP can also help assist with stubborn movements such as horizontally impacted cuspids. After 2 years of making space and creating a beautiful archform, the cuspid was exposed, and a button with chain was placed to bring it into the arch. While bringing the cuspid into the arch, it stopped moving. I used two MOP applications, and it immediately began coming down into the arch.

Our profession will see tremendous impact from advances in accelerated treatment modalities such as vibration, light therapy, surgery first, low-level lasers, and bone repair/response procedures such as micro-osteoperforation (MOP) with Propel’s Excellerator Series drivers.

Case 4: posterior arch collapse This patient had prior orthodontic treatment with severe relapse in her posterior arch. She presented for a consultation and informed me that she had 7 months before her family was moving out of town and asked about accelerated treatment. The patient chose Propel, and we engaged in full upper arch MOP. We had nice arch expansion and uprighting in 4 months after one MOP application. 50 Orthodontic practice

Conclusion I lecture to thousands of orthodontists a year in what I am seeing in my office using the advanced procedures integrating Damon and Propel’s MOP. Yes, new efficiencies provide some challenges. Changes need to be made in scheduling, time between appointments, and payment schedules when patients finish early by integrating financial

programs like OrthoFi, but we are currently working on figuring these pieces out. In my opinion, it is well worth it to untap this new market opportunity making orthodontic treatment a broader option for adult patients with great efficiency. OP

This information is sponsored and provided by Propel Orthodontics.

Volume 7 Number 3

EDUCATION EXPLORATION

Reflections on Ormco’s Forum 2016 Q&A with Drs. Michael Hess and Toby VanLandschoot

he Forum — Ormco’s annual user conference — is one of the orthodontic industry’s most unique educational opportunities. With engaging clinical mentoring sessions, panel discussions, and collaborative opportunities, The Forum provides personalized educational paths intended to help both doctors and staff bring their practices to the next level. The Forum 2016 once again delivered on this promise. Deemed the “Face 2 Face” Forum — one where industry experts, peers, and friends can gather to create meaningful relationships and discuss advancements in orthodontics — the sold-out event welcomed 1,400 orthodontic professionals to sunny Southern California for 4 days of education, networking, and fun. We sat down with Dr. Michael Hess and Dr. Toby VanLandschoot to hear about their experiences and key learnings from The Forum 2016. Hess & VanLandschoot Orthodontics has four practice locations in the Tampa, Florida, area.

How many years have you attended The Forum? Do you bring your staff? Dr. Hess: I’ve been going to The Forum for about 8 years now, and it’s always something to look forward to. In the past, we’ve had the opportunity to bring our staff, especially when it’s in the Florida area, given our practice location. Dr. VanLandschoot: On my end, I’ve attended The Forum for about 5 years. I think there’s a ton of value in bringing our staff to the conference, as it really opens up their perspective on the industry as a whole and allows them to see how other practices interact and excel at their craft.

What were your impressions of The Forum 2016? Dr. Hess: First, we have to acknowledge the absolutely stunning location. Hosted at the Terranea Resort in Rancho Palos Verdes, California, we had beautiful views of the Pacific Ocean, gorgeous weather, and an amazing venue. As far as the sessions go,

Michael Hess, DMD, MS, attended the University of Florida College of Dentistry where he received his Doctorate of Dental Medicine and graduated as the valedictorian of his class. He continued his education at the prestigious University of Michigan and earned his master’s degree in orthodontics. Dr. Hess is a member of the American Dental Association, Florida Dental Association, the West Coast Dental Association, the American Association of Orthodontists, the Southern Association of Orthodontists, the Florida Association of Orthodontists, as well as other local and regional dental societies. Orthodontics is a passion for Dr. Hess, and he is committed to achieving the highest level of quality for his patients. He enjoys the difference that a beautiful smile can make in a person’s life. In his spare time, he enjoys spending time with Julianna and their son, Jackson. Some of his other interests include traveling, playing piano, guitar, tennis, flying, scuba diving, and skydiving. Toby VanLandschoot, DDS, MS, attended the University of Michigan School of Dentistry where he earned his Doctorate of Dental Surgery. He then continued his education at the University of Michigan, earning his master’s degree in orthodontics. Dr. VanLandschoot is a member of the American Association of Orthodontists, Florida Dental Association, and the American Dental Association. Dr. VanLandschoot loves orthodontics and the way creating a beautiful smile impacts a patient’s life forever. He and his wife, Ann, keep busy with their son, Tommy, and young daughter, Simone. In their spare time, they are avid football fans, and enjoy traveling and dining out.

52 Orthodontic practice

Dr. Dwight Damon’s presentation during general session on his vision for the future of orthodontics was compelling. You could tell the crowd was completely enamored with his work and commitment to thinking outside of the box to present new mechanics and practices. Outside of this, there were many other sessions related to the Damon™ System, where participants discussed both the fundamentals and advanced mechanics of the Damon System to gain deeper knowledge on how to employ passive self-ligation treatment mechanics. Dr. VanLandschoot: I’m always impressed with how well executed and put together The Forum is. Ormco truly wants to make it an amazing event — from both a social and educational standpoint — and it shows. It’s a professional conference, yet still incredibly fun and allows you to get to know your colleagues better, learn about the latest and greatest in orthodontics, and hear from a number of well-respected doctors.

How was The Forum 2016 different from previous years? Dr. Hess: This year there were smaller breakout sessions for attendees. Playing along with the “Face 2 Face” theme, the sessions allowed us to not only ask more questions to the presenters but also have valuable discussions around the topics they were presenting. Dr. VanLandschoot: One thing that really stood out was a breakfast that Ormco hosted with its upper management to discuss Insignia™ and its use in our day-to-day lives. Their team brought us together to get our thoughts and opinions on the all-inclusive system, where we see it going in the future, Volume 7 Number 3

Was there a panel or session that really stood out to you? Dr. VanLandschoot: Dr. David Sarver’s “Face 2 Face” mentoring session was

tremendous. It was all about the esthetic implications of orthodontic treatment — which is becoming more and more important to patients. Over the past several years, the industry has seen a significant jump in the demand for esthetic, yet effective, treatment choices. Furthermore, when you consider the fact that adults undergoing treatment account for 22% of all orthodontic cases, there’s a demand to cater to these esthetically minded individuals. Dr. Sarver is well respected and a great lecturer, so being able to interact with him in a small, intimate setting gave us the opportunity to ask questions and connect with him on a more personal level.

What key learnings or ideas did you bring back to your staff? Dr. Hess: At one of the clinical workshops, we were exposed to a new placement technique for TADs — infrazygomatic crest TADs — and we immediately shared it with our staff and have already leveraged it in our practice. Outside of this, we enjoyed learning about Smile for a Lifetime (S4L), a charitable foundation on a mission to provide free-quality orthodontic care to individuals with financial challenges and special orthodontic needs. Given the fact that Ormco is a corporate sponsor of the organization, and that one of our goals as a practice is to be more involved in charity efforts this year, we knew this was something we wanted to pursue. When we presented the information to the staff, they were instantly on board and excited about the opportunity. The S4L team at The Forum had a number of ideas as it relates to putting together a team and how to execute the program, especially when it comes to identifying patient candidates.

From your perspective, how important are continuing education courses, and how does Ormco cater to practice education needs?

Dr. Dwight Damon unveils his vision for the future of orthodontics and how he’s working with Ormco to develop industryadvancing appliances

Dr. Hess: First, I’ll say that education is a core value of our practice, and we’re grateful for all the courses and opportunities that Ormco provides for doctors and our teams. You always want to be on the cutting edge of the industry, and to do that, you have to be aware and knowledgeable of new techniques, technologies, and products that are out there. Before we adopted Insignia, we participated in an in-office course with Dr. Jamie Reynolds about a year ago. The hands-on training course proved incredibly valuable for our entire staff, and today, one year later, the investment is paying off. The technology is fully integrated into our practice, and treatment efficiencies have hugely improved. Dr. VanLandschoot: To echo that, we also attended Dr. Stuart Frost’s Advanced Damon In-Office course, which discusses how facial esthetics and the smile are further related — small details make all the difference in the final result. Attending these educational courses is an investment, but one that I’m willing to make time and time again. The Forum 2017 is scheduled to take place February 22-25, 2017, in Orlando, Florida. To see Ormco’s full schedule of upcoming CE courses and events, visit www. ormco.com/education/. OP

Dr. Chris Chang presents several challenging cases “made easy” at the sold-out Forum 2016 Volume 7 Number 3

This information was provided by Ormco™.

Orthodontic practice 53

EDUCATION EXPLORATION

and what improvements they can make. We talked at length about the power of customized brackets, wires, and placement trays. It was also informative to hear how peers are combining treatment strategy with the precision of computer-aided smile design to give patients an optimal occlusion and smile arc specifically proportioned to their unique facial features. To me, this really showed how much Ormco cares not only for its doctors and our opinions, but also about continuously improving its products.

PRACTICE MANAGEMENT

Unlocking the code to medical insurance for oral appliances for OSA Rose Nierman, founder and CEO of Nierman Practice Management, offers advice to facilitate insurance reimbursement

nlocking the code to reimbursement for oral appliances for obstructive sleep apnea (OSA) is accomplished by understanding medical insurance. Seminars and workshops in cross-coding from medical to dental insurance can be helpful to decipher International Classification of Diseases (ICD) codes, Current Procedural Terminology (CPT) codes, medical claim forms, and proven processes.

Preauthorization Successful medical billing for oral appliances typically necessitates a preauthorization, started by telephone, along with specific documentation demonstrating medical necessity. A proficient insurance coordinator initiates a benefit check call in much the same way you would for orthodontic care, with the exception of bringing ICD and CPT medical codes into play. Deductibles and copayments are then discussed with the patient. Keep in mind that there are no lifetime limits for oral appliances for OSA. In fact, some medical carriers will provide a replacement appliance within 3 or sometimes 5 years. Once the process is started, providing documentation of medical necessity is key.

Documentation requirements Documentation to substantiate the medical necessity of oral appliance therapy involves a copy of the sleep study confirming

Rose Nierman has been at the forefront of educating dental practices on medical billing in dentistry, cross-coding, and the expansion of patient services for more than 26 years. She is the creator of DentalWriter™ Software and a CE provider for Cross-Coding; Unlocking the Code to Medical Billing in Dentistry™. Contact Nierman Practice Management tollfree at 1-800-879-6468, or visit www.NiermanPM.com.

54 Orthodontic practice

a diagnosis of OSA (ICD-10 G47.33), a written physician order (Rx for oral appliance therapy), and confirmation of comorbidities such as hypertension, excessive daytime sleepiness, cognitive disorder, stroke, or insomnia. Some insurers ask for a written affidavit stating that the patient refused CPAP or is intolerant to CPAP. It’s vital to ask the insurer what documentation is wanted and needed.

Exams Medical codes for exams, referred to as Evaluation and Management codes, may be submitted for an OSA oral screening and for follow up visits such as a 6-month or yearly check of the device. Just as dental insurance has different levels of exam codes, so does medical. There are five levels of medical exam codes, which range from a problemfocused exam to a comprehensive history taking and exam. When billing these “office visit” codes, it’s essential that the practice document medical history taking and exam components to support the level of the code billed, whether it be a quick check or a more detailed encounter.

Imaging CT scans may be considered for reimbursement but do generally require preauthorization. A panoramic view is more likely to be covered by a medical insurer with the diagnosis of OSA, and preauthorization is not required.

Oral appliance therapy A sleep appliance is billed as E0486 — Oral Device/Appliance Used to Reduce Upper Airway Collapsibility, Adjustable or Non-Adjustable, Custom Fabricated, Includes Fitting and Adjustment. Most insurers will reimburse for repairs (unless neglect is a factor), and some also reimburse for a lost, missing, or stolen appliance. Good and consistent documentation and records are the keys to unlocking the code to medical billing for OSA. Detailed narrative reports should be generated and sent to medical insurers to expedite reimbursement and to protect your practice. The narrative reports can also be sent to patients’ other caregivers to coordinate care and educate physicians about oral appliance therapy as an alternative to CPAP. OP Volume 7 Number 3

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.

LABORATORY LINK

Digital Positioners James Bonham discusses how new Digital Positioners have improved orthodontic treatment and work-flow

henever braces are removed, teeth go through a settling-in process. If a clinician’s goal is to treat to a mutually protected occlusion with even posterior stops and anterior guidance, it would be critical to treat to a CR=CO finish. No matter how precise one finishes fixed-appliance therapy, the dentition adapts by settling. The use of a gnathologic positioner built on an articulator is the most accurate way to control the settling process with the condyles seated in the fossae. In the past, positioners were cumbersome to make because of the many steps involved both at the chair and in the lab. It would not be uncommon to take alginate impressions at debanding to fabricate temporary Essix retainers while the positioner was being made. It was also necessary to take at least one set of upper and lower alginate impressions along with a CR bite record and a facebow recording. The alginate impressions would then be poured, trimmed, and mounted before mailing to the lab for fabrication. Some commercial labs would require two upper and two lower mounted models. The turnaround time was usually 2 to 3 weeks. In today’s digital world, it can be done much easier, better, and with less hassle for the clinician and the patient. Specialty Appliances laboratory recommends the following protocol. Two weeks before debanding, the patient is scheduled for a pre-deband appointment. Prior to scanning, the archwires and any molar bands should be removed. If a lower 3-3 fixed retainer is required, it can be bonded in at this appointment. The arches are scanned with an intraoral scanner with the remaining brackets still in place. A CR bite record is captured anteriorly with four thicknesses of DeLar wax, which was warmed to 140º in a water bath. The wax is then chilled and placed back in the mouth James Bonham is a partner and VP of Sales and Marketing at Specialty Appliances. He has spent the past 13 years in orthodontics with a strong focus on the integration of digital technology into orthodontic practices.

56 Orthodontic practice

with the patient lightly squeezing. The posterior teeth, which are about 2 mm apart, are scanned with the anterior wax in place to capture CR three dimensionally in space. The scanned arches are saved and exported to the lab as “in occlusion,” although the teeth are separated by the thickness of the bite recording. A Kois facebow recording can be taken and scanned at this appointment and also sent to the lab electronically as an STL file. Braided archwires are then placed, and the patient is scheduled in 2 weeks for appliance removal. Specialty Appliances receives the STL files along with a digital prescription within minutes of scanning. The scanned arches in CR are then mounted on a virtual articulator from 3Shape software and closed to first contact. A virtual gnathologic set up with anterior guidance and posterior disclusion is done with 3Shape software on the virtual articulator. The setup is then printed and mounted on a Panadent articulator for positioner fabrication. At debanding, all brackets and adhesive are removed, and the gnathologic positioner is delivered that day. Compliance is good because the patient has not become accustomed to low-profile Essix retainers first. Also, the teeth are more mobile at debanding, which makes the positioner more effective. The patient is asked to wear the positioner for 4 waking hours per day plus during sleep. It may fall out during sleep for the first few days, but that is expected. After 6 weeks, the positioner has settled the occlusion to CR, and the detail of tooth positions and fit is excellent. Removable retainers can be used at night from this point. Specialty’s digital positioners have made finishing to CR more streamlined and easier for staff and patients alike. OP Note: Positioner treatment protocol and patient images provided by John Oubre, DDS.

Pretreatment

Pre-positioner

Positioner setup

Post-positioner Volume 7 Number 3

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M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT American Orthodontics announces Empower 2 — the latest generation of Empower Self Ligating Brackets American Orthodontics (AO) is proud to announce an upgrade of Empower — the world’s most complete self-ligating bracket system. Empower metal brackets and molar tubes will now be known as Empower 2 and feature upgrades designed to enhance the bracket’s strength and dependability. Empower 2 metal brackets and molar tubes feature 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 and adds a visual cue to confirm the clip is closed. 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. In addition, the company has introduced MRX molar bands, manufactured at AO’s manufacturing facility in Sheboygan, with a state-of-the-art process that ensures consistency and functionality. The bands feature a highly anatomical shape for precise crown fit, high strength, and exceptional elastic spring back, and an etched interior that virtually eliminates loose bands and cement washout. MRX bands are permanently laser-marked with sizes 1-32 and are available precision-welded with AO’s industry-leading LP Tubes. Learn more at http://www.american ortho.com/bands-attachments.html and about Empower 2 at www.americanortho. com/Empower.

3M expands efficient bonding procedure across bracket 3M has introduced Victory Series™ Low Profile Brackets with APC Flash-Free Adhesive (to be available in August), enabling this 3M line of best-selling brackets to now offer best-in-class bonding efficiency. Victory Series Low Profile Brackets with APC Flash-Free Adhesive will join Clarity™ ADVANCED Ceramic Brackets, the SmartClip™ SL3 and Clarity™ SL Self-Ligating Appliance Systems and Victory Series™ Superior Fit Buccal Tubes in offering orthodontists advanced adhesive technology that allows them to move directly from bracket placement to bracket cure without removing adhesive flash. Patients treated with 3M brackets that include APC Flash-Free Adhesive also benefit from added protection for tooth enamel and a quicker and easier debonding appointment. Further positioning orthodontists for productivity and patient satisfaction, 3M will also introduce enhancements to the SmartClip SL3 SelfLigating Appliance System, resulting in improved rotational control and reduction in engagement and disengagement forces. For more information, visit 3M.com.

Align Technology and 3Shape announce new workflow integration, including TRIOS® Scanner interoperability with the Invisalign® case submission process

DDS Solution — an innovative Orthodontic Lab DDS Solution is an innovative Orthodontic Lab that specializes in digital study models and interactive communication tools. We can take your impressions or exported intraoral scans and turn them into finished study models that are imbedded in interactive PDF reports. These documents allow the orthodontist to share patient study models, both before and after with the referring dentist, the patient, and any other specialist or team member that needs to see them, without requiring specialized software. Using Adobe Reader, which is found on most any computer, these PDFs are accessed and manipulated. Adobe Reader includes built-in measurement and annotation tools useful in visually communicating treatment options and plans. or more information, visit http://ddssolution.com/.

58 Orthodontic practice

Align Technology, Inc., and 3Shape announced that 3Shape’s TRIOS® Standard, TRIOS Color, and TRIOS 3 scanners will be able to be used for Invisalign® case submissions upon completion of the final validation process expected in Q4 this year. This will enable Invisalign providers with a 3Shape TRIOS intraoral scanner and TRIOS software upgrade 1.3.4.5, or higher, to submit a full arch digital impression in place of a traditional PVS impression as part of the Invisalign case submission process. The companies also announced a collaborative agreement to enhance the existing STL export workflow with iTero® scanners and laboratory partners using 3Shape Dental System™ Software, which will enable improved consistency for customers using the workflow. Align Technology supports an open systems approach to digital impressions and continues to work with intraoral scanning companies interested in developing interoperability for use with Invisalign treatment. 3Shape TRIOS customers who are interested in becoming an Invisalign-trained provider can find further information on training courses at http://provider.invisalign.com for North America and www.invisalign.eu for international regions.

Volume 7 Number 3

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Ormco™ announces commercial availability of its Alias™ Lingual Bracket System Ormco™ Corporation debuted the commercial availability of its Alias™ Lingual Bracket System, the world’s first straight-wire, passive self–ligating, square-slot lingual bracket. The innovative esthetic solution has been designed with enhanced functionality, making it easier than ever for clinicians to provide a leading-edge and discreet orthodontic treatment solution. Ormco worked closely with world-renowned lingual leaders and product inventors Drs. Kyoto Takemoto and Giuseppe Scuzzo to develop this advancement in lingual orthodontics that utilizes passive self-ligation and light forces, provides excellent torque and rotational control, and facilitates easy, fast, and comfortable wire changes. Ormco’s Alias Lingual Bracket System is designed for lingual users and incorporates convenient indirect bonding set ups provided by AOA lab. With passive self-ligating technology, the Alias Lingual Bracket System features brackets designed for optimized movement — the unique .018 vertical square slot keeps the archwire properly engaged, allowing for more precise treatment and greater rotational and torque control. In addition, gingivally offset positioning, combined with the system’s straight-wire mechanics, allows Alias brackets to be positioned closer to the lingual tooth surface. This bonding approach can minimize premature occlusal contacts between the maxillary anterior brackets and mandibular anterior teeth. Orthodontists interested in the Alias Lingual Bracket System can order indirect bonding through AOA Lab, the lab appliance division of Ormco, by calling 1-800-262-5221; alternatively, an Ormco sales representative can be reached at 1-800-854-1741.

Ormco™ announces Insignia™ Advanced Smile Design™ software updates Ormco™ Corporation announced a new software update for Insignia™ Advanced Smile Design™, a sophisticated computerdesigned treatment planning and custom-fabricated software system. The Insignia software upgrade offers doctors redesigned Insignia Custom TIB tube options, case scoring, and dynamic case tracking for enhanced treatment planning. Outside of the software upgrade, Ormco is also working collaboratively with 3Shape to establish a seamless workflow for doctors leveraging Insignia and 3Shape’s TRIOS® Ortho System™. To learn more about Insignia, visit www.ormco.com.

60 Orthodontic practice

DEXIS Eleven software drives efficiency in and out of the operatory with the power of the Cloud DEXIS, LLC, a brand of the KaVo Kerr Group, announced its latest software release — DEXIS™ Eleven. Customers will benefit from a range of workflow improvements, including drag-and-drop tooth numbering, enhanced security, and fewer clicks for case presentation. Building on the solid foundation of DEXIS Imaging Suite, DEXIS Eleven helps dental practices in and out of the operatory. In the operatory, DEXIS simplifies your tooth numbering and reduces the number of clicks required for case presentation and common workflows. The software also provides peace of mind through security improvements, always-on Cloud Backup of patient images, and the ability to access images from anywhere through CloudVu. Existing DEXIS users can upgrade quickly while their patient images migrate in the background. To experience DEXIS Eleven’s workflow improvements, enhanced security, and new Cloud Backup and CloudVu features, current DEXIS owners can visit www.dexis.com/upgrade to schedule their upgrade to DEXIS Eleven.

Dentsply Sirona introduces the INTEGO Transcendental Treatment Center Dentsply Sirona, Inc., is continuing its tradition of unparalleled innovation and award-winning design with its INTEGO Transcendental Treatment Center. Designed for easy expansion and integration of all current and future technologies, INTEGO sets the stage for the ultimate operatory experience for both clinician and patients at competitive pricing. INTEGO allows practitioners to seamlessly integrate all components of digital dentistry, including CAD/CAM tabletop peripheral equipment, into one easy-to-use unit, streamlining workflow while increasing efficiency. Ergonomically built to ensure optimum patient comfort while maximizing clinical proficiency, INTEGO exceeds the industry standard for digital practice growth and performance. INTEGO is available in two flexible models, the INTEGO TS (Traditional Delivery) and INTEGO CS (Continental Delivery). Both the INTEGO TS and INTEGO CS are equipped with an EasyTouch user interface that provides complete control of all operatory instruments via the touchscreen. A generously sized, easy-to-read 22" medical-grade monitor screen allows the clinician to better showcase patient treatment modules including intraoral and X-ray images, software and planning views, media player files, and even PowerPoint presentations. For more information, visit www.sironatc.com.

Volume 7 Number 3

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INDUSTRY NEWS Transition year for “Best of Class” Award recognizing game-changing dental technologies In 2016, the most prestigious award for dental industry companies will transition sponsorship from the Pride Institute to the newly launched Cellerant Consulting Group, founded by Lou Shuman, DMD, CAGS. The Cellerant “Best of Class” Technology Award, formerly known as The Pride “Best of Class” Technology Award, recognizes innovative gamechanging technology offerings, services, and devices. Since the inaugural presentation in 2009, the “Best of Class” Technology Awards have grown to occupy a unique space in dentistry by creating awareness in the community of manufacturers that are driving the discussion as to how practices will operate now and in the future. Prior to founding Cellerant Consulting Group, Dr. Shuman served as the President of Pride Institute where he created and developed the “Best of Class” Technology Awards. In just 8 years, the “Best of Class” designation has become a trusted criterion for dental professionals to make educated, informed product and technology investment decisions for their practices and their patients.

Darby Dental Supply announces national service agreement with Dental Fix Rx Darby Dental Supply, LLC, all-telesales distributor of dental products, recently formed a partnership with the Dental Fix Rx, service franchise, to bring dental equipment service and repair to their customers. Scott Walsh, Vice President of Sales at Darby Dental Supply, said, “Partnering with expert technicians at Dental Fix Rx provides the services that our customers want and need, while allowing us to continue to offer products at more competitive pricing without carrying the fixed expense of an in-house team of service technicians.” Darby expanded its capital equipment offerings a few years ago, after redefining its overall business model. Richard Kelstein, Darby’s National Equipment Sales Manager added, “We have had ongoing discussions with manufacturers and are working to expand new and existing product lines now that we are partnering with Dental Fix Rx to provide direct service and repair to our customers.” For more information about all Darby services and products, visit www.darby.com. For more information about Dental Fix Rx franchises and services, visit www.dentalfixrx.com

EVENT NEWS llllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll Sir Richard Branson to deliver keynote address during SIROWORLD event Dentsply Sirona, Inc., The Dental Solutions Company™, enlisted business magnate and Virgin Group founder Sir Richard Branson to speak at SIROWORLD in Orlando, Florida, in August. Branson, who is listed on the Forbes “World’s Billionaires” list, will engage the SIROWORLD audience with his tale of success, technological innovations, philanthropic efforts, and the conflicts and triumphs of his journey. In addition, Grammy-Award nominated band, OneRepublic, will perform a private concert on Friday evening, August 12. SIROWORLD is Dentsply Sirona’s 3-day educational event in which thousands of doctors are expected to gather to attend inventive breakout sessions, benefit from copious networking opportunities, and relish in the astonishing entertainment planned throughout the event. Register for the event at www.siroworld.com

62 Orthodontic practice

Motion View Software, LLC, sponsors conference with the Andrews™ Foundation and Henry Schein® Orthodontics This first-ever Joint Orthodontic Conference sponsored by Motion View Software, LLC, the Andrews™ Foundation, and Henry Schein® Orthodontics took place at The Point Orlando Resort in Orlando, Florida, April 27-29. This event debuted the automated Six Elements module developed by Motion View, along with demonstrating other tools and strategies that can transform the work of attendees in their own practices. Motion View demonstrated the benefits of using its groundbreaking system including 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. Demonstrations also included how to use the Ortho Insight 3D™ software to create treatment plans with transfer trays for more precise positioning of brackets, to customize appliances such as retainers and aligners, and to create surgical guides for implants and surgical splints. With powerful tools in 3D modeling, 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. For more information, visit http://motionview3d.com/.

Volume 7 Number 3

Up to

The Great Lakes Association of Orthodontists (GLAO) and Middle Atlantic Society of Orthodontists (MASO) have planned an exciting and stimulating learning experience for orthodontists and their staff! Speakers include: Dr. Dan Bills, Ms. Joan Garbo, Dr. Christian Groth, Dr. Uche Odiatu, Dr. Jae Park, Dr. W. Eugene Roberts, and Dr. Ron Roncone. An exhibit hall will be available, in addition to multiple networking and social opportunities!

CEUs

The 2016 GLAO/MASO Annual Session will be held at the elegant, historic Arizona Biltmore, a Waldorf Astoria Resort, in Phoenix. The Arizona Biltmore has been recognized as one of the best hotels in the world for their luxury hotel accommodations. An Arizona landmark since opening in 1929, this resort is nestled in the heart of the Phoenix Camelback Corridor. Register Now to join your colleagues and their families at the beautiful Arizona Biltmore as we Connect, Grow and Energize, in the Valley of the Sun!

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