Orthodontic Practice US July/August 2016 Vol 7 No 4 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews July/August 2016 – Vol 7 No 4

PROMOTING EXCELLENCE IN ORTHODONTICS Airway orthodontics the new paradigm: part 2, a vision for the future

Facial asymmetries Dr. Bradford N. Edgren

Dr. Barry Raphael

Reframing orthodontics: Ortho 3.0 Dr. Rohit C.L. Sachdeva

Is your retirement plan strategy due for an annual checkup? Tom Zgainer

Corporate profile 3Shape Digital Orthodontics

Practice profile Dr. Blair Adams

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1. Fracture Strength of Ceramic Bracket Tie Wings Subjected to Tension Gerald Johnson, DDS; Mary P. Walker, DDS, PhDb; Katherine Kula, DDS, MSc Angle Orthodontist, Vol 75, No 1, 2005 2. G. Scuzzo, MD, DDS, K. Takemoto, DDS, PHD, Y. Takemoto, DDS, G. Scuzzo, DDS, L. Lombardo, DDS. “A New Self-Ligating Lingual Bracket with Square Slots”, Journal of Clinical Orthodontics, Volume XLV, No. 12 (2011): 682 - 683. 3. John. H. Hickham, D. M. (1993). Predictable Indirect Bonding. Journal of Clinical Orthodontics, 215-218.

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INTRODUCTION

Indirectly speaking

July/August 2016 - Volume 7 Number 4 EDITORIAL ADVISORS Lisa Alvetro, DDS, MSD

f you know me, you’ll know that I’m not shy. I say what I think — admittedly sometimes too soon — but rarely with regret. I will say that “I’m sorry” has become a key phrase in the longevity of my marriage. Just keep moving forward. That’s why some of you who know me in our world of orthodontics are often surprised that I’m a firm practitioner of digital indirect bonding. “It’s a hassle.” “It takes to much chairtime.” “I never really have gotten the hang of it.” Yes, I’ve heard it all, and yet, I persist. It’s all or nothing when it comes to bonding for me. “Why?” you ask. The answer is simple. It’s the most precise way I know to position brackets on my patients’ teeth. Today’s technology gives me 3D automation that makes it possible for me to quickly evaluate and adjust bracket placement. That means that I’m able to simulate bracket placement digitally prior to placement and get each and every bracket just where I want it on the teeth. I just can’t convince myself that placing one bracket at a time is more pleasant for the patients, either. Mine frequently express their surprise at how easy it was. They regard me as an artist — in my mind, anyway. You are probably thinking that there has to be a downside. Yes, there is lab work involved in preparing the setup, which can take 10 days to get back. You’re thinking that all that kid’s parents have to do is drive down the street to the next office and get some brackets on their kid’s teeth right away. You’ll never see them again. But that’s not how it works, at least, not for me. Every patient or parent of a patient who sets foot in your office wants the best treatment possible. The placement accuracy, the comfort of the process, and the reduced office visits — it’s an easy case to make. (Don’t take this personally, but most of my patients would rather be someplace else than in their orthodontist’s office.) To my knowledge, I’ve never lost a patient because I use indirect bonding. Not one. I think perhaps the most powerful aspect for the patient of digital indirect bonding is the technology. I know it is for me. The simulation software gives me the ability to anticipate potential interferences before they happen, puts the brackets perfectly where I want them, and still allows for adjustable bracket and tooth positioning. My suggestion is that you try a digital indirect case or two. I think that both you and your patients will be pleased.

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 Bradford N. Edgren, DDS, MS 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

Edward Y. Lin, DDS, MS, is a partner of Orthodontic Specialists of Green Bay (OSGB), a private group practice in Green Bay, Wisconsin. Dr. Lin received both his dental (DDS) and orthodontic (MS) degrees from Northwestern University Dental School. OSGB is a completely digital practice and has been utilizing suresmile® for 10 years at three different practice locations. Dr. Lin converted his practice to a 100% suresmile practice in February 2007 and has not looked back. With more than 3,000 suresmile and suresmile lingual cases completed, OSGB was recognized for Top Case Finishes in 2014.

2 Orthodontic practice

© 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 4

Practice Growth. Patient Satisfaction. MTM Clear•Aligner is the simple, cost–effective esthetic treatment for correcting the minor anterior misalignments seen in up to 50% of your patients.*

MTM® Clear•Aligner can be used for making cosmetic enhancements, correcting orthodontic relapse, preparing for restorative procedures and/or finishing other orthodontic treatments. Easy to integrate into any practice. MTM® Service Center accepts iTero®, Carestream, 3M™ True Definition, Cerec® and 3Shape® Trios Digital Intraoral Scans. Unlimited aligners**, one free refinement and reduced chairtime give you a predictable, low operating cost.

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To learn more about MTM ® Clear·Aligner, visit mtmclearaligner.com or call 1.888.898.4mtm(4686)

* Proffit, W. (1998). Prevalence of malocclusion and orthodontic treatment need in the United States: estimates from the NHANES III survey. International Journal of Adult Orthodontics and Orthognathic Surgery, 13(2), 97-106. **Initial treatment plan and first refinement, if needed. RTE-004-16 Issued 1/16

TABLE OF CONTENTS

Financial focus Is your retirement plan strategy due for an annual checkup? Tom Zgainer discusses the benefits of reviewing your 401(k) plan on a regular basis.....................................18

Practice profile Blair Adams, BSc, DDS

Enjoyable, efficient, effective, excellence

Case study Early intervention in a case of severe mandibular retrusion Drs. German O. Ramirez-YaĂąez and Carlos M. Mejia-Gomez discuss intercepting developing malocclusions as early as possible to reduce the risk of more complicated treatments .......................................................20

Orthodontic concepts

Corporate profile 3Shape Digital Orthodontics Digital solutions for the orthodontic practice 4 Orthodontic practice

Reframing orthodontics: Ortho 3.0 Dr. Rohit C.L. Sachdeva discusses the eight major forces shaping the future of orthodontics.................................22 Volume 7 Number 4

The Mastery of Movement Introducing New BioForceÂŽPLUS NiTi Archwire Nickel titanium BioForce PLUS archwires feature a graded thermodynamic formulation, starting with low, gentle forces for the anteriors, increasing in the posteriors and plateauing in the molar regions. Three force zones, delivering gradually increasing forces from the anterior to the posterior Ability to enter the working stage earlier, in many cases eliminating a wire from your sequence Near constant force designed for a comfortable treatment experience Superelastic to express even the most extreme bends Heat activated for ideal workability at room temperature Designed to take displacements up to 90o without permanent deformation Higher capacity for stored energy than beta-titanium or stainless steel wires Available with IonGuard to reduce friction Ask your DENTSPLY GAC representative about new BioForce PLUS, the most expressive archwire we have ever created.

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TABLE OF CONTENTS

Continuing education Airway orthodontics the new paradigm: part 2, a vision for the future Dr. Barry Raphael discusses how added exercise protocols can help correct common problems related to facial and oral function..................35

Abstracts Abstracts • Accuracy and reliability of Dolphin 3D voxel-based superimposition • Screw-type device diameter and orthodontic loading influence adjacent bone remodeling • The effects of corticotomies on frontonasal suture expansion and bone modeling in mature rabbits ....................................................... 40

Step-by-step Scanning with CEREC Ortho for clear aligner treatment Dr. Peter Gardell outlines the steps in a process for taking digital impressions for use with clear aligners................ 42

Laboratory link

Continuing education Facial asymmetries

Dr. Bradford N. Edgren discusses the importance of diagnosis and treatment of facial asymmetries

Product profile 3M — A system of proven products

PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com

A beautiful smile throughout treatment ....................................................... 46

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

Product profile Avex® CX2 brackets by Opal® Orthodontics ....................................................... 48

Materials & equipment.........................50 Industry news................52 Small talk

Digital indirect bonding

Practice integrity: fulfilling the promise

James Bonham describes how CAD technology delivers precision bracket placement....................................... 44

Dr. Joel Small discusses a strategy to create and maintain long-term success ....................................................... 56

6 Orthodontic practice

MANAGING EDITOR | Lou Shuman, DMD, CAGS Email: lou@medmarkaz.com 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 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 www.orthopracticeus.com | www.medmarkaz.com SUBSCRIPTION RATES 1 year (6 issues) 3 years (18 issues)

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Volume 7 Number 4

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PRACTICE PROFILE

Blair Adams, BSc, DDS Enjoyable, efficient, effective, excellence What can you tell us about your background? I have a busy, single-doctor orthodontic practice in the eastern suburbs of Ottawa, Canada, a mere 5 miles from where I grew up as a child. When I was young, I was always fascinated by science. I read biographies of great scientists such as Newton, Galileo, Einstein, and da Vinci, and I used my chemistry set to create large smells and small explosions. In grade school, my best friend’s father was a periodontist. He encouraged us to consider dentistry as a career, so that option was always somewhere in the background of my career planning. Also, my high school skiracing coach was a dental student. When he told me, “Hey Blair, you know, dentists take Fridays off to go skiing,” that was enough for me! Done deal; sold to the highest bidder! It may seem a frivolous way to have chosen a career, but these personal considerations are often the points on which destiny turns. After doing an honors BSc in Biochemistry at Ottawa’s Carleton University, I found myself in dental school at Western University in London, Ontario. (Sadly, no skiing to be had there!) In dental school the course that interested me was orthodontics. Much of my free time was spent observing things at the Orthodontic Graduate Department. But a larger part of my free time was spent with a wonderful girl named Joselyn. The day after my dental school graduation, Joselyn and I were married in Oakville, her hometown just outside of Toronto. For our honeymoon, we spent 2 weeks driving to Vancouver, where I worked as a general practice dentist and Joselyn, a kinesiology grad, worked in the Vancouver fitness industry. We spent as much time as possible skiing at Whistler. (Are you starting to notice a theme here?) Two years later, just after we had bought our first home, each of us arrived home with some big news. 8 Orthodontic practice

Dr. Blair Adams

I had received a letter accepting me to the Graduate Orthodontic Program at Tufts University, 3,000 miles away, in Boston. And Joselyn had been given the wonderful news that she was pregnant! We were stunned! We went out to a nice restaurant and just sat there in shock! What to do? Reluctantly, we sold the cute little house we really loved and moved to Boston. Boston was a big surprise. We didn’t know much about it, so we didn’t know what to expect. Boston is a wonderful city with so much culture and history, and the people are so nice. We loved it! I started the Ortho grad program at Tufts in August. In October, our wonderful baby, Nicola, was born. Nicola is our only and most favorite child. She is now a third-grade teacher. As I am writing this, Nicola has just sent me the ultrasound

image of her new baby! We’re going to be grandparents! We had a wonderful time in Boston. Dr. Everett Shapiro, head of the Tufts Orthodontics Department, was loved and respected by all and ran a very happy program. Joselyn was not eligible for a work visa, so she spent her time learning early childhood education — Boston has so many great resources for that. My message to young people having children — get Burton White’s book, The First Three Years of Life. At the end of each chapter, there’s a cheat sheet for fathers. I found it extremely helpful. The spring before I graduated, we had so much rain in Boston that we decided not to go back to Vancouver. Some people feel it rains excessively in Vancouver. Instead, we chose to go to my home town, Ottawa, so we could be closer to Nicola’s grandparents. Volume 7 Number 4

What do you think is unique about your practice? Digital diagnostics — we are the only Ottawa orthodontic practice using computerscanning technology to straighten the teeth “in the computer world” before we put on the braces. Image-guided orthodontics, combined with 3D treatment planning, is like the GPS in your car. It allows me to predict and avoid potential pitfalls that could occur in treatment. We achieve our treatment goals more directly and quickly, with less stress and more comfort.

As a side note, I am beta testing an entirely new self-ligating bracket and archwire system developed by Dr. Rohit Sachdeva, and I hope to present the results shortly.

What training have you undertaken? I am a committed lifelong learner. Also, I encourage the ethos of a learning organization in my team. I am an ardent believer and practitioner of reflective learning as well. As recently shared with me by Dr. Rohit Sachdeva, this zest for learning is best described in the words of Ryan Hoover — “It’s the wanting that makes you a learner. That’s what absorbs you. That’s what makes you lose track of time, overcome fear, build grit, knowledge, and grow. Learning happens when you are not aware of it. It’s the wanting that makes you a mother, an inventor, a friend, a learner. When you look back at yourself 6 months from today and don’t

What systems do you use? Let me start by answering this at the macro level. I am a firm believer in “systems-based” thinking. When systems are implemented in any process, the power of teamwork is amplified to produce superior patient care that is consistent and patient-centric. Now, at the micro level, if we are thinking of systems of “orthodontic therapeutic devices,” I use self-ligating .022 brackets. I’ve been using these exclusively in my practice for the last 10 to 12 years. In about 70% of patients, I use active clip brackets like the DENTSPLY GAC InOvation®, American Orthodontics Empower®, and Ormco Nexus™. I like the way the active clip controls rotations and allows me to correct torque. We use passive self-ligation such as the Ortho Classic H4™ and Ormco’s Damon® brackets in about 30% of our cases. The low-friction mechanics and early use of light elastics allow me to achieve beautiful non-extraction, nonsurgical treatment no one would have dreamed of 20 years ago. We also use these techniques in our Phase I cases to create amazing, beautiful nonextraction changes for 7- to 9-year-olds. Volume 7 Number 4

feel embarrassed by your naiveté, there’s a problem. That means you’re not learning, growing …” Any learning that make me a better person or a better doctor allows me to make a difference in my patients’ lives. Their orthodontic care experience is improved. That will always be worth my investment in time and effort. I love to visit an excellent clinician who gives a course in his/her own office for a few days. When you can spend time in someone else’s own environment and hangout in the evening having informal, far-ranging discussions long into the night, that’s when the real learning takes place. That is the way I learned the Herbst techniques of Dr. Terry Dischinger, which have been indispensable for many years. This allowed me to dispense with using the “headgear,” something that always gets a huge vote of appreciation from patients and their parents. Dr. Bill Arnett’s in-office surgery course is one of the best courses I’ve ever taken. I persuaded our own surgeon, Ottawa’s Dr. Kevin Butterfield, to take this course, and now, together, we produce beautiful, stable results for our patients with more severe problems that can only be dealt with by combining orthodontics with facial surgery. I am also trained to provide care for those suffering from sleep apnea.

Who has inspired you? Recently, we were in Toronto, listening to a speaker talk about gratitude. We have so much to be thankful for. We get caught up in our daily lives and rarely take time to appreciate what we have. At the same time in Toronto, we were watching the unfolding tragedy of the burning of Fort McMurray.

Adams Orthodontics in Ottawa, Canada Orthodontic practice 9

PRACTICE PROFILE

Orthodontics is an immensely rewarding career. It involves the right brain and the left brain. Smile design is art and architecture. Creating harmonious occlusion is the science of applied biophysics, an engineering project in miniature. Spiritually, as the Buddha advised, it is “Right Occupation.” We help people to get what they want, and we spread the joy of smiles around the world. Our love of our profession and the patients we serve encourages us to continuously pursue the path of mastery. The joy of watching our young patients grow in confidence as we sculpt their beautiful new smiles is truly heartwarming.

PRACTICE PROFILE We were inspired to be thankful for the wonderful neighbors we have, the dependable team we work with, and the people we serve and care for on a daily basis. We were inspired to be grateful for having clean water and a place to sleep. Not everyone has that. It’s not automatic. Creating beautiful smiles is a favorite conversation topic with our patients and their parents. The techniques I’ve learned from Drs. Tom Pitts and Duncan Brown in their Masters Continuum course have made differences that people really notice. They love the results. Dr. Rohit Sachdeva is my coach. If Wayne Gretzky could benefit from having a coach, I believe every high-level professional can benefit from having a coach. Over time, daily routines can lead to complacency and overconfidence. Rohit’s insightful perspectives on life in general and orthodontics in particular have awakened my awareness of new horizons in patient care and practice management. Our intensive, weekly, Adams Orthodontics staff 2- to 3-hour Skype sessions smiles for our patients by using the best of dissect every facet of patient care in my the newest in image-guided orthodontic practice. technology. Last year, we won both the Rohit has shown that solutions to the Consumer’s Choice award and Faces most complex problems can be found by Magazine Award for best orthodontic office investing time in proactive planning. The key in Ottawa and surrounding area. lies in reduction of complex interactions to It just wouldn’t be possible to do this the fundamentals of applied biomechanics. without our team. They are truly indispensable. Rohit fondly calls this the “pre-mortem.” I Eleven years ago, we built a beautiful truly believe he has awakened hidden talents 5,000-square-foot orthodontic care center, within me. expressly designed to have a homelike atmosphere. We spend a large proportion of our What is the most satisfying aspect time there, and we wanted our patients and of your practice? their families to feel as though they have been Watching our patients grow up and go invited into our home. out into the world armed with one of the best I am truly blessed to have this great team success tools you can give someone — a creating gorgeous smiles with me in such a beautiful smile. We know many of them from beautiful environment. age 7 to 17. It’s wonderful. And then 10 or 15 years later, they’re What has been your biggest back with their own little 7-year old. The circle challenge? of life. Like most orthodontists, I’m sure, our Pretty cool, n’est ce pas? biggest challenge is assembling an outstand-

Professionally, what are you most proud of? Adams Orthodontics is a team of skilled professionals dedicated to “Patient First” care, guided by the principles of servant leadership. We are known for providing empathetic care and designing personalized 10 Orthodontic practice

ingly talented team. Training and retaining wonderful people who can routinely deliver memorable patient care experiences is a constant, daily project. Everyone has individual strengths and weaknesses. Nurturing the strengths and finding others to fill in for the weaknesses can be like conducting a symphony orchestra.

We made custom mouth guards for this patient’s hockey team. His father told me that, as a result, the players could communicate more clearly as they were playing. He felt this played a significant part in helping them to win their division for the season

What would you have become if you had not become a dentist? Architect or engineer. My parents’ worst nightmare was ski bum!

What is the future of orthodontics and dentistry? There have always been and always will be issues that raise concerns with regard to the integrity of dentistry as a whole and the safety of the public. As the French say, the more things change, the more they stay the same. Personal integrity, mastery of clinical skills, and systems that provide service excellence are the keys to success and fulfillment in any field. Focus on the pursuit of excellence. We strive to provide “An Experience of Enjoyable, Efficient, Effective, Excellence.” There will always be clients who seek out and appreciate this level of service. There will always be those who seek the best in esthetic results and long-term healthy function. These are the people we want to serve. This is what makes us feel good at the end of the day. Research into why people don’t adequately plan for their retirement discovered that many people have a “disconnect” between their “present selves” and their “future selves.” Subjects who were shown an image of themselves that had been aged to look as they would far in the future consistently increased the amount of money they intended to save for their retirement. The researchers concluded that subjects who Volume 7 Number 4

Designed by Orthodontists, for Orthodontists Priced lower than most competitors’ sale pricing Extreme Versatility. Exceptional Control. The EasyClip+® Systems can be used as fully passive, fully interactive, or a combination of both. This hybrid approach enables you to use both passive and interactive brackets, offering a variety of treatment options.

THOUGHTFUL DESIGN • • •

Familiar twin design / spacious tie-wing undercuts if ligation is needed Ultra low profile, rounded corners, provide maximum patient comfort Torque in base for level slot line up and improved finishing

Passive (Flat Tab)

TOTAL CONTROL Mesial-to-distal coverage offers total rotational control

PROVEN RELIABILITY

EASY POSITIONING

Thermal NiTi Clip will not deform or degrade for the life of the treatment

V channel for easy positioning and visual reference - unlike competitor brackets that do not have a reference on the vestibular base.

SUPERIOR BONDING

Interactive (Curved Tab)

Mushroom-shaped pylons provide up to a 40% stronger bond

MANY OPTIONS & CHOICES

Lever action opening of the clip offsets forces for patient comfort - no special instruments required. To close, use a utility plier, tweezer, or fingertip. Audible ‘Click’ when closing the clip. Opens easily using an explorer.

Passive Interactive Interactive & Passive MBT

• • • •

Roth Damon Low Damon Standard Damon High

Great Lakes’ version of the Damon, Roth, and MBT prescriptions. Does not imply endorsement by the doctor. Damon is a registered trademark of Ormco Corporation.

SMPP586Rev062116

EASY TO OPEN & CLOSE. STAYS SHUT

• • • •

PRACTICE PROFILE felt more “connected” to their “future selves” demonstrated more responsible behavior. Achievement of beautiful, healthy orthodontic results requires the full participation of a committed, educated patient who has a supportive, helpful family. Orthodontics is a

Top 10 favorites 1. My brilliant, beautiful wife and daughter and Quito our 6-year-old Sheltie. 2. Skiing in deep snow. My daughter tells me I’m a snow snob. 3. Continuing education. I love learning new techniques I can use to create better smiles. 4. Hiking up a mountain or cycling down a mountain on a beautiful, sunny, cool day. 5. Spending time with brilliant thinkers. Learning from the best in my profession has given me a network of deep friendships that brings fulfillment and support. 6. Music — rock, classical, folk, jazz, country. Good music stirs the soul. 7. Photography — never leave the house without a camera! 8. Reading. Thirty minutes with a great book at the end of the day takes me to a different world. 9. Mont Tremblant any time of year except the month of May — bug season! 10. That beautiful smile on the faces of our patients and their parents when the braces come off. It’s fun to get braces, but it’s way more fun to get ‘em off.

team sport. There will always be those who don’t plan for the future and merely wish to avoid pain and expense in the here and now. These are not people we can count on to be part of the team. There is a place in the world for “emergency dentistry.” There is no “emergency orthodontics.” (Except for crossbites and associated cr-co shifts that are causing gingival destruction.)

What are your top tips for maintaining a successful practice? • Let your patients and their families know that you and your team are there for them. • Do “whatever it takes” to provide a first-class experience and first-class results. • Keep your facility up-to-date. Provide a warm, welcoming environment for your patients, their families, and your team. • Train, train, train. Help your team learn to provide a consistently excellent customer service experience. Read the book The E-Myth Physician by Michael E. Gerber. • Stay current on the “best of the newest” in orthodontic techniques and technology. • When hiring staff, hire for “nice.” You can train people to make appointments and bend wires. You can’t train people to be nice. People are “born nice.”

What advice would you give to budding orthodontists? When I told my family dentist that I had been accepted into dental school, he told me — “Don’t make patients of your friends. Make friends of your patients. Get to know them and their families.” You won’t be busy from Day One. Go out and meet every single dentist within 10 miles. Find out what kind of dentistry they want their patients to have, and how they want their patients to be treated. Communicate on a regular basis with all dentists who trust you to care for their patients. They are the contractors; we are the sub-contractors. They need to know what’s happening. Take photos of every patient at every visit. Get into this habit before you get busy. It will save you years of chairtime. When things go off track — and they will — these photos will tell you when it happened, and how to prevent it from happening again. Experience is the ability to recognize a mistake when you make it again. We all make mistakes. Get over it, and learn from them. You can’t provide excellent customer service without learning to manage a business. Dr. Ron Roncone’s JSOP Orthodontic Management course is the best there is. Take it. Dr. David Sarver’s facial esthetics course is the best. It doesn’t happen often. Grab it! Invest in a clinical coach to sharpen your focus on the pursuit of excellence. I have found Dr. Rohit Sachdeva to be one of a rare breed. He has transformed my approach to orthodontics and my perspective on life.

What are your hobbies, and what do you do in your spare time? Spare time? What’s that? See favorites list. OP

ESLO dinner at Lake Como. (left to right) Dr. Ron Roncone, his wife, Elizabeth; Dr. Blair Adams,his wife, Joselyn; Dr. Bren Bankhead, and his wife 12 Orthodontic practice

Joselyn and daughter Nicola and Dr. Adams. Nicola sings with the Ottawa Bach Choir, a world-class choir. We were in Italy for the European Society of Lingual Orthodontics meeting Volume 7 Number 4

SMPP587Rev062116

CORPORATE PROFILE

3Shape Digital Orthodontics Digital solutions for the orthodontic practice

rthodontics is racing into the digital era faster than most anticipated. Industry professionals agree that the trend will only accelerate. There are many reasons. The clinical and patient benefits of going digital have become so well documented that the only reason not to use the technology is lack of resources, which is understandable. But for orthodontists and orthodontic labs alike, ROI studies and testimonials from colleagues and patients should help offset financial concerns. When Italian orthodontist, Dr. Santiago Isaza Penco, discussed CAD/CAM’s impact on his practice, he summed it up: “Now anything is possible!”

Creating the digital patient Digital technology provides doctors and labs with a unique, all-encompassing, and predictive view of their patients. In essence, you now create the digital patient. Using software like 3Shape Ortho Analyzer™, orthodontists and lab technicians can merge CT/CBCT data, intraoral scans, X-ray panoramics, cephalometric tracings, and photos with digital models. Enabling professionals to take what were once separate steps in the workflow and melt them into a more comprehensive single step and process: digital patient analysis, treatment planning and monitoring, and orthodontic appliance production — are all achieved onscreen.

Choose treatments like Invisalign® with just a click And because you are now working digitally, your team shares treatment analysis, planning, monitoring, and even applianceproduction effortlessly between the lab, orthodontist, and when relevant, the patient. For example, doctors using TRIOS® who choose an Invisalign treatment for their patients can simply just pick Invisalign from the drop-down menu list of orthodontic solution providers in TRIOS’ software and click to send the case. This is synergy driven by digital technology that makes the entire orthodontic workflow more efficient and more 14 Orthodontic practice

TRIOS Battery-Powered Cart model

effective. TRIOS case submissions to Invisalign will be available from Q4 2016.

Digital improves your workflow When discussing the clinic-to-lab workflow benefits of going digital, the aforementioned Dr. Penco says, “Communication between a lab and orthodontist is very, very important. In Italy, labs must build all orthodontic appliances, so the cooperation between the two is extremely important. In the old days, our lab partner would come to my office every 2 days from hundreds of miles away to pick up and check models and design appliances. Now this is no longer necessary — everything is done in real time, digitally. “Just 2 years ago, we were still sending traditional impressions. It would take 3 to 4 weeks to have the appliance designed and shipped back. Now it only takes 2 to 3 days for a retainer. This is a tremendous change!”

Digital promotes patient buy-in Achieving patient buy-in is obviously important to any orthodontic practice. But an interesting and rarely discussed benefit of using digital technology is its impact on young people: an orthodontist’s biggest customer. As Dr. Penco points out, “The majority of my patients are young people, which is great because they are also the best for marketing our work. They go on our Facebook page or website and watch the videos. They want to see our intraoral scanner (3Shape TRIOS) because they have seen videos about it. “With children, it has always been difficult to take traditional impressions. Having TRIOS has made it much easier. I also discovered, if I switch off the lights, the children watch the screen when I scan. It’s a show. We both can relax and take our time. Like adults, it is important for children to see everything. In that way, they are convinced about the treatment from the start.” Volume 7 Number 4

even bring the parents in during diagnosis, show the scans, and describe the treatment. Patients believe that because I am using new technology when I demonstrate the treatment, I will deliver better results. When the patient understands where we can put the tooth to achieve the best results, it becomes very important information for them. It makes the patient’s decision easier and the whole process go faster. They can go home and make a decision based on knowing what the treatment will entail. They accept it. And the reason they accept it is because of digital scans and treatment simulation.” Young people are digital by nature; it make sense to involve them digitally in their treatment.

TRIOS® digital color impressions The tagline — making a great first impression — may apply to orthodontics more than any other branch in dentistry. There are numerous benefits to using intraoral scans within orthodontics. The Austin Journal of Orthopedics & Rheumatology recently listed what it considered the advantages were in an article, “Intra-oral Scanners: A New Eye in Dentistry.” For the orthodontist, advantages of digital scanning include improved diagnosis and treatment planning, increased case

acceptance, faster records submission to laboratories and insurance providers, fewer retakes, reduced chair time, standardization of office procedures, reduced storage requirements, faster laboratory return, improved appliance accuracy, enhanced workflow, lower inventory expense, and reduced treatment times. Benefits to the patient include an improved case presentation and a better orthodontic experience with more comfort and less anxiety, reduced chair time, and easier re-fabrication of lost or broken appliances, as well as potentially reduced treatment time. The advantages of intraoral scanning are exactly what make 3Shape’s TRIOS intraoral scanner your right choice too. TRIOS separates itself from the pack because of the award-winning intraoral scanner’s documented accuracy, speed, RealColor™ digital color impressions, automatic occlusion capture in real time, and never a need for powder. Plus TRIOS and 3Shape Orthodontics continue to create more and more integrations with global orthodontic solution providers like Invisalign®, Incognito, and many more, making it easy for orthodontists and GPs to pick and choose the right treatment for their patients from TRIOS’ long list of partner integrations. And because the integrations are cloud-based, doctors can share cases with solution providers and TRIOS® Ready labs with just a click from within the TRIOS software.

Digital model production

TRIOS Pod model Volume 7 Number 4

The practice of digital model-making is surging forward as better digital impression systems, new CAD software, and improved manufacturing technologies create digital model-making solutions at lower costs with higher accuracy and increased efficiency. For orthodontic labs, providing digital model-making as well as digital archiving services have now become revenue generators. As orthodontists are required by law to keep models of their patients, digital models provide them with a regulatory compliant, space, and cost-saving alternative to storing gypsum models. Dr. Carlo Marassi discusses what digital model-making has meant to his practice, “I have been practicing orthodontics for more than 20 years now, and by law, we have to keep our case records for 10 years. We rent another office just to store all our gypsum models. 3Shape technology is now enabling us to digitize all our models and Orthodontic practice 15

CORPORATE PROFILE

Brazilian orthodontist, Dr. Carlo Marassi, elaborates: “Digital orthodontics makes it easier for us to communicate with patients. It’s great to have a 3D image of the patient’s occlusal situation and to show this to the patient during clinical examinations. Showing the 3D model makes it much easier to describe problems and treatments because most people do not know what occlusion means or have never even seen their own posterior teeth. “Patients don’t know what a crossbite, or other orthodontic problems, look like. When you can show the patient a 3D image, including occlusion already from the first visit, it helps their understanding of the problem and its treatment options. This understanding also helps motivate them towards taking the next step in treatment.” Italy’s Dr. Penco agrees: “Patient compliance is very important in orthodontics and medicine, in general. When you are convinced that you need an orthodontic treatment, you cooperate. But you need tools to explain the treatment with. That’s where the TRIOS intraoral scans are invaluable. They make it easy. When your patient understands what you can do to solve the problem, they cooperate. Communication is key. In fact, with the scans and software, I can simulate my proposed treatment. I can

CORPORATE PROFILE close our special storage rooms. This will save us money, not to mention the time and manpower it takes to maintain a physical storage system.” He adds, “Gypsum models are typically fragile and can break, and then you simply lose the case information. This can’t happen with digital models. Naturally, we back up our digital archives like any critical IT system. But the option to create digital models makes the whole matter of archiving cases cheaper, more efficient, and more robust.” 3Shape orthodontic solutions enable you to create digital study models from alginate impressions and plaster models as well as digital intraoral scans.

CAD-designed digital appliances CAD-designed orthodontic appliances are nothing new. Global orthodontic solution providers use state-of-the art digital technology to create treatment solutions on an assembly line scale. Up until recently, that amount of programming power and connectivity was unavailable to ordinary orthodontic labs — at least not at an affordable price. The development of our Ortho Analyzer™ and Appliance Designer™ solutions have made analysis, treatment planning and appliance design simpler, repeatable, faster, and affordable for smaller labs. Orthodontic labs using CAD/CAM software like Appliance Designer can now design and manufacture with the same accuracy and efficiency as the global orthodontic solution providers. From clear aligners, night guards, and retainers to splints, Herbst appliances, and more, labs can essentially design any type of orthodontic appliance. Depending on their CAM equipment, they can manufacture the appliance themselves or outsource the production. This cuts delivery time down from weeks to days and hours. And it makes it possible for smaller orthodontic labs to offer competitive services to global orthodontic solution providers. Throw into the mix new generation 3D printers that make it affordable to print 3D models as well as fabricate orthodontic appliances, including retainers, metal appliances, aligner technology, and indirect bonding, and it makes CAD/CAM an indispensable asset for orthodontic labs.

“Digital being better would be stating the obvious” According to Australian orthodontic lab owner, Ari Sciacca, “CAD/CAM has enabled my lab to do things virtually and streamline and/or eliminate laborious processes like 16 Orthodontic practice

Digital technology provides doctors and labs with a unique, all-encompassing, and predictive view of their patients. In essence, you now create the digital patient.

duplicating models, cutting out teeth, and doing them in wax.” He adds, “Digital being better would be stating the obvious.” Italian Orthodontic Laboratory, Team Orthodonzia Estense’s owner, Stafano Negrini agrees, saying, “CAD/CAM has enabled us to compete against bigger labs. We can provide everything from digital study models, digital archiving, to planning and manufacturing. And we can do it quickly. Going digital means that the work we do is now virtual. We can edit, save, share, and even remake a patient’s appliance with just a click. It’s a much more effective way to work.”

Digital treatment monitoring Perhaps no other area in orthodontics benefits more through digital technology than patient treatment monitoring. Intraoral scans can be compared side-by-side to precisely monitor and document tooth movement, the oral situation, and the treatment plan. Digital technology also enables orthodontists and labs to virtually debond brackets and compare the current patient situation with their treatment plan. Because of this, more and more orthodontists and labs are using 3Shape orthodontic software to digitally remove and place brackets on virtual models to save their patients visits and to better ensure that treatment plans stay on the right track. Doctors and labs can simulate orthodontic treatments like extractions, interproximal reductions, the constraints, and full details of tooth movement digitally. If you combine this with using virtual articulators to optimize occlusion in real time, the benefits of digital technology are just too powerful an opportunity for professionals to ignore. Digital technology has changed the way we live. Orthodontics maybe its greatest benefactor. While not practicing in the orthodontic branch, leading prosthodontist and 3Shape-user, Dr. Jonathan L. Ferencz, sums up the digital advantage best: “My patients get it. My staff gets it. I get it. Go digital!”

Orthodontic solutions for practices TRIOS® digital color impression solution TRIOS® intraoral scanner features RealColor™ intraoral photographs to enable orthodontists to create high-quality digital impressions in lifelike colors as well as capture the bite automatically in real time. TRIOS’ speed and accuracy helps orthodontists to save time, see more patients, and digitally archive cases to save storage space. TRIOS is integrated with many leading orthodontic solution providers like Invisalign®. The easy-to-use digital color impression solution features a removable autoclavable tip and comes in a pen grip design, handle grip, and chair-integrated versions. 3Shape orthodontic treatment planning and analysis software enables orthodontists to integrate all patient data, including IO and CBCT scans, to improve diagnostics, patient comfort, and treatment acceptance

Orthodontic solutions for labs 3Shape orthodontic treatment analysis and planning and appliance-design software help labs to attract new customers and expand the services they offer. Coupled with 3Shape’s complete range of lab scanners, orthodontic labs can now create and archive digital study models as well as digitally plan treatment and design and manufacture orthodontic appliances.

3Shape orthodontic lab scanners 3Shape delivers a full range of orthodontic lab scanners from the industry’s most powerful, R2000 all-in-one scanner with simultaneous two-model scanning, to the entry-level R500. All 3Shape lab scanners are ISO-documented accurate and provide industry-leading speed. Importantly, lab scanners are the perfect tool for digitizing orthodontic gypsum study models. For example, this enables labs to lease their lab scanners to orthodontic practices for digitizing models. OP This information was provided by 3Shape.

Volume 7 Number 4

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FINANCIAL FOCUS

Is your retirement plan strategy due for an annual checkup? Tom Zgainer discusses the benefits of reviewing your 401(k) plan on a regular basis

egular maintenance regarding our health, be it a twice a year teeth cleaning or an annual physical, allows the experts to determine if we are as fit as we think we are, or see if there might be some issues under the hood that need attention. Likewise, each April, we are reminded of whether our tax planning is sufficient or perhaps needs a tuneup. Similarly, your retirement plan strategy is worth reviewing with a pension plan expert as well. Often the original plan and strategy you implemented get away from your intended individual and corporate goals. Your employee populace may experience turnover, the actual age demographics of your staff may take on a different makeup, and by the way, you are now a year closer to retirement. You can find these changes limit your personal contributions due to required employer contributions or, more positively, open up new opportunities to design a plan that accelerates your personal contributions. Retirement plans — whether a 401(k), profit-sharing plan, a defined benefit, or

Tom Zgainer is CEO of America’s Best 401(k). He has helped over 2,800 businesses obtain a new or improved retirement plan over the past 13 years with a focus on strategic plan design to help achieve individual and corporate objectives. You can learn more at www. americasbest401k.com.

18 Orthodontic practice

a cash balance plan — all require some give-and-take. For owners, principals, key associates, or partners to take advantage of the opportunity to maximize annual contributions, you’ll need to give a proportional amount that passes all the required compliance tests to eligible employees. These employer contributions at first might not be palatable to you and your bottom line. However, utilizing a long vesting schedule — for example up to 6 years — can help ensure an employee needs to stay and contribute to your practice that long to earn any 1 year’s contribution. Plus, you receive the tax deduction benefit of the full amount of employer contributions in the tax year of the contribution, up to 25% of gross payroll. A great reason to go through an annual plan design checkup is to see if there is a better plan type option for you. As you get closer to retirement, generally over age 45, plan types, such as a new comparability profit-sharing plan, a cash balance or defined benefit plan, can be paired with a 401(k) to rapidly accelerate your personal contribution objectives. For 2016, you can defer $18,000 into a 401(k) plan, with a $6,000 catch-up provision if over age 50. That’s generally the best first thing to try and accomplish. If your plan

demographics are suitable, meaning staff is younger than the owners, principals, or partners (HCEs), and you are over age 45, a new comparability profit-sharing plan can provide a maximum benefit for a select employee group, while providing the lowest possible contribution to non-key groups allowed by law. This plan design can help you add to your deferrals and get up to the $53,000/$59,000 maximum annual limits from combined employee and employer contributions. To really accelerate your contributions, consider looking into adding a cash balance or defined benefit plan to the 401(k). Maximum contributions for these plans range from $102,000 at age 45 to $237,000 at age 62. When added to the 401(k)/profit-sharing contributions, it’s like squeezing 20 years of retirement saving into 10, not to mention the significant reduction to your tax liability that you will enjoy. Just as you might make an appointment with your physician or CPA, this is a great time of year to get a retirement plan checkup as well. It’s easy and painless, as a census with your current firm demographics will enable a experienced pension specialist or actuary help determine if there is a better way to proceed into the years ahead for your retirement planning. OP

Receive your retirement plan checkup here: http://americasbest401k.com/medmark. Volume 7 Number 4

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CASE STUDY

Early intervention in a case of severe mandibular retrusion Drs. German O. Ramirez-YaĂąez and Carlos M. Mejia-Gomez discuss intercepting developing malocclusions as early as possible to reduce the risk of more complicated treatments Abstract A clinical case is presented showing a non-syndromic child born with a severely retruded mandible and deep bite. An early intervention permitted improvement of the sagittal and vertical relationships between both maxillaries before the patient enters into the mixed dentition. This clinical case supports the idea that developing malocclusions in children should be intercepted as early as possible in order to reduce the risk of more complicated treatments in the future, as well as preventing other problems that can associate with a deviated or diminished craniofacial growth and development.

Figures 1A-1E

Introduction At birth, the mandible is positioned distal to the maxilla in a sagittal relation.1 The mandible presents a high growing rate over the first year of life,2 improving the sagittal, transverse, and vertical relationships between both maxillaries.3,4 Some children are born with a severely retruded mandible, which makes their face appear as if they had Pierre Robin syndrome but without the cleft palate and glossoptosis characteristic of that congenital malformation. The higher potential for mandibular and maxillary growth has been reported to happen over the first 5 years of life.2,5 Even more, a distocclusion at the primary dentition is going to perpetuate or even worsen through the mixed dentition.6,7 Also, a retruded mandible is associated with a retrusive tongue position.8,9 A child with those conditions is at higher risk of developing sleep-related breathing disorders,10 and therefore, an early intervention in a child with a retruded mandible may be German O. Ramirez-YaĂąez, DDS, Pedo Cert, MDSc, MSc, PhD, is an adjunct professor at the College of Dentistry, University of Manitoba, and is in private practice in Aurora, Ontario, Canada. Carlos M. Mejia-Gomez, DDS, Ortho Cert, is the chairman of the Craniofacial Abnormalities Unit for the Fundacion Abrazar in Colombia.

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Figures 2A-2B

beneficial, as it may reduce the severity of the problem and its detrimental effects on the oral functions.6,11 This paper reports a clinical case of a non-syndromic child born with a severely retruded mandible and deep bite. An early intervention permitted improvement of the sagittal and vertical relationships between both maxillaries before the patient enters into the mixed dentition.

Case report The patient was initially seen at 10 months old since the mother was concerned that he had a small mandible with no chin and was sleeping with the mouth open and breathing noisily. The medical history was not relevant, and he was naturally delivered with no complications. The patient was receiving respiratory therapy. Breastfeeding happened over the first 4 months, and then the mother gave up as she did not produce enough milk. She had been feeding him with formula since then.

The first clinical exam revealed a distal position of the mandible (8 mm), associated with deep bite (OB 100%). The patient had hyperactivity of the mentalis muscles at swallowing and lips unsealed at rest. The initial position of the mandible and the dental occlusion are shown in Figures 1A, 2A, and 3A. At this age, myofunctional therapy was initiated in order to stimulate lip seal. The mother was advised to exercise this area by maintaining the lips together with her fingers for 5 minutes for 3 to 5 times per day. That exercise was practiced over a 3-month period. At 14 months old, the patient was maintaining a lip seal most of the time (Figure 1B). After maintaining lip seal, the mother was instructed to add other exercises, such as massage on the tongue to stimulate an anterior movement of the tongue and massage on the incisive papilla and mandibular traction with her fingers, bringing the mandible forward. These exercises were also recommended 3 to 5 times per day. Besides that, Volume 7 Number 4

Discussion A disto-occlusion diagnosed in the primary dentition does not improve with natural growth. A longitudinal study reported that conversely, the developmental problem is going to be present in the mixed dentition or even become worse.6 Furthermore, that developmental problem can associate with sleep-breathing disorders,10 which may further affect the growth and development of the child.13 The case presented here was intercepted at an early age in the primary dentition, so growth and development of both maxillaries were stimulated during the period of his life when they expressed the highest growth potential.2,5 In that context, the developmental problem was successfully intercepted, and the mouth was brought to a situation where growth and development can continue within normal limits.11,14 The patient was initially treated with myofunctional exercises and diet guidance, which help to improve the relationship between the maxillaries. Also, that treatment improved the activity of the masticatory and facial muscles, making them able Volume 7 Number 4

CASE STUDY

the mother was instructed to slowly harden the diet by progressively introducing food with fiber, such as carrots, crackers, and meats, into his diet. At 36 months old, the patient showed some improvement in the sagittal relationship between the maxillaries and the profile (Figure 1C). Another exercise was introduced at this stage. The mother was instructed to place a piece of paper on the side of his mouth and ask the child to bite toward that side. The Planas Direct Tracks (PDTs) were built up when the patient was 42 months old. They were built up on the first primary molars as described by Ramirez-Yañez for disto-occlusion.12 The patient was followed up over the next 12 months, adjusting the PDTs in order to stimulate a forward displacement of the mandible. The overjet and overbite were within normal limits at 48 months old (Figure 2B). Since then, the patient has been wearing a functional removable appliance, the Indirect Planas Tracks, as a retainer waiting for the eruption of the first permanent molars. The patient was instructed to wear the latest appliance 24 hours per day, removing it only for eating. At 5 years old, the patient is showing a normal sagittal, transverse, and vertical relationship for his age (Figure 2B). Also, his profile has improved with the treatment (Figures 1A-1D and Figures 3A-3B).

Figures 3A-3B

to hold the mandible in a centric position.15 The improvement in the maxillaries’ relationship was associated with an improvement in the oral functions, such as swallowing, lip seal, and tongue posture at rest16,17, which can make the results of the treatment more stable.18 Later, when the patient was more cooperative, a simple, fixed technique was designed for primary dentition. The PDTs were introduced to further stimulate the relationship of the maxillaries in a sagittal and vertical way, with the intent of guiding the craniofacial growth and development. In this case, early treatment improved the relationship between both maxillaries and guided the craniofacial growth and development. Thus, all the tissues composing the oral system can continue expressing their highest growing potential over the following stages. In other words, the message received by the trigeminal nerve through the mechanoreceptors in the periodontal ligament is sent to the brain, which in turn will change the activity of the mandibular and facial muscles. This produces better loading of the craniofacial bones, including both maxillaries.14,19,20 In conclusion, the clinical case presented here supports the idea that developing malocclusions in children should be intercepted as early as possible in order to reduce the risk of more complicated treatments in the future, as well as preventing other problems that can associate with deviated or diminished craniofacial growth and development, such as sleep-breathing disorders. OP

REFERENCES 1. Smartt JM Jr., Low DW, Bartlett SP. The pediatric mandible: I. A primer on growth and development. Plast Reconstr Surg. 2005;116(1):14e-23e. 2. Liu YP, Behrents RG, Buschang PH. Mandibular growth, remodeling, and maturation during infancy and early childhood. Angle Orthod. 2010;80 (1):97-105.

3. Kobayashi HM, Scavone H Jr., Ferreira RI, Garib DG. Relationship between breastfeeding duration and prevalence of posterior crossbite in the deciduous dentition. Am J Orthod Dentofacial Orthop. 2010;137(1):54-58. 4. Westover KM, DiLoreto MK, Shearer TR. The relationship of breastfeeding to oral development and dental concerns. ASDC J Dent Child. 1989;56(2):140-143. 5. Laowansiri U, Behrents RG, Araujo E, Oliver DR, Buschang PH. Maxillary growth and maturation during infancy and early childhood. Angle Orthod. 2013;83(4):563-571. 6. Baccetti T, Franchi L, McNamara JA Jr., Tollaro I. Early dentofacial features of Class II malocclusion: a longitudinal study from the deciduous through the mixed dentition. Am J Orthod Dentofacial Orthop. 1997;111(5):502-509. 7. Ovsenik M, Farcnik FM, Korpar M, Verdenik I. Followup study of functional and morphological malocclusion trait changes from 3 to 12 years of age. Eur J Orthod. 2007;29(5):523-529. 8. Bacon WH, Turlot JC, Krieger J, Stierle JL. Cephalometric evaluation of pharyngeal obstructive factors in patients with sleep apneas syndrome. Angle Orthod. 1990;60(2):115-122. 9. Yılmaz F, Sağdıç D, Karaçay S, Akin E, Bulakbası N. Tongue movements in patients with skeletal Class II malocclusion evaluated with real-time balanced turbo field echo cine magnetic resonance imaging. Am J Orthod Dentofacial Orthop. 2011;139(5):e415-e425. 10. Guilleminault C, Akhtar F. Pediatric sleep-disordered breathing: New evidence on its development. Sleep Med Rev. 2015;24:46-56. 11. Ovsenik M. Incorrect orofacial functions until 5 years of age and their association with posterior crossbite. Am J Orthod Dentofacial Orthop. 2009;136:375-381. 12. Ramírez-Yañez G. Early treatment of malocclusions: prevention and interception in primary dentition. 2009; 2nd ed:www.kidsmalocclusions.com. Accessed May 27, 2016. 13. Huang YS, Guilleminault C. Pediatric obstructive sleep apnea and the critical role of oral-facial growth: evidences. Front Neurol. 2013;3:184. 14. Sohn BW, Miyawaki S, Noguchi H, Takada K. Changes in jaw movement and jaw closing muscle activity after orthodontic correction of incisor crossbite. Am J Orthod Dentofacial Orthop 1997;112(4):403-409. 15. Maffei C, Garcia P, de Biase N, et al. Orthodontic intervention combined with myofunctional therapy increases electromyographic activity of masticatory muscles in patients with skeletal unilateral posterior crossbite. Acta Odontol Scand. 2014;72(4):298-303. 16. Korbmacher HM, Schwan M, Berndsen S, Bull J, KahlNieke B. Evaluation of a new concept of myofunctional therapy in children. Int J Orofacial Myology. 2004;30:39-52. 17. Schievano D, Rontani R, Bérzin F. Influence of myofunctional therapy on the perioral muscles. Clinical and electromyographic evaluations. J Oral Rehabil. 1999;26(7):564-569. 18. Smithpeter J, Covell D Jr. Relapse of anterior open bites treated with orthodontic appliances with and without orofacial myofunctional therapy. Am J Orthod Dentofacial Orthop. 2010;137(5):605-614. 19. Forwood MR. Mechanical effects on the skeleton:are there clinical implications? Osteoporos Int. 2001;12(1):77-83. 20. Frost HM. A 2003 update of bone physiology and Wolff’s law for clinicians. Angle Orthod. 2004;74(1):3-15.

Orthodontic practice 21

ORTHODONTIC INSIGHTS

Reframing orthodontics: Ortho 3.0 Dr. Rohit C.L. Sachdeva discusses the eight major forces shaping the future of orthodontics

he development of the orthodontic specialty has generally followed the cultural, scientific, and technological evolution of society, although it has not necessarily always been in step. The historical transformation of our society to the present time has clear footprints. The agrarian society was symbolized by the farmer with the plough and the industrial society by the assembly-line worker. Today’s “knowledge” worker can best be characterized by the computer. Similarly, the orthodontic profession has witnessed a transformational process that I describe as Ortho 1.0, 2.0, and 3.0. Ortho 1.0 typically defined the orthodontist’s role as a craftsman whose skills lie in manual dexterity and the use of a plier to bend wire and provide personalized care. In some ways, this was no different than a farmer in an agrarian society whose skills lay in tilling the land to provide for his family. Ortho 2.0 extended the orthodontist’s role into that of a manager leading a team of chairside assistants and support staff to provide care to a broader base of patients with the use of standardized and modular orthodontic appliances. Again, one can clearly visualize parallels of this environment with that of the Henry Ford model of mass production in the early 20th century and the introduction of prefabricated modular parts assembled by a labor force. Furthermore, both the agrarian and industrial models

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.

22 Orthodontic practice

represented an authoritarian “closed system” of management with the manager occupying a privileged position at the apex of the pyramid. Both Ortho 1.0 and 2.0 can be characterized by a hierarchical model of care delivery; i.e., a “doctor–centered” model with little participation from patients in defining their personal treatment wants or needs. Today, we are at the beginning of an orthodontic care revolution driven by the following eight major forces poised to redefine the practice of orthodontics as we know it, including the following considerations of their impact on the profession.

Eight major forces poised to redefine the practice of orthodontics 1. Health information technology and health literacy 2. Computer-aided design and manufacturing and “omics” technologies/ bioinformatics 3. Public policy 4. Direct-to-consumer marketing and social networks 5. The rise of the expert non-expert 6. The shift in patient demographics 7. The rise of dental tourism 8. Do-it-yourself (DIY)/IKEA orthodontics in the era of cognitive computing

Health information technology and health literacy Developments in healthcare information technologies support almost instant connectivity and communication between all stakeholders in the healthcare system. The ability to transfer massive amounts of data on demand, the enablement of cost-effective data-warehousing and data-mining resources, is driving the genesis of a healthcare information exchange that is accessible to all. The increased porosity of information exchange is breaking the traditional communication barriers between patients, doctors, hospitals, academia, and industry. Healthcare is being democratized rapidly through the rise of the informed patient. This new dynamic is already leading to the reframing of the traditional roles and relationships between doctor and patient.

Computer-aided design and manufacturing and “omics” technologies/ bioinformatics The development of computer-aided design and manufacturing technologies, coupled with the biological revolution in the “omics” arena — namely, genomics, proteomics, and metabolomics — has the potential to provide unprecedented abilities to the orthodontist in designing and delivering personalized and targeted care to patients.

Public policy Western economies are crumbling under the weight of high healthcare costs,

Figure 1: Growth of dental management group practices. Source: http://www.dentalcarealliance.net/wp-content/uploads/ 2012/01/infographic-why-dental-service-organizations-are-here-to-stay-1000.png Volume 7 Number 4

Direct-to-consumer marketing and social networks Bypass marketing efforts by industry are challenging the traditional role of the doctor as the legitimate source of healthcarerelated information to patients (Figures 5 and 6). Furthermore, the rapid proliferation of support groups on the Internet is extending their reach and influencing the mind-set of patients through conversations of “realworld” care experiences and disease-specific resources of information.

The rise of the expert non-expert

Figure 2: Growth of dental management group practices. Source: http://www.dentalcarealliance.net/wp-content/uploads/ 2012/01/infographic-why-dental-service-organizations-are-here-to-stay-1000.png

Ortho 3.0 seeks transformational leadership, new awakenings through patient participation, interprofessional and transdisciplinary collaborations, and new learning that will redesign the orthodontic care system.

The rise of the generalist dental practitioner is upsetting the traditional role of the specialist orthodontist in providing orthodontic care. Adding to the fuel is the almost pervasive lack of recognition by patients

Figure 3: Interest in affordable care. Source: Kathleen Irwin. “An Untapped Revenue Opportunity.” http:// profitable-practice.softwareadvice.com/dental-tourism-anuntapped-revenue-opportunity-0914/. The Profitable Practice. Published September 10, 2014. Accessed May 31, 2016. Volume 7 Number 4

Figure 4: Regional interest. Source: Kathleen Irwin. “An Untapped Revenue Opportunity.” http://profitable-practice.softwareadvice.com/dental-tourism-an-untapped-revenue-opportunity-0914/. The Profitable Practice. Published September 10, 2014. Accessed May 31, 2016. Orthodontic practice 23

ORTHODONTIC INSIGHTS

especially in the United States. Public policy, driven by government agencies, the insurance industry, and the patient communities at large, is demanding high fidelity and quality care. In other words, care delivery is effective, efficient, patient-centered, safe, affordable, and value-driven (Figures 3 and 4). Additionally, the pressures from these agencies are requiring the doctor to be more transparent and accountable for the care given to patients. Finally, in the race to provide value-based care through the economies of scale, we are witnessing a proliferation of managed-care dental practices that are challenging the role of the solo practitioner (Figures 1 and 2).

ORTHODONTIC INSIGHTS

Figure 5: Pharma’s spending on direct-to-consumer TV advertising (DCTA). Source: http://pharmamkting.blogspot.com/2016/01/is-direct-to-consumertv-advertising.html

regarding the professional capabilities of the specialist orthodontist. Furthermore, the generalist is equipped to address the needs of a patient as a “whole,” with comprehensive dental treatment adding to the convenience of care under “one roof.” All these factors unfortunately bring into question the value of specialist education.

Figure 6: Consumers’ response to multiple channels; global averages. Source: http://www.nielsen.com/us/en/insights/ news/2012/consumer-trust-in-online-social-and-mobile-advertising-grows.html

The shift in patient demographics In the western world, we are witnessing a significant decline in birthrates and, concurrently, a rise in the aging population as well as growth in the immigrant population. These dynamics represent a shift in the patient population base and demand that the specialist attune his practice to deal with patients whose needs and aspirations for orthodontic care are very different from the traditional teenager. The demand of care for the geriatric population is generally limited in nature, and furthermore, many of these patients are afflicted with chronic diseases requiring a total healthcare approach in managing them effectively. The firstgeneration ethnic population is generally not as well acquainted with the benefits of orthodontic care and require novel approaches in communication to encourage their participation in care (Figure 7).

Rise of dental tourism The “repackaging” of dental care as an esthetic need rather than a health need in the western world, combined with cost pressures and globalization of expertise, are defining new channels for affordable patient care. It is highly conceivable that patients 24 Orthodontic practice

Figure 7: The Great Shift, the Browning of America. Orthodontic practices must understand the various cultures within their patient base and make some accommodations for the changing demographics of their communities (such as having some bilingual staff members). Source: Passel, Jeffrey and D’Vera Cohn. 2008. “U.S. Population Projections: 2005-2050.” Washington, D.C.: Pew Hispanic Center, February; Census Bureau 2011 population estimates. Pew Research Center Volume 7 Number 4

Do-it-yourself (DIY)/IKEA orthodontics in the era of cognitive computing Figure 8: Dental destination advertisement. Source: https://cancundentistdentaris.wordpress.com/tag/cosmetic-dentistry-mexico/

Figure 9: Health-tourism.com website. Source: https://www.health-tourism.com/dental-braces/

Figure 10: Defiition of cognitive computing. Source: http://www.slideshare.net/ViperVarunT/cognitive-computing-33845238 Volume 7 Number 4

We are rapidly approaching the era of cognitive computing driven by transformational developments in the area of artificial intelligence (Figures 10, 11, and 12). A realworld product of this technology is Google’s autonomous car. I believe in the next couple of decades, it will be possible to use the power of machine intelligence through input provided directly by the patient to design a care plan. Orthodontic appliances would be directly manufactured in the “home lab” with the use of computer-aided manufacturing such as 3D printing. And patients could manage their personal care by scanning themselves periodically and matching their response against a guidance or tracking system based upon patient-matched data. This “DIY/IKEA orthodontics” is a real possibility. In fact, the ability to design and manage one’s own care

ORTHODONTIC INSIGHTS

will have access to orthodontic care from orthodontic practitioners “beyond borders,” especially when it comes to providing limited care with aligners. And such a model could easily be offered under the auspices of dental tourism. In fact, the more the clinician relies upon outsourcing planning of care by external agencies (laboratories) for patients, especially in the arena of digital orthodontics, the greater the likelihood of such a model gaining a foothold (Figures 3, 8, and 9).

ORTHODONTIC INSIGHTS was recently demonstrated by a design student, Amos Dudley1 (Figure 13). The orthodontic profession is at a crossroads. The dilemma lies in recognizing the new realities “on the ground” and the need to evolve into an environment that is more system-based. This will undoubtedly come at a price and loss of some professional autonomy in order to achieve greater good. Furthermore, the orthodontist will need to commit to acquiring new knowledge and skills through personal drive in order to harness the promise of new learning and technologies to improve patient care, to increase its accessibility Figure 12: Enablement of cognitive computing; the cost of computing power. Source: John Hagel III, John Seely Brown (JSB), Tamara while remaining mindful of the cost and, Samoylova & Michael Lui. From exponential technologies to exponential innovation. Deloitte University Press. http://dupress.com/ articles/from-exponential-technologies-to-exponential-innovation/. most importantly, to maintain professional Published October 4, 2013. Accessed May 31, 2016. dignity and be the font of empathy for every patient. Ortho 3.0 defines this “New Look” for our practices of a learning/teaching organizaOrtho 3.0 can only gain a foothold profession, moving beyond the monolithic tion, to employ evidence-based clinical practhrough a spirit of collective professional symbolism of the computer and the image of tices, to offer highly reliable organization and resolve that is supported by the backbone the orthodontist practicing in solitude behind care management, to support and advance of professional antifragility. This mandates a desktop, always distanced from patients patient healthcare literacy, and engagement, growth through deliberate experimentation by cyberspace. as well as achieving truly connected care. fueled by intelligent failure. Ortho 3.0 places the patient at the Ortho 3.0 challenges conventional Yes, in some ways, it is a departure from epicenter of the care-delivery model with all models and ways of thinking of orthodontic the past. Yet in many ways, it retains the core other actors and agencies coalescing within care delivery, while seeking transformavalues, belief systems, and some of the praca system designed to serve the patient as tional leadership, new awakenings through tices of conventional orthodontics. To state patient participation, interprofessional and an individual. It is designed around systemit explicitly: “patients matter.” This does not based thinking that continuously strives transdisciplinary collaborations, and new and will not change. to improve patient care, to enhance both learning that will redesign the orthodontic Aeger Primo, patients first. OP personal and community care through the care system.

Figure 13: Student Amos Dudley designs his DIY aligners using $60 and a 3D printer. Source: http://www.mnn.com/health/healthy-spaces/blogs/student-designs-his-own-braces-using-3d-printer

REFERENCE 1. Fiona MacDonald. A college student has 3D-printed his own braces for less than $60. Science Alert. http://www.sciencealert.com/a-college-student-has-3d-printed-his-own-braces-for-less-than-60. Published March 21, 2016. Accessed May 31, 2016.

26 Orthodontic practice

Volume 7 Number 4

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CONTINUING EDUCATION

Facial asymmetries Dr. Bradford N. Edgren discusses the importance of diagnosis and treatment of facial asymmetries Abstract The most important key to any successful orthodontic treatment is a proper and thorough diagnosis. The same is true for the diagnosis and treatment of facial asymmetries. If a patient’s facial asymmetry is not initially diagnosed, the risk of treatment failure increases, especially in cases with inappropriate/irreversible permanent tooth extraction and/or treatment mechanics. This is especially important in children because facial asymmetries in these young patients generally become more severe with growth and time; therefore, early recognition is imperative. Improper early interceptive orthodontic treatment can accentuate the asymmetry rather than improve it. This includes the underdiagnosis and consequent lack of treatment of upper airway obstructions, enhancing the development and degree of facial asymmetries.1

Introduction Ideal bodily symmetry in all organisms rarely, if ever exists. Consequently, subtle asymmetries are common in all patients and considered normal. However, the point where the subtle facial asymmetry falls outside the range of normal and becomes aberrant/divergent is not as easily delineated. Often it is the patient’s perception of the lack of facial symmetry, as well as the degree of the imbalance, that determines the necessity and the extent of treatment warranted.2 The investigation of McAvinchey, et al., into the perception of facial asymmetries reported that recognition of an asymmetry was dependent upon the profession of the observer and the severity of the anomaly. Findings of their layperson group classified an asymmetry of Bradford N. Edgren, DDS, MS, earned both his Doctorate of Dental Surgery, as Valedictorian, and his Master of Science in Orthodontics from the University of Iowa, College of Dentistry. He is a Diplomate, American Board of Orthodontics, and a member of the Southwest Component of the Edward H. Angle Society. Dr. Edgren has presented nationally and internationally to numerous orthodontic groups on the importance of orthodontic diagnosis, early interceptive orthodontic treatment, CBCT, and upper airway obstruction. He has been published in AJO-DO, the American Journal of Dentistry, as well as other orthodontic publications. Dr. Edgren currently has a private practice in Greeley, Colorado.

28 Orthodontic practice

Educational aims and objectives

This article aims to discuss some ways that early orthodontic treatment can successfully improve and resolve facial asymmetries in young patients.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 34 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Realize the importance of diagnosis and treatment of facial asymmetries. • Identify various etiologies of skeletal asymmetries. • Recognize important aspects of the clinical exam for proper evaluation of asymmetries. • Identiify the radiographic techniques necessary to determine facial asymmetries. • Realize the different treatment modalities for distinct types of asymmetries.

5.6 mm ± 2.7 mm at the chin to be “normal.” They also reported that orthodontists were found to be far more conscious of the presence of an asymmetry than the layperson.3 Treatment of dental asymmetries due to premature deciduous tooth loss, tooth size discrepancies, and/or missing teeth is more easily addressed compared to structural, skeletal asymmetries. Orthodontic treatment techniques to regain space loss, permanent tooth replacement, and asymmetrical extractions are often employed to successfully treat dental asymmetries. Significant skeletal asymmetries require a combination of orthodontics, dentofacial orthopedics, and possible future orthognathic surgery after the finalization of growth in adolescents. Adults with skeletal anomalies require orthodontics and surgical considerations, unless the patient dictates certain compromises before the initiation of treatment,2 necessitating the importance of informed consent. Even though facial asymmetries can present in Class I malocclusions, they are more often associated with Class II and Class III malocclusions.4 Severt and Proffit reported that clinically apparent facial asymmetries were most often recorded at the level of the chin in 74% of patients, and midface asymmetries were documented in roughly a third (36%). Interestingly, they also noted that when a transverse deviation of the chin occurred, there was a predilection to the left. An exception was with long-faced patients where there was an equal distribution between left and right asymmetries.5 Functional asymmetries, which often result from the mandible deflecting to one side due to maxillary constriction or even a

single malpositioned tooth preventing proper intercuspation, can develop into permanent deformities following the cessation of growth. Functional shifts of the occlusion can accentuate or even mask structural asymmetries underscoring the importance of a thorough clinical exam.4 Young patients exhibiting true functional asymmetries can be successfully treated with early interceptive dentofacial orthopedic treatment, including maxillary expansion and orthodontics. Etiologies of skeletal asymmetries vary and fall into three basic categories, including congenital, environmental, and developmental.4 Congenital and genetic causes of facial asymmetries include cleft lip and palate, hemifacial microsomia, unilateral craniosynostosis6, and zygomaticotemporal synostosis.7 Infection, tumors, and trauma are examples of environmental or acquired etiologies of facial asymmetry. Growth of benign and malignant tumors can distort the dentofacial architecture, misshaping the dentoalveolar arches and jaw bones, resulting in significant facial asymmetries. Early trauma to the temporomandibular joint can result in ankylosis, unilateral condylar hypoplasia, and/or subcondylar fracture, precipitating the onset of facial deformities. Age of onset of an acquired etiology will determine the severity of the asymmetry. Often the earlier the onset, the greater the facial deformity due to growth. Asymmetries that are developmental in nature are relatively uncommon. Developmental asymmetries are non-syndromic, idiopathic, non-congenital, and gradually develop over time, becoming apparent during adolescence.4 Volume 7 Number 4

A thorough evaluation, including clinical assessment, panoramic imaging, submentovertex radiography, and a complete cephalometric survey with analyses are all important for diagnosis of patients with facial asymmetries. The clinical exam should include an evaluation of dental midlines, Angle classification, open bites, functional shifts, and the presence of anterior and posterior crossbites. Unilateral posterior crossbites can be an indication of a bilateral maxillary constriction with a functional shift to the affected side resulting in a functional asymmetry. A unilateral posterior crossbite can also be indicative of a midface skeletal asymmetry. Lateral cephalograms, though useful for evaluation of anteroposterior and vertical evaluations of the jaws and dentition relative to the cranial base, are less reliable for assessment of asymmetries. Superimposition of left and right structures as well as magnification errors can mask skeletal asymmetries.4 Posteroanterior radiographs do not result in superimposition or the unequal magnification of the left and right halves of the face and are an important tool in the diagnosis of

Figure 1: Diagnostic photos of a 8-year 5-month-old female with a functional facial asymmetry resulting in a unilateral right posterior crossbite

Figure 3: Diagnostic lateral CBCT image Volume 7 Number 4

asymmetries.2 Routine use of the posteroanterior cephalogram and frontal cephalometric analysis can reduce the risk of missing skeletal asymmetries, especially in the young patient who possesses a mild, incipient facial asymmetry that hasnâ&#x20AC;&#x2122;t been fully expressed because of remaining, future growth. Submentovertex imaging is another valuable radiographic technique that can be used to assess the shape and symmetry of the inferior border of the mandible, zygomatic arches, and relative position of the condyles. A facial asymmetry that is detected on a posteroanterior cephalogram can be diagnosed as a functional asymmetry when evaluated by the submentovertex radiograph because the left and right inferior borders of the mandible are determined to be symmetrical. The panoramic radiograph is a convenient image for an initial evaluation of the dentition, maxilla, mandible, pathology, and gross asymmetries. However, it is not as valuable a tool for determination of skeletal asymmetries due to the inherent distortions of this radiographic technique because of patient positioning.8 Observed differences between the left and right halves, unless

overt between the temporomandibular joints, ramuses, and the bodies of the mandible, should be interpreted with discretion. Cone beam computed tomography (CBCT) has neither the magnification errors nor the complications of superimposition of anatomical structures that traditional radiographic techniques possess. Consequently, CBCT imaging is a valuable tool when evaluating facial asymmetry patients.

Patient therapies Early interceptive treatment of patients diagnosed with functional asymmetries includes a combination of dentofacial orthopedics and orthodontics. This 8-year 5-month-old female presented with a right functional shift of the mandible resulting in a lower facial asymmetry, posterior crossbite, and a lower dental midline discrepancy of 4.5 mm (Figure 1). Panoramic CBCT imaging reveals dental crowding (Figure 2). The lateral CBCT image shows no evidence of an asymmetry since both lower borders of the mandible are coincident (Figure 3). The frontal CBCT image demonstrates a significant facial asymmetry to the right (Figure 4). Cephalometric analysis of the frontal image revealed

Figure 2: Initial panoramic CBCT image acquired by an i-CAT Next Generation scanner

Figure 4: Initial frontal CBCT image with right posterior crossbite and facial asymmetry Orthodontic practice 29

CONTINUING EDUCATION

Diagnosis and radiographic techniques

CONTINUING EDUCATION

Figure 6: Axial CBCT image

Figure 5: Frontal cephalometric analysis

a skeletal lingual crossbite pattern due to the maxilla (Figure 5). Axial CBCT images of the patient demonstrate relatively good symmetry of the inferior border of the mandible but with a functional deviation to the right (Figures 6 and 7). The patient was treated with a bonded maxillary expander and orthodontics. Early interceptive treatment time was 31 months. Her maxillary constriction and right posterior crossbite were corrected, and her facial symmetry significantly improved as well (Figures 8, 9, and 10). Treatment of patients with structural craniofacial asymmetries is more challenging than those with functional asymmetries. Younger patients can benefit from early interceptive treatment, lessening the severity of a facial asymmetry and therefore reducing the extent of future orthognathic surgery. This 7-year 9-month-old female presented with right-sided hemifacial microsomia (Figure 11). The panoramic CBCT image displays ectopic maxillary lateral incisors and significant crowding (Figure 12). Her frontal volume rendering image discloses a hypoplastic right 30 Orthodontic practice

maxilla and mandible manifesting in significant middle and lower face asymmetries (Figure 13). Frontal cephalometric analysis reveals a notable occlusal cant with the right side superior to the left (Figure 14). The axial image exhibits a misshapen inferior border of the mandible with the right half being notably more underdeveloped than the left (Figure 15). This young patientâ&#x20AC;&#x2122;s treatment included maxillary expansion with a bonded expander to stimulate maxillary development and orthodontics. Treatment time was approximately 30 months resulting in a nice Class I occlusion and improvement in her facial asymmetry (Figure 16). Her panoramic image following early interceptive treatment demonstrates acceptable root parallelism and proper eruption of the permanent dentition (Figure 17). Frontal and axial images exhibit improvement in facial asymmetry and lower borders of the mandible (Figures 18 and 19). A boost in self-esteem was an added benefit of early treatment for this patient. The extent of future orthognathic surgery has been reduced, if desired, for this patient.

Figure 7: Volume rendering of axial CBCT image displays relative symmetry between the right and left inferior borders of the mandible

Adult patients generally require a combination of orthodontics and orthognathic surgery to correct significant facial asymmetries. This 27-year 6-month-old adult female fractured her mandible at the age of 5 (Figure 20). At the time, the left subcondylar neck fracture was treated with closed reduction. She suffered from chronic headaches and left jaw joint pain. Intraoral photographs demonstrate a 5 mm lower dental midline deviation to the left, a right-sided Class I malocclusion, and a Class II malocclusion on the left. The panoramic image discloses a complete adult dentition with the exception of the previously extracted third molars (Figure 21). Frontal and axial CBCT images display a significant left-sided facial asymmetry and severely misshapen mandible (Figures 22 and 23). A sectional axial image at the level of the condyles shows a significant alteration in the morphology of the left condyle secondary to the subcondylar fracture at age 5 (Figure 24). Volume 7 Number 4

Figure 8: Interim deband photos demonstrating correction of posterior crossbite and functional facial asymmetry

Figure 10: Frontal CBCT image at interim deband showing significant improvement in facial symmetry

Figure 12: Panoramic CBCT imaging displaying significant crowding Volume 7 Number 4

Figure 11: Diagnostic photos of a 7-year 9-month-old female with hemifacial microsomia and right facial asymmetry

Figure 13: Frontal CBCT imaging revealing a hypoplastic right maxilla and mandible Orthodontic practice 31

CONTINUING EDUCATION

Figure 9: Panoramic CBCT image at interim deband demonstrating reduction in dental crowding

CONTINUING EDUCATION

Figure 14: Frontal cephalometric analysis demonstrating canted occlusal plane and significant facial asymmetry

Figure 16: Interim deband photos show improvement in dental midlines and facial symmetry

Figure 18: Frontal CBCT image at interim deband demonstrating improvement in facial symmetry with early interceptive treatment 32 Orthodontic practice

Figure 15: Axial CBCT image illustrating the difference in the size and shape of the inferior borders of the mandible

Figure 17: Interim deband panoramic image

Figure 19: Axial image at interim deband

Splint therapy was initially employed to resolve her left temporomandibular joint pain and tension headaches. Following cessation of her joint pain and headaches, the patient was treated with comprehensive orthodontics and orthognathic surgery to improve her alignment, stability, and jaw function. Surgical correction included a LeFort I osteotomy, bilateral sagittal split osteotomy, and genioplasty to correct her maxillofacial skeletal and dental anomalies. Post-surgical extraoral and intraoral photos show notable improvement in facial symmetry and dental midline alignment (Figure 25). The post-surgical frontal CBCT image displays significant improvement in her maxillofacial skeleton, especially in mandibular shape and form (Figure 26). Volume 7 Number 4

Figure 22: Frontal CBCT image illustrating left-sided skeletal asymmetry

Figure 21: Panoramic CBCT imaging demonstrating a gross difference in the size between the right/left ramuses and condyles

Figure 23: Axial CBCT image revealing severe difference in size and shape of the inferior border of the mandible

Figure 24: Sectional CBCT image at the level of the condyles. Note the significantly misshapen and displaced left condylar head

Figure 25: Post-surgical photos reveal significantly improved facial symmetry

Figure 26: Post-surgical CBCT frontal image demonstrating significantly improved skeletal symmetry

Conclusion Appropriate early orthodontic treatment can successfully improve and resolve, especially functional, facial asymmetries in young patients. Early treatment requires time to take necessary advantage of growth to be successful. Surgical intervention is sometimes required for these patients as adults; however, the extent of surgical intervention can be reduced with proper early treatment. Adult patients with facial asymmetries require a combination of orthodontics and orthognathics. Careful diagnostic evaluation is essential for successful outcomes. OP

REFERENCES 1. Edgren BN. Upper airway obstruction – poor function becomes poor form (CE). Orthodontic Practice US. 2013; 4(2):34-37. 2. Bishara SE, Burkey PS, Kharouf JG. Dental and facial asymmetries: a review. Angle Orthod. 1994;64(2):89-98. 3. McAvinchey G, Maxim F, Nix B, Djordjevic J, Linklater R, Landini G. The perception of facial asymmetry using 3-dimensional simulated images. Angle Orthod. 2014;84(6):957–965. 4. Cheong YW, Lo LJ. Facial asymmetry: etiology, evaluation, and management. Chang Gung Med J. 2011;34(4):341–351. 5. Severt TR, Proffit WR. The prevalence of facial asymmetry in the dentofacial deformities population at the University of North Carolina. Int J Adult Orthodon Orthognath Surg. 1997;12(3):171-176. 6. Arvystas MG, Antonellis P, Justin AF. Progressive facial asymmetry as a result of early closure of the left coronal suture. Am J Orthod. 1985;87(3):240-246. 7. Rogers GF, Greene AK, Oh AK, Robson C, Mulliken JB. Zygomaticotemporal synostosis: a rare cause of progressive facial asymmetry. Cleft Palate Craniofac J. 2007;44(1):106-111. 8. Rondon RH, Pereira YC, do Nascimento GC. Common positioning errors in panoramic radiography: A review. Imaging Sci Dent. 2014;44(1):1-6.

Volume 7 Number 4

Orthodontic practice 33

CONTINUING EDUCATION

Figure 20: Diagnostic photos of a 27-year 6-month-old female with a history of a left subcondylar fracture at age 5

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

REF: OP V7.4 EDGREN

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Facial asymmetries EDGREN

1. Often it is the _____ that determines the necessity and the extent of treatment warranted. a. patient’s perception of the lack of facial symmetry b. degree of the imbalance c. parents’ request d. both a and b 2. Treatment of dental asymmetries due to ________ is more easily addressed compared to structural, skeletal asymmetries. a. premature deciduous tooth loss b. tooth size discrepancies c. missing teeth d. all of the above 3. Severt and Proffit reported that clinically apparent facial asymmetries were most often recorded at the level of the chin in ______ of patients, and midface asymmetries were documented in roughly a third (36%). a. 30% b. 45% c. 74% d. 82% 4. ___________ of facial asymmetries include cleft lip and palate, hemifacial microsomia,

34 Orthodontic practice

unilateral craniosynostosis (Arvystas MG), and zygomaticotemporal synostosis. a. Congenital and genetic causes b. Environmental causes c. Developmental causes d. Insignificant types 5. Infection, tumors, and trauma are examples of __________ of facial asymmetry. a. developmental causes b. environmental or acquired etiologies c. congenital causes d. anomalies 6. Asymmetries that are _______ in nature are relatively uncommon. a. developmental b. congenital c. environmental d. acquired 7. A unilateral posterior crossbite can also be indicative of a ___________. a. hemifacial microsomia b. subcondylar fracture earlier in life c. midface skeletal asymmetry d. unilateral condylar hypoplasia

8. Routine use of the ___________ can reduce the risk of missing skeletal asymmetries, especially in the young patient who possesses a mild incipient facial asymmetry that hasn’t been fully expressed because of remaining, future growth. a. 2D FMX b. posteroanterior cephalogram c. frontal cephalometric analysis d. both b and c 9. _____________ is/are a convenient image for an initial evaluation of the dentition maxilla, mandible, pathology, and gross asymmetries. a. The panoramic radiograph b. Submentovertex imaging c. Lateral cephalograms d. Posterioanterior cephalograms 10. _________ has/have neither the magnification errors nor the complications of superimposition of anatomical structures that traditional radiographic techniques possess. a. Submentovertex imaging b. Cone beam computed tomography (CBCT) c. Lateral cephalograms d. Panoramic radiographs

Volume 7 Number 4

CE CREDITS

ORTHODONTIC PRACTICE CE

Dr. Barry Raphael discusses how added exercise protocols can help correct common problems related to facial and oral function

lex checks in for his after-school appointment. Instead of going to the operatory, he takes his activity scorecard and exercise mouthpiece to the Activity Center. The Activity Center has no dental chairs, no lights to shine in his eyes, and no scary handpieces or pliers sticking up from racks. Instead Alex walks into a fun-looking room with video screens and mirrors on the walls surrounded by cartoon characters with word balloons saying, “Are you breathing through your nose?” and “Is your tongue on the spot?” He sees Sara, his health coach, who greets him with a big smile. Sara is a college graduate with an interest in health and wellness. Sara has a clean approach to diet and exercise and loves to work with younger kids. She inquires, “So how did you do this week?” “I got up to 40 paces, but I had some trouble wearing my trainer every day,” Alex confesses as though he was talking with a teacher about his homework. “But I can definitely breathe through my nose better, and my soccer coach said I’m doing better on the team.” “Fantastic,” says Sara encouragingly. “So let’s see what your obstacles are with your wear time and get you moving forward.” And so they sit at a video monitor and review his exercises for that week. “Paces” teaches nasal breathing and makes it easier for Alex to keep his mouth closed and his tongue on the palate. The two spend about 15 minutes together before Sara assigns a video on nutrition and gives the next exercise prescribed by the orthodontist. Then Alex heads for the orthodontic operatory. Barry 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 transition.” He teaches these concepts at the Mt. Sinai School of Medicine in New York City. He is the owner of the Raphael Center for Integrative Orthodontics and the founder of the Raphael Center for Integrative Education.

Educational aims and objectives

This article aims to discuss natural physiological competencies that are required for optimal growth and development.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 39 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify certain natural physiological “competencies” required for the optimal growth and development of the occlusion, the jaws, the joints, the airway, and the cranium. • Realize some habits that cause the alveolar processes to deform and prevent the teeth from easily erupting into place. • Realize that certain common problems with facial and oral function must be corrected by training patients with certain exercises facilitated by a health coach. • Recognize the parts of a comprehensive myofunctional treatment plan. • Realize some steps to becoming a myofunctional orthodontic practice.

When he sits in the chair, the orthodontic assistant asks about the comfort of the light wire expander he is wearing to develop his upper arch and checks for hygiene and breakage. Then the orthodontist comes over, removes the expander, makes adjustments, and replaces it. He/she also asks Alex, “So how does your trainer fit? Is there anything I can do to make it more comfortable? Are you making sure you are keeping your lips together even when you’re not wearing your trainer?” Of course, Alex gives a shy nod. He knows that he has always had a problem keeping his lips together and hates the way it makes his face look. Someone once teased him for looking like Napoleon Dynamite. It’s been hard changing his habits, but it’s hard playing soccer too, sometimes. He knows it’s paying off, though, because not only is his stamina improving, but his teeth are getting straighter, too! “You’ll see Sara again in 2 weeks and me again in a month,” his orthodontist smiles. “Keep up the good work. You look great!” And Alex is off to soccer practice. Author’s first note: Now guess what? This is what my practice looks like now, and the future is here. ———————————————————

Volume 7 Number 4

Trainer? Training? So what is behind these added protocols that are being introduced into the modern orthodontic office? While most orthodontic techniques focus on taking cooperation out of the hands of the patient, why in the world would we want to be bringing “exercises” of all things back into our treatment program? The patient illustrated above is typical of what we see every day in practice. Most all children with malocclusions have some degree of soft tissue dysfunction.1 Unless there are congenitally missing or extra teeth or premature loss due to caries or trauma, most malocclusions are to some degree acquired — or at very least exacerbated by — habits that cause the alveolar processes to deform and prevent the teeth from easily erupting into place. Muscle influence on genetically programmed eruption sequences, especially during resting oral postures, herds the teeth into places they don’t belong, and malocclusion is the result. The maxilla, being one of the most malleable bones in the growing face, is especially susceptible to distortions of the functional matrix (or spatial matrix) in all three planes of space becoming not only narrower, but falling down and back under the cranial base.2 Then the mandible has to compensate resulting in a variety of occlusal schemes.3 Orthodontic practice 35

CONTINUING EDUCATION

Airway orthodontics the new paradigm: part 2, a vision for the future

CONTINUING EDUCATION

Although the orthodontic literature has known about the influence of habit and function on the growing face and jaws for a long time,4,5,6,7,8 there has been inconsistent effort in developing scientifically validated protocols that reliably and consistently mitigate the effects of function on form. It is too simplistic to declare that “function follows form,” as many orthodontic philosophies do, so that we only have to pay attention to one part of what is actually an unending cycle of form and function and form and function, ad infinitum. (What adult even asks which came first?) Addressing function, which is invariably the result of a behavior, is certainly harder to do in an orthodontic practice than the mechanics required for “form treatments.” But as a society, we do address behavioral issues all the time with teaching and coaching. We do it in schools. We do it in sports and the arts. We do it with psychological and social guidance. And, by and large, we do it well. Certainly, kids are able to accomplish things today that children of past generations never could. Have you been to a cheer competition, dance festival, martial arts class, or track meet lately? When there is a will to change behavior — on both the part of the child and the parents — miraculous things can happen.

What do we have to train? Behind the idea that function is an etiological component in a majority of malocclusions9 is a recognition of certain common problems with facial and oral function that must be corrected for the teeth to come in straight, or to stay straight if they had to be corrected orthodontically. (Each of these has ample evidence behind them). There are certain natural physiological “competencies” that are required for the optimal growth and development of the occlusion, the jaws, the 36 Orthodontic practice

joints, the airway, and the cranium. They are the following: 1. Upper airway patency and nasal breathing. While there has been much controversy over the influence of mouth breathing on the influence of facial growth in the orthodontic literature, nasal and pharyngeal airway obstruction is a damaging influence to the growing (and aging) face not because of the change in respiratory mode but because of the change in oral rest posture that results from it.10,11,12,13 The human being is supposed to breathe primarily through the nose. Otherwise we couldn’t nurse as an infant. Unfortunately, something — inflammation, allergy, metabolic challenge, injury, etc. — can induce a change to chronic oral breathing, and the mouth begins to hang open. This will, over time, change the trajectory of the growing maxilla for children just as surely as it did for Harvold’s monkeys.14,15,16 2. Lip competency. The ability to keep the lips closed at rest is critical for several reasons: • It assures that breathing will be through the nose. • It seals the mouth during chewing and swallowing to keep contents from spilling out and air from getting in (as in aerophagia). • It allows for the third major competency, which is having the tongue rest on the palate. Good lip seal should be accomplished without strain or tension of the orbicularis oris or mentalis muscles. These muscles, when active during function, place a significant molding force on the

anterior arch form, crowding or flattening the arch as the teeth make their way into the mouth. 3. Tongue-to-palate resting position. Of all the molding influences on the growing maxilla, this is probably the most important and least appreciated.17,18 While many people attribute narrow palates to genetics or “mouth breathing,” it is the lack of tongue presence on the palate that lets the bone collapse in all three dimensions of space. Just like the brain is the scaffold for the growing calvaria, and the eyeball is the scaffold for the growing orbit, the tongue is the scaffold around which the palate takes its shape. In fact, the tongue creates its entire nesting area based on its size, shape, tonus and, most importantly, resting position. The collapse of the maxilla (in all three planes of space) is perhaps the most common feature of modern malocclusion. The specific arrangement of the teeth reflects just what the tongue has been doing all day and night long. If the tongue is a bear, then the teeth are the bear tracks: an impression left by the presence of a being that leaves the place orderly or wreaks havoc. 4. A quiet swallow without use of CN VII. In the infant, the facial nerve efferents participate in suckling with an “infantile” swallow but should become inactive when we transition to a mature, tongue-to-palate swallow when the primary teeth come in. When this transition fails to occur, we learn to use our lips, chin, cheeks, and neck musculature to counter the remaining forward or lateral “thrusting” motion of the tongue. In this way, we get beyond Volume 7 Number 4

Incompetence and compensation Each of these eight competencies were part of our evolutionary upbringing and were at the root of our survival. Anthropologists tell us that “recent” changes in our environment (i.e., modern civilization) have challenged these competencies with chronic stressors such as changes in our bodily actions (posture, sitting, activity levels, soft diet, etc.); changes in our exposures (quality of food, air, water, skin contacts, etc.); and changes in our attitude (our reactions to chronic mental frustrations and challenges).19,20,21 We have had to make a variety of compensations to deal with these changes. Volume 7 Number 4

in our treatments, there is no way around it anymore. We must ask our patients to change their habits in order to change their health. As they say, “If nothing changes, nothing will change.”

Doing form and function

Unless there are congenitally missing or extra teeth or premature loss due to caries or trauma, most malocclusions are to some degree acquired — or at very least exacerbated by — habits that cause the alveolar processes to deform and prevent the teeth from easily erupting into place.

For one of thousands of examples, if our bodies are unable to process or tolerate a certain food (dairy or wheat) and we activate immune system functions to combat them (swollen tonsils and adenoids), making nasal breathing (the first competency) difficult. We compensate by opening our mouths to breathe. As noted above, the consequence of that new “habit” is maxillary collapse and hence, malocclusion. This principle is at the heart of Evolutionary Medicine (and Darwinian Dentistry, per Boyd) and explains in great measure not only the increasing incidence of malocclusion but also all the other chronic non-communicable diseases of civilization (lifestyle diseases) that plague us (including caries and sleep apnea among many others like heart disease, obesity, diabetes, osteoporosis, certain cancers, and so on).22,23 In other words, chronic disease like malocclusion is the result of something we do (compensations), and hence can be changed by something we do (foster competencies). Since these are behaviors, then the solution must be behavioral as well. Much to the chagrin of orthodontists who have been inventing and implementing numerous ways to eliminate cooperation as a variable

Orthodontics is quite proficient in changing form and has long argued that if you “change the form, function will follow.” We must now see this as an incomplete approach to the problem. While it may be perfectly suitable in any one case to begin with a “form” treatment (i.e., maxillary arch development), it must be followed by functional treatment to break the spiral and prevent relapse. Other patients may need only functional treatment to set growth on a better trajectory. Most importantly, the orthodontic practice of the future must handle both form and functional deficiencies with modalities appropriate to each. In general, a comprehensive myofunctional treatment plan includes the following: 1. A complete assessment. Malocclusion is only the tip of the iceberg. We have to start asking “why?” and looking for the etiologies of the problem. That means learning to see and looking for soft tissue dysfunctions and their side effects. Look for where the major competencies are lacking, and realize that the Angle classification is only a symptom, not a diagnosis. 2. Foster competencies. The ultimate in preventive orthodontics is when you can change outcomes by changing behaviors. Of course, this means starting very early. It means talking with moms about their infants and toddlers. It means looking for the habits (blocked airway, lip incompetence, low tongue posture, aberrant swallow, etc.) that create the problems before the problems take hold. If we continue to wait for “braces age” or continue to argue that Phase II treatment is adequate for aligning the teeth, we completely miss the opportunity to assist facial growth. In many ways, the teeth are not the problem at all, rather a symptom of an imbalance elsewhere. 3. Relieve the compromises. This means reversing the damage already caused by the dysfunctions and not just in the transverse dimension. Maxillary shape has to be, if possible, reconstituted in four dimensions of Orthodontic practice 37

CONTINUING EDUCATION

drooling and dribbling, but the bad habit remains. A telltale sign of a soft tissue dysfunction during swallowing is the appearance of any contraction of the facial muscles. When the tongue has been properly trained to rest and function on the palate, those facial dysfunctions will disappear. Then there are competencies that also influence facial growth that go beyond the teeth attached to the child and on to the child attached to the teeth. 1. Efficient breathing using the diaphragm. Optimal minute/volume (low and slow) ensures proper gas exchange and the best delivery of oxygen to target tissues. The diaphragm also is the pump for the upper body lymphatic system helping infection drain from swollen tonsils. 2. A nourishing (not challenging) diet requiring masticatory fitness. Much of what we eat contains elements not recognized as food by our bodies. We have to work extra hard to eliminate, destroy, or sequester these non-nutritional materials (e.g., preservatives, antibiotics, pesticides, colorants, fertilizers, etc.). 3. Proper posture of the head and body against gravity. Holding the head forward may open the airway, but it puts excessive strain on lingual, suprahyoid, infrahyoid, and cervical strap muscles in a chain that leads down to the feet. 4. Restorative, refreshing sleep. More than the teeth, the quality of our sleep suffers the most from the morphologic changes to the airway that occur from the poor habits listed above. The above competencies can be encouraged in the orthodontic office but may require referral to appropriate healthcare providers.

CONTINUING EDUCATION space: width, sagittal, vertical, and cant. This is where orthodontics can be most helpful, and it is why we must be involved in this field. Many of our current techniques have limitations (i.e., they tend to be retractive of an already deficient maxilla), but alternative treatments do exist. As specialists, we need to expand our repertoire to include modalities that help the face grow forward, create more tongue space, and preserve or enhance the nasopharyngeal airway.24,25,26,27,28 4. Reduce compensations. To reiterate, changing form is not enough. If you don’t correct the reason the malocclusion started in the first place, why should it be stable at all? Splinting incisors together and calling a case stable are no longer a satisfactory endpoint unless you started treatment too late. We have to teach and foster the good habits — as noted previously — that will not only keep our orthodontic results more stable but also lead to better health all around for our children.

Becoming a myofunctional orthodontic practice There are a few necessary steps to take in upgrading an orthodontic practice to deal with a bigger picture of health. There are protocols to change, techniques to adopt, and some simple changes to the office environment. But most important of all is to establish the position of a Health Educator on your staff. You, the orthodontist, are much too busy with the form treatments to have the time to sit and educate your patients. While you will soon "talk the talk" to each of your patients and parents about the importance of good health habits, you will need someone by your side to actually do the teaching. The analogy is the dental hygienists (who, by the way, are naturally great educators) who stand by the side of the general or perio practitioner to support his/her efforts. What dental practice today doesn’t have a hygienist doing what the GP doesn’t need to do? The orthodontic practice of the future will similarly have an adjunctive professional position to complete the care model. This person will augment your assessment and record taking. He/she will help spot some of the problems the children have (it’s amazing what you can see in the reception area) and be able to explain your program to the moms. He/she will run the education program, track 38 Orthodontic practice

the progress of the patients, and troubleshoot the cooperation and motivation issues of each child. In short, health educators take care of the work for you. The transition into a myofunctional, airway-aware orthodontic practice takes work, time, training, and a lot of commitment. But it can be done and needs to be done if our profession is going to rise above the fray of people looking to do orthodontics faster, cheaper, and easier. More importantly, our children are suffering from a whole host of chronic diseases that orthodontics can favorably affect since their origin is within our scope of concern — the stomatognathic system. We need to regain our position as physicians of the face and nurture a new generation into better health.

——————————————————— Health Coach Sara greets Alex again the next month and sees he’s got a sparkle in his eye. “I did it!”, crows Alex, “I wore my trainer every day, and look at my teeth! They’re getting straighter!” The two sit down at the video screen and go over the next set of exercises and set his goals for next time. His orthodontist is amazed to see the open bite closing on the right side and breathes a sigh of relief. “Boy, that makes life easy,” he/ she thinks. Author’s second note: Now give this article to the one person on your staff who is sharp and might be excited about this concept, and see what he/she says. OP

REFERENCES 1. Bakor, SF, Enlow DH, Pontes P, De Biase NG. Craniofacial growth variations in nasal-breathing, oral-breathing, and tracheotomized children. Am J Orthod Dentofacial Orthop. 2011;140(4):486-492. 2. Boyd K. Darwinian Dentistry part 1: an evolutionary perspective on the etiology of malocclusion. JAOS. 2011;11(3):34-39. 3. Bronson, J. Case Report: rapid improvement of enlarged tonsils following treatment with and ALF (Advanced Light Force) appliance. Journal of Gnathologic Orthopedics and Facial Orthotropics. 2013;5-7. 4. Corruccini RS, Flander LB, Kaul SS. Mouth breathing, occlusion, and modernization in a north Indian population. Angle Orthod. 1985; 55(3):190-196. 5. Graber, TM. The “three M’s”: muscles, malformation, and malocclusion. AJO-DO. 1963; 49(6):418-450. 6. Guilleminault C, Huang YS, Montero PJ, Sato R, Quo S, Lin CH. Critical role of myofascial reeducation in pediatric sleepdisordered breathing. Sleep Med. 2013;14(6):518-525. 7. Gungor A, Turkkahraman H. Effects of airway problems on maxillary growth: a review. Eur J Dent. 2009;3(3):250-254. 8. Harvold EP, Tomer BS, Vargervik K, Chierici G. Primate experiments on oral respiration. Am J Orthod. 1981;79(4):359-372. 9. Huang YS, Quo S, Berkowski JA, Guilleminault C. Short lingual frenulum and obstructive sleep apnea in children. 2015;1:1-4. 10. Lieberman, D, The Evolution of the Human Head. Harvard University Press, 2011. 11. Lieberman, D. The Story of the Human Body: Evolution, Health, and Disease. Pantheon Press, 2013. 12. Mew JR. The postural basis of malocclusion: A philosophical review, Am J Orthod Dentofacial Orthop. 2004;126(6):729-738. 13. Mew J. ibid. 14. Mew, M. Craniofacial dystrophy. a possible syndrome? Br Dent J. 216(10):555-558. 15. Moss ML, Rankow RM. The role of the functional matrix in mandibular growth, Angle Orthod. 1968;38(2):95-103. 16. Nesse R, Williams G. Why we get sick: the new science of Darwinian medicine. Vintage Books, 1994. 17. Ovsenik, M. Incorrect orofacial functions until 5 years of age and their association with posterior crossbite. Am J Orthod Dentofacial Orthop. 2009;136(3):375-381. 18. Ramirez-Yañez G, Sidlauskas, Junior E, Fluter J. Dimensional changes in dental arches after treatment with a prefabricated functional appliance. J Clin Pediatr Dent. 2007; 31(4):279-283. 19. Ramirez-Yañez GO, Farrell C. Soft tissue dysfunction: a missing clue when treating malocclusions. Int J Jaw Func Orthop. 2005;1:483-494. 20. Rogers AP. A restatement of the myofunctional concept in orthodontics. Am J Orthod. 1950;36(11):845-855. 21. Seeman J, Kundt G, and Stahl de Castrillon F. Relationship between occlusal findings and orofacial myofunctional status in primary and mixed dentition, J Orofac Orthop. 2011;72(1):21-32. 22. Singh GD, Garcia-Motta AV, Hang WM. Evaluation of the posterior airway space following Biobloc therapy: geometric morphometrics. Cranio. 2007;25(2):84-89. 23. Singh GD. Spatial matrix hypothesis. Br Dent J. 2007;202(5):238-239. 24. Singh GD, Griffin TM, Chandrashekhar R. Biomimetic oral appliance therapy in adults with mild to moderate obstructive sleep apnea. Austin J Sleep Disord. 2014;1(1):5. 25. Timms DJ, Tremouth MJ. A quantified comparison of craniofacial form with nasal respiratory function. Am J Orthod Dentofacial Orthop. 1988;94(3):216-221. 26. Vig K, Nasal obstruction and facial growth: the strength of evidence for clinical assumptions. Am J Orthod Dentofacial Orthop. 1998;113(6):603-611. 27. Woodside DG, Altuna G, Harvold E, Metaxaz A Primate experiments in malocclusion and bone induction. Am J Orthod. 1983;83(6)460-468. 28. Woodside, DJ, Linder-Aronson S, Lundstrom A, McWilliam J. Mandibular and maxillary growth after changed mode of breathing. Am J Orthod Dentofacial Orthop. 1991;100(1):1-18.

Volume 7 Number 4

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Airway orthodontics the new paradigm: part 2, a vision for the future RAPHAEL

1. Most all children with malocclusions have _________ associated with them. a. some degree of soft tissue dysfunction b. supernumerary teeth c. severe trauma d. congenitally missing teeth

4. The ability to keep the lips _______ is critical for several reasons. a. moist b. open at rest c. closed at rest d. slightly parted

2. Unless there are ______, most malocclusions are to some degree acquired — or at very least exacerbated by — habits that cause the alveolar processes to deform and prevent the teeth from easily erupting into place. a. congenitally missing teeth b. extra teeth c. premature loss due to caries or trauma d. all of the above

5. Just like the brain is the scaffold for the growing calvaria, and the eyeball is the scaffold for the growing orbit, _____ is/are the scaffold around which the palate takes its shape. a. mentalis muscles b. the tongue c. the teeth d. orbicularis oris

3. While there has been much controversy over the influence of mouth breathing on the influence of facial growth in the orthodontic literature, ________ is a damaging influence to the growing (and aging) face not because of the change in respiratory mode but because of the change in oral rest posture that results from it. a. TMD b. nasal airway obstruction c. pharyngeal airway obstruction d. both b and c

Volume 7 Number 4

6. The collapse of the maxilla (in all three planes of space) is perhaps ________ of modern malocclusion. a. the most common feature b. the most uncommon feature c. a very painful result d. an unusual result 7. In the infant, the facial nerve efferents participate in suckling with an “infantile” swallow ________ when we transition to a mature, tongue-to-palate swallow when the primary teeth come in.

a. and should remain just as active b. but should become inactive c. and should strengthen d. and should be exercised 8. Holding the head forward may open the airway, but it puts excessive strain on ______ and cervical trap muscles in a chain that leads down to the feet. a. lingual b. suprahyoid c. infrahyoid d. all of the above 9. Look for where the major competencies are lacking, and realize that the Angle classification is _________. a. only a diagnosis, not a symptom b. neither a diagnosis nor a symptom c. only a symptom, not a diagnosis d. both a symptom and a diagnosis 10. The ultimate in preventative orthodontics is when you can change outcomes by _______. a. changing behaviors b. encouraging the use of expanders c. testing for allergies before orthodontics d. enforcing mouth breathing

Orthodontic practice 39

CE CREDITS

ORTHODONTIC PRACTICE CE

ABSTRACTS

Abstracts

Accuracy and reliability of Dolphin 3D voxel-based superimposition Mohamed Bazina, DDS, MSD Background Superimposition of cephalograms has many uses in orthodontics, including growth evaluation and outcome assessments, but cephalograms are distorted and show incomplete two-dimensional data. Cone beam computed tomography (CBCT) provides a three-dimensional, undistorted, and more complete analysis of our patients. Superimposition of 2 CBCTs is possible by using landmarks, surfaces, or density information (voxel-based). Voxel-based superimposition is automated and uses the most image content, providing the most accurate result. Until recently such superimposition was extremely laborious, but a user-friendly voxel-based superimposition has recently been introduced. 40 Orthodontic practice

Aim To evaluate the accuracy and reliability of Dolphin 3D voxel-based superimposition.

Methods This was a retrospective study using existing scans of 31 surgical orthodontic patients. The sample included 19 females and 12 males with a mean age of 21. Each patient had a pre-surgical (T1) and a postsurgical (T2) scan taken within 12 months. Surgical patients were used due to lack of expected growth to reduce outcome bias. The volumes were superimposed using voxelbased methods from Dolphin Imaging Systems and the accepted method used by Cevidanes, et al. The Cevidanes method, considered as the gold standard, uses two different opensource programs and takes about 3 hours to complete, while the Dolphin method takes

under 5 minutes. T2 was superimposed on T1 cranial base. T2 registrations for both methods were compared to each other using the absolute closest point color map, with emphasis on 7 regions (Nasion, A point, B point, bilateral zygomatic, and bilateral gonion).

Results Intraclass correlation showed excellent reliability (0.96). The mean differences between the two methods were less than 0.21 mm (voxel size = 0.38). The least difference was in the left zygomatic area with 0.09 mm Âą0.07, while the largest was in the right gonion region with 0.21 mm Âą0.13.

Conclusion Dolphin 3D voxel-based superimposition, a fast and user-friendly method, is accurate and reliable. Volume 7 Number 4

J. Christian Francis, DDS, MS, University of Kentucky Background Utilization of screwtype devices for orthodontic anchorage continues to increase. These screws have been designed progressively narrower to allow for interradicular placement, but failure rates are significantly higher than those of wider endosseous implants. Bone remodeling adjacent to these anchorage screws is critical to maintaining a healthy bone-screw interface and sustaining orthodontic forces.

Research Design Anchorage devices (n = 70) with 1.6 mm, 2.0 mm, 3.0 mm, and 3.75 mm diameters were placed into edentulous sites in skeletally mature beagle dogs following premolar extraction and healing. In a split-mouth design, devices on one side were loaded (2N) utilizing calibrated coil springs. Epifluorescent bone labels were given i.v. prior to sacrifice. Bone-implant sections (~ 70 Âľm) were prepared using undecalcified methods. Bone formation rate (BFR, %/yr) and other histomorphometric variables were assessed using imaging software.

Results

Purpose The purpose of this study was to evaluate the effect of diameter and orthodontic loading of a screw-type device on supporting bone remodeling.

The BFR varied by jaw. The mean BFR ranged from 10.93%/yr. to 38.91%/yr. The BFR was significantly (p <0.05) lower in bone adjacent to the 1.6 mm diameter screws compared to bone adjacent to the 2.0 mm,

3.0 mm, and 3.75 mm diameter screws. BFR was lower adjacent to loaded 1.6 mm screws compared to non-loaded 1.6 mm screws (p <0.01) or loaded 2.0-3.75 mm diameter screws (p <0.01). No significant differences in BFR were noted, regardless of loading condition, between the 2.0 mm, 3.0 mm, and 3.75 mm diameter screws.

Conclusion We detected a dramatic reduction in a critical biologic parameter, bone remodeling, in a controlled experimental design. While orthodontic loading of 2N did not alter bone remodeling associated with screws of 2.0 mm diameter or larger, it did decrease bone remodeling adjacent to the 1.6 mm screws. 2.0 mm diameter or larger machined screws may be more likely to maintain a healthy bone-implant interface under typical orthodontic forces.

The effects of corticotomies on frontonasal suture expansion and bone modeling in mature rabbits Brittany M. Wright-Graves, DDS, MS Background Although expansion of complex adult sutures with continuous forces has been shown to be possible, the amounts of expansion obtained were limited. Whether the bony sutural interface can be altered to enhance sutural separation has not been experimentally investigated.

Purpose This split-skull study was designed to evaluate whether corticotomies enhance bone modeling and reduce the resistance of sutural articulations during expansion in mature rabbits

Materials and Methods Nine adult female rabbits, 8 to 9 months old, had miniscrew implant (MSI) supported Volume 7 Number 4

expansion devices with 150 g open-coil nickel-titanium springs placed bilaterally across the frontonasal sutures. Corticotomies were performed, anterior and posterior to the frontonasal suture, on one randomly chosen side. The other side served as the control. Sutural separation was measured bi-weekly for 7 weeks. Using ÂľCT scans of each specimen, bone material density and bone volume fraction were measured. Qualitative histologic analyses of the tissues were performed using H&E staining.

than control side. The amount of expansion that occurred was negatively correlated (R = .860; p = <.001) with bone density. Blinded histological evaluations showed increased numbers of osteoblasts along the bone fronts on the corticotomy side. Compared to the control side, the sutural margins on the corticotomy side exhibited greater numbers of elongated Sharpeyâ&#x20AC;&#x2122;s fiber insertions, greater amounts of immature woven bone, and more osteocytes.

Results

Mature sutures expanded with adjunctive corticotomies undergo 31% more separation than sutures expanded without corticotomies, with the amount of expansion that occurs being inversely related to bone density. OP

Most (94.4%) of the MSIs remained stable throughout the experiment. There was significantly (p <.05) more sutural separation on the corticotomy side (3.73 mm) than the control side (2.83 mm). Bone volume fraction was 5.1% less, and bone density was 1.6% less on the corticictomy

Conclusion

Abstracts are courtesy of DENTSPLY GAC.

Orthodontic practice 41

ABSTRACTS

Screw-type device diameter and orthodontic loading influence adjacent bone remodeling

STEP-BY-STEP

Scanning with CEREC Ortho for clear aligner treatment Dr. Peter Gardell outlines the steps in a process for taking digital impressions for use with clear aligners

or years now, I’ve been using the CEREC Omnicam for intraoral scanning and ClearCorrect’s clear aligner system for orthodontics. Now that CEREC Ortho has arrived, I can use my Omnicam to take digital impressions for use with clear aligners and finally get rid of PVS material once and for all. About CEREC Ortho CEREC Ortho is a newly released software that has made capturing high-quality full-arch digital impressions much faster than was previously possible. It does this by using a well-defined imaging pattern, in which the software guides the clinician through step by step. When doing full-arch scans, I have found two items that help with the scanning process: 1. The Isolite® retraction system offers control of the patient’s soft tissue and control of saliva, which can interfere with the imaging process. Half of the arch can be scanned, and then the Isolite Mouthpiece can be repositioned and the rest of the dentition captured. 2. The OptraGate® from Ivoclar Vivadent® is indispensable for efficient imaging. I love this product to be in place when taking the photographic

records as well. It retracts the lips and keeps the buccal mucosa away back to the first molar. It does this comfortably for the patient, so leaving it in place during the visit is acceptable and speeds up the entire process. Before you get started with the scanning process, special attention should be paid to ensure that all embrasures of the teeth are captured, and at least 2 mm of gingiva should be captured as well. Full-arch scanning When scanning, you will image the mouth in a set, specified manner. You will start by positioning the camera over the mandibular second right molar and holding it still for a few seconds. The camera will activate, and an audio signal will alert the operator that imaging has commenced. Roll the camera to the lingual surfaces, and be sure to move the camera anterior in a smooth and steady manner. Do not move the camera distal at this point. Once you are in the area of the lower left lateral and canine, again hold the camera steady for a few seconds. An audio tone will then signify that this sweep has been completed. Return the camera to the occlusal of the right mandibular second molar, and again wait for the audio signal. Move the camera

Peter Gardell, DDS, graduated from New York University College of Dentistry with honors. He has received numerous awards for clinical excellence. Dr. Gardell has attained faculty and clinical mentor positions at some of the most prestigious educational institutions in the United States. He has written articles and lectured extensively on many of the technologies he has implemented in his office. Dr. Gardell is a member of the American Academy of Cosmetic Dentistry. Disclosure: Dr. Gardell acknowledges having received no compensation from ClearCorrect.

42 Orthodontic practice

anterior, capturing the occlusal surfaces of the teeth. As you move forward over the lower incisors, the camera will beep indicating that you have completed your second sweep. Next, bring the camera back to the occlusal of the second molar. Wait for the audio cue, and then rotate the camera to the buccal side. Move the camera forward until a beep is heard, signifying that the third sweep has been completed. To complete the imaging, one more sweep is required to tie the buccal, lingual, and occlusal sweeps together. You should look for any unclear areas on the digital model, which can be filled in where needed. (These areas will be displayed in yellow.) Hold the camera over an area that has already been captured, and wait for the camera to activate. Now you can fill in any existing holes freehand. There is no set imaging protocol for this (if this step is needed at all). You will then repeat this entire process for the upper jaw. Buccal-bite scanning The next step is the most exciting for seasoned CEREC users — capturing the dual buccal bite. Capturing the buccal bite has proven to be difficult for many doctors who were previously scanning in CEREC Connect. This is yet another reason why CEREC Ortho is superior for full-arch scanning. Similar to the scanning of the arches, the buccal scan is done in a well-defined process, which the software will guide the clinician through. It is very important to explain to the patients to bite firmly and to keep their teeth together as you image one side, followed by the opposing side. When the buccal scan begins, there will be a start point displayed on the screen. Hold the camera steady on the mark (which is in the area of the first and second maxillary premolar), and wait for the audio signal. Move the camera down toward buccal surfaces of the mandibular teeth trying to overlay the camera placement with the target on the screen. Repeat the process on the contralateral side. Once both sides have been scanned, the models will autoarticulate (or “snap”) into position, which will Volume 7 Number 4

STEP-BY-STEP

conclude the imaging phase of the CEREC Ortho software. Videos of this process are available to view at www.Cerecdoctors.com. Advantages There is an immediate advantage of scanning with CEREC Ortho as compared to scanning with CEREC Connect — the first being dramatically decreased file sizes. There are also significant advancements with CEREC Ortho in the processing of virtual models: Unwanted and unnecessary soft tissue and artifacts will be automatically removed by the software. All of this adds up to a crisper and cleaner virtual model for the orthodontist to evaluate and for ClearCorrect to fabricate the aligners from. Case submission After the scan has been submitted, the orthodontist will need to access ClearCorrect doctor’s portal in order to submit the corresponding case to ClearCorrect (dr.clearcorrect.com). Basic patient information will be entered, and a checklist will be filled out on the desired treatment and movements. There is even a section where radiographs

and photos can easily be uploaded. Once the case has been submitted, a case number will be assigned. This number will be used to identify this case from start to finish. ClearCorrect will then amass all the information submitted, including the scans, and in short order will send a confirmation of receipt. And that’s it — all of the patient’s records have been submitted to ClearCorrect, without having to mail a single thing to the lab. No

need to waste money on PVS materials and shipping fees, and even better — the clinician will receive the treatment setup from ClearCorrect in as quickly as 24 hours. When using traditional PVS impressions, the impressions would likely still be at the shipping carrier’s sort facility after 24 hours, likely not arriving to the lab for days! Patients are sure to be thrilled with the expedited treatment they’ll receive. OP

Quality. We’ve been making clear aligners for almost ten years. We’ve gotten very good at it.

Free Limited 6 Case Use promo code OPRAC2 when you sign up for free at clearcorrect.com/doctors

Volume 7 Number 4

Orthodontic practice 43

LABORATORY LINK

Digital indirect bonding James Bonham describes how CAD technology delivers precision bracket placement

omputer-aided design (CAD) software enables engineers and architects to design, inspect, and manage engineering projects within an integrated graphical user interface (GUI). Computers are proven to enhance the precision and efficiency of creation, modification, and analysis of any design. Dental professionals currently use CAD technology every day to design appliances like implant surgical guides, crowns and bridges, and tooth aligners to name a few. More recently, CAD technology is assisting orthodontists with treatment planning and precision bracket placement. 3DiB (three-dimensional indirect bonding) is the latest bracket-placement CAD technology from ARCAD Digital Lab (the software developer) and Specialty Appliances orthodontic laboratory. 3DiB has many unique features, including an online communication portal, a web-based approver software, and an extensive bracket file library. The advanced CAD software simulates the patient’s ideal posttreatment finish derived from the doctor’s treatment plan, and then identifies the exact bracket location for efficient straight-wire tooth alignment. Orthodontists have the flexibility to quickly view, edit, and approve their cases from almost any Windows®-based computer. Instead of forcing clinicians to use an unfamiliar appliance, 3DiB allows them to select their preferred bracket system for each individual orthodontic case. Every orthodontic bracket has a unique prescription of torque, tip, and angulation built into the bracket. 3DiB software understands how the bracket’s prescription is expressed when attached to the tooth and engaged with the doctor’s finishing archwire. Using this knowledge, the software finds the best bracket location on each tooth’s unique anatomical surface that will perfectly align the archwire slots and achieve the doctor’s ideal treatment finish. James Bonham is a partner at Specialty Appliances and manages sales and marketing. He has spent the past 12 years in orthodontics with a strong focus on the integration of digital technology into orthodontic practices.

44 Orthodontic practice

Once the ideal setup is completed and checked for quality by experienced technicians, the orthodontist is notified through 3DiB’s secure communication portal. Clinicians can log into their portal and have full control to adjust either teeth in the ideal setup, or bracket location on the pretreatment malocclusion model. If they decide to adjust the posttreatment setup, brackets automatically adjust to their new location on the pretreatment malocclusion. To the contrary, doctors can also choose to move brackets on the pretreatment malocclusion and instantly witness the adjusted tooth position on the posttreatment setup. This easy approval process usually takes 5 minutes or less of the doctors’ valuable time. When doctors are happy with their case setup, they simply click on the approve button, and the case gets forwarded to Specialty Appliances for indirect tray fabrication. Specialty Appliances then reviews the doctor-approved setup and prints the malocclusion model. Using a proprietary system to capture the doctors’ ideal bracket position, the lab places the brackets on a printed malocclusion model. Specialty then manufactures an indirect transfer tray with custom adhesive bases on each bracket pad. This process ensures a perfect custom fit of each bracket to the tooth’s enamel surface. 3DiB’s indirect transfer trays will efficiently deliver

the doctors’ approved ideal placement of their brackets. Transfer trays can be sectioned or delivered in whole to each arch by a single orthodontic chairside assistant. Specialty Appliances recommends a chairside delivery system using a light-cured flowable composite. This reliable delivery system has proven results of excellent bond strength and minimal to no adhesive flash. Indirect bonding training materials and on-site training are available through Specialty Appliances’ upon request. Excellent bracket placement has always been a sure way to move teeth efficiently, decreasing orthodontic treatment time. 3DiB is a fine use of CAD technology to help orthodontists achieve greater precision in bracket placement. OP Volume 7 Number 4

CUSTOM CLASS II FIXED APPLIANCES

Specialty’s M4™ MiniScope® Herbst is known for durability and patient comfort. The compact design offers room for orthodontic bracket therapy while simultaneously correcting the class II malocclusion. M4 also delivers the greatest range of motion, allowing 40 degrees of lateral movement and a maximum incisal opening of 64mm. Request Applecore Screws for any herbst design and we will provide them at no additional charge!

Specialty’s custom M.A.R.A. is a simple and predictable appliance for mandibular advancement on class II patients. The appliance is attached to the first molars, or the deciduous second molars, with crowns or Specialty’s ROC crowns. Adjustments are achieved by adding shims and/or bending the removable upper elbow. Expansion can be incorporated into each arch as needed.

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

800.522.4636 • SpecialtyAppliances.com 4905 Hammond Industrial Drive, Suite J • Cumming • Georgia 30041

PRODUCT PROFILE

3M — A system of proven products A beautiful smile throughout treatment

our patients look to you to enable their most beautiful smile, even while they’re undergoing orthodontic treatment. While esthetics might begin with ceramic brackets with clear or colored ligatures — it doesn’t end there. Class II correction is an everyday part of your practice, and it’s a process that can be esthetic too. 3M has put years of science to work to develop a system of proven products that allows your patients to be comfortable, happy, and confident while you’re correcting their Class II malocclusion.

A brilliant system

APC Flash-Free Adhesive coating means increased efficiency at placement and superior strength. Treatment for Class II malocclusion has traditionally been limited to products that are easy to install, but require patient compliance,

or products that are fixed but difficult to work with. Many appliances are worn outside the mouth. With Forsus™ Class II correctors, treatment becomes both hidden and fixed — but without the hassle. Forsus Class II correctors can be added at any time, without molar bands. Cheek bulges are eliminated, and the device remains in place 24/7 without the need for patient compliance. Today, Forsus Class II correctors have been used in the treatment of more than 1-million patients.

Patient-pleasing esthetics begins with the leading ceramic system. Clarity™ ADVANCED Ceramic Brackets provide exceptional esthetics and strength in a small size, with smooth surface uppers and lowers that resist staining and discoloration throughout treatment. These ceramic brackets are proven — offering predictable debonding and enhanced patient comfort. Clarity ADVANCED brackets are the first step to truly esthetic Class II correction. Adding efficiency and timesavings, APC™ Flash-Free Adhesive provides an improved patient bonding experience. The system eliminates the flash removal step completely, reducing bonding time, and there is no compromise in bond strength. Early users have reported less than a 2% bond failure rate. The adhesive on the tooth after bonding has been shown to protect enamel under the adhesive, further contributing to a beautiful smile after treatment. Designed with extensive user input, Victory Series™ Superior Fit Buccal Tubes eliminate the need to band molars. They feature a complex-contour curvature base for superior fit, are easy to place and handle, and offer a sleek, low-profile, and tapered body for Actual patient wearing Clarity™ ADVANCED Brackets and Forsus™ Class II correctors patient comfort. Availability with 46 Orthodontic practice

The result? Simply beautiful For you and your practice, this intelligent system works around the clock to speed progress and help ensure optimal, esthetic results. External hardware is eliminated, with no headgear, face bow, or elastics that can be embarrassing for patients of all ages; and compliance issues are no longer a threat to effective treatment. Pairing this with brilliant, patient-pleasing esthetic brackets and more efficient application means you can spend more time with patients and more time building a successful practice. To see how 3M can make a difference for you, visit 3M.com/ Aesthetics, and get your complimentary samples. Or call 3M at 800-423-4588. OP Complimentary samples are for U.S. doctors. This information was provided by 3M.

Volume 7 Number 4

Beautiful, together.

Your patients trust you to provide them a beautiful smile throughout treatment. Trust 3M for proven solutions to achieve your desired end result. Together with 3M Science, you can deliver beautiful smiles throughout treatment, even when correcting Class II malocclusion — and as an end result, have a happier, more confident patient. The answer is proven products that work beautifully together — together with you — to deliver a beautiful smile.

Forsus™ Correctors — used in treatment by more than 1 million patients!

Call to see how 3M can make a difference for you. (800) 423-4588 | 3M.com/ortho

PRODUCT PROFILE

Avex® CX2 brackets by Opal® Orthodontics

atients seeking a world-renowned orthodontic prescription that doesn’t compromise esthetics or their confident smile need look no further than the recently introduced Avex® CX2 brackets. Avex CX2 brackets are the newest part of the worldrenowned McLaughlin Bennett System 4.0™ and are available exclusively through Opal® Orthodontics. Designed to help give patients confidence throughout every step of their orthodontic treatment, Avex CX2 brackets blend naturally with tooth enamel and resist staining, thanks to each bracket’s unique polycrystalline-material makeup. The small, low-profile design also provides maximum patient comfort throughout treatment. Avex CX2 brackets offer predictable, reliable results allowing patients to reach their treatment goals in less time.

Each Avex CX2 bracket features purchase points on the tie wings that enhance patient comfort and make ligation easier. Additionally, generous undercuts on the tie wings enable double tying of ligatures and chains throughout orthodontic treatment. Precision wire slots on each bracket are true to specified dimensions, providing optimum torque control, and the universal color identification markings correspond with the rest of the Avex® Suite — making a complete and compatible system from start to finish. Color indicators in the wire slots also provide an effective visual reference for precise positioning. Additionally, mesial and distal pockets on each Avex CX2 bracket provide greater interbracket distance, reducing wire force while offering improved patient comfort. True torque in the base of the bracket delivers optimal positioning and minimal occlusal interference while the base ridge enables better handling. 48 Orthodontic practice

Avex CX2 brackets offer predictable, reliable results allowing patients to reach their treatment goals in less time.

Opal Orthodontics crafts each and every Avex CX2 bracket with control and predictability in mind and has even improved the base of each bracket for simplified, easier bonding. The new compound contoured base also ensures maximum bracket-totooth fit. Furthermore, the features of the Avex Suite enable clinicians to treat to board standards more efficiently, thanks to the

precision with which each and every bracket is manufactured. To learn more about the Avex CX2 brackets or the Avex Suite — part of the McLaughlin Bennett System 4.0 — please visit opalorthodontics.com, or call 888-863-5883. OP

This information was provided by Opal® Orthodontics.

Volume 7 Number 4

Clearly Confident.

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

To purchase Avex CX2, call 888.863.5883 or visit opalorthodontics.com to learn more. Zara Guinard Professional Triathlete, Coach, and Model

M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT 3Shape and Ormco announce TRIOS® integration with Insignia™ Advanced Smile Design™ TRIOS® — 3Shape’s digital color impression solution — is now integrated with Insignia™ Advanced Smile Design™, a sophisticated computer-designed treatment planning and custom-fabricated appliance software system by Ormco, a manufacturer and provider of advanced orthodontic technology and services. The timesaving workflow integration enables orthodontists to send TRIOS intraoral scans with just a click to Ormco for the planning and delivery of its Insignia™ bracket treatment system. For orthodontists using TRIOS, the integration eliminates the steps of having either to take an analog PVS impression or to manually upload a large and bulky intraoral scan file to a server. Now orthodontists can just choose Insignia from their 3Shape Communicate™ account to submit the case and send the TRIOS digital color impression file to Ormco, which then uses the intraoral scan to create its customized digital orthodontic treatments. For more information, visit the Ormco website at http://www. ormco.com/. For information about 3Shape, visit www.3shape.com.

Steripod® now available at CVS and Walgreens Bonfit America, Inc., maker of products for living well, recently doubled distribution for its market leading Steripod® clip-on toothbrush protector, which is now available in 30,000 stores across the United States, including for the first time 6,000 CVS and 6,000 Walgreens stores. Additionally, Steripod added 200 Meijer stores, Shopko Wisconsin locations, and will roll out to approximately 1,000 Kroger Co. stores nationwide later this year. Steripod is a clip-on protector that fits any standard or electric toothbrush and keeps it fresh and clean for up to 3 months using a patented vapor shield of thymol — used in many mouthwashes and oral antiseptics. Simply clip Steripod on an electric or manual toothbrush, and it goes to work; no cables or batteries are needed. Learn more at GetSteripod.com.

Americo Dry Mouth Nightguard System New from Great Lakes, the Americo Dry Mouth Nightguard System is designed to protect teeth from the effects of abnormal dry mouth and prevent permanent periodontal damage during sleep. The custom-made upper and lower appliance trays are fabricated to fit comfortably and hold a specially formulated gel that increases salivary flow to protect tooth enamel. The Dry Mouth Nightguard Gel contains xylitol, an anti-cariogenic agent that consistently maintains moisture around the teeth and gums throughout the night, reduces dental decay, plaque formation, and bacteria growth and decreases the risk of oral infection. The Americo System, invented by Dr. Americo Fernandes of Winnipeg, Canada, includes an upper and lower appliance tray, Dry Mouth Nightguard Gel, appliance case, and application brush. For more information about the Americo Dry Mouth Nightguard System, contact Great Lakes laboratory customer service at 800-828-7626, or visit GreatLakesOrtho.com.

Ormco announces commercial availability of Alias™ Lingual Bracket System Ormco announced the commercial availability of its Alias™ Lingual Bracket System, the world’s first straightwire, passive selfligating, square-slot lingual bracket. 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. With passive self-ligating technology, Alias 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. The Alias Lingual Bracket System is designed around three product pillars: simplicity, efficiency, and comfort. To learn more about Ormco, visit www.ormco.com.

New shopping cart from DGS Ortho DGS Ortho, a Bristol Pennsylvania-based supply company, is proud to announce its new shopping cart. Visit DGSortho.com, and view hundreds of money-saving items. The new site is easy to navigate and very easy to place orders. Email with any questions: dgsortho@gmail.com.

50 Orthodontic practice

Volume 7 Number 4

Turn Complex Class II and Class III Patients into Simple Class I Patients

Class llI Appliance Pre-treatment

In-treatment

Post-treatment

Class ll Appliance Pre-treatment

Corrected in 3 months, 20 days

Post-treatment - 13 Months

CARRIERE MOTION™ APPLIANCES ®

Motion Appliances shorten overall treatment time by correcting Class II and Class III malocclusions at the beginning of treatment, prior to bracket placement, when patient motivation is highest.

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

M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT

Ortho Technology showcases Plaque HD™ at AAO Ortho Technology’s recent partnership with Plaque HD™ put the company’s booth in a green spotlight, revealing a new hygiene approach to customers and passersby alike. Plaque HD, a new toothpaste, has green disclosing agents that color and identify plaque — proven to help consumers remove up to 4 times more plaque than standard toothpaste, according to its makers, with published results in the International Journal of Dentistry and Oral Science. Ortho Technology also launched two other well-established products that proved popular — Chewies™ Aligner Tray Seaters and ComfortBrace™ Dental Brace Protective Strips, a wax alternative that offers superior protection, esthetics, and longevity. For more information on Tampa, Florida-based Ortho Technology, call 1-800-999-3161.

American Orthodontics announces enhancements to PowerScope™ 2 Class II Corrector American Orthodontics announced two new features on its PowerScope™ 2 Class II Corrector. PowerScope 2 now features a magnetic sleeve that slides onto the hex head driver, ensuring a secure hold on the appliance during installation and stabilizing the attachment nut when seating it on the wire. In addition, PowerScope 2 has new activation lines that provide a clear visual cue during activation. The three distinct lines are spaced 2 mm apart and reference the level of appliance activation, ranging from no activation to partial to full. The appliance also includes an improved attachment nut to increase durability and ease of installation. PowerScope 2 is a one-size-fits-all appliance that requires no lab setup or special band assemblies. It attaches wire to wire for quick and easy chairside installation and features an internal NiTi spring mechanism that delivers 260 grams of force for continuous activation during treatment. For more information, visit www.americanortho.com, or call 1-800-558-7687.

INDUSTRY NEWS llllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll DDS Solution offers digital study models and interactive communication tools DDS Solution is an innovative orthodontic lab that specializes in digital study models and interactive communication tools. The lab can take the orthodontist’s 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 who needs to see them, without requiring specialized software. Using Adobe Reader, which is found on most computers, these PDFs are accessed and manipulated. Adobe Reader includes built-in measurement and annotation tools useful in visually communicating treatment options and plans. For more information, call 719-347-1188, or visit http://www. ddssolution.com.

52 Orthodontic practice

Great Lakes Orthodontics wins ethics award Great Lakes Orthodontics was recently named as the winner of the 2016 Buffalo Niagara Business Ethics Association (BNBEA) Award in the large business category. The BNBEA recognizes Buffalo Niagara companies that exemplify the highest standards of ethical behavior and business practices. Great Lakes Orthodontics, an employee-owned company founded in 1967 and located in the Buffalo, New York, suburb of Tonawanda, provides products, laboratory services, and both in-house and online appliance fabrication training to members of the orthodontic, prosthodontic, restorative, and general dental professions worldwide. To learn more, visit greatlakesortho.com.

Volume 7 Number 4

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 Volume 7 Number 4

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 in chief, with any questions via email: Mali@medmarkaz.com

Orthodontic practice 53

INDUSTRY NEWS KaVo Kerr Group Imaging announces second annual Dental 3D University event Registration is open for the second annual Dental 3D University (3DU), hosted by KaVo Kerr Group imaging brands Gendex™, NOMAD™, SOREDEX™, and Instrumentarium™. 3DU is a one-ofa-kind 2-day event that offers dental professionals an educational environment dedicated to cone beam 3D (CBCT) solutions that will enhance their practices and put them in full control of treatment outcomes. 3DU will be held October 7-8, 2016, in Boston, Massachusetts. Welcoming doctors, staff, and dental students, 3DU gives attendees the opportunity to earn up to 12 CE credits courtesy of world-class speakers and industry experts, including: • Christine Taxin on medical billing and insurance reimbursement • Lou Graham, DDS, on his journey to 3D • Kaveh Ghaboussi, DMD, on using 3D for implant planning and more • Lisa Koenig, BCHD, DDS, MS, offering anatomy and pathology review • Lou Shuman, DMD, CAGS, on social media and online marketing 2016: search engine optimization, website and mobile Visit dental3DU.com/win for details and additional information about the event.

OrthoAccel® granted three new patents OrthoAccel® Technologies, Inc., has been granted two new patents from the United States Patent and Trademark Office, and one international patent from the State Intellectual Patent Office of the People’s Republic of China, in the category of vibrating dental devices. The new patents protect key design elements and ranges of parameters for AcceleDent. To use AcceleDent, patients bite down on the product mouthpiece for 20 minutes daily while gentle vibrations from its patented SoftPulse Technology™ accelerate bone modeling and remodeling in the craniofacial region. To learn more, visit AcceleDent.com.

LED Dental Inc. announces international VELscope® Vx distribution agreement with major dental technology provider in China LED Medical Diagnostics Inc. reports that its wholly owned subsidiary, LED Dental Inc., has signed an exclusive distribution agreement with Biocare Health Supply Ltd. for the sale and distribution of its award-winning VELscope® Vx system in China and Hong Kong. The VELscope Vx Enhanced Oral Assessment System is utilized by dentists and health-care providers as an adjunct to the traditional comprehensive oral examination. The VELscope Vx’s tissue fluorescence technology enhances the visualization of oral mucosal abnormalities that many not be apparent or visible to the naked eye, such as oral cancer and premalignant dysplasia. The VELscope Vx is also intended to be used by surgeons to aid in the identification of diseased tissue around a clinically apparent lesion, thus assisting in the determination of the appropriate margin for surgical excision. For more information, visit http://www.velscope.com/.

Brace yourself for Bracees

OrthoBanc announces winners of $3 Billion Collected Contest After announcing Bourne Orthodontics of Marysville, Washington, as the first-prize winner of their $3 Billion Collected Contest, OrthoBanc paid off the remaining balance of two deserving responsible parties chosen by Bourne. One of the selected recipients is a single dad who serves in the armed forces, and the other is a single mom who has been diligent about paying on her balance. OrthoBanc announced their $3 Billion Collected Contest last August. “We were getting close to collecting nearly $3 billion in payments for our valued customers, so we decided to use that milestone as a chance to give something back to our customers and also to a few deserving patients,” said Marla Merritt, Director of Sales and Marketing for OrthoBanc. For more information about OrthoBanc, visit orthobanc.com, or call 888-758-0585, option 2.

54 Orthodontic practice

Dr. Sy Viet Nguyen, a dentist from Ohio and the creator of Bracees accessories for your mouth, is launching his new company, Bracees LLC. The company projects that his patent-pending product will be the next “it” thing for kids for years to come. He came up with Bracees while working on his orthodontic patients. Initially, kids are very excited to get braces, and then in the middle of treatment, he usually hears, “When do I get my braces off?” He thought there has to be a better way to get kids more excited about braces than just colored rubber bands, so he created Bracees. Bracees will allow kids to customize their braces daily — they can wake up in the morning and pick out Bracees to match their daily outfits. They can also show people their true personality through their braces. To find out more, visit www.bracees.com.

Volume 7 Number 4

Address the Orthodontic Complexities You Face Everyday with... clinical articles • management advice • practice profiles • technology reviews July/August 2016 – Vol 7 No 4

3 EASY WAYS TO SUBSCRIBE VISIT www.orthopracticeus.com

PROMOTING EXCELLENCE IN ORTHODONTICS Airway orthodontics the new paradigm: part 2, a vision for the future

Dr. Bradford Edgren

Dr. Barry Raphael

EMAIL subscriptions@medmarkaz.com

Reframing orthodontics: Ortho 3.0 Dr. Rohit C.L. Sachdeva

Is your retirement plan strategy due for an annual checkup? Tom Zgainer

CALL 1.866.579.9496

Corporate profile 3Shape Digital Orthodontics

Practice profile Dr. Blair Adams

PAYING SUBSCRIBERS EARN CONTINUING EDUCATION CREDITS PER YEAR!

CE Credits -----------------6 Issues

clinical articles • management advice • practice profiles • technology reviews May/June 2016 – Vol 7 No 3

Orthodontic and surgical diagnosis and management of OSA — case presentations: part 2

SUBSCRIBERS BENEFIT FROM: 24 continuing education credits per year

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

Clinical articles enhanced by high quality photography Analysis of the latest groundbreaking developments in orthodontics Practice management advice on how to make orthodontics more profitable Real-life profiles of successful ortho practices Technology reviews of the latest products

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

129 $ 3 years 319 1 year

Facial asymmetries