Orthodontic Practice US September / October 2016, Vol 7 No 5 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews

PROMOTING EXCELLENCE IN ORTHODONTICS A review of accelerated orthodontics Dr. David Alpan

Reframing orthodontics: part 2 Dr. Rohit C.L. Sachdeva

Precision and acceleration: utilizing advancements in orthodontic technology to achieve optimal results Dr. Edward Lin

Is your 401(k) plan a ticking time bomb of personal and professional liability? Tom Zgainer

Practice profile Dr. Melissa Shotell

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ENHANCING PREDICTABILITY OF CLINICAL OUTCOMES WITH ACCELERATED INNOVATIONS

September/October 2016 – Vol 7 No 5

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INTRODUCTION

Accelerated orthodontic treatment — win-win for patients and orthodontists

September/October 2016 - Volume 7 Number 5 EDITORIAL ADVISORS Lisa Alvetro, DDS, MSD Daniel Bills, DMD, MS Robert E. Binder, DMD S. Jay Bowman, DMD, MSD Stanley Braun, DDS, MME, FACD

his is such an exciting time to practice orthodontics because we’re able to enhance the patient treatment experience with innovative technologies. The emergence of accelerated orthodontic treatment is the most notable advancement in improving patient satisfaction. Patients have long wanted faster orthodontic treatment with no pain, but until recently, there were very few clinically proven methods that were noninvasive, efficient, and effective. For the past 3 years, I’ve been meeting patients’ requests for faster and more comfortable orthodontic treatment by offering them AcceleDent®, the first and only FDA-cleared vibratory orthodontic device that has been clinically proven to Manal Ibrahim, DDS speed up orthodontic treatment by as much as 50% and reduce discomfort associated with treatment. In addition to these benefits to the patient, I have also experienced clinical and practical advantages in providing AcceleDent to our braces and aligner patients and have heard similar feedback from colleagues who offer this accelerated technology. I’ve completed nearly 1,000 aligner cases with AcceleDent, and what I’ve noticed is that I have more control of my treatment plan and greater predictability of outcomes with AcceleDent than without it. Using patented SoftPulse Technology®, AcceleDent works at the cellular level to ensure that the programmed movements in my aligners or my custom suresmile® wires will be expressed more predictability. What is most impressive is that the Class II medical device practically guarantees that all of the control I want and need to achieve the treatment outcomes that I plan for my patients will actually happen. With AcceleDent, I’m able to more predictably achieve an outcome for a patient than has previously been possible in orthodontics. Additionally, since my treatment philosophy focuses on enhancing my patients’ smiles for life, their overall health is extremely important to me. Accelerated treatment helps mitigate various health challenges associated with prolonged orthodontic treatment such as caries and periodontal disease. By using this technology, I help ensure that the patient’s dental hygiene stays intact while in my care. I’ve found that patient motivation plays an important role in maintaining dental hygiene, and that faster orthodontic treatment increases motivation throughout treatment. This is especially true among adult orthodontic patients who, according to the American Association of Orthodontists, are at an all-time high. The association reports a 14% increase in adult orthodontic patients since 2012. I encourage every orthodontist to embrace accelerated orthodontic technology because I believe it is here to stay and will soon become the standard that patients demand of our industry. AcceleDent has been the game changer for my practice and for the field of orthodontics. For me, it’s about greater control and predictability in executing treatment plans; and as a result, practicing orthodontics is a lot more enjoyable, and patients are a lot happier. Dr. Manal Ibrahim

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

Manal Ibrahim, DDS, is the owner of Innovative Orthodontic Centers in Illinois. She completed dental school at the University of Illinois and went on to obtain a certificate in Advanced Combined Prosthodontics. She previously practiced restorative, prosthetic, and implant dentistry for nearly 10 years. Due to this unique background, Dr. Ibrahim has the ability to treat orthodontic patients presenting with any degree of complexity. She is a member of the American Association of Orthodontists, the American College of Prosthodontics, the American Academy of Fixed Prosthodontics, the American Dental Association, the Chicago Dental Society, and the Illinois State Dental Society. Her philosophy and ambition are to enhance her patients’ dental esthetics, health, and function for life.

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 5

TABLE OF CONTENTS

Clinical Pulse vibration technology in orthodontic treatment Dr. Gary Brigham presents a viable alternative to accelerate orthodontic treatment......................................... 18

Maintaining clearly defined treatment objectives: part 1

Practice profile Melissa Shotell, DMD, MS Positive impact on patients

Drs. Domingo Martin and Jorge Ayala demonstrate how to achieve perfect functional and esthetic outcomes using the FACE Evolution bracket prescription..................................... 24

Case study Precision and acceleration: utilizing advancements in orthodontic technology to achieve optimal results Dr. Edward Lin discusses efficient and effective digital innovations...............30

Financial focus Is your 401(k) plan a ticking time bomb of personal and professional liability? Tom Zgainer discusses how small business owners may be overlooking a significant source of liability in their practices: their 401(k) plans

14 4 Orthodontic practice

Orthodontic concepts Reframing orthodontics: a new manifesto driven by BioDigital orthodontics, part 2 Dr. Rohit C.L. Sachdeva explores a proactive, quality-focused approach to orthodontics.................................... 38

ON THE COVER Inset X-ray photo on cover courtesy of Drs. Harold Rosenberg, Austin Chen, and Shervin Abbaszadeh. Article begins on page 50.

Volume 7 Number 5

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TABLE OF CONTENTS

Continuing education A review of accelerated orthodontics

Dr. David Alpan discusses several technologies that deliver orthodontic treatment in less time

Continuing education Palatally displaced canines — is there a way to prevent impaction of these teeth? Drs. Harold Rosenberg, Austin Chen, and Shervin Abbaszadeh discuss early detection and diagnosis of PDCs ........................................................50

Aligner technology VPro5™ — more efficient aligner seating with high-frequency vibration Dr. Thomas Shipley discusses the advantages of high-frequency vibration ....................................................... 55

Laboratory link Smile maintenance James Bonham discusses developments in retainer technology ....................................................... 58

Practice development Is your website really working? Ian McNickle, MBA, discusses how to convert website visitors into new patients...........................................60

PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com 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 Inspire ICE™ Clear ceramic brackets by Ormco Corporation.....................................61

MANAGING EDITOR | Lou Shuman, DMD, CAGS Email: lou@medmarkaz.com ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkaz.com MANAGER – CLIENT SERVICES | Adrienne Good Email: agood@medmarkaz.com

Banding together

CREATIVE DIRECTOR/PROD. MGR. | Amanda Culver Email: amanda@medmarkaz.com

Brooks’ heroes

WEBSITE MANAGER | Anne Watson-Barber Email: anne@medmarkaz.com

Editor-in-Chief Mali Schantz-Feld shares an unforgettable act of kindness..........................................62

Industry news................63

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)

6 Orthodontic practice

$129 $319

Volume 7 Number 5

Orthodontists Under Attack

Guess What Will Kill Corporate Dentistry? If you own an orthodontic practice or know someone who does, I urge you to request your free chapter from Dustin Burleson’s latest book. Discover how to inspire your team to greatness, grow an orthodontic practice you love and live a life of meaning, while politely telling corporate dentistry to go jump in a lake. Sign up now to download the first chapter for free. You will also be added to our VIP list to receive special promotions when the book launches soon! In Dustin Burleson’s latest book, you’ll discover: • The only way to stop corporate dentistry from squeezing your practice and stealing your patients • How only seven weeks of proper study in sustainable practice growth can totally change your life forever • Why only 37% of employees today are highly engaged in their companies and what to do about it quickly, before it’s too late • What “happiness hacks” the best orthodontists use each day and how they get more done in less time without all the stress • The exact tools I share with my employees across five practice locations to serve over 11,000 active patients with world-class service learned from the Disney Institute and Ritz Carlton Professional Development Center “Wow! HUGE Growth...” “Dustin Burleson Seminars has completely changed how we Dr. Blake Borello do new patient exams and our practice is up over 35% this year!”

Dr. Lisa Grant

“Hands Down...” “The best information I’ve implemented into our office in almost 20 years of Dr. Nicole Teifer orthodontic practice.”

“I wish I had found this sooner!” We have implemented Dr. Burleson’s strategies with tremendous growth in our practices. I only wish we had found him sooner.”

If you’re frustrated about the future of orthodontics and you’re finally ready to grow your practice with big leaps in customer service for your patients, big leaps in productivity for your employees, big leaps in income for you and your family, all while living a life you love…The Ortho Manifesto is the book for you.

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PRACTICE PROFILE

Melissa Shotell, DMD, MS Positive impact on patients What can you tell us about your background? I grew up in Southern California, and my parents ran a small family-owned manufacturing business. Since I was a small child, I have always been fascinated with dentistry. I attended a preschool trip to the dentist’s office when I was about 4 years old and made up my mind that I was going to be a dentist.

When did you become a specialist, and why? As a young teenager, I needed complex orthodontic care — multiple impacted teeth, crowding, overbite — it changed my life. I personally saw the impact orthodontic care can provide. After dental school, I was not sure what direction I wanted to take with my career so I practiced as a general dentist for 4 years. After 4 years in general practice, I felt that orthodontics was my true professional calling, and I returned to Loma Linda University to study orthodontics.

Dr. Melissa Shotell in her Greece treatment room

Pumpkin is the practice mascot

Is your practice limited solely to orthodontics, or do you practice other types of dentistry? My practice is limited solely to orthodontics, but I do practice with my husband 8 Orthodontic practice

Michael D. Scherer, DMD, MS, a prosthodontist. This gives me an opportunity to treat many patients with interdisciplinary treatment plans. I have conducted research focused on the remodeling of the temporomandibular joint with the use of functional appliances utilizing cone beam imaging. I also am interested in dental ergonomics and have taught CE events focused on providing clinicians with simple and effective techniques as foundational principles of ergonomics to help prevent musculoskeletal disorders.

Why did you decide to focus on orthodontics? My own orthodontic treatment was very complex, and this gave me a great interest in the field of orthodontics. Through my own treatment, I saw the tremendous impact that orthodontic care can have on a patient’s life and wanted to pursue an area of dentistry where I could help make these same positive impacts for my patients.

Do your patients come through referrals? Some of my patients come to me through referrals; however, most of my patients are Volume 7 Number 5

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How long have you been practicing orthodontics, and what systems do you use? I have been practicing orthodontics for 2 years. I use American Orthodontics for my traditional bracket treatment and 3M TrueDefinition for my digital scans to send to Align for Invisalign treatment. I also have a Vatech CBCT and a Form 2 3D printer by Formlabs.

What training have you undertaken? I completed my master’s degree in Orthodontics and Dentofacial Orthopedics at Loma Linda University. I attend multiple CE courses and training programs throughout the country each year.

Who has inspired you? I have been most inspired by my grandmother who grew up in an impoverished part of rural Oklahoma. She left the small town she was from at the age of 18 to join the World War II war effort working in a factory to manufacture airplanes. My grandmother always encouraged education since she grew up in an era when most women were not given the opportunity to pursue education. My grandmother was a strong advocate of hard work and education, and she had a tremendous influence on me when I was young to pursue my personal and professional goals.

Our office utilizes the latest, modern technology and intraoral scanning (3M™ True Definition Scanner)

Through my own treatment, I saw the tremendous impact that orthodontic care can have on a patient’s life and wanted to pursue an area of dentistry where I could help make these same positive impacts for my patients.

What is the most satisfying aspect of your practice? I enjoy working with many of our adult patients who have given up hope on their dental health. Working with these patients to achieve their personal goals for their treatment and finding comfort and function are a very rewarding experience.

Professionally, what are you most proud of? I am very proud of the opportunities I have had to mentor both my patients and my staff. The office has four operatories and a staff of seven team members. I have sent one of my assistants to become an expanded functions assistant. Three of my assistants have become hygienists, and one of my hygienists went to dental school to become a dentist. I also volunteer and take part in Science Night and Dinner With a Scientist for the local elementary school and middle school to encourage 10 Orthodontic practice

Dr. Shotell teaching ergonomics at a recent training course Volume 7 Number 5

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PRACTICE PROFILE young students to pursue a career in the sciences.

What do you think is unique about your practice? My practice is unique in that it allows collaboration between my husband and myself to combine our two specialties for the benefit of our patients. By combining our two practices, it allows us to treat very challenging interdisciplinary cases for adolescents and adults.

What has been your biggest challenge? Ironically, even though our practice is

a high-tech dental hub, technology is my biggest challenge! I love traditional orthodontic techniques combined with a dusting of the latest, modern equipment. The only problem with modern technology is that it can be temperamental! Thankfully, my husband is a computer nerd.

What would you have been if you had not become a dentist? If I wasnâ&#x20AC;&#x2122;t a dentist, I would have become an attorney. I love the logics and the methodical nature of the law. Reasoning and debate are two skills that I excel in. Maybe Iâ&#x20AC;&#x2122;ll go back to school in retirement and get my JD!

What is the future of orthodontics and dentistry? The future of orthodontics is definitely embracing technology. New technology utilizing cone beam, optical scanning, and 3D printing is going to be the future of orthodontics. These new technologies will allow us to highly customize individual patient care.

What are your top tips for maintaining a successful specialty practice? My best advice for maintaining a specialty practice is to maintain highly individualized patient care. Patients are unique individuals, and they want to see how their personal needs are recognized with their treatment.

What advice would you give to a budding orthodontist? For a budding orthodontist, I would recommend spending a lot of time on practice management. Developing your own brand of orthodontics sends a clear message to patients about the type of doctor you are and the care they will receive. Having good practice management skills will help in every aspect of your daily routine at the office.

What are your hobbies, and what do you do in your spare time? I love to cook and travel with my husband. We enjoy spending our free time with our two Shih Tzus, Pumpkin and Flower. Our two dogs are very mischievous and keep us on our toes. OP Dr. Shotell and her husband show their interdisciplinary treatment around the country at national meetings

Top 10 favorites 1. Practicing orthodontics 2. Traveling 3. Spending time with my two fourlegged children, Pumpkin and Flower 4. Exploring the beautiful landscape of the California Gold Country 5. Visiting with family and friends 6. Cooking 7. Teaching dental continuing education 8. Teaching ergonomics to help dentists and their staff members extend their careers 9. Yoga classes 10. Sleeping in on the weekends! Traveling is one of our top hobbies 12 Orthodontic practice

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FINANCIAL FOCUS

Is your 401(k) plan a ticking time bomb of personal and professional liability? Tom Zgainer discusses how small business owners may be overlooking a significant source of liability in their practices: their 401(k) plans

lass-action lawyers seeking plaintiffs are reaching out to employees in businesses of all kinds with opportunistic letters that highlight how they have been harmed by excessive fees in their 401(k) plans. These letters encourage plan participants to join lawsuits against their employers for breach of their fiduciary obligation to provide a retirement plan that is set up for the sole benefit of the employees. While you are busy running your practice and offering a 401(k) as a benefit for your team, a recent ruling by the Supreme Court has officially started the clock on this ticking time bomb. Larger employers in a variety of industries are already under attack, and many others have paid to settle such suits. Smaller companies (under 100 employees), where excessive fees are most prevalent, are now also in litigation. Employee Benefit Advisor, an industry trade publication, recently prophesied that Tom Zgainer is CEO and founder of America’s Best 401k and has helped thousands of companies repair or rescue their retirement plans over the past 15 years. You can learn more at http://americasbest401k.com/feechecker-medmark.

14 Orthodontic practice

an “onset of 401(k) lawsuits should prompt rigorous plan evaluations.” The 401(k) is a great piece of tax code, but the problem lies in the method by which 401(k) plans are sold — and the surprising number of hands in the retirement plan pie. Over the past 3 decades, 401(k) plan providers have been making big money through hidden or opaque fee arrangements. In fact, it took a full 30 years before the industry was required to disclose just how much they make on your plan! Only since 2012 are they now required to produce a fee disclosure document (known as a 408b2), that plan sponsors are required to review, articulate, and take action if necessary, yet the actual fees are often buried in fine print. This is why over 60% of Americans think they pay no 401(k) fees when nothing could

be further from the truth. So just how do plan providers make their money? Primarily by taking a cut of the fees charged by the mutual funds offered in the 401(k) plans they sell. And those fees directly subtract from your returns. Or if that’s not enough to wet their beaks, they layer on additional fees such as “asset management charges” or “contact asset charges.” And so we have a business model where nearly all the major plan providers are conflicted. They choose funds for your plan that charge hefty fees so that there is plenty to go around (or worse, they just sell you their own name-brand funds, which are more profitable for them). Did you think the funds were chosen because they were the best performing? Think again. They were probably chosen because the fund company will “pay to play”— which is why superior-performing, low-cost index funds tend to be a rarity in 401(k) plans. But it doesn’t stop there. The broker who sold the plan wants his cut. So he too will receive commissions from the funds or simply layer on additional fees. And let’s not forget the third-party administrator. They typically charge a fee directly to the employer, Volume 7 Number 5

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FINANCIAL FOCUS but many will also accept a portion of the mutual fund fees. This often buys their loyalty to specific providers. The net result is an industry with layers upon layers of incestuous relationships that funnel excessive fees from your plan and puts numerous conflicts of interest in play — hence the lawsuits.

Do fees really matter? Although the fees your plan charges might sound like small percentages, they have a massive impact over time. Fees subtract directly from your returns. John Bogle, founder of Vanguard, says that costs can cut returns by 66% over the course of our saving years. Said another way, simply controlling costs could double your future nest egg in size. The Department of Labor (DOL) says that hidden fees and backdoor payments in retirement plans are costing Americans over $17 billion annually. The head of the DOL, Secretary Thomas Perez, rightly stated, “The corrosive power of fine print and buried fees can eat away like a chronic illness at a person’s savings.”

It’s your problem At first glance, you might be thinking these issues and conflicts should be the

liability of the provider. After all, they sold you the plan. But ERISA rules make you, the employer, the fiduciary to the plan and to your employees. As the plan sponsor, it’s your job to make sure the plan is set up for the sole benefit of the employees. It’s your job to review and periodically benchmark your plan against other options. For many employers, this is alarming news, as running a business is already challenging enough. So where do you go from here? There are five key steps we advise all plan sponsors to take: 1. Benchmark your plan to determine how it compares to alternatives. A periodic benchmark is required by the DOL anyway, so it’s an exercise that can reap great rewards while also taking care of your duty as a plan sponsor. Beware that if you use a broker to do this, they will typically show other similar plan options where they will also make big commissions. As Warren Buffet says, “Never ask a barber if you need a haircut.” 2. Eliminate layers of fees wherever possible. The first and easiest way is to eliminate the use of a broker who is paid by commission. Brokers typically add little ongoing value short of

Costs can cut returns by 66% over the course of our saving years. Said another way, simply controlling costs could double your future nest egg in size.

bringing donuts to your office twice a year to keep everyone happy. Many employers were sold their plans by brokers who may also be personal friends. Breaking up is hard to do, but a personal relationship is not a defensible position with the Department of Labor. 3. Remove conflicts of interest. If you are using a plan where the provider is being paid by the mutual funds in the plan, they have an inherent bias to select more expensive funds or sell you their own name-brand proprietary funds. This is nearly always the case with plans offered by insurance companies, payroll companies, or mutual fund companies. You can simply ask your provider if they are “revenue sharing” with the mutual funds they offer. 4. Install a third-party fiduciary on your behalf. This is known as a 3(38) fiduciary, who will take over nearly all of the responsibilities and much of the liability of the plan sponsor. Their job is to make sure that the plan is continually operated in the best interests of the plan participants. This is a best practice adopted at many Fortune 500 companies but is rarely seen in small to midsize plans. 5. Look for a plan that has access to the lowest-cost index funds. Index funds consistently outperform nearly all actively managed mutual funds over the long term. One note of caution: Many providers don’t make money off these funds due to their rock-bottom fees, so they sometimes charge additional layers of fees, or they will say your plan isn’t big enough to qualify. Nonsense! Every 401(k) participant in America should have access to the same low-cost funds regardless of the balance in their company’s 401(k) plan. The 401(k) is an amazing retirement solution when there is alignment between the provider and the saver. It’s time that Americans wake up and take back their retirement plans from the providers that have been milking them for every dime they can get. It’s time for business owners to feel proud of the plans they offer, knowing that they will give themselves and their employees the absolute best chance at a successful retirement. OP

Check to see how your 401(k) plan compares to industry averages here: http://americasbest401k.com/fee-checker-medmark. 16 Orthodontic practice

Volume 7 Number 5

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.

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EASY TO OPEN & CLOSE. STAYS SHUT

• • • •

CLINICAL

Pulse vibration technology in orthodontic treatment Dr. Gary Brigham presents a viable alternative to accelerate orthodontic treatment

ver the past few years, clinicians have increasingly used accelerated orthodontic treatment modalities. Currently, over 400,000 manual osteo-perforations (MOPs) have been performed and are believed to have contributed significant value to orthodontic treatments.1-6 Nonetheless, some practitioners remain reluctant to offer adjunctive treatment to their patients or feel that MOPs are too invasive. However, many professionals have regarded pulse vibration technology as a reasonable and less invasive alternative to MOPs. The number of patients who accept MOP treatment is impressive, especially adults and teens between the ages of 15-19-years old and anxious to shorten their treatment times. More importantly, some patients have expressed interest in reducing their time in treatment but were unwilling to undergo MOPs. For these patients, pulse vibration devices may present a viable alternative.

The potential benefits of pulse vibration in orthodontics With so many physiologic systems demonstrating sensitivity to specific ranges of vibration frequency (i.e., digestion, hearing, breathing, sight, etc.), it would seem logical that bone would also respond to a range of vibrational frequencies. A number of studies have described the potential benefits of pulse vibration in orthodontic tooth movement: 1. non-pharmacological analgesic effects7 2. enhanced clear aligner fit 3. accelerated tooth movement 4. promotion of stability in orthodontic retention8

Non-pharmacological analgesic effects The non-pharmacologic analgesic effects diminish the discomfort associated with both fixed appliance delivery/adjustment and with new clear aligner delivery/exchange. Lobre, et al., reported a significant decrease in pain in a randomized clinical trial of fixed appliance patients using a low-frequency vibration device when compared with controls. However, the study did not include a sham device to evaluate a placebo effect. Regardless, clinicians have reported that their patients have experienced a significant decrease in pain and increased appliance comfort when they included pulse vibration.

Clear aligner fit Clinicians understand the importance of continuous, exacting fit in aligner treatment. Continuation of aligner exchange with improper tracking can undermine effective tooth movement. This results in aberrant and unanticipated tooth movement and prolonged treatment, which frustrates patients and doctors. Pulse vibration devices may enhance tracking and tooth movement, assuming patients cooperate and doctors use correct aligner protocol. Moreover, pulse vibration has prevented potential tracking issues generated when patients wear aligners less than the prescribed time. This benefits patients, as successful tracking is fundamental to accelerated aligner exchange and reduces treatment time significantly.

Tooth movement Reports of accelerated tooth movement with pulse vibration have been equivocal. Animal research (rats and rabbits) has shown

Gary Brigham, DDS, MSD, earned his doctorate at Case Western Reserve University, where he also received his certificate in orthodontics and a master’s degree in Immunology. He was awarded the Harry Sicher Award from the AAO for his graduate research and served as an Assistant Professor of Pediatric Medicine at the Center for Craniofacial Anomalies at the University of Illinois at the Medical Center in Chicago. He has lectured throughout the United States for Align Technology since 2004 and is the recipient of Align’s first award for service to the orthodontic profession. Dr. Brigham currently serves as an Adjunct Professor of Orthodontics in the orthodontic graduate program at the A.T. Still School of Dentistry and Oral Health, where he is the dedicated Invisalign® instructor. He maintains a full-time practice in Scottsdale, Arizona. Disclosure: Dr. Brigham reports no conflicts with products mentioned in this article.

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that vibrating forces can cause separation of cranial sutures, induce cranial growth, and accelerate tooth movement (rats).10-14 The manufacturer of the first-to-market pulse vibrator operating at a low frequency of 30 Hz; 25g, used these animal studies to validate its claim for accelerated tooth movement. Using a low-frequency pulse vibration prototype in 2009, Kau, et al.,15 reported accelerated tooth movement in both arches of 14 patients. In a more recent retrospective study, Bowman16 reported statistical in arch leveling in a group of patients with fixed appliances treated with low-frequency pulse vibrations in contrast to a group of control patients. The clinician, however, determined the degree of leveling subjectively without any objective calibration. A company that produces a low-frequency vibratory device funded a randomized, controlled clinical trial with 45 patients, and the authors reported statistically significant tooth movement and canine retraction compared to patients using a sham device.17 Recently in a randomized clinical trial using a low-frequency vibratory device, Woodhouse, et al.,18 studied its effect on tooth alignment of 81 premolar extraction patients with fixed appliances. This study found no evidence of acceleration in tooth alignment compared to control patients. Yadav, et al.,19 investigated low-frequency mechanical vibration in the tooth movement of mice and found no significant acceleration in movement at frequencies of 5, 10, and 20 Hz. Significantly, Kalajzic, et al.,20 evaluated vibrational forces (30 Hz, 0.4N) in a study of movement in 26 rat molars (n=9), and concluded that tooth movement was significantly inhibited by the application of cyclical forces at this frequency, possibly due to a decrease in the number of osteoclasts. They suggested that cyclical forces may cause contrary effects depending upon force magnitude, the frequency of vibration (Hz level), or the point of application. In a review of vibrational therapy effects on tooth movement, Lala²¹ hypothesized that vibration may require a significantly higher frequency to cause consistently accelerated tooth movement. By citing studies by Judex and Rubin²² and Alikhani, et al.,²³ that found Volume 7 Number 5

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CLINICAL greater osteogenic effects at higher frequencies of vibration, Lala arbitrarily defined low frequency as any vibration at or below 45 Hz and high frequency as any vibration at or higher than 90 Hz. Nishimura, et al.,¹³ used a resonant frequency of 60 Hz on maxillary molars and reported an acceleration of tooth movement with vibration. Additionally, Leethanakul, et al.,24 reported significant acceleration of canine retraction in 15 patients following first premolar extractions. Using high-frequency electric toothbrushes (125 Hz) applied to the canines, they also noted a threefold increase in IL-1ẞ, a cytokine protein associated with osteoclastic activity.

Both clinical trials and experience suggest that pulse vibrational orthodontic devices may have a role in orthodontic therapy.

Stability in orthodontic retention Results of some research suggest that pulse vibration may have a stabilizing effect for orthodontic retention. Low vibration frequency (5, 10, and 20 Hz) has been found to increase bone volume factor and collagen tissue density in periodontal ligaments,19 while Rubin, et al.,25 have reported low level vibration frequency (15-90 Hz) as strongly anabolic, which increases the quantity and quality of bone volume in sheep.

Figure 1: Low-frequency device (30 Hz; .25N)

Figure 2: High-frequency device (120 Hz; 0.3G)

Pulse vibration devices in orthodontics Clinicians currently use one of two principal pulse vibration devices now available. One, a low-frequency device (Figure 1), and the other, a high-frequency mechanism. The low-frequency device vibrates at 30 Hz, and 0.25 N and recommends that patients use the vibratory device continuously for 20 minutes daily to affect the accelerated tooth movement. The high-frequency option (Figure 2) vibrates at 120 Hz and 0.3G, and the manufacturer recommends that patients use the device for only 5 minutes each day for the

Figures 3-4: Class I malocclusion characterized by open extraction sites and significant maxillary incisor protrusion. Posttreatment. Patient initiated high-frequency treatment using VPro5™ at aligner 6 and exchanged aligners every 7 days rather than every 14 days from that point forward. Total 24 aligners. Total treatment time 7 months 1 week

Figures 5-7: Patient is showing excellent tracking. Patient is currently at aligner 20 out of 34, exchanging aligners every 5 days with high-frequency treatment using VPro5 Aligners in: Note excellent tracking at aligner No. 20 20 Orthodontic practice

Volume 7 Number 5

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CLINICAL indication of achieving proper aligner seating. Some preliminary research suggests that high-frequency vibratory devices may accelerate tooth movement.22-24 The high-frequency vibrator initially starts at a lower frequency and rapidly increases to the 120 Hz. The low-frequency device vibrates at 30 Hz immediately. Independent, randomized, controlled trials have not yet established the efficacy of these appliances. Nevertheless, the website for the low-frequency vibrator along with testimonials by clinicians claims significantly reduced treatment times when patients use them with either fixed appliances or aligners. Additionally, numerous clinicians and patients attest to the relief of patient discomfort with the use of pulse vibration.

Conclusion Bone resorption remains a critical factor in tooth movement, and increasing studies indicate that low-frequency pulse vibration has an anabolic effect that accelerates tooth movement. This has caused some researchers to speculate that accelerated tooth movement would require pulse vibration to also accelerate the catabolic phase of bone remodeling. Light orthodontic forces are needed in conjunction with vibration to effect accelerated movements, and research has shown that light forces with the application of vibration enhances the secretion of IL-1ẞ, one of the pro-inflammatory cytokines associated with bone resorption. Thus, clinicians might hypothesize that pulse vibration may also increase the secretion of a host of pro-inflammatory cytokines that facilitate bone resorption. Moreover, this cascade of cytokines could simultaneously stimulate a reactionary secretion of modulating glycoproteins that constrain cytokine activity and stimulate osteoblastic activity in response to osteoclasis. Some clinicians, including myself, have begun incorporating both MOPs and highfrequency vibration (many times simultaneously) to accelerate treatment. The intent is to use MOPs on the more difficult movements, and high-frequency vibration to improve aligner seating. Both clinical trials and experience suggest that pulse vibrational orthodontic devices may have a role in orthodontic therapy. Pulse vibration appears to have a non-pharmacological analgesic effect, which reduces patient discomfort. Additionally, these devices have a potential for accelerating treatment and reducing treatment time, particularly when used in aligner treatment. However, the molecular and 22 Orthodontic practice

Figure 8

cellular mechanisms by which various pulse vibration frequencies become anabolic or catabolic remain unidentified. Most importantly, the ultimate effectiveness of pulse vibration remains largely dependent upon patient compliance, as do the other features of orthodontic therapy. Additional research regarding the most effective frequencies, or range of frequencies to produce the desired clinical effects is necessary.

While there is scientific evidence that vibration produces a dynamic force to assist in remodeling bone, it may be of benefit in orthodontic treatment with aligners simply by providing consistently well seated aligners. After using these devices with patients, I would encourage clinicians to familiarize themselves with the research and experience with pulse vibration, and consider how these might benefit their patients. OP

REFERENCES 1. Alikhani M, Raptis M, Zoldan B, et al. Effect of microosteoperforations on the rate of tooth movement. Am J Orthod Dentofacial Orthop. 2013; 144(5):639-648.

tissue activation by vibration: intermittent stimulation by resonance vibration accelerates experimental tooth movement in rats. Am J Orthod Dentofacial Orthop. 2008;133(4):572-583.

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

15. Kau CH, Nguyen JT, English JD. The clinical evaluation of a novel cyclical force generating device in orthodontics. Orthodontic Practice US. 2010;1(1):10-15.

3. Shipley TS. The use of Propel to increase aligner progression. Orthodontic Practice US. 2014;5(2):52-56. 4. Shipley TS. Proactive treatment with Propel. Orthodontic Practice US. 2015;6(2):38-39. 5. Boschken DR. Increasing case acceptance and practice differentiation with Propel. Orthodontic Practice US. 2015;6(4):36-37. 6.

Brigham G. The Propel® System: the next generation orthodontic disruptor. Orthodontic Practice US. 2015;6(5)36-38.

7. Rubin C, Judex S, Qin YX. Low–level mechanical signals and their potential as a non-pharmacological intervention for osteoporosis. Age Ageing. 2006; 35(suppl): ii32-ii36. 8. Zhang C, Zhang L, Xu X, Duan P, Wu H. Mechanical vibration may be a novel adjuvant approach to promoting stability and retention following orthodontic treatment. Dent. Hypotheses. 2014;5(3):98-102. 9. Lobre WD, Callegari BJ, Gardner G, Marsh CM, Bush AC, Dunn WJ. Pain control in orthodontics using a micropulse vibration device: a randomized clinical trial. Angle Orthod. 2016;86(4):625-630. 10. Kopher RA, Mao JJ. Suture growth modulated by the oscillatory component of micromechanical strain. J Bone Miner Res. 2003;18(3): 521-528. 11. Peptan AI, Lopez A, Kopher RA, Mao JJ. Responses of intramembranous bone and sutures upon in vivo cyclic tensile and compressive loading. Bone. 2008;42(2):432-438. 12. Vij K, Mao JJ. Geometry and cell density of rat craniofacial sutures during early postnatal development and upon in vivo cyclic loading. Bone. 2006;38(5):722-730. 13. Kopher RA, Nudera JA, Wang X, O’Grady K, Mao JJ. Expression of in vivo mechanical strain upon different wave forms of exogenous forces in rabbit craniofacial sutures. Ann Biomed Eng. 2003;31(9):1125-1131. 14. Nishimura M, Chiba M, Ohashi T, et al. Periodontal

16. Bowman SJ. The effect of vibration on the rate of leveling and alignment. J Clin Orthod. 2014; 48(11):678-688. 17. Pavlin D, Anthony R, Raj V, Gakunga PT. Cyclic loading (vibration) accelerates tooth movement in orthodontic patients: a double-blind, randomized controlled trial. Semin Orthod. 2015;219(3):187-194. 18. Woodhouse NR, DiBiase AT, Johnson N, et al. Supplemental vibrational force during orthodontic alignment: a randomized trial. J Dent Res. 2015; 94(5): 682-689. 19. Yadav S, Dobie T, Assefnia A, Gupta H, Kalajzic Z, Nanda R. Effect of low-frequency mechanical vibration on orthodontic tooth movement. Am J Orthod Dentofacial Orthop. 2015;148(3):440-449. 20. Kalajzic Z, Polusa EB, Utreja A, et al. Effect of cyclical forces on the periodontal ligament and alveolar bone remodeling during orthodontic tooth movement. Angle Orthod. 2014; 84(2):297-303. 21. Lala A. Vibration therapy in orthodontics: Realizing the benefits. Ortho. 2016; 1(1):24-27. 22. Judex S, Rubin CT. Is bone formation induced by high -frequency mechanical signals modulated by muscle activity? J Musculoskeletal Neuronal Interact. 2010;10(1):3-11. 23. Alikhani M, Khoo E, Alyami B, et al. Osteogenic effect of high-frequency acceleration on alveolar bone. J Dent Res. 2012;91(4):413-419. 24. Leethanakul C, Suamphan S, Jitpukdeebodintra S, Thongudompom U, Charoemratrote C. Vibratory stimulation increases interleukin-1 beta secretion during orthodontic tooth movement. Angle Orthod. 2015;85;(5):74-80. 25. Rubin C, Turner AS, Müller R, et al. Quantity and quality of trabecular bone in the femur are enhanced by a strongly anabolic, noninvasive mechanical interaction. J Bone Miner Res. 2002;17(2):349-357.

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CLINICAL

Maintaining clearly defined treatment objectives: part 1 Drs. Domingo Martin and Jorge Ayala demonstrate how to achieve perfect functional and esthetic outcomes using the FACE Evolution bracket prescription

n today’s orthodontic treatment of patients, the outcomes should no longer simply focus on creating a beautiful smile by correcting the malocclusion. Regardless of the patient’s age, the goal should be the best possible alignment of the teeth to enable their integration into a system of correctly positioned joints, efficient masticatory function, promotion of a healthy state of the tooth surrounding tissue, appropriate coordination of the lips, as well as ideal facial balance. Clinicians can achieve this with a thorough and complete diagnosis that accounts for not only the teeth but also the joints, a stable condylar position, facial esthetics, and optimal muscle function. In many instances, that cannot be achieved with orthodontics alone; and therefore, close cooperation is necessary between the orthodontist, and the treating dentist and/or colleagues from other specialties.

FACE (Functional and Cosmetic Excellence) Some time ago, Dr. Ronald H. Roth initiated a treatment philosophy based on a comprehensive orthodontic diagnostic and treatment system. The philosophy embraces the objective evaluation and diagnosis of the jaw position as well as functional occlusion and implementation of treatment based on this diagnostic information. Based on Roth’s basic principles, which were initially advanced further by the Roth Williams International Society of Orthodontists (RWISO)

Figure 1: The four steps of the FACE treatment philosophy

and later by the RW FACE Initiative (Roth Williams Functional and Cosmetic Excellence) and today’s FACE Group (Functional and Cosmetic Excellence), respectively, the focus is on the clinical objective: a functionally and esthetically perfect treatment outcome. State-of-the-art technology permits even more accurate diagnosis, treatment planning, and treatment.

Treatment philosophy The FACE treatment philosophy harmonizes facial and dental esthetics, periodontal health, functional occlusion with an orthopedic stable joint position, open airway, and stable results. It relies on clearly defined treatment objectives, which are summarized in the following four steps (Figure 1). Step 1: proper joint function (form of joints; centric occlusion = centric relation [CO=CR]) Clinicians should first check for a stable orthopedic position of the joints, which

Dr. Domingo Martin has a BA from the University of Southern California and an MD and DDS from the University of the Basque Country in Spain. He also earned a Master in Orthodontics from the University of Valencia in Spain. He is the Director of the FACE/Roth Williams Center for Functional Occlusion for Europe and has postgraduate work in Bioesthetic Dentistry from the OBI Foundation for Bioesthetic Dentistry. Dr. Martin gives courses and conferences all over the world, and he has a private practice limited to orthodontics in San Sebastián, Spain. He is also a FACE Member. Dr. Jorge Ayala has a medical degree from the University of Chile with a specialty in Orthodontics and Maxillary Orthopedics from the University of Chile. He is Director of the FACE/Roth Williams Center for Functional Occlusion from Latinoamérica and a professor of the FACE/Roth Williams Center for Functional Occlusion in California. He runs a private practice limited to orthodontics in Santiago de Chile. He is the author of numerous articles and publications and speaker at national and international courses and conferences. Disclosure: Dr. Martin is a consultant for Forestadent.

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allows for correct diagnosis and treatment planning. Step 2: functional occlusion (form of occluded dentition) The posterior teeth should have correct three-dimensional positions so that the mandible stays in a stable position. Additionally, the occlusion should have a correct vertical dimension. Step 3: anterior guidance (form of tooth, vertical and horizontal overbite) The anterior teeth (from canine to canine) should have three-dimensionally correct positions that maximize good function and esthetics. Step 4: facial esthetics (ideal proportions) Realization of steps 1 to 3 finally leads to step 4, the facial esthetics, whereby the final treatment represents the best possible combination of esthetics, function, and a stable orthopedic mandibular position.

Key factors Over the years, the FACE Group has accumulated extensive clinical experience based on numerous studies. This allows definition of those key factors within the framework of the FACE treatment philosophy that are crucial for achieving perfect functional and esthetic treatment results. Facial esthetics Which tooth movements benefit the facial esthetics of a patient, and which Volume 7 Number 5

Dental esthetics Many factors determine dental esthetics. For example, the individually correct proportions of crown length and crown width of the anterior teeth have importance. If disproportion occurs between length and width — i.e., too square or too long — teeth will distort the esthetic impression. The length and shape of the premolars and molars also affect esthetics. For example, the mesial buccal cusps of the first maxillary molars should be more prominent in the dental arch of the maxilla than the second molars, as exemplified by the Roth arch shape. Clinicians should also consider gingival esthetics and the gingival margins, for example, when deciding about vertical tooth movement or intrusion of the anterior teeth. When the lips are at rest position, approximately 3 mm to 4 mm of the incisors should show. Also, the incisors should converge mesially to the midline and incline labially. Dental and facial esthetics form a close relationship. The dental midlines of the maxilla and mandible should therefore largely correspond to the facial midline. For good esthetics, the upper lip should be at the level of the gingival margin when the patient smiles. In contrast, 2 mm to 3 mm of visible gingiva would present a perfect full smile. The position of the occlusal plane also has importance, and this should lie parallel to the interpupillary plane. Functional occlusion Peter E. Dawson,1 Jeffrey P. Okeson,2 and many others have described the important role of the temporomandibular joints in establishing functional occlusion. Roth also recognized the significance of the joints and pointed out that any changes to the joints Volume 7 Number 5

The FACE treatment philosophy harmonizes facial and dental esthetics, periodontal health, functional occlusion with an orthopedic stable joint position, open airway, and stable results.

would have a direct effect on the occlusal relationship of the teeth. He also regarded the condylar shift as a major contributing factor to unstable treatment outcomes. Okeson suggests that “an orthopedic stable joint position (orthopedic stability) exists when the stable intercuspal position of the teeth has harmony with the musculoskeletally stable position of the condyles in the fossa. When this position exists, functional forces can apply to the teeth and joints without injury.”3 However, if this harmony does not exist, Okeson applies the term orthopedic instability with overload and injury, such as tooth wear, periodontal changes, and TMJ alterations as the consequences.4 Instead of using the term centric relation (CR), we should therefore better focus on the orthopedic stable joint position. Periodontal tissues Stable results can occur only if healthy tissue surrounds the teeth. Clinicians should follow some important rules — e.g., ensuring adequate attachment of keratinized gingiva prior to any orthodontic tooth movement to avoid recession of the gingiva.5 Epithelial attachment, connective tissue, alveolar crest, and CEJ should also harmonize. The apices of the teeth should be centered within the alveolus to avoid fenestrations, gingival recessions, and root resorption. Ideally, the teeth should be positioned at the interproximal bone height and in such a manner that the forces can be guided adequately and without distracting interference and deviation. It is also important to provide the best possible conditions for performing oral hygiene — i.e., correct interproximal contacts with as little crowding as possible, appropriate axial positioning of the teeth, and correction of vertical bone defects. Airway By using cone beam imaging, we can analyze the airway volume of our patients

and detect possible alterations or blockage of the upper airway tract at an early stage. Additionally, the CBCT images provide important information on possible complications in the maxillary sinus. Stability Regarding the stability of orthodontic treatments, numerous studies examine the factors that can contribute to stability, and others promote non-stability. However, no studies have yet related stability to occlusion; still, in our experience, stable joint positions and harmony between the teeth and condylar positions play important roles in stability. When this condition exists, the mandible can open and close on a closure arc without posterior interferences, and no mandibular deflection. Stability also depends on bilateral protected occlusion as well as uniform contact on the central cusps with forces acting on the long axes of the teeth.

FACE Evolution bracket prescription Since the introduction of the straight-wire appliance in 1970 by Lawrence F. Andrews, several prescriptions have arisen that modify some torque, angulation, and rotational values; however, they basically maintain many of Andrews’ original prescription. Even so, these modifications try to resolve problems in orthodontic biomechanics. Recent developments reveal that variable prescriptions continue to gain favor in their ability to treat a variety of malocclusions. Technical progress of the past years has opened up new opportunities in diagnostics and treatment planning. Thus, scientific studies using the cone beam computed tomography (CBCT) have shown a significant percentage of patients present with dehiscences and fenestration. Additionally, evaluations using CBCT during the final stages of treatment reveal a disturbing rate of roots outside the bone in Orthodontic practice 25

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movements tend to have a negative effect on facial esthetics? Bearing optimal facial esthetics in mind, as professionals, we are able to determine not only the ideal position of maxilla and mandible, but also the exact position and torque of the teeth. We also can determine the treatment cephalometric measurements necessary and implement them accordingly. For example, we know that counterclockwise rotation of the mandible moves the mandible and chin forward and shortens the lower facial height, thus allowing improved facial esthetics. We also know that facial asymmetry closely relates to the status of the joint, the occlusal function, as well as the alignment of the teeth. Clinicians need to consider this.

CLINICAL

Figures 2A–2D: 2A-2B. Tomography that reveals the radicular position of the maxillary premolars 2 months after inserting a .019” x .025” stainless steel archwire in a bracket with torque –7°; 2C-2D. The radicular position of the upper canines with straight arch brackets with –2° torque, 2 months after inserting a stainless steel archwire of the same dimension

different sectors of both jaws (Figures 2A-2B). These disturbing observations give us cause to critically question negative torque used in most prescriptions. We have recently determined the value of a bracket system that brings us closer to the aim of a functional and esthetic ideal treatment outcome — the FACE Evolution bracket prescription*. We admire the contribution made by Andrews as one of the most important advances for orthodontics, and everything indicates that the values obtained from his sample of normal non-orthodontic patients do not apply to all orthodontic patients, especially those presenting poor apical bases and/or thin periodontium, which is quite common. We hypothesize that the individuals studied by Andrews had ideal occlusions, probably because of their correct basal and alveolar development, which differs from that of most patients. When Andrews performed his research, none of the sophisticated instrumentarium we can now use existed.

Figures 3A-3B: Difference between the information supplied in regard to bone by Orthopantomography (3A) and CBCT (3B)

Modification of torque Extensive clinical research has enabled us to tackle and resolve problems revealed on CBCT. Previously, we could not observe the thickness of the vestibular and lingual alveolar bone (Figures 3A-3B); CBCT examinations revealed the mesial and distal bone levels of the dental roots, and we commonly see that the vestibular or lingual alveolar bone limits some tooth movements. Quite commonly, mandibular incisors and maxillary and mandibular canines have compromised alveolar bone.

Figures 4A-4B: Tomography revealing a common situation with canines: a very poor or no vestibular bone, which contraindicates any kind of negative torque

Torque in the canines Canines often have thin bone on the labial and appreciably thicker bone on the palatal surfaces. Several patients have such prominent canine radicular prominences that require unusual treatment plans. On these occasions, the CBCT reveals a thin layer of vestibular cortical bone, and in 26 Orthodontic practice

Figures 5A-5B: 5A. Clinical picture that clearly shows the radicular prominence and especially delicate periodontal situation in the maxillary canines. 5B. After using a .019" x .025" rectangular archwire with brackets of torque –2° in the maxillary canines, the radicular problem was increased Volume 7 Number 5

effect is greater on the crown than the root, in patients with fenestrated roots. This enables us to attain bone re-coating of the alveolar defect. Once we obtain the needed effect, we switch the working bracket to a standard prescription bracket (+3°) or (–6°).

Torque in the lower incisors For the mandibular incisors, FACE Evolution has brackets with torque –1° and –6° and can transform into +6° by merely inverting the bracket by –6°. Theoretically, a

Figures 6A-6B: 6A. Orthopantomography and CBCT. 6B. The CBCT images show the bone limitations for movement of the incisors

Figures 7-7B: 7A. Picture of a tube of a known brand that reveals the features of the slot and the lack of rectangular form of a .019” x .025” steel archwire. Obvious explanation of the lack of efficiency to produce torque. 7B. FORESTADENT tube

+6° torqued bracket for mandibular incisors ideally compensates Class II malocclusions to give correct position anterior anchorage. The truth is the available alveolar bone will determine the bracket chosen. The FACE Evolution bracket chosen depends on available bone, teeth in inclination, and the type of movement needed.

Torque in the molars Maxillar molar tubes have required modification. Orthodontists concerned about functional occlusion know that premature contacts in the second molars are common. Positive molar torque frequently causes “hanging” palatal cusps, which interfere with mandibular closure and often lead to lateral interferences. The problem often forces us to use transpalatal bars and/or torsion bends in the archwires. Clinicians need to remember that manufacturing tolerances commonly give us oversized brackets and tubes and undersized wires, which manifests as inefficiencies. One of the causes of this inefficiency is the play presented by the arches in the lumen of the tubes. Several studies have demonstrated that this play is because of a slight oversizing of the slots of the brackets and play of the tubes, and also the fact that the arches are slightly smaller than stated by manufacturers and often even have rounded edges. Tests performed with tubes from several companies reveal to us angles of torque loss of up to 26° with .019" x .025" steel archwires and up to 11° with .021" x .025" archwires (Figure 7A). The FACE Evolution system has developed maxillary molar tubes. A negative torque of –30° has been introduced into the

Figures 8A–8C: 8A. Tomography that reveals this clinical situation in a second left maxillary molar, in this case with an appropriate bone for correction of the torque (V = vestibular). 8B. Tomography revealing the radicular situation to consider during correction of the torque (V = vestibular). 8C. Common situation especially in the maxillary second molars with positive torque, which leads not only to increased occlusal vertical dimension but also to interference with centric and eccentric mandibular movements Volume 7 Number 5

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some cases, bone fenestration that contraindicates any radicular vestibular movement (Figures 4A-4B, 5A-5B). This common situation caused us to modify torque values –2° to +3° for maxillary canines and from –11° to –6° for mandibular canines. Extreme radicular prominence requires a bracket with a 20° torque for maxillary and mandibular canines. This bracket quickly moves the canine root into the thick lingual cancellous bone. This excessive torque barely leads to sufficient movement, as its

CLINICAL maxillary molar tubes. This compensates for the poor fit of the wire to the tube. Still, doctors must take special care regarding available bone since some cases could contraindicate any kind of movement. The aim of this modification is not to attain a torque of –30°, but rather a way of compensating the torque loss of the arches in the tubes. To summarize, the differences in torque in regard to Roth’s prescription are found in the maxillary and mandibular canines and the upper molars. The alternative for the mandibular incisor of –6° and +6° is also added.

Rotations One attribute of the Roth prescription is the excellent anchorage obtained by the distal rotation produced in the maxillary and mandibular molars. However, this feature, so useful for retrusion of the anterior teeth, turns into a hindrance in two situations: the first, in patients requiring minimal anchorage, especially in the mandibular jaw; the second, when obtaining suitable finishing, and the molar rotation does not enable correct intercuspation and coordination of the antagonist molars. Indeed, virtually 100% of patients treated with this prescription, analyzed in

Figures 9A-9B: Models that reveal the before and after the correction of torque for the 7s

centric relation, present interference with the closure. This is especially true of the second molars, which Roth’s philosophy resolves, once the appliances are withdrawn, by using a gnathologic positioner. This situation occurs because of the loss of alignment of the mesiodistal occlusal groove of both the maxillary and mandibular first and second molars (Figure 10B). The reason for this loss of alignment is found in the distal rotation of 14° in the first molars, which has the consequence of an antagonistic reciprocal effect in the second molars as they displace toward the vestibule region. This undesired movement occurs when applying positive rotations above 10°, which ordinary prescriptions have. To solve this problem, we use 10° rotation in the maxillary molars and 0° rotation in the mandibular molars. This enables perfect finishing in most

cases and simultaneously facilitates space closure patients needing minimal or medium anchorage. In the next article, we will look at one of the most interesting aspects of the new prescription: a bracket that serves not only during the working phase, but at the same time, takes into account the finishing phase. Another feature introduces the hybrid possibility — i.e., active in the anterior brackets and passive in the posterior brackets. Last but not least, the working tubes and working brackets compensate for lack of torque in some cases and reduction of torque in other cases. To finish we will show a variety of patient therapies where the prescription was used and how of our goals were achieved. OP * Fa. FORESTADENT

Figures 10A-10B: Occlusal photo that presents correct alignment of the mesiodistal sulci of the molars and premolars, a fundamental aspect to attain correct occlusion. 10A. The tubes used have a distal rotation of +10°. 10B. Occlusal photo that reveals the misalignment of the marginal ridges of the first and second maxillary molars, with tubes of +14° distal rotation

REFERENCES 1. Dawson PE. Functional harmony. In: Dawson PE. Functional Occlusion: From TMJ to Smile Design. St. Louis, MO: Mosby; 2007.

7. Roth RH. The maintenance system and occlusal dynamics. Dent Clin North Am. 1976;20(4):761-788. 8. Dawson PE. Functional Occlusion: From TMJ to Smile Design. St. Louis, MO: Mosby; 2007.

2. Okeson JP. Criteria for optimal functional occlusion. In: Okeson JP, ed. Management of Temporomandibular Disorders and Occlusion. 5th ed. St. Louis, MO: Mosby; 2003.

9. Lee RL. Esthetics and its relationship to function. In: Rufenacht C. ed. Fundamentals of Esthetics. Carol Stream, IL: Quintessence; 1990.

3. Okeson JP. General considerations in occlusal therapy. In: Okeson JP, ed. Management of Temporomandibular Disorders and Occlusion. 5th ed. St. Louis, MO: Mosby; 2003.

10. McNeill C. Fundamental treatment goals. In McNeill C, ed. Science and Practice of Occlusion. Carol Stream, IL: Quintessence; 1997.

4. Okeson JP. Criteria for optimal functional occlusion. In: Okeson JP, ed. Management of Temporomandibular Disorders and Occlusion. 5th ed. St. Louis, MO: Mosby; 2003.

11. Spear FM. Fundamental occlusal therapy considerations. In: McNeill C, ed. Science and Practice of Occlusion. Carol Stream, Quintessence, IL; 1997.

5. Roth RH. The Roth functional occlusion approach to orthodontics. Notes from lecture introducing the functional occlusion section of the Roth/Williams Center for Functional Occlusion 2-year program.

12. Dawson PE. Functional Occlusion: From TMJ to Smile Design. St. Louis, MO: Mosby; 2007.

6. Andrews L.A. Straight Wire: The Concept and Appliance. San Diego, CA: LA Wells; 1989.

28 Orthodontic practice

13. Melsen B, Allais DA. Factors of importance for the development of dehiscences during labial movement of mandibular incisors: a retrospective study of adult orthodontic patients. Am J Orthod Dentofacial Orthop. 2005;127(5):552-561.

Volume 7 Number 5

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CASE STUDY

Precision and acceleration: utilizing advancements in orthodontic technology to achieve optimal results Dr. Edward Lin discusses efficient and effective digital innovations

arlier this year, I followed the groundbreaking thought leadership that came out of the Davos World Economic Forum in Switzerland, and I found that the theme of the event, “Mastering the Fourth Industrial Revolution,” was an accurate description of my treatment philosophy. The fourth industrial revolution is the notion of blurring the boundaries that separate physical, digital, and biological spheres. Typically, patients want orthodontic treatment because they are seeking the perfect smile or long-term relief from health challenges such as sleep apnea, TMJ pathology, occlusal breakdown, or worn dentition as a result of patients living longer. It’s obvious that these scenarios touch on the biological and physical spheres, and now we have digital innovations that enable orthodontists to better deliver quality results efficiently and effectively. I practice alongside three orthodontists at two practices in Wisconsin — Orthodontic Specialists in Green Bay and Apple Creek Orthodontics in Appleton. Together we’ve beta tested and have been early adopters of innovative, disruptive, and transformative technologies that have changed our profession. My passion for technology stems from my enthusiasm to create healthy and beautiful smiles for patients and to far exceed their expectations of orthodontic treatment. The key to this is constantly evaluating new technologies that are introduced to orthodontics on the basis of safety, effectiveness, and how seamlessly they integrate into my current standard of care in clinical practice.

Edward Lin, DDS, MS, is a respected orthodontic lecturer who practices at Orthodontic Specialists in Green Bay, Wisconsin, and at Apple Creek Orthodontics in Appleton, Wisconsin. A member of the American Dental Association, the American Association of Orthodontists, and the World Federation of Orthodontists, Dr. Lin is passionate about orthodontics and being an early adopter of technology that makes treatment more enjoyable for patients and orthodontists. He completed dental school and orthodontic residency at Northwestern University and has been in private practice since 1999. Disclosure: Dr. Lin has no conflicts of interest to report.

30 Orthodontic practice

These two case studies highlight technologies that have had a major imprint on delivering more predictable and desirable results. Technologies such as AcceleDent®, i-CAT™ FLX, 3D printers, temporary anchorage devices (TADs), and the suresmile® digital software have evolved the way that I practice orthodontics. I’ve studied each of these individually and how they work in tandem with each other to deliver precise results the first time.

CBCT Precision starts with having a very clear picture at the beginning that dictates where you want and need to end. Without a doubt the i-CAT FLX has revolutionized digital treatment planning through cone beam computed tomography (CBCT) that involves the shortest scan time and lowest radiation dose. CBCT 3D imaging gives us the most comprehensive views for evaluating airway, TMJ imaging, eruption paths, bone and nerve anatomy, and root positions that we just cannot see and evaluate with 2D imaging. In my opinion, I believe that 3D imaging should be the standard of care, especially with the availability of low-dose CBCT scanners. Cone beam technology is invaluable when evaluating patients who have the risk for obstructive sleep apnea syndrome (OSA) as is the case with Patient 1. Orthodontists are seeing an increase in patients who have potential airway restriction. An American Journal of Orthodontics and Dentofacial Orthopedics article detailed how CBCT can assess the dimensional changes of the upper airway in patients whose maxillary constrictions are being treated with rapid palatal expansion appliances (RPE).1 The study demonstrates from the CBCT that the cross-sectional area of the upper airway at the posterior nasal spine to basion level significantly gains a moderate increase after RPE. Orthodontists are in a unique position with having the opportunity to evaluate younger patients who may be at a higher risk for OSA. Treatment for airway restrictions

is much more effective when patients are diagnosed and treated at an early age, so I encourage orthodontists to leverage this advanced CBCT technology and collaborate with their local pediatricians and dentists.

Digital impressions and 3D printing My colleagues and I have been striving toward 100% digital-impression dentistry. It’s better for patient comfort, there’s no powder, and it’s not messy. With our intraoral scanner (3Shape TRIOS®), there’s never a need for retakes, which creates efficiencies by saving chair time. It also offers enhanced precision. Patient 2 in this case study was one of our aligner patients who benefitted from this efficiency and precision. Since we have our own EnvisionTEC Perfactory® Micro and Perfactory® Vida 3D printers, we upload the digital intraoral scan to the suresmile cloud, create the virtual digital occlusal treatment plan, and then send to our in-house lab to 3D print the aligner trays. This all happens in-house. It’s a major efficiency that allows us to save on shipping costs, lab material, and payroll expenses, and it also helps ensure continuous patient engagement and motivation from the consult to their start date.

Accelerated treatment When we talk to patients about all of the technologies that we use in our office for their orthodontic treatment, they are impressed, but they still want to know how long is it going to take, and if it’s going to hurt. They are intrigued and excited when we tell them about AcceleDent and how the device’s SoftPulse Technology® has been clinically proven to speed up orthodontic treatment by as much as 50% while also relieving discomfort.2,3 I’ve researched other accelerated treatment technologies, but ultimately decided to continue offering AcceleDent because patients say it makes their teeth feel better.2 The reduction in discomfort that AcceleDent gives patients is the differentiator among the current accelerated technologies. Since we’re putting AcceleDent into the hands of the patients and asking them to Volume 7 Number 5

CASE STUDY

use it for 20 minutes a day throughout treatment, it’s important that orthodontists explain to patients the science of how it works. We underscore that AcceleDent is the first and only FDA-cleared vibratory orthodontic device that uses gentle vibrations to accelerate bone remodeling at the cellular level. The prescription-only device is cleared for use in conjunction with brackets or aligners. We also explain to patients that the SoftPulse Technology employs 25 grams of force at 30 Hz, which is 200 times less force than ordinary chewing. We evaluate compliance throughout treatment with our accelerated patients by asking them to bring their AcceleDent units with them to appointments, so that we can view the FastTrac Usage Report that’s available via the USB charging port. Compliance is a non-issue for these patients because they want to complete treatment as fast as possible with no pain.

Blending technologies in practice The following case studies illustrate how patients treated with the latest advancements in orthodontic technologies can achieve quality finishes with an accelerated treatment plan.

Figure 1: December 4, 2012

Patient 1 The patient presented at his new patient examination on December 4, 2012, as a 47-year 3-month-old adult male. He was referred to our office by his dentist due to concerns with a Class III malocclusion, gingival recession, and incisal wear, which had developed as a result of a dental sleep appliance that had been made by his sleep specialist. The patient’s sleep apnea was diagnosed 10 years prior. For the first 2 years, the patient’s sleep apnea was being treated with continuous positive airway pressure (CPAP) therapy, which he was not tolerating well. The patient was concerned about his “uncomfortable” bite and that his teeth were beginning to chip. His diagnosis in my office determined that he was a Class III with generalized maxillary and mandibular spacing (Figure 1).

Treatment plan The patient was given two options for treatment. The first and ideal option consisted of treatment with full-fixed orthodontic appliances in combination with two-jaw maxillary and mandibular advancement surgery for Class III correction and to increase his airway volume for correction of his OSA. The second option consisted of treatment with full-fixed orthodontic appliances in combination with temporary anchorage devices (TADs). I use TADs for all of my nonsurgical Volume 7 Number 5

Figure 2: September 25, 2013

Class II and Class III cases because they provide us with control that we previously did not have in orthodontics. TADs give us skeletal anchorage instead of dental anchorage with excellent control of the direction and vectors of forces utilized with them. I estimated treatment time of 36 months due to the complexity of his case, but suggested his treatment length could be closer to 24 months if he used AcceleDent. The patient chose AcceleDent to minimize the length of treatment. His treatment was actually completed in 21 months.

Treatment summary On the patient’s full-bonding appointment, we placed labial brackets 7-7 and

bilateral TADs (8 x 1.4 mm) in the mandibular arch distal to the first bicuspids. The TAD was tied with a steel ligature tie to his lower first bicuspids for anchorage in distalizing the L7s only not the L5s and L6s (Figure 2). Active open coil springs were placed distal to the upper laterals and distal to the lower first molars. A closed coil spring was placed distal of UL5. The patient was instructed to wear Class III elastics full time and use his AcceleDent unit for 20 minutes daily. Since the patient was using AcceleDent, I let the wire express for about 8 weeks before I brought him in for his second appointment. Before accelerated treatment, I would have to wait 10 weeks before checking on hygiene, elastic wear, and bracket placement and Orthodontic practice 31

CASE STUDY

Figure 3: January 28, 2014

Figure 4: July 21, 2014

then wait another 10 weeks for the wires and open coil springs to fully express themselves. As space was redistributed in the maxillary arch, I placed TADs distal to the upper laterals to help protract his posterior teeth forward in the maxillary arch (Figure 3). Ten weeks later, I repositioned his mandibular TADs so they were mesial to the lower second molars and continued to facilitate retraction in combination with elastics. Approximately 15 weeks later and 12 months from starting treatment, we removed all TADs and submitted a supplemental scan of all four quadrants to suresmile (Figures 4 and 6). Thereâ&#x20AC;&#x2122;s a noticeable difference with AcceleDent that allows me to do the virtual wire bends in the suresmile software sooner, eliminating an appointment and overall completing the case faster. On January 27, 2015, and 18 months into total treatment time, we ordered his final finishing wire through the suresmile software with virtual bends for space closure and overjet. On April 21, 2015, we debonded his brackets and placed bonded lingual retainers upper 2x2 and lower 3x3 (Figure 5). Total treatment time for this patient was 21 months with a total of 15 appointments from the initial

Figure 5: January 27, 2015 32 Orthodontic practice

Volume 7 Number 5

CASE STUDY

bonding appointment to his debond appointment (Figure 7). Understanding he chose to pursue treatment nonsurgically and that it wasn’t treating his OSA, the patient elected to resume CPAP therapy.

Figure 7: July 9, 2015 — Final records 10 weeks after his debond Figure 6: suresmile pre (blue) and post (white) images

Patient 2 The patient was first seen in our office on March 15, 2014, as a healthy 30-year 5-month-old adult male who was about to get married in September. Prompted by his fiancée, he wanted straighter teeth and needed treatment to be completed in time for their wedding photos. Upon exam, he presented as Class I with mild spacing (Figure 8). He had been treated prior with orthodontia, but hadn’t worn his retainers.

Treatment plan

Figure 8: March 15, 2014

The patient was interested in only aligners for treatment, so we planned and created his aligner trays virtually using suresmile’s aligner design software. Prior to finalizing his aligner treatment plan, I did a minor amount of IPR in the lower arch from L5-5 to address his mandibular excess as seen through the software in his Bolton analysis. His initial set of trays was planned for 14 aligners in the maxillary arch and nine aligners for the mandibular arch (Figure 11). Without AcceleDent, I have my aligner patients changing aligner stages every 2 weeks, putting his estimated duration for

Volume 7 Number 5

Orthodontic practice 33

CASE STUDY treatment in the 7-month range and beyond his goal for completion. With a significant milestone to complete treatment in 5 months or less, the patient was highly motivated to use AcceleDent and changed aligner stages every 7 days, which is my general protocol for aligner change frequency for my AcceleDent patients.

Treatment summary Approximately 1 month after being seen for his initial exam, the patient was seen for his first aligner delivery appointment. At this time, we seated stage 1 of his upper and lower aligners and gave the patient aligners 2-6 (Figure 9). When I fit patients for the aligners, I trim them a little longer past the gingival margins so that there is better retention or a natural undercut of the cemento-enamel junction (CAJ). The patient was instructed to change aligners to the next sequential stage every 7 days and use his AcceleDent unit for 20 minutes daily. His next appointment was scheduled for 6 weeks to check progress.

In the patient’s second appointment 6 weeks later, we checked the progress of his stage 6 aligners, and being satisfied with the progress, gave him the remaining aligners planned for his initial phase prior to any refinement, which included aligners 7-14 for the upper arch and 7-9 for the lower arch. The patient was instructed to continue to change aligners to the next sequential stage every 7 days and use his AcceleDent unit for 20 minutes daily. In the patient’s third appointment 4 weeks later, we checked the progress of his upper arch and evaluated the results in his lower arch as he was on his final stage (Figure 10) in the initial aligners planned for that arch. We created a refinement aligner for the lower arch to place the lower centrals 0.2 mm lingually and to tighten spaces by 0.2 mm, and this could be done through the software and without additional scans or impressions. The patient was instructed to continue to use his AcceleDent unit for 20 minutes daily and to change aligners

to the next sequential stage every 7 days for the upper arch and to continue to wear stage No. 9 in the lower arch until his next appointment. At his fourth appointment on July 29, 2014, we delivered his refinement aligner for the lower arch and determined his upper arch on stage 13 was tracking nicely. His next appointment was scheduled for 2 weeks to evaluate final aligner stage results. Two weeks later on August 12, 2014, and less than 4 months from starting treatment, the patient’s treatment was complete, and we finished a month ahead of his goal to be done by his September wedding! I did some re-contouring of his anterior teeth for esthetics at this appointment. I generally do any reshaping of teeth after the aligners have been worn to completion so that I have as much surface area possible for the aligners to grasp during the treatment period. I’ve noticed that AcceleDent has enhanced the quality of my aligner therapy patients because the bone remodeling

Figure 9: June 3, 2014

Figure 10: July 1, 2014 34 Orthodontic practice

Volume 7 Number 5

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PROMOTING EXCELLENCE IN ORTHODONTICS A review of accelerated orthodontics Dr. David Alpan

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CASE STUDY

Figure 11: suresmile pre (blue) and post (white) images

caused by the SoftPulse Technology helps better seat the teeth into the aligner trays. In addition to acceleration, AcceleDent offers enhanced predictability and precision. With AcceleDent, this patient finished treatment in 3 months and 3 weeks. We used direct bond lingual retainers for the U 2-2 and L 3-3 for retention (Figure 12). Our total treatment costs for this aligner treatment approach was approximately $350. suresmile’s aligner design software also gives us complete control throughout the treatment period to make modifications as needed.

Conclusion Accelerated orthodontics, 3D imaging, and 3D digital orthodontics are the future of our profession, and these technologies are at our fingertips. The goal is to embrace technologies that make sense for your practice. For us it’s CBCT, suresmile, TADs, and AcceleDent. Technology should be unique to each individual practice and orthodontist based on treatment philosophy, standard of care for that practice, and the typical cases that are referred. Orthodontists are sought after as the premier leaders in the dental field, so the burden is on us to investigate orthodontic advancements. We have to collaborate as we evaluate technologies on the basis of safety, effectiveness, and how well they integrate into our practices. I know I’m a better orthodontist because of the technologies that we’ve integrated into our practice, and I’m confident that my clinical results prove that these innovations yield a much higher quality of care, a more efficient practice, and increased patient satisfaction. The bonus is that I also find greater enjoyment practicing orthodontics because of them. OP 36 Orthodontic practice

Figure 12: November 13, 2014

REFERENCES 1. Chang Y, Koenig LJ, Pruszynski JE, Bradley TG, Bosio JA, Liu D. Dimensional changes of upper airway after rapid maxillary expansion: a prospective cone-beam computed tomography study. Am J Orthod Dentofacial Orthop. 2013 Apr;143(4):462-270. 2. Pavlin D, Anthony R, Raj V, Gakunga PT. Cyclic loading (vibration) accelerates tooth movement in orthodontic patients: A double-blind, randomized controlled trial. Seminars in Orthodontics. 2015;21(3):187 –194. 3. Lobre WD, Callegari BJ, Gardner G, Marsh CM, Bush AC, Dunn WJ. Pain control in orthodontics using a micropulse vibration device: A randomized clinical trial. Angle Orthod. 2106;86(4)625-630.

Volume 7 Number 5

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 5

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Orthodontic practice 37

ORTHODONTIC INSIGHTS

Reframing orthodontics: a new manifesto driven by BioDigital orthodontics, part 2 Dr. Rohit C.L. Sachdeva explores a proactive, quality-focused approach to orthodontics Abstract The current approach to orthodontic care is largely error-prone and, therefore, reactive. Such error-ridden care practices negatively impact the quality of the care delivered. In this article, the author discusses his manifesto for BioDigital orthodontics, a proactive, qualityfocused approach to orthodontics. The principles and practice of patient-centered care, patient safety, and clinical effectiveness as they relate to the practice of quality care are presented.

“

Be a yardstick of quality. Some people are not used to an environment where quality is expected. — Steve Jobs

Introduction Quality orthodontic care is a commodity. Why? Because almost all doctors believe they provide quality care to their patients. The reason this myth prevails is that the definitions of quality practices and metrics remain vague at best.1 Currently, said

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.

38 Orthodontic practice

practices measure the spatial relationships of the dentition and are not rooted in scientific evidence in terms of their clinical or physiological significance (such as blood pressure or body temperature) thus diminishing their validity as effective measures of well-being. Also, these measures are not universally accepted by the specialty or the profession of dentistry at large. In this way, the clinician acts as both judge and jury, rubber-stamping an autonomous verdict of “all looks well; no harm done” in the treatment delivered to patients. Such behavior has a ripple effect within the orthodontic care ecosystem. For instance, said behavior blunts the patient’s understanding of quality care, diminishing the value of the genuine quality-driven orthodontist; hence, the rise of the “nonexpert expert,” the dentist orthodontist, laboratory technician-orthodontist, and more recently, the consumer-orthodontist. The ambiguous definition of quality care has facilitated the proliferation of marketdriven orthodontics. Practices measure their success on the basis of business metrics, such as profit and production, rather than patient-care outcomes. This is not all bad news. The recognition of these deficiencies provides us with the springboard upon which to explore opportunities to better our specialty and reinforce

the covenant of trust between the specialist and her patient. So how do we cure our ills? First, we must redefine our metrics and build the engine that allows us to practice quality care. This requires improvements in both the relational and functional components of our care giving. Henry Ford described this notion best when he said, “Quality means doing it right when no one is looking.” We must embrace and commit to a new cultural fluency that fosters patient centeredness, patient safety, and clinical effectiveness.2

“

Ordo ab chao (order out of chaos)

Patient-centered care Past and present Historically, a paternalistic, hierarchical model defined the doctor-patient relationship. The doctor “knew best,” effectively silencing the voice of the patient. Recently, however, the consumer-driven orthodontic care model has redefined the doctor-patient relationship, establishing a contractual relationship between buyer (patient) and seller Volume 7 Number 5

What exactly is patient-centered care? Patient-centered care is not just about giving patients whatever they want or educating them about their needs. It is, first and foremost, about the doctor establishing trust and credibility with the patient.4 It is about the orthodontist and care team showing empathy and humanity in embracing the patient as a person, not a case; a patient named John who is afflicted with a malocclusion, not a case labeled a Class 1 malocclusion. Patient-centered care means the orthodontist recognizes he/she is a guest in the patient’s life.5 In a patient-centered practice, the patient is aware of and understands his/ her “bill of rights.”6 Patient-centered care teams value the patient’s opinion, engage in active listening and shared decision-making with the patient, and establish rapport with the patient in addressing care needs. Said care teams respect the patient’s ability to assert his or her individuality. Patientcentered care also means complete transparency; the care team offers full, unbiased information about the options, benefits, and risks of any care measures planned. Potential disconnects between the voice of the doctor and that of the patient are best resolved using a casuistic approach to clinical decision-making. This model considers patient values, backgrounds, and preferences alongside empirical evidence, experiential evidence, pathophysiological rationale, and system features.7 As such, orthodontic patient-centered care practices carry the banner of a “patient of one.”5

Patient safety Past and present Conventional orthodontic care has been and continues to be craft-based and reactive. We practice “wayfaring” orthodontics and manage patient care through the rear-view mirror. This model of care provides fertile soil for the seeding and proliferation of error-associated events. It is important to note that human error is a consequence, not a cause. Human error is the product of a chain of causes in which Volume 7 Number 5

precipitating psychological factors include lapses in attention, forgetfulness, misjudgment, and preoccupation. Errors are generally described by what I call the 8 M’s: 1. miscommunication 2. misunderstanding 3. misdiagnosis 4. misplanning 5. mismanaging 6. misdesigning 7. misprescribing 8. misadministering. Errors are commonly “long tail” in nature and are often the last and least manageable links in the chain. As such, errors are recognized in the finishing stage of orthodontic treatment, a stage in treatment in which the clinician intends to correct for errors and the patient, accordingly, is admitted into the intensive care unit.8 The finishing stage is challenging for both the patient and doctor. If we were to enter the patient’s mind during the finishing stage, we might encounter a patient who suffers from anxiety and orthodontic exhaustion. The patient falsely believes her treatment to be complete and now must undergo additional treatment. Candidly put, the patient is burnt out. From the clinician’s perspective, much treatment remains to be done. The clinician, too, is anxious as he/she wrestles with the professional commitment to properly treat the patient, a patient who is now half-heartedly committed to treatment. At this point in treatment, patient adherence to the doctor’s recommendations decreases, the timing of the patient’s appointments becomes erratic, and the doctor’s skills are put to the test. The finishing stage is therefore disruptive to both the patient’s expectations of care and lifestyle, the clinician’s mindset and schedule, and the orthodontic practice’s operations. The very fact that we accept finishing as a stage in patient care suggests that we condone a system that allows for error propagation. This practice must be prevented, or at very least, contained. Another shortfall in our practice model is that we lack both intrapractice and system-wide transparency. We neither report nor disclose error; failure is merely paid lip service, not action. If we do not document error, we cannot analyze, learn, and subsequently improve upon our ways. Given our avoidance of error reporting, the waters always appear calm; nothing appears broken, so we convince ourselves that there is nothing to fix. Thus, our modus operandi continues with little recognition of the undermining forces that affect our quality of care.

Such an error-prone environment comes at a substantial cost to both the patient and doctor and also delays care. Unfortunately, failures in outcomes occur more often than not. (One just needs to see transfer patients to appreciate the extent of this problem). Failures in outcomes are commonly attributed to biological and psychosocial factors, such as poor patient growth or cooperation. The patient bears the brunt of responsibility for a less than desirable result, and the doctor remains unaccountable for her probable misaction. If the doctor is “brave enough” to report failure, she does so at the risk of her reputation and potential litigation. We have yet to mature into a blame-free culture and recognize that humans commit errors. Systems, processes, and technology must be appropriately used by a skilled care team to prevent or arrest the propagation of errors. What exactly is patient safety? Patients almost entirely depend upon the skills and professional judgment of the orthodontist and his/her team to receive the best in care. The overarching goal of an orthodontic practice that subscribes to patient safety is to protect patients from harm. This requires building a trustworthy system for the delivery of orthodontic care. Patient safety is the prevention of the errors that result in unwanted and adverse effects. It is also concerned with minimizing the incidence of and maximizing the recovery from spurious or adverse events. Errors must be continuously reported, analyzed, and communicated to all team members in an ongoing effort to error-proof the care delivery system. The practice of patient safety is grounded in the principles and practice of safety/ reliability science.9 Reliability refers to failure-free operation over time. Practically speaking, reliability is the ability of a process, procedure, or service to perform its intended function in the required time under existing conditions. Reliability is measured by dividing the number of actions to achieve the intended result by the total number of actions.10 Orthodontic practices must adopt the principles of High Reliability Organizations (HRO). An HRO is designed to minimize danger by balancing effectiveness, efficiency, and safety. An HRO preserves a culture of system-wide transparency and errorreporting. An HRO is both proactive and generative in its actions and also shares the cultural framework of learning organizations. Orthodontic practice 39

ORTHODONTIC INSIGHTS

(doctor).3 In this setting, the buyer “knows best” and pays for her wants, not her needs. The buyer’s commonly misinformed expectations of care now muffle the voice of the well-intentioned, evidence-driven doctor. Both of these models of doctor-patient relationships are flawed, warranting a more balanced doctor-patient relationship.

ORTHODONTIC INSIGHTS Roberts and Bea note, “More specifically HROs actively seek to know what they don’t know, design systems to make available all knowledge that relates to a problem to everyone in the organization, learn in a quick and efficient manner, aggressively avoid organizational hubris, train organizational staff to recognize and respond to system abnormalities, empower staff to act, and design redundant systems to catch problems early.”11 The success of an HRO is partly based on its ability to stay mindful. An HRO promotes five mindful practices to manage safety, including12: 1. Preoccupation with failure. Team members must incessantly seek ways to error-proof the system and mitigate risk. 2. Reluctance to simplify. Simple processes are strived for, but oversimplified explanations for error are avoided. Analyses of the root causes of error are performed. 3. Sensitivity to operations. Team members must be consistently mindful of noting and preventing risks. 4. Commitment to resilience. Team members are trained to 1) anticipate or know what to expect 2) pay attention or know what to look for, and 3) respond or know what to do. 5. Deference to expertise. Each and every team member carries an equal voice in calling out violations or reporting errors or adverse events. The baseline of an HRO’s core processes operates correctly 99% of the time. In healthcare, the baseline of core processes is defective 50% of the time, for 50% of patients receive recommended care. Healthcare practices are less reliable than industrial practices; as a result, the Institute of Health Care Improvement (IHI) recommends that healthcare organizations should focus on process reliability as a first step on the road to safe care before focusing on the mindful practices of an HRO. (I would tend to agree that orthodontics take the same

approach.) Baseline performance reliability for non-catastrophic processes in healthcare is currently said to be less than 80%. What does this mean? The IHI has established a measure termed “‘failure rate’ (calculated as 1 minus reliability, or ‘unreliability’) as an index, expressed as an order of magnitude.”10 Thus, 10-1 means approximately one defect (error) per 10 process opportunities. If 10 brackets were bonded on a patient, and one of them was misplaced, the defect rate would be 10-1; 10-2 is approximately one defect per 100 process opportunities.10 Recognizing that the strict adherence to this formula may pose difficulties in interpreting unsafe or error-prone practices, the IHI developed a broader classification to evaluate the failure rate (Table 1). As clinicians can see, the rate of two defects per 10 process opportunities represents less than 80% success; this measure indicates a chaotic or unreliable process. Translating this measure into the world of orthodontics suggests that the incorrect placement of just two brackets on 100 teeth (five patients) would be classified as an unreliable process. We know our defect rate is, unfortunately, much higher, begging the need for reliable processes in orthodontics. The IHI’s three-step reliability design model offers a path to consider in building safer care processes (Table 2). With a sense of urgency and commitment, the profession of orthodontics needs to embark upon a journey to develop and implement minimal error, ultra-safe practices.

“

I believe there will always be some of us who have a passion for giving their best. And quite frankly, if there aren’t, then no process will save us. — Tony Cusano, MD

Table 1: Reliability labels10 Definition Chaotic, or lack of defined, reliability-focused processes

Defect rate

One or two failures out of 10 (80% or 90% success)

Five failures or less out of 100 opportunities (95% success)

Five failures or less out of 1,000 opportunities

-2

-3

40 Orthodontic practice

Past and present Reactive care orthodontics encourages a “do first, think later” mentality. Clinically, this translates to “let’s slap on the braces and see what happens.” This practice encourages epistemic complacency. Diagnosis, care design, and planning provide little value to the reactive care practitioner in her management of patient care. The “intelligence manufactured” into the appliance overrides the clinician’s cognitive tools of reason, judgment, and sense making. Evidentiary practices are reserved for the ivory tower and find little use for the wet finger, reactive-care orthodontist. Unfortunately, unscientific, dogmatic care protocols primarily designed to maximize the use of latest and best “smart” appliances are promoted by industry-appointed thought leaders. It then follows that the influencers who create the loudest echo chamber are responsible for defining the standard of care. As a result, the doctor becomes entangled in the web of “a la mode” or market-driven orthodontics, distancing even further from science and value-based practice. Recently, the orthodontic industry has adopted the practice of recruiting patients, or care customers, to promote products through the powerful channel of social media.13, 14 To appeal to a wider audience, much of the messaging is emotional rather than evidence-driven. This mode of communication commonly results in a misinformed patient who attempts to drive his care with little regard for professional advice. The combination of the reactive care model and the strong influence of industry and its appointed thought leaders has channeled the practice of orthodontics into a cafeteria or standardized, mass manufacturing product- and profit-driven approach. The orthodontic enterprise is populated with misguided doctors and misinformed patients. The practice of orthodontics needs to reframe itself. Another cultural pill it needs to be prescribed is that of clinical effectiveness.

Table 2: Three-step Reliability design model10 Step 1

Prevent failure: Use standardization to achieve 10-1 (80%-90% reliable or 10-1 performance expected)

Step 2

Identify failures and mitigate failures if possible to achieve 10-1 (of the 10% or 20% failures from Step 1, expect 80% or 90% identification and mitigation in Step 2)

Step 3

Prioritize failure modes, and redesign Steps 1 and/or 2 if articulated goal of 10-2 performance has not been achieved

More than two defects out of 10 (less than 80% success)

-1

Clinical effectiveness

Volume 7 Number 5

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ORTHODONTIC INSIGHTS

“

Whenever you find yourself on the side of the majority, it is time to pause and reflect. — Mark Twain

What is clinical effectiveness? Clinical effectiveness is defined as “the application of the best knowledge, derived from research, clinical experience, and patient preferences to achieve optimum processes and outcomes of care for patients. The process involves a framework of informing, changing, and monitoring practice.”15 Clinical effectiveness is concerned with demonstrating continual improvements in quality and performance. The properties of clinical effectiveness follow15: • Doing the right thing (evidencebased practice requires that decisions about patient care are based on the best available, current, valid, and reliable evidence) • In the right way (developing a care team that is skilled and competent to deliver the care required) • At the right time (accessible services provide treatment when the patient needs them) • In the right place (location of care services) • Resulting in the right outcome all the time (clinical effectiveness) Clinical effectiveness is about improving the “total care experience” of the patient. It requires thinking critically about what the care team does, questioning whether the team is achieving the desired result, and making necessary changes to unreliable practices. This can only be accomplished if the doctor and her care team are committed to measuring the quality of care. Continuous improvement methodologies such as the Plan-Do-Study-Act cycle may be used to effect improvement.16 Measures from such initiatives are critically evaluated to seek evidence of what is effective in order to improve a patient’s care and experience. The doctor and the care team should always be attentive and respectful of the patient’s care preferences. Patientreported outcome programs such as Patient-Reported Outcome Measures (PROM) and Patient-Reported Experience 42 Orthodontic practice

Measures (PREM) should be implemented to directly seek the voice of the patient in care improvement initiatives.17 Also, patient literacy programs to better educate patients in evaluating the quality and source of healthcare information and judge doctor skills should be considered.

“

Never underestimate the power of a small group of committed people to change the world. In fact, it is the only thing that ever has. — Margaret Mead

Conclusions Our profession is at a crossroads. We have a unique opportunity to better patient care by implementing creative solutions. Change can only succeed if we act with a sense of purpose, purpose defined by the values and the belief system we adopt — our culture. We need to acculturate ourselves to a “patient first” care model. This requires that we migrate to a platform that supports mindfulness, is proactive in its practices, and is performance based. The orthodontic practice of the future will be designed around what I term the E. A. A. R. model: Empathy for patients Anticipate issues to prevent problems Attention to processes and procedures Reflective thinking to continuously improve Four important points must be noted. First, the quality of our outcomes is driven by the quality of how we practice. Second, change without measurement is not change. Third, we must rid ourselves of our mindset of orthodontic exceptionalism and restore humility within ourselves and our practices. Fourth, we must take the initiative to measure our personal performance and practice performance on the basis of our deeds, patient feedback, and professionalism — profit or production should be secondary determinants of success. More specifically, we should implement broader system wide measures at multiple levels to understand and improve upon the quality of care we offer patients. At the patient level, measures should include whether patient care expectations are met, the number of disruptive episodes in the

patient’s life (e.g., wait times, discomfort), and the patient’s understanding of his/her care needs and treatment. Such measures would provide a gauge for the effectiveness of the patient’s care experience in the practice. At the doctor level, measures should include the proximity of the initial plan to the outcome and the conformity of her treatment approach to the prevailing evidence. Such measures would provide a basis for assessing the doctor’s knowledge and skills and also shed light on the effectiveness of the quality assurance program in the practice. I also believe that the doctor should periodically make available his/her report card to the public. The societal benefit of such transparency outweighs the limited loss of professional freedom. At the process level, measures should include error rates, acts of commission and omission, resource utilization, and costeffectiveness of care. Learnings from these measures would provide an understanding of the effectiveness of the practice’s qualitycontrol program. Furthermore, quality should be measured temporally. The trend line would reveal the effectiveness of continual improvement initiatives in the practice. Generative practices would tend to show a positive trajectory in their efforts to continually improve. At the system-wide level, the profession must implement a total quality assessment program and patient literacy program to educate the patient on the metrics of quality care. Furthermore, we must establish a national registry to report the errors or adverse events we see during our patient care. It is only by sharing and collectively learning from our failures that our specialty can better patient care. Academia should implement educational and effective training programs on patient safety and improvement science for the residents and the practicing community. They should also take the responsibility to regularly report on their institutional care performance to both the public and professional communities. Industry must take an active and responsible role in working with the

“

Never accept the proposition that just because a solution satisfies a problem, that it must be the only solution. — Raymond E. Feist

Volume 7 Number 5

Acknowledgments This article is republished with permission from the European Journal of Clinical Orthodontics — Sachdeva RCL. Novus Ordo Seclorum. A manifesto for practicing quality care — part 1. EJCO. 2014;2:7176. I sincerely thank the publishers and editors of the European Journal of Clinical Orthodontics, Dr. Raffaele Schiavoni and Ms. Lorella La Leggia for giving me permission to publish the above article in Orthodontic Practice US. Also, I wish to express my sincerest gratitude to my daughter, Nikita Sachdeva, for her editorial assistance.

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Volume 7 Number 5

Tonelli MR. Advancing a casuistic model of clinical decision making: a response to commentators. J Eval Clin Pract. 2007;13(4): 504-507.

Sachdeva RCL. Integrating Digital and Robotic Technologies: Three-Dimensional Modeling, Diagnosis, Treatment Planning, and Therapeutics. In Graber L, Vanarsdall R, Vig K, eds. Orthodontics: Current Principles and Techniques. 5th ed. Philadelphia: Elsevier Mosby, Inc.; 2012.

Emanuel L, Berwick D, Conway J, Combes J, Hatlie M, Leape L, Reason J, Schyve P, Vincent C, Walton M. What Exactly Is Patient Safety? In Henriksen K, Battles JB, Keyes MA, Grady ML. eds. Advances in Patient Safety: New Directions and Alternative Approaches. Rockville (MD): Agency for Healthcare Research and Quality, 2008.

10. Resar RK. Making Noncatastrophic health care processes reliable: learning to walk before running in creating high-reliability organizations. Health Serv Res. 2006; 41(4 Pt 2):1677-1689. 11. Roberts KH. and Bea RG. “Must accidents happen? Lessons from high-reliability organizations.” Academy of Management Executive, 2001;15(3):70-79.

REFERENCES 1.

Always do right — this will gratify some and astonish the rest. — Mark Twain

American Board of Orthodontics (ABO). Grading System for Dental Casts and Panoramic Radiographs. ABO. June 2012. https://www.americanboardortho.com/media/1191/ grading-system-casts-radiographs.pdf. Accessed August 3, 2016. NHS West Norfolk Clinical Commissioning Group. Quality and Patient Safety. National Health Service West Norfolk Clinical Commissioning Group. 2014. http://www.westnorfolkccg.nhs. uk/about-us/quality-patient-safety. Accessed August 3, 2016.

Hartzband P, Groopman J. The new language of medicine. N Engl J Med. 2011;365(15):1372-1373.

Dorr Goold S, Lipkin M Jr. The doctor-patient relationship: challenges, opportunities, and strategies. J Gen Intern Med. 1999;14(Suppl 1):S26-S33.

Berwick DM. What “patient-centered” should mean: confessions of an extremist. Health Aff (Millwood). 2009;28(4):w555-w565.

American Academy of Pediatric Dentistry. Policy on a Patient’s Bill of Rights and Responsibilities. 2009;37(6):188-119. http:// www.aapd.org/media/policies_guidelines/p_patientbillofrights. pdf. Accessed August 3, 2016.

12. Weick KE, Sutcliffe KM. Managing the unexpected: resilient performance in an age of uncertainty. San Francisco, California:Jossey-Bass;2007. 13. Fogel J, Janani R. Intentions and Behaviors to Obtain Invisalign. Journal of Medical Marketing. 2010;10(2):135-145. 14. Invisalign. Invisalign Teen Mom Advisory Board Disclosure Statement. Invisalign. 2014. Web. 23 Aug. 2014. http://www.invisalign. com/pages/mabdisclosure#sm.0001pfsd3awaieofv7c1yk4ob r8tm. Accessed August 3, 2016. 15. NHS Lanarkshire. “Clinical Effectiveness Strategy: 2009-2012.” NHS Lanarkshire. June 2009;1-13. http://www.nhslanarkshire.org.uk/boards/Archive/2009BoardPapers/Documents/ June%202009/Clinical%20Effectiveness%20Strategy%20 2009-2012%20-%20June%202009%20Board.pdf. Accessed August 3, 2016. 16. Sollecito, W, Johnson J. McLaughlin and Kaluzny’s Continuous Quality Improvement in Health Care. 4th ed. Burlington Massachusetts:Jones & Bartlett Learning:2011. 17. National Health Service (NHS). Patient Reported Outcome Measures (PROMS). NHS. Updated January 21, 2015. http:// www.nhs.uk/NHSEngland/thenhs/records/proms/Pages/aboutproms.aspx. Accessed August 3, 2016.

Orthodontic practice 43

ORTHODONTIC INSIGHTS

professional community to educate the public on quality care. Our calling as orthodontists is to carry the slogan “always do right by the patient.” Let this be the mantra that raises our professional conscience to the highest of levels. Let it also be a reminder to us to serve our patients to the best of our abilities. A positive externality of quality patient care is the sustainability of the orthodontic profession. This manifesto forms the bedrock of BioDigital orthodontics, a philosophy of care that I have developed. In my next article, I will discuss the principles and practice of BioDigital orthodontics with specific reference to building reliable care practices through error minimization. OP

CONTINUING EDUCATION

A review of accelerated orthodontics Dr. David Alpan discusses several technologies that deliver orthodontic treatment in less time Abstract Accelerated orthodontics (AO) historically has been associated with negative sequela, but with the use of bone modulation technology, it is now considered progressive. Reducing treatment time or increasing treatment predictability are the tangible benefits that are desired by patients and practitioners alike.22 Completing treatment early reduces possible risks and creates a more pleasant experience.17 Increasing predictability allows practitioners to treat more severe malocclusions in reasonable treatment times. Incorporating AO into practice requires changing treatment planning and practice management systems. Orthodontics creates change in the alveolar bone through biomechanics of applying force to teeth, but AO provides bone modulation affecting the biology of tooth movement on a cellular level. This article will describe my introduction, implementation, clinical, and practice management systems to effectively deliver any orthodontic treatment in less time with decreased sensitivity. The evolution of our profession will incorporate AO into the armamentarium of all orthodontists.

Introduction “When will my treatment be completed?” Orthodontists are asked this question repeatedly. Eventually, I started to ask my patients, “When will your treatment be finished?" They always look at me funny and say, “You’re the doctor — you tell me.” My typical response is, “In a few more visits,” (which we know is probably not true). Orthodontists have a reputation of extending treatment in an effort to create perfect outcomes.

Educational aims and objectives

This article aims to discuss possible ways in which the clinician can introduce and implement clinical and practice management systems to effectively deliver any orthodontic treatment in less time with decreased sensitivity.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 49 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify the process of accelerated orthodontics. • Realize some ways to introduce the concept to patients. • Realize some of the history and clinical research behind accelerated orthodontics. • Identify techniques regarding micro osteo-perforations. • Identify uses for vibration for seating of aligners.

The clinician’s dilemma is a wide variety of malocclusions, ethnicities, size of teeth, variable bone biology, and various levels of patient compliance. Predicting accurate treatment time is not easy, and many times, the answer is an estimate, based on our individual clinical experience. Unfortunately, no orthodontist can predict treatment length accurately 100% of the time. Research clearly demonstrates that accelerating the biology of tooth movement is a modality to add to our armamentarium.6,18,19,20,21 The practice of clinical orthodontics is managing the science of biomechanics, which inherently is harnessing the biology of tooth movement (Figure 1).1,7 My research project as a senior dental student in 1995 was on the influence of secondary messengers on calcium regulation in osteoblasts. I wanted to discover how orthodontists could influence the biology of tooth movement to reduce treatment time. My mentor and I were interested in finding the secondary messengers for calcium regulation, so we could influence the calcium regulation of osteoblasts

and osteoclasts. We researched how to accelerate the biology of tooth movement, so we could create a drug to modulate the alveolar bone response. My research project was awarded first place from the ADA/ Dentsply Student Research Competition in 1995 at University of the Pacific Dental School. I was invited to present this research at the Student Clinicians of American Dental Association (SCADA) at the 37th annual ADA convention in Las Vegas in 1995 as the sole representative from my dental school. We were searching to see which mechanism of increased calcium in the cell could regulate cyclic nucleotides in the arachidonic acid cascade. Our research found that the arachidonic acid cascade has no effect by cyclic nucleotides. Overall, stretch of the cell membrane was still the primary stimulator to increase calcium intracellular.22 Our goal was to isolate a messenger such as cytokines, find a stimulator, or create a drug that could attach to the proper receptor, so we could influence the biology or the rate of tooth movement.

David Alpan, DDS, MSD, received his Doctor of Dental Surgery (DDS) degree from Arthur Dugoni School of Dentistry (UOP) and was licensed in California and Nevada in 1996. He earned an Orthodontic Specialty Certificate in 1998 and was awarded a Masters in Science in Dentistry (MSD) for his research on a TMJ project. Dr. Alpan founded his private practices, Alpan Orthodontics, in Los Angeles, Beverly Hills, and Las Vegas in 1999. In 2015, the Las Vegas practice was sold, and in 2016, the Century City location was added. He played an integral role for Align Technologies’ Clinical Education Department from 2002-2008 and participated as a consultant and a speaker for 6 years. He is a member of Ormco Insiders Group, Incognito Circle of Excellence, and a part of 3M Unitek’s research panel. Dr. Alpan is a Key Opinion Leader (KOL) for Propel and speaks for AcceleDent. 3D Digital Accelerated Orthodontics is his passion, so he has incorporated Propel and AcceleDent with his Insignia, Invisalign®, and Incognito daily practice. He is an active member of ADA, CDA, LADS, PCSO, AAO, CAO, AO, OKU, and TKO. His hobbies are racing cars as a member of NASA, POC, CSM, and BMW CCA, and he spends his free time with his wife, Mary, son Zephyr, and daughter Ambryn.

Figure 1: The biology of tooth movement 44 Orthodontic practice

Volume 7 Number 5

Figure 2: Large 10 mm spaces

even more efficient bracket systems using 3D modeling and planning to build custom brackets and wires to reduce treatment time with even greater levels of mechanical efficiency.

Research and clinical results From 1988 to 2010, multiple researchers found that the application of NSAIDs decreased the rate of tooth movement significantly, and cytokines played an important role in activating the bone remodeling machinery.1,7,13 Other research showed that high forces created zones of necrosis through hyalinization. Thus optimal forces were considered to be lighter and more constant, facilitating efficient tooth movement with reduced or no sequela. As an early adopter of DamonÂŽ passive self-ligation (PSL), I saw the benefits of frictionless movement with lighter forces. Improved mechanical advantages and reduced treatment time lead me to believe PSL mechanics had accelerated tooth movement more efficiently than traditional metal twin brackets. Most of

the PSL cases finished 6 months faster, but detailing was more challenging. Leveling and aligning became super easy, but the anterior/ posterior (AP) and transverse corrections still took as much time to correct as traditional braces. As more research was conducted on AO, various products and techniques began to emerge. For example, using PSL in conjunction with TADs, NiTi closing springs, and three MOPs; we closed a 10 mm space with no sequela in 8 months (Figures 2-3). Reduction in treatment time can now be directly controlled by choosing more efficient appliances (PSL, NiTi wires and springs, 3D setups, custom brackets), removing all NSAIDs, in combination with accelerating the biology of tooth movement via MOPs or with vibration. Research shows if inhibiting the expression of certain cytokines decreases the rate of tooth movement, then if we perform an iatrogenic trauma to stimulate the expression of inflammatory cytokines with MOPs, clinically we see an increase in the rate of tooth movement. Previous studies demonstrated bone injury causes cytokine

Figure 3: 10 mm spaces closed in 8 months PSL, TADs, NiTi springs and 2-3 micro-osteoperforations

Figure 5: Performing MOPs with Propel

Figure 4: Propel 1st, 2nd, and 3rd Generations Volume 7 Number 5

Figure 6: Propel light is activated at designated depth Orthodontic practice 45

CONTINUING EDUCATION

In 1998, AO meant applying greater than 150 gm of force over less than 30 days. This concept was considered taboo, due to the negative sequela created (root resorption, bone loss, recession etc.). The main topics of discussion around acceleration were mechanical efficiency and friction. There was little research on the effect of trauma, sound, light, or vibration at that time. There was extensive literature in orthodontics comparing various biomechanics of appliances and their efficiencies regarding tooth movement. The introduction of biomechanical efficiencies such as prescription brackets, straight-wire mechanics, self-ligating versus non-self-ligating, clear brackets with various levels of friction, introduction of passive versus active self-ligation, lots of biomechanics with loops via Burstone mechanics, constant non-decaying force applications such as nickeltitanium wires, and nickel-titanium springs were the only forms of acceleration at that time. In 2016, AO now means having bone modulators (vibration and micro-osteoperforations) trigger the physiologic process of bone resorption and apposition at an increased rate. We also have

CONTINUING EDUCATION release and leads to an accelerated bone turnover, as well as a decrease in regional bone density.2,3,4,5,8 The idea of traumatizing the bone is not novel and is now correlated with the increase in the inflammatory cytokines that can increase bone remodeling.6 Since MOPs were introduced with the use of TADs in 2009, a company called Propel® Orthodontics launched a patented tool to facilitate MOPs. Propel is uniquely designed to perform MOPs to stimulate the alveolar bone to increase cytokines locally. The devices are FDA-registered 510(k) exempt Class I medical devices designed for single-use only (Figure 4). The first-generation Excellerator had a LED with a depth indicator and was disposable after one use. The device has a sleeve around the screw; when it is depressed, the screw penetrates into the bone. The pressure on the sleeve would trigger the light at the depth it was set to. The second-generation (Excellerator RT) has a reusable handle that can be sterilized with a disposable one-time use tip. There is no more LED, and depth can be measured with 3 mm markings on the sleeve, or a sleeveless tip is available. The third-generation Excellerator PT power tip is an automated slow speed driver with a contra-angle head attachment and single use burs with no measuring gauge. This device requires less time and effort, and offers improved access for the doctor to perform MOPs. Propel drivers are made with a surgical stainless-steel microleading edge designed and patented to be used to atraumatically perforate the alveolus directly through keratinized gingiva as well as movable mucosa. The Excellerators are designed to maximize the remodeling process, while reducing soft-tissue damage, and enable any orthodontist to perform MOPs easily chairside. We routinely perform this procedure as if we were placing a TAD or changing an archwire.

The decrease in number of visits leads doctors to be more profitable, independent of how they charge or do not charge for Propel.21 MOPs can be localized to two teeth whereas vibration affects all the teeth. When using MOPs, there is no issue of patient compliance, as there is with vibration. MOPs are performed every 12 to 16 weeks depending on the patient’s treatment response. When using MOPs reactively (during treatment), patients typically require 1 to 2 sessions. Those who want to reduce overall treatment time proactively (at the start) from the initial appointment may need 2 to 3 sessions. I create 2 to 3 MOPs interdentally vertically aligned from the crest, and I place the MOP driver 90 degrees to the tissue. The depth of perforation is usually 3 mm-5 mm. Patients’ soft tissue can vary in thickness from 1 mm-2.5 mm in thickness. So, the tip will go into the cortical plate and micro-fracture the cortical bone about 1.5 mm-3 mms in depth. Many patients can have the first and second MOP in attached tissue; the third MOP may be in the mucosal tissue.

Since OrthoAccel publicly launched AcceleDent® Auran (Figure 19) in early 2012, clinicians and patients are experiencing reduction in treatment time23,24,25, increased treatment predictability, and an analgesic effect26. Micropulse vibration, 20 minutes per day at a frequency of 30 Hz at a force of 0.25N (25g) is seeing incredible results with accelerating tooth movement. The clinical research states 50% increase in the rate of tooth movement,6,23,24,25 but I have found this does not correlate to the same reduction in overall treatment time. Acceleration is more efficient during leveling and aligning then sagital corrections.24 With AO, I am seeing a clincal average of 35%-40%

reduction in overall treatment time dependent on the appliance choice, mechanics utilized, or acceleration device used. AcceleDent Aura offers an analgesic effect26 which MOPs do not. The theory behind the effective mechanism of vibration is explained with an increased blood supply or the wiggle effect. Both reduces binding of the wire in the bracket (friction) or lack of tracking in aligners and allows for the biology of tooth movement to be more efficient. I strongly advise all patients using vibration not to use NSAIDs during treatment. To be efficient, and make AO work, doctors have to change patients appointment intervals. Patients that choose vibration need to be compliant daily: I check the compliance interface at each visit, which gives us a chronologic history by day, month, time and length of use. My Invisalign patients change aligners every 5-7 days, and I deliver 4 to 10 aligners per visit. Depending on how treatment is progressing, I may graduate to delivering more aligners at each visit or reduce the time in each aligner depending on progress. For 3M Incognito™, Insignia®/Damon, and mini twin mechanics we are activating treatment every 3 weeks for wire changes or repositioning bracket. During initial leveling, I am seeing results in one appointment that would normally take 3 visits. My current clinical protocol includes MOPs or vibration in conjunction with Invisalign, Incognito, Insignia/Damon and traditional metal mini twins. For patients who chose both MOPs and vibration, I am finding a 50% reduction in treatment time. With the combination of two bone modulators only a 10-15% improvement, we are finding that MOPs and/or vibration can be used on all types of difficult malocclusions, such as severe crowding or spacing (Figures 7-8), for all of our TAD cases, open bite cases (Figure 9),

Figure 7: Large 4 mm diastema

Figure 8: Space closed and deep bite improved in 4 months with 1 MOP and PSL mechanics

Vibration technique

MOPs technique Mild discomfort is experienced by the patient postoperatively, usually for 1 to 2 days, and is moderated with TYLENOL® only, not NSAIDs.6,18,20,21 Some patients require the use of a local anesthetic via syringe, but in most cases, profound topical is sufficient. We start with benzocaine 20% for 3 to 5 minutes locally, then a compounded topical (lidocaine 10%, prilocaine 10%, and tetracaine 4%) for 30 to 60 seconds, followed by a MadaJet with lidocaine 2% 1:100,000 epinephrine spray. This is the same technique used for my TAD placements. The Propel technique is clearly outlined and explained in Nicozisis’ article.18 46 Orthodontic practice

Figure 9: AY Adult nonsurgical Invisalign before and after with AcceleDent 16 months overall treatment. Estimated 24 months = 35% reduction in treatment time Volume 7 Number 5

Practice management considerations My initial application of MOPs was for difficult or stubborn tooth (e.g., maxillary laterals) with aligners. Treatment acceptance with MOPs is higher with existing patients

who need to get completed just based on cost. All extended treatments are recommended AO as we begin to see they will not meet their estimated treatment time. Patients toward the end of treatment wanting to finish as soon as possible, find AcceleDent to be cost prohibitive and are more receptive to MOPs. Fee consideration plays a role in the doctors and patients decision. I charge $250 for each MOP treatment and $800-$1,200

Figure 10: AY maxillary advancement with Invisalign TADs and Class III elastics with AcceleDent 22 months - Nonsurgical

Figure 11: CP non-extraction with surgery AcceleDent and insignia completed in 15 months or 37% faster than the original estimate of 24 months

Figure 13: Final for CP Volume 7 Number 5

for a low-frequency vibration device. I have also chosen a no-fee MOP treatment, as there is a benefit to completing treatment early (extended treatment costs are greater than the cost of the Propel tip). Patients are able to reliably accelerate their treatment with a cost-effective, minimally invasive procedure like MOPs21 or with low-frequency vibration. Some AO alternatives like Wilkodonticsâ&#x201E;˘ (Figure 17) or Piezosurgery (Figure 18) are not cost-effective, and require surgery at a price range of $5,000 to $10,000. There is a potential for negative sequela and extended recovery time with these surgical procedures. AcceleDent may be more costly, but vibration requires no doctor chair time, and is less clinical work. If the patient is not compliant, vibration has little to no clinical effect. VPro5 is Propelâ&#x20AC;&#x2122;s new vibration device (frequency 120Hz), that is recommended for aligner seating only. The device is priced lower than AcceleDent and requires only 5 minutes per day. The idea is improved aligner seating or reduced aligner lag thus increased predictability. They do not

Figure 12: Initial start for CP

Figure 14: CP profile before and after treatment 15 months with AO and surgery Orthodontic practice 47

CONTINUING EDUCATION

surgical treatment plan (Figures 11-14), and nonsurgical (Figures 9-10, 15, 16), impacted teeth,19 intrusion of gummy smiles19, extraction cases, or molar protraction (Figures 2-3).21

CONTINUING EDUCATION REFERENCES 1. Teixeira CC, Khoo E, Tran J, et al. Cytokine expression and accelerated tooth movement. J Dent Res. 2010; 89(10):1135-1141. 2. Frost HM. The regional acceleratory phenomenon: a review. Henry Ford Hosp Med J. 1983(1); 31:3-9. 3. Frost HM. The biology of fracture healing. An overview for clinicians. Part I. Clin Orthop Relat Res. 1989; 248(11):283-293.

Figure 15: DH nonsurgical treatment with AcceleDent, elastics, and Invisalign

Figure 16: AY nonsurgical treatment with AcceleDent TADs, elastics, and Invisalign

4. Frost HM. The biology of fracture healing. An overview for clinicians. Part II. Clin Orthop Relat Res. 1989; 248(11):294-309. 5. Shih MS, Norrdin RW. Regional acceleration of remodeling during healing of bone defects in beagles of various ages. Bone. 1985; 6(5):377-379. 6. Alikhani M, Raptis M, Zoldan B, et al. Effect of the microosteoperforations on the rate of tooth movement. Am J Orthod Dentofacial Orthop. 2013;144(5):639-648. 7. Arias OR, Marquez-Orozco MC. Aspirin, acetaminophen, and ibuprofen: their effects on orthodontic tooth movement. Am J Orthod Dentofacial Orthop. 2006;130(3):364-370. 8. Yaffe A, Fine N, Binderman I. Regional accelerated phenomenon in the mandible following mucoperiosteal flap surgery. J Periodontol. 1994;65(1):79-83.

Figure 17: Wilkodontics procedure

9. Adachi Y, Okazaki M, Ohno N, Yadomae T. Enhancement of cytokine production by macrophages stimulated with (1-->3)-beta-D-glucan, grifolan (GRN), isolated from Grifola frondosa. Biol Pharm Bull. 1994; 17(12):1554-1560. 10. Alhashimi N, Frithiof L, Brudvik P, Bakhiet M. Orthodontic movement induces high numbers of cells expressing IFNgamma at mRNA and protein levels. J Interferon Cytokine Res. 2000; 20(1):7-12. 11. Arend WP, Palmer G, Gabay C. IL-1, IL-18, and IL-33 families of cytokines. Immunol Rev. 2008;223(1):20-38.

Figure 18: Piezosurgery procedure

Figure 19:

advocate reduction in treatment time through increased rate of tooth movement, but only an improved aligner fit reducing the need for case refinement. Biolux offers a mouthpiece with a lightactivated photobiomodulation 800 nm-1000 nm wavelength, which creates enhanced tissue metabolism increasing ATP on a cellular level. Research shows 30% reduction in treatment time with photobiomodulation with Biolux. Orthodontic fee agreements are either paid in full or spread over time. The majority of orthodontists require the full fee due by treatment finish. Patients appreciate the convenience of paying the treatment over time, as it lowers their monthly fee. Since AO has changed the original estimated treatment time, we have had to update existing contracts. This poses a new challenge with our new starts, since we don’t have as much time to amortize their fee. For some patients, we have extended the payment arrangements past the finish date, but most patients we ask to complete payment by the end of their treatment. We have added this language to our contract to assist us with this issue: “If the active phase of treatment is completed before the agreed estimated time, the full fee is due and payable at that time.” The commitment needs to be agreed upon before AO treatment is initiated. 48 Orthodontic practice

12. Başaran G, Ozer T, Kaya FA, Hamamci O. Interleukins 2, 6, and 8 levels in human gingival sulcus during orthodontic treatment. Am J Orthod Dentofacial Orthop. 2006;130(1):E1-E6.

Conclusion In conclusion, my participation with AO has opened my eyes to the possibilities of what osseous modulation can offer orthodontic patients for the future. My traditional routines are now changing and so is my treatment planning. I am able to offer alternative treatment plans that would never be an option with traditional mechanics alone. I feel an ethical and moral obligation to inform my profession and patients of the latest technology, especially if it will make their treatment experience shorter and more pleasant. Since AO is now part of my everyday practice, I have had an increase in my capacity, due to faster finishes and a reduction in negative sequela. The benefits of decreased treatment time far outweigh any of the costs or additional work required by the patient or the practitioner utilizing AO. Performing MOPs has clinically shown to increase the rate of tooth movement or decrease the overall treatment time by 35% to 40% but has no analgesic effect and requires no compliance. Low frequency vibration can reduce treatment time by as much as 35% to 40% and offers an analgesic effect but requires compliance to be effective. Completing treatment early, with less visits, a more predictable result, and reduced negative sequela are compelling reasons to introduce AO into daily orthodontic practice. OP

13. Dale DC, Boxer L, Liles WC. The phagocytes: neutrophils and monocytes. Blood. 2008;112(4):935-945. 14. Davidovitch Z, Nicolay OF, Ngan PW, Shanfeld JL (1988). Neurotransmitters, cytokines, and the control of alveolar bone remodeling in orthodontics. Dent Clin North Am. 1988;32(3):411-435. 15. Dienz O, Rincon M. The effects of IL-6 on CD4 T cell responses. Clin Immunol. 2009;130(1):27-33. 16. Henneman S, Von den Hoff JW, Maltha JC. Mechanobiology of tooth movement. Eur J Orthod. 2008;30(3):299-306. 17. Krishnan V, Davidovitch Z. On a path to unfolding the biological mechanisms of orthodontic tooth movement. J Dent Res. 2009;88:597-608. 18. Nicozisis J. Accelerated orthodontics through micro-osteoperforation. Orthodontic Practice US. 2013;4(3):56-57. 19. Guinn K. Propel orthodontics enabling faster and more predictable results. Orthotown. December 2013: 38-41. 20. Pobanz JM, Storino D, Nicozisis J. Orthodontic acceleration: Propel alveolar micro-osteoperforation. Orthotown. May 2013:22-25. 21. Nicozisis J. (2013) Accelerated tooth movement technology. Orthotown. July/August 2013:46-48. 22. Garlet TP, Coelho U, Silva JS, Garlet GP. Cytokine expression pattern in compression and tension sides of the periodontal ligament during orthodontic tooth movement in humans. Eur J Oral Sci. 2007;115(5):355-362. 23. Uribe F, Padala S, Allareddy V, Nanda R. Patients’, parents’, and orthodontists’ perceptions of the need for and costs of additional procedures to reduce treatment time. Am J Orthod Dentofacial Orthop. 2014;145(4)(suppl):65-73. 24. Pavlin D, Anthony R, Raj V, Gakunga P. Cyclic loading (vibration) accelerates tooth movement in orthodontic patients: a double-blind, randomized controlled trial. Seminars in Orthodontics. 2015; 21 (3):187-194. 25. Bowman SJ. The effect of vibration on the rate of leveling and alignment. J Clin Orthod. 2014;48(11): 678-688. 26. Ortan-Gibbs S, Kim NY. Clinical Experience with the use of pulsatile forces to accelerate treatment. J Clin Orthod. 2015; 49(9): 557-573. 27. Lobre WD, Callegari BJ, Gardner G, Marsh CM, Bush AC, Dunn WJ. Pain control in orthodontics using a micropulse vibration device: a randomized clinical trial. Angle Orthod. 2016; 86(4): 625-663.

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A review of accelerated orthodontics ALPAN

Palatally displaced canines — is there a way to prevent impaction of these teeth? ROSENBERG, ET AL.

Orthodontics creates change in the alveolar bone through biomechanics of applying force to teeth, but AO provides _______ affecting the biology of tooth movement on a cellular level. a. bone modulation b. root resorption c. Burstone mechanics d. hyalinization

In 1998, AO meant applying greater than ____ gm of force over less than 30 days. a. 50 b. 75 c. 100 d. 150

In 2016, AO now means having bone modulators (vibration and micro-osteoperforations) triggering the physiologic process of _______ at an increased rate. a. hyalinization b. bone resorption c. apposition d. both b and c

From 1988 to 2010, multiple researchers found that the application of NSAIDs ________, and cytokines played an important role in activating the bone remodeling machinery. a. increased the rate of tooth movement significantly b. decreased the rate of tooth movement significantly c. decreased the rate of tooth movement only a small amount d. had no effect on tooth movement

a. delay b. increase c. decrease d. interval 6.

10. 5.

Research shows if inhibiting the expression of certain cytokines decreases the rate of tooth movement, then if we perform an iatrogenic trauma to stimulate the expression of inflammatory cytokines with MOPs, clinically we see a/an ____________ in the rate of tooth movement.

Volume 7 Number 5

The idea of traumatizing the bone is not novel and is now correlated with the increase in the inflammatory __________ that can increase bone remodeling. a. osteoblasts b. osteoclasts c. cytokines d. catecholamines Mild discomfort is experienced by the patient postoperatively, usually for 1 to 2 days, and is moderated with _________. a. NSAIDs only, not Tylenol® b. Tylenol® only, not NSAIDs c. penicillin d. epinephrine spray only MOPs are performed every ______ weeks depending on the patient’s treatment response. a. 1 to 2 b. 4 to 8 c. 12 to 16 d. 18 to 20 For MOPs, the depth of perforation is usually _______. a. 1 mm-2 mm b. 3 mm-5 mm c. 7 mm-9 mm d. very difficult to predict For patients who chose both MOPs and vibration, I am finding a _______ reduction in treatment time. a. 30% b. 50% c. 70% d. 90%

The ratio of palatal to buccal canine impactions is 8:1 and is twice as common in ________, with a total reported prevalence of between 0.8%-5.2% of the population. a. males than females b. females than males c. children than adults d. adults than children

Furthermore, the treatment of canines, when they become impacted, often involves ______. a. surgical exposure of the tooth b. the need for subsequent forced orthodontic eruption c. a root canal d. both a and b

On average, the maxillary permanent canines erupt between the ages of ____, usually earlier in females than males. a. 6 to 7 b. 8 to 9 c. 11 to 12 d. 14 to 16

Assessment of the maxillary canines should begin by the age of ___, with a visual inspection and palpation for a canine bulge. a. 3 b. 8 c. 10 d. 16

A non-palpable maxillary buccal canine bulge after the age of ____ and beyond should be considered abnormal and is an indication of a palatally displaced canine. a. 3 b. 8 c. 10 d. 16 _____ provide assessment of the horizontal overlap of the canine crown over the root of the lateral incisor.

a. Palpations b. Radiographs c. Intraoral photographs d. Visual examination 7.

In a classic observation study (no control group was used for comparison), Ericson and Kurol prospectively studied 35 children aged 10 to 13 who had PDCs and showed successful eruption of the permanent canines after extraction of the primary canines in _____ of cases. a. 25% b. 47% c. 78% d. 92%

Subsequent well-controlled studies of preventive treatment of PDCs have combined the extractions of maxillary primary canines with __________. a. the extraction of primary first molars b. concomitant use of headgear (HG) c. subsequent use of rapid maxillary expansion (RME) d. all of the above

__________ is/are evidence of a palatally displaced maxillary canine. a. A lingually displaced mandibular canine b. The absence of a buccal canine bulge intraorally c. The presence of an erupting canine crown that is overlapping the maxillary lateral incisor on a radiograph d. both b and c

10. Nevertheless, because successful selfcorrection and eruption of the permanent canine can take as long as ______, a long observation period is required to monitor the eruption of these teeth. a. 6 months b. 12 months c. 18 months d. 24 months

Orthodontic practice 49

CE CREDITS

ORTHODONTIC PRACTICE CE

CONTINUING EDUCATION

Palatally displaced canines — is there a way to prevent impaction of these teeth? Drs. Harold Rosenberg, Austin Chen, and Shervin Abbaszadeh discuss early detection and diagnosis of PDCs

ctopic eruption is defined as a disturbance in which a tooth does not follow its usual path of eruption.1 Maxillary canines are one of the most common ectopically erupting teeth, second only to third molars2; and of importance, once displaced palatally, most result in impactions.3,4 The ratio of palatal to buccal canine impactions is 8:1 and is twice as common in females than males,5-7 with a total reported prevalence of between 0.8%5.2% of the population.8 Palatally displaced canines (PDCs) can be associated with significant resorption of adjacent teeth9-11 (Figures 1A-1B). Furthermore, the treatment of canines, when they become impacted often involves surgical exposure of the tooth (Figure 2) and the need for subsequent forced orthodontic eruption. This type of treatment can have associated morbidity such as root resorption, bone loss, recession, necrosis, and can lead to prolonged orthodontic treatment time and cost.12 Therefore, preventive treatment to avoid subsequent impaction of maxillary canines becomes an important tool so that patients can be spared these negative consequences alongside potential surgery and prolonged orthodontic treatment. As such, early detection and diagnosis by the primary care dentist is of utmost importance so that appropriate interceptive treatment can be prescribed when indicated.

Educational aims and objectives

This article aims to discuss diagnosis and preventative treatment for partially displaced canines.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 49 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Realize the incidence of ectopic eruption of maxillary canines. • Recognize some reasons for partially displaced canines (PDCs). • Realize some ways to identify PDCs. • See some radiographic indications of PDCs. • Identify some preventative treatment for PDCs.

Figure 1A: Panorex of a 12-year-old girl who noted that her maxillary incisors were becoming mobile. Teeth No. 1.3 and No. 2.3 are mesioangularly impacted. Significant external resorption of the roots of the maxillary incisors has occurred

Figure 1B: CBCT reconstruction of displaced maxillary canines causing severe resorption of the maxillary incisors. The crown of the impacted tooth No. 2.3 is positioned palatally to the residual root apices of teeth Nos. 2.1 and 2.2 and has caused extensive root resorption of those teeth

Harold Rosenberg, BSc, DDS, MSc (Ortho), FRCD(C), is an Orthodontist in private practice in Etobicoke, Ontario. He can be reached at drhr@humbertownortho.com. Austin Chen, BSc, DDS, MSc (Ortho), FRCD(C), is a Staff Orthodontist at the Hospital for Sick Children, Associate Professor at the University of Toronto, Exam Coordinator for the Royal College of Dentists of Canada and is in private practice in Vaughan, Ontario. He can be reached at drchen@vaughanortho.com. Shervin Abbaszadeh BSc, DDS, MSc (Ortho), FRCD(C), is a Staff Orthodontist at Holland Bloorview Kids Rehab Hospital, Associate in Dentistry at the University of Toronto, an Examiner for the Royal College of Dentists of Canada, and is in private practice in North York, Ontario. He can be reached at shervin@clearlyortho.com.

50 Orthodontic practice

Figure 2: Surgical exposure of a palatally impacted maxillary canine. Note the retained primary canine, a common finding in these cases Volume 7 Number 5

On average, the maxillary permanent canines erupt between the ages of 11 to 12, usually earlier in females than males.13 Assessment of the maxillary canines should begin by the age of 8, with a visual inspection and palpation for a canine bulge (Figure 3). Positive palpation of a canine bulge on the buccal typically correlates to approximately a 92% positive chance that the canine will erupt normally.14,15 A non-palpable maxillary buccal canine bulge after the age of 10 years and beyond should be considered abnormal16 and is an indication of a palatally displaced canine (Table 1). Assessment of the degree of mobility of the primary canine is also important starting at this age. Mobility of the primary canine indicates that the tooth is undergoing physiological root resorption, which is most likely due to a normally erupting permanent canine. In addition, radiographic investigations such as panoramic, periapical, or maxillary occlusal films can be considered when there is doubt to the whereabouts of the permanent canine. Panoramic radiographs can provide two pieces of information that are important in determining impaction. First is the absence of physiologic root resorption of primary canines, as ectopically positioned permanent canines typically do not cause resorption of the primary canine roots. Second, radiographs provide assessment of the horizontal overlap of the canine crown over the root of the lateral incisor (Figures 4A-4B). The more overlap there is, and the more the canine crown is positioned toward the midline, the poorer the prognosis for spontaneous correction and the greater the probability of impaction occurring.16-18 Other radiographic findings associated with PDCs include an increased mesial inclination (>15Â°) of the canine long axis with

Early detection and diagnosis of PDCs is crucial in the prevention of impacted canines.

Figure 3: The presence of a canine bulge developing at the age of 9 years and enlarging prior to its eruption is an important milestone in the development of the dentition. Note the blanching of the gingiva above tooth No. 6.3, indicating the advancement and normal eruption of the maxillary permanent canine

Table 1: Clinical and radiographic findings of maxillary palatally displaced canines (PDCs) Screening for maxillary PDCs should be performed between the ages of 8-11 Clinical findings

Panoramic radiographic findings

Non-palpable buccal canine bulge

Horizontal overlap of the canine crown over the adjacent permanent lateral incisor

Retained non-mobile maxillary primary canine (especially if the contralateral primary canine is mobile)

Increased mesial inclination (>15Âş) of the canine long axis with the midline

Figure 4A: This 8-year-old patient presented for examination in the early mixed dentition. Note the early overlap of tooth No. 2.3 with the developing tooth No. 2.2. No treatment or intervention was completed at this time Volume 7 Number 5

Canine apex is distally positioned (distal to normal canine position)

Figure 4B: The same patient returns at the age of 13, now with a palatally displaced tooth No. 2.3 that required surgical exposure

Orthodontic practice 51

CONTINUING EDUCATION

Diagnosis of palatally displaced canines

CONTINUING EDUCATION the midline and a distally positioned canine apex16 (Table 1).

Table 2: Probability of self-correction (i.e., successful eruption of canine) with stated preventive treatment

Preventive treatment for palatally displaced canines The most documented and common preventive treatment for PDCs is the extraction of the primary canine. In a classic observation study (no control group was used for comparison), Ericson and Kurol prospectively studied 35 children aged 10 to 13 who had PDCs and showed successful eruption of the permanent canines after extraction of the primary canines in 78% of cases.19 The success of the interceptive extractions depended on the extent of radiographic overlap of the permanent canine over the lateral incisor. If the crown of the permanent canine was overlapping distal to the midline of the lateral incisor root, the primary canine extraction normalized the eruption of the permanent canine in 91% of the cases. Otherwise, only 64% of canines normalized after extraction of the primary canines if they were mesial to the midline of the lateral incisor root. Subsequent well-controlled studies of preventive treatment of PDCs have combined the extractions of maxillary primary canines with the extraction of primary first molars,20 concomitant use of headgear (HG)4,21 and subsequent use of rapid maxillary expansion (RME).22 Another study used a combination of RME and HG without maxillary primary canine extraction as preventive treatment of PDCs.23 For the purpose of this paper and for ease of clinical application, we will limit our discussion to preventive treatment of PDCs to: 1) the extraction of maxillary primary canines only,24 2) the extraction of maxillary primary canines in combination with headgear,21 and 3) the extraction of maxillary primary canines in combination with rapid maxillary expansion (RME) and/or transpalatal arch (TPA).22 Furthermore, included studies will be limited to prospective randomized controlled studies that included untreated controls for comparison and used the eruption of the PDC as the final outcome measure.

Randomized controlled trials on preventive treatment of PDCs Results of the selected studies have been summarized in Table 2. Extraction of maxillary primary canine It was documented in a prospective randomized controlled study on the effect of interceptive extraction of primary canines on palatally displaced maxillary canines that 52 Orthodontic practice

Preventive treatment options for PDCs to avoid canine impaction Preventive treatment Extraction of maxillary primary canine only

Probability of self-correction (i.e., successful of eruption of canine)

Probability of self-correction over comparative controls (no treatment)

62%-67%

25%-34%

87.5%

51.5%

Extraction of maxillary primary canine followed by RME and TPA

80%

52%

Extraction of maxillary primary canine followed by TPA

79%

51%

28%-42%

Extraction of maxillary primary canine in combination with HG

No treatment (control)

Figure 5A: This 9-year-old patient presented for examination in the early mixed dentition. Note the early overlap of tooth No. 2.3 with tooth No. 2.2. Note the lack of physiologic root resorption on tooth No. 6.3

Figure 5B: Clinical photos of the same 9-year-old patient with no mobility of tooth No. 6.3 or prominent canine bulge warranting the preventive extraction of the maxillary primary canines

the rates of successful eruption of the PDCs at extraction and control sites were 67% and 42%, respectively, after an 18-month interval.24 What was unique about this study was the fact that each individual acted as their own control. This was possible by only including bilateral PDC cases and randomly assigning one of the two primary canines for extraction while the other side served as a control. Incidentally, only 8% of palatal canine impactions are bilateral.25 Of interest

was the fact that this was most effective if the primary canine was extracted early at the age of 10 to 11 years. Furthermore, the authors recommended maintenance of the upper arch perimeter with the use of a transpalatal arch space-holding device. Applying this to a clinical scenario, if a PDC is identified clinically by the absence of a buccal canine bulge and radiographically by the overlap of the erupting permanent canine over the permanent lateral incisor, then extraction Volume 7 Number 5

Extraction of maxillary primary canine in combination with headgear A randomized clinical study comparing the effect of extraction of maxillary primary canines with and without headgear showed that the additional use of a headgear resulted in a significantly higher probability of successful eruption (87.5%) over extraction of the primary canine alone (65.2%).21 Both treatment modalities resulted in a higher percentage of self-correction and eruption of the PDCs over the control group receiving no treatment (36%). Interestingly, for the primary canine extraction group the percentage of

successful cases in this study (65.2%) was in agreement with the successful cases reported in the prospective RCT discussed previously (67%).24 The authors reported a mesial drifting of first molars in both the extraction-only and control groups and attribute the higher percentage of successful cases in the headgear group to minimizing mesial drift of the maxillary first molars thus maintaining space for the eruption of the canines. An earlier study by the same authors documented an 80% probability of successful eruption of PDCs in patients who had the primary canines extracted combined with headgear treatment.4 In contrast, only 50% of PDCs successfully erupted when the primary canines were extracted as an isolated measure to intercept PDCs, which was not significantly greater than the success in untreated controls. When applying this data to clinical practice, a case exhibiting PDCs with a Class II occlusion and excess overjet may be an ideal candidate for this interceptive treatment approach (Figures 6A-6D).

Figure 6A: This 11-year-old patient presented with non-palpable bilateral buccal canine bulges and no mobility of the primary canines. Furthermore, she presented with a half-cusp Class II molar relationship and excessive overjet

Figure 6C: A CBCT of the canines confirmed the palatal position of the erupting canines (palatally displaced canines) and confirmed that there was no external root resorption of tooth No. 2.2. Note the lack of physiologic root resorption on tooth No. 6.3 Volume 7 Number 5

Extraction of maxillary primary canine in combination with RME A study to investigate the effect of rapid maxillary expansion (RME) and/ or transpalatal arch (TPA) therapy in combination with deciduous canine extraction (CE) on the eruption of palatally displaced canines showed successful eruption of these canines in 80% of cases for the RME/TPA/CE group.22 When the extraction of deciduous canines was coupled with a TPA appliance to hold back the first permanent molars, the success of eruption was 79%, whereas extraction of the primary canine alone resulted in selfcorrection and eruption in 62.5% of cases. In contrast, only 28% of cases in the control group receiving no interceptive treatment resulted in self-correction/eruption. Of significance was the fact that PDCs with a fully developed root demonstrated significantly less probability of successful eruption following interceptive treatment. This outlines the importance of early detection of PDCs to allow for the provision of successful interceptive treatment. Given the findings of this

Figure 6B: Panoramic radiographic findings show maxillary permanent canines that are overlapping the lateral incisors, a mesial crown angulation (>15 degrees), and minimal physiological root resorption of the primary canines

Figure 6D: Preventive treatment consisted of the extractions of the maxillary primary canines in combination with headgear therapy resulting in improved eruption of the PDCs. Note the improved angulation of the erupting canines to the midline when compared to the pretreatment radiograph in Figure 6B Orthodontic practice 53

CONTINUING EDUCATION

of the primary maxillary canine will improve the chance of self-correction and decrease the probability of impaction by 25%. Cases showing the absence of other orthodontic problems such as crossbites, excess overjet, deep overbites, crowding, and spacing are good candidates for this type of treatment (Figures 5A-5B). Nevertheless, space maintenance or space opening after extraction of the primary canine may be recommended.

CONTINUING EDUCATION

Figure 7A: This 12-year-old female patient presented for examination in the early mixed dentition. Note the significant overlap of both tooth No. 1.3 and No. 2.3 with the maxillary lateral incisors

Figure 7C: Preventive treatment consisted of the extractions of the maxillary primary canines in combination with a rapid palatal expander resulting in improved eruption of the PDCs

Figure 7B: This same patient also presents with a narrow maxillary arch, right posterior crossbite, and significant maxillary and mandibular midline discrepancy

study, extraction of maxillary primary canines in combination with RME may be best suited to cases in which there are other findings present that warrant maxillary expansion (posterior crossbite, transverse discrepancy, narrow maxillary arch with crowding, etc.) (Figures 7A-7C).

or expansion appliance/TPA, the probability of self-correction further increases to 87.5% and 80% respectively. Nevertheless, because successful self-correction and eruption of the permanent canine can take as long as 18 months, a long observation period is required to monitor the eruption of these teeth. OP

Clinical recommendations

This article was reprinted with permission from September 2015 Oral Health..

15. Ericson S, Kurol J. Longitudinal study and analysis of clinical supervision of maxillary canine eruption. Community Dent Oral Epidemiol. 1986; 14(3):172-176.

REFERENCES

16. Counihan K, Al-Awadhi EA, Butler J. Guidelines for the assessment of the impacted maxillary canine. Dent Update. 2013; 40(9):770–777.

Early detection and diagnosis of PDCs is crucial in the prevention of impacted canines. The primary care dentist is in a great position to screen patients at the ages of 8 to 11 by simple clinical palpation of the maxillary buccal canine bulge and radiographic evaluation of the maxillary erupting canines. The absence of a buccal canine bulge intraorally and the presence of an erupting canine crown that is overlapping the maxillary lateral incisor on a radiograph are evidence of a palatally displaced maxillary canine. This finding should raise a flag and initiate a conversation with the patient’s parents regarding preventive treatment to avoid future impaction. With no treatment, one can expect self-correction and successful eruption in merely 30% to 40% of cases. In other words, as many as 70% of these PDCs will become impacted. However, by extracting the maxillary primary canine, the probability of self-correction increases to around 65%; and when coupled with a headgear 54 Orthodontic practice

1. Yaseen SM, Naik S, Uloopi KS. Ectopic eruption – a review and case report. Contemp Clin Dent. 2011;2(1):3-7. 2. Shah RM, Boyd MA, Vakil TF. Studies of permanent tooth anomalies in 7,886 Canadian individuals. Dent J. 1978; 44(6): 262-264. 3. Power SM, Short MB. An investigation into the response of palatally displaced canines to the removal of deciduous canines and an assessment of factors contributing to a favorable eruption. Br J Orthod. 1993; 20(3): 215-223. 4. Leonardi M, Armi P, Franchi L, Baccetti T. Two interceptive approaches to palatally displaced canines: a prospective longitudinal study. Angle Orthod. 2004;74(5):581-586. 5. Ericson S, Kurol J. Radiographic examination of ectopically erupting maxillary canines. Am J Orthod Dentofacial Orthop. 1987; 91(6):483-492. 6. Hitchin AD. The impacted maxillary canine. Br Dent J. 1956; 100:1-14. 7. Dachi SF, Howell FV. A survey of 3,874 routine full mouth radiographs. II. A study of impacted teeth. Oral Surg Oral Med Oral Pathol. 1961; 14: 1165-1169. 8. Thilander B, Jakobsson SO. Local factors in impaction of maxillary canines. Acta Odontol Scand. 1968; 26(2): 145-168.

11. Ericson S, Bjerklin K, Falahat B. Does the canine dental follicle cause resorption of permanent incisor roots? A computed tomographic study of erupting maxillary canines. Angle Orthod. 2002;72(2): 95–104. 12. Bishara SE, Kommer DD, McNeil MH, Montagana LN, Oesterle, LJ, Youngquist HW. Management of impacted canines. Am J Orthod. 1976; 69(4): 371-387. 13. Wedl JS, Schoder V, Blake FA, Schmelzle R, Friedrich RE. Eruption times of permanent teeth in teenage boys and girls in Izmir (Turkey). J Clin Forensic Med. 2004; 11(6): 299-302. 14. Kettle MA. Treatment of the unerupted maxillary canine. Trans Br Soc Orthod. 1957; 32:74-84.

17. McSherry P. The assessment of and treatment options for the buried maxillary canine. Dent Update. 1996;23(1):7-10. 18. Pitt S, Hamdan A, Rock P. A treatment difficulty index for unerupted maxillary canines. Eur J Orthod. 2006;28(2):141-144. 19. Ericson S, Kurol J. Early treatment of palatally erupting maxillary canines by extraction of the primary canines. Eur J Orthod. 1988;10(4):283-295. 20. Alessandri Bonetti G, Zanarini M, Incerti Parenti S, Marini I, Gatto MR. Preventive treatment of ectopically erupting maxillary permanent canines by extraction of deciduous canines and first molars: a randomized clinical trial. Am J Orthod Dentofacial Orthop. 2011;139(3):316-323. 21. Baccetti T, Leonardi M, Armi P. A randomized clinical study of two interceptive approaches to palatally displaced canines. Eur J Orthod. 2008; 30(4):381-385. 22. Baccetti T, Sigler LM, McNamara JA Jr. An RCT on treatment of palatally displaced canines with RME and/or a transpalatal arch. Eur J Orthod. 2011;33(6):601-607. 23. Armi P, Cozza P, Baccetti T. Effect of RME and headgear treatment on the eruption of palatally displaced canines: a randomized clinical study. Angle Orthod. 2011;81(3):370–374.

9. Rimes RJ, Mitchell CN , Willmot DR. Maxillary incisor root resorption in relation to the ectopic canine: a review of 26 patients. Eur J Orthod. 1997;19(1): 79–84.

24. Bazargani F, Magnuson A, Lennartsson B. Effect of interceptive extraction of deciduous canine on palatally displaced maxillary canine: a prospective randomized controlled study. Angle Orthod. 2014; 84(1):3-10.

10. Ericson S, Kurol J. Resorption of incisors after ectopic eruption of maxillary canines: a CT study. Angle Orthod. 2000;70(6): 415–423.

25. Litsas G, Acar A. A review of early displaced maxillary canines: etiology, diagnosis and interceptive treatment. Open Dent J. 2011; 5:39-47.

Volume 7 Number 5

Dr. Thomas Shipley discusses the advantages of high-frequency vibration

s an orthodontist, my goal is to devise treatment plans that result in beautiful, straight smiles. My patients and I also have an additional goal — of completing treatment as quickly as possible. My practice has boomed with the use of manual osteo-perforations (MOPs) with Propel’s Excellerator drivers, which, in my opinion, is still the gold standard for aiding orthodontic tooth movement. Now, I am using another product, VPro5™, an aligner seating vibration device from Propel. Ensuring that my patients are fully seating their aligners has resulted in more predictable treatment. Over the years, I have explored ways of improving orthodontic treatment, I originally integrated accelerated orthodontic treatment through Wilckodontics®, Accelerated Osteogenic Orthodontics™ (AOO). Although I only pursued this treatment on a limited amount of patients, I had incredible results. However, due to the invasive nature of AOO, I reserved its use for for the most severe malocclusions, usually also requiring bone grafting. Next, I turned to MOPs, using Propel’s Excellerator Drivers, so that patients could attain movement with a less invasive procedure. This allowed me to offer the benefits to a wider array of patients, including a range of mild Class I patients to some of the most severe malocclusions. Patients reported very little discomfort, and I could complete the procedure with just a few minutes of doctor time. Especially with my Invisalign® cases, it was a great leap forward. But even though 70%- 80% of my adult Invisalign patients

accepted MOPs as a course of treatment, the remaining 20%-30% still desired a treatment that was even less invasive. Then, I discovered VPro5. VPro5 uses high-frequency vibration for better seating of the aligners. This, in turn, helps the teeth track better with the Invisalign trays, leading to more predictable results. As an additional benefit, because the aligners were fitting better to the teeth, I was needing fewer refinements and was able to treatment plan for more difficult movements. With use of the VPro5 to seat aligners, I am able to offer my aligner patients the following advantages: • More treatment predictability • Less refinements • Less discomfort • Better patient compliance with a 5-minute usage time • Greater patient satisfaction Besides the benefits to the patients who are reporting less aligner discomfort because the aligners fit better, I also experience more efficient orthodontic workflow. Because the aligners are seating and tracking better, I can spend less time in each aligner. Now, because of better seating, my patients are changing their aligners faster.

Why efficient aligner seating is so important Efficient aligner seating is one of the most important aspects of clear aligner treatment. Align Technology has become very sophisticated in delivering orthodontic forces in very

Thomas Shipley, DMD, received his bachelor of science degree in Business Management from Brigham Young University and earned his doctorate from the University of Kentucky’s College of Dentistry. Dr. Shipley completed a master’s program in Orthodontics at West Virginia University and has been providing outstanding orthodontic care in Peoria, Arizona, and surrounding areas since 2005. In order to stay up-to-date on the latest advancements in his field, Dr. Shipley maintains membership in numerous prestigious professional organizations such as the American Dental Association, the Arizona Dental Association, the American Association of Orthodontics, the Pacific Coast Society of Orthodontists, Adjunct Professor at Arizona School of Dentistry, Department of Orthodontics in Mesa, Arizona, and he is the coordinator of the International Dental ED Continuing Education Study Group for the entire Northwest Valley. He is board certified by the American Board of Orthodontics where his professional achievements and contributions to his field have helped him achieve Diplomate status.

Volume 7 Number 5

specific ways. If the trays are not adequately seated, the plastic can lose its grip around the teeth. As a result, the forces cannot be properly delivered. If this happens, the teeth could move in an unplanned or non-advantageous direction. Aligners should be inspected during every visit to make sure that the teeth are tracking properly in the aligners. The easiest method is a visual inspection, making sure that the teeth are fitting snugly and that there is no airspace between the aligner and the teeth. It is also important to check that the Invisalign attachments that are bonded to the teeth are seated within the attachment wells. If the aligners aren’t seated well over the attachments, then the forces aren’t going to be delivered correctly to the teeth. Under certain circumstances, if it is too difficult to get a visual inspection, you can take a pencil or articulating paper and darken the attachments in order to see them more clearly once the trays are placed over the attachments. After the inspection, the marks can be wiped off with a cotton swab dipped in alcohol. Because proper aligner seating is so integral to proper tooth movement, the VPro5 is an excellent seating tool to help achieve the movements that we planned and eliminate unwanted tooth movements.

Patients’ nightly protocol Each night the patient is expected to wear the VPro5 for 5 minutes after putting their aligners in for the last time of the day. For some, that may be bedtime; for some, that may be after dinner. My intention is for them to put the vibration device in before they expect to sleep, which should be the time that the aligner is in the mouth for the longest continuous period of time during the day. Another benefit that I found with the VPro5 is that its recommended use time is 5 minutes which results in better patient compliance. I am able to confirm patient compliance by accessing data from the Orthodontic practice 55

ALIGNER TECHNOLOGY

VPro5™ — more efficient aligner seating with high-frequency vibration

ALIGNER TECHNOLOGY device. I understand time constraints from my own life and family — most adults in the prime Invisalign age group are very busy professional people as well as parents with children, and they do not have many minutes out of their day to sit with a vibration device in their mouth. With VPro5, set at 120 hertz, they can use the aligner seater for 5 minutes. I am getting a higher compliance rate with the VPro5. The VPro5 offers benefits for everyone involved in the treatment: Patients become more involved in a positive way. My patients have been very compliant and have a more positive outlook for their treatment because they are taking on a more active role than just putting in their aligners. They are able to accomplish their task in 5 short minutes and are proud that they can get it done. They get excited and talk about these technologies. The highest referral group in my office had treatment including MOPs and/or VPro5. Orthodontists benefit because the device can be plugged in during the patients’ appointment to recall the results. Patients know they will be held accountable, and that helps to motivate them. We plug it in at every visit and attach the results to the patient’s chart. I have used VPro5 for mild to moderate cases, and am starting to use it on patients with more complicated malocclusions. Better aligner seating with VPro5 increased the complexity of the Invisalign cases that I am able to accept. The following case illustrates the progress of one of my first VPro5 patients. A 25-yearold female adult patient presented with a Class I, mild upper-crowding, and moderate lower-crowding malocclusion. Minor tooth wear was also present (Figures 1-9). The patient chose to be treated with Invisalign. An iTero® digital scan was completed and submitted to Align Technology. Class I molars but slight Class II canines were noted on the initial ClinCheck®. No changes were made to the initial ClinCheck other than to add hooks and cutouts for Class II elastics. Twenty-four (stage 25 is an occlusal jump due to elastics) active aligners were prescribed with attachments to be placed for aligner 3 (Figure 10). Aligners 1 and 2 were delivered, and the patient wore each for 2 weeks. At aligner 3, 4 weeks after the initiation of treatment, attachments were bonded, and the patient began Class II elastic wear. The Propel VPro5 56 Orthodontic practice

Figures 1-9

Figure 10 Volume 7 Number 5

ALIGNER TECHNOLOGY

Figures 11-12

Figures 13-17

was delivered. The patient followed the proceeding protocol by placing the aligners for the last time for the evening, using the VPro5 device for 5 minutes with the aligners in place. The patient did not remove the aligners again until the morning. The patient was asked to wear each subsequent aligner for 5 days each (Figures 11 and 12). Figures 13-17 show the final results with aligners 25 seated in place. The aligners are seating perfectly after the patient wore each aligner for 5 days each. The case was completed in 20 weeks, including the first month with 14-day aligner changes. No refinement was needed. The lower crowding was resolved, and the Class II canines were corrected with Class II elastics to a Class I relationship. Minor enameloplasty was completed to resolve irregular upper incisor edges from occlusal wear. The patient is to be credited with excellent aligner wear, elastic wear, and VPro5 compliance. The patient reported less discomfort after starting usage of VPro5 and changing aligners every 5 days. Overall, she stated the VPro5 was easy to use, comfortable, and reliable (Figures 18-26). OP

This information is sponsored and provided by Propel Orthodontics.

Figures 18-26 Volume 7 Number 5

Orthodontic practice 57

LABORATORY LINK

Smile maintenance James Bonham discusses developments in retainer technology

good orthodontic retention plan is crucial for every successful practice. Patients not only expect great results from their orthodontic treatment, but also expect those results to last a lifetime. An orthodontist’s ability to meet these high expectations depends on a solid long-term retention plan. There is no such thing as a perfect retention appliance. In theory, a fixed lingual retainer is the best answer to maintain longterm tooth position, but many orthodontists consider them a potential hygiene threat. For this reason, most doctors choose removable retainers such as Hawley or clear plastic vacuum-formed retainers. They work great but often fail in the long run due to poor patient compliance. Removable retainers are often lost or damaged. Replacing them usually requires a visit to the orthodontist for new impressions. Patients are always at risk of their teeth shifting if time passes without a retainer. Backup retainers would be ideal, but traditionally, they are not cost-effective. Recent technologies such as digital impressions and 3D printing have influenced new developments for retention appliances. Specialty Appliances’ laboratory uses this technology to give orthodontists improved options for long-term retention success. All appliances made from the digital process, including fixed lingual retainers (FLR) and clear plastic retainers, are more accurate compared to the traditional impression and stone-model construction process. The digital process can also eliminate the patient’s time without a retainer. Orthodontists have the option of scanning for impressions one appointment before braces are removed. Specialty will digitally remove the braces and construct the initial retainers to be delivered at the debond

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.

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The Guardian retention system includes backup retainers and a printed model for future in-office retainer construction

Guardian™ invisible retainers

Fixed lingual retainers are efficiently delivered at the debond appointment with an indirect bonding tray

appointment. Plastic 3D printed construction models are more durable than stone, so multiple backup appliances can be made from a single construction model.

Fixed lingual retainers (FLR) Many orthodontists make their own FLR and deliver it at the debond appointment. This in-office process can be timeconsuming. Staff members often get frustrated working with wire, dental floss, and low viscosity adhesive to deliver a FLR. Specialty Appliances offers an easy and affordable alternative. As mentioned previously, orthodontists can capture a digital impression and have Specialty make the FLR prior to the debonding appointment. Practices will receive the pre-constructed lingual retainer embedded in an indirect delivery tray. Staff members simply prepare the lingual tooth surfaces, add a small bead of flowable composite to the custom tooth-shaped pads, and then light cure the seated indirect tray. If doctors also prescribe a clear retainer for the same arch, Specialty manufactures a clear vacuum-formed retainer that fits over the FLR. Specialty Appliances reports that 25% of its clear retainers are ordered with an integrated FLR.

The best way to prevent orthodontic relapse is to provide backup retainers. The Guardian retention system includes multiple clear retainers and a 3D-printed plastic model. Patients now have backup retainers for when they lose or break the original. This sturdy plastic model can be used for the construction of multiple future retainers. Most orthodontists own the proper equipment for in-office construction of vacuumformed retainers. Patients simply drop off their plastic model when they transition to their backup retainer. Backup retainers do not require a costly appointment for new impressions. The Guardian retention system proactively eliminates a patient’s time without a retainer. Guardian retainers are also very costeffective. The original set, including two retainers and the printed model, is about the same cost as a Hawley retainer. Making future retainers from the plastic model is also a great source of revenue for orthodontic practices. Participating orthodontists will charge as little as $50 for backup Guardian retainers. Patients save money, and orthodontists have healthy profit margins making backup retainers without taking up precious chair time. OP

Clear vacuum-formed retainers can be pre-constructed to fit over a fixed lingual retainer and delivered at the same appointment Volume 7 Number 5

PRACTICE DEVELOPMENT

Is your website really working? Ian McNickle, MBA, discusses how to convert website visitors into new patients

he world of websites and online marketing can be confusing. Dentists and their staff often feel as though their website could be doing more for them, but aren’t quite sure how to determine this or what to do about it. The goal of this article is to help you understand how to get more value and new patients from your website.

The goal of online marketing Online marketing is primarily concerned with the following two objectives: 1. Driving traffic to the website 2. Converting that traffic to take the actions you want them to take Driving traffic to your website is achieved by the use of search engine optimization (SEO), pay-per-click (PPC) paid ads, social media, review sites (Google+, Yelp, Facebook, Healthgrades®, etc.), and other methods. Once people arrive at your website, you’ll want them to take action to contact your office via phone call, email, or filling out an appointment request form. These actions are called “website conversion.” The ultimate marketing goal of the website is to drive new patients to the

Ian McNickle, MBA, is a national speaker, writer, and marketer. He is a co-founder and partner at WEO Media, winner of the 2016 Cellerant “Best of Class” Technology Award for Dental Marketing and Dental Websites. If you have questions about any marketing-related topic, please contact Ian McNickle directly at ian@ weomedia.com, or by calling 888-246-6906. For more information, you can visit www.weodental.com.

60 Orthodontic practice

practice. This is achieved by maximizing both traffic and website conversion. The focus of this article will be on website conversion, and our next article will focus on driving traffic.

Improve your website conversion rate Far too many dental practices use common, templated websites with stock photos and stock content. This does not differentiate you from other practices and does not reflect the unique personality of your practice. In addition, the calls to action are often poorly implemented. Instead, consider implementing the following items to improve your website conversion: • A custom website design should properly reflect your practice. • Phone number should be easy to find at the top of every page in large font. • Appointment request button (or form) should be easy to find on every page and be located further up the page (not at the bottom). • Use actual photos of the practice, staff, and equipment with minimal use of stock photos. • Write unique content that is specific to your treatment philosophy and approach. • Embed an overview video of the practice on the home page to help

communicate who you are/your personality, what is unique about your practice, highlight technology and training, etc.

Track and optimize results over time In order to properly track conversion, we always recommend using a phone call tracking number that routes to your actual office phone. Using a tracking number will allow you to more accurately understand how many calls are coming from your website. We also recommend recording the phone calls for training purposes. Dental practices that want to get the most from their online marketing efforts should make it a regular monthly activity to review website traffic and conversion. Plotting these trends over time will allow practices to understand if their activities to increase traffic are working, if their conversion rate is getting better or worse, and to determine the return on investment (ROI) for this portion of their marketing.

Marketing consultation If you have questions about your website, social media, or online marketing, you may contact WEO Media for a consultation to learn more about the latest industry trends and strategies. The consultation is FREE if you identify yourself as a reader of this publication. OP

Receive your free marketing consultation today: 888-246-6906 or info@weomedia.com Volume 7 Number 5

PRODUCT PROFILE

Inspire ICE™ Clear ceramic brackets by Ormco Corporation

ithin the past several years, the orthodontic industry has witnessed a notable increase in the demand for esthetic, yet effective, treatment options. Extending beyond the teen patient demographic, the numbers indicate that adults undergoing treatment account for 22% of all orthodontic cases — that’s more than one in every five patients. With vast potential to treat adults, doctors have an opportunity to significantly grow their practices by promoting esthetic appliances that appeal to adult consumers. Fixed appliances have long been favored by clinicians focused on treatment excellence and efficiency. Furthermore, advancements in ceramic processing have resulted in more durable brackets that are easy and safe to bond and debond. Ormco has been leading the industry with innovations for over 50 years and pioneered developments in ceramic technologies for decades. The combination of material and processing in Ormco’s Inspire ICE™ brackets provides doctors with bracket strength to meet the treatment flexibility they require, while also offering esthetically conscious patients a discreet option that can eliminate the compromises and compliance that accompany alternative methods. Inspire ICE brackets utilize proprietary heat-treating technology, which produces low-profile, crystal clear brackets that are two times stronger than the competition.1 The strong dependable tie-wings feature ample undercuts for double-tying, and the unique manufacturing process ensures a

The brackets are a patient favorite for their efficient, reliable performance and esthetic look.

smooth surface and rounded facial contours for patient comfort. Similarly, with its small design and translucent appearance, the brackets are a patient favorite for their efficient, reliable performance and esthetic look. Additional features of the Inspire ICE brackets include: • Crystal clear — Unlike many ceramic brackets that are opaque, Inspire ICE brackets are crystal clear and virtually invisible regardless of tooth shade. For patients seeking a true esthetic solution, Inspire ICE is a completely transparent bracket with uncompromising results.

• Easy to bond and debond — Inspire ICE utilizes Ormco’s proprietary ball-base technology, which ensures mechanical retention during bonding and is designed to reduce the force required to debond. The simplified debonding procedure ensures that brackets come off easily and consistently without destroying the bracket. • Maximum tie-wing strength — Ormco’s heat-treatment technology produces brackets that are twice as resistant to breakage as other ceramic appliances.1 In addition, this true twin bracket sports ample area under the tie-wings for easy ligation. • Accurate bracket placement — Inspire ICE’s rhomboid shape, toothspecific pad contours, and unique Face Paint™ system for bracket-totooth contrast provide fast, accurate bracket placement. To learn more about Inspire ICE brackets, visit www.ormco.com/products/inspire-ice, or speak with your Ormco representative. To learn how your patients can benefit from Inspire ICE, or to find your name in the doctor locator, visit www.iceclearbraces.com. OP 1. Johnson G, Walker MP, Kula K. Fracture strength of ceramic bracket tie wings subjected to tension. Angle Orthod. 2005;75(1):95-100.

This information was provided by Ormco.

Inspire ICE patient Volume 7 Number 5

Orthodontic practice 61

BANDING TOGETHER

Brooks’ heroes Editor-in-Chief Mali Schantz-Feld shares an unforgettable act of kindness

n these high-tech times, news travels fast. Social media, television, newspapers, and the Internet bombard us with stories, and we skim and move on. This story, however, touched the hearts of our entire MedMark team — especially since two of the people involved change lives every day as dental specialists. These heroes banded together and performed an unforgettable act of kindness that saved a toddler’s life. The story starts on a beautiful July day on Newport Beach in California. Twin brothers from Mesa, Arizona, Orthodontist Stuart Frost, Endodontist Steve Frost, cousin Jesse Martin, and many other family members were having a reunion vacation. Down the beach, they heard screams for help and saw a mother frantically searching for her 2-year old son, Brooks. Most people didn’t give the Endodontist Steve Frost and Orthodontist Stuart Frost mother’s screams a second look — maybe because it’s easy for a child have to know how to rescue breathe and do to wander off on a packed beach. compressions, but in reality, it is the chest According to one source, at least compressions that saved this little boy’s 10 children were reported missing in life.” Stuart added, “I went to the beach that Newport on that day. The mother said morning to relax and enjoy the day; I never that she had just turned her head for dreamed I would be using my CPR training a minute to apply sunscreen to her to help save a life. After looking back on that other child. The Frost twins’ mother’s experience, I have realized more than ever words echoed in their minds. “Our before that we have to act in crisis situations mother always taught us that when instead of sitting back and letting someone someone is in need, you step up to else help out. Too many times we may be help them,” said Stuart. tempted to let someone else help, and we While the parents were scanning miss an opportunity to serve someone else the ocean water, the three men had in a life-changing way.” another idea. Noticing that some chilNewport Beach Lifeguard Battalion Chief dren had been digging deep holes Brent Jacobsen noted that entrapment under in the sand near where the toddler the sand is a realistic danger. No one should Steve Frost, Brooks, Jesse Martin, and Stuart Frost was sitting, they remembered warnever dig a hole that is deeper than 1 foot, ings from past years about collapsing and climbing into a tunnel dug in the sand is beach sand. They started digging. Then, as mouth and started compressions — putting extremely hazardous since sand can weigh Stuart recalls, “I’ll never forget it as long as I into action the skills they review every 2 years several hundred pounds. live. Jesse said, ‘I found him!’ and he pulled during CPR training. And then, the boy’s lips A couple of days later, the heroes and the him by the hips out of the hole.” The ordeal started to quiver, he started breathing, and family met on the beach. What do you say was not yet over. After lying face down under screaming for his mother. “It was truly the to people who saved your child’s life? Stuart the sand for about 5 minutes, the boy had most miraculous thing I ever experienced in summed up the reunion: “There were tears sand in his mouth and was not breathing. my life,” said Stuart. Brooks was transported of joy, hugging each other, crying together. Stuart continued, ““He was ash gray; he was to the hospital and made a full recovery. Wow, talk about a happy ending; it was just “After spending 22 years in endodontics dead. So we pulled him out, and the mom spectacular.” OP and recertifying my CPR every other year, I was just beside herself.” felt like instinct took over, and I knew what Before paramedics arrived, the two This article was compiled from news articles, news videos, to do,” said Steve. Many of us think that we dentists cleared the sand from Brooks’ and interviews with the dentists. 62 Orthodontic practice

Volume 7 Number 5

5-year warranty now included on all 3Shape lab scanner purchases The 5-year warranty applies to all purchases of 3Shape lab scanners made after June 6, 2016, which include either Dental System™ Premium or Ortho System™ Premium software. If a problem arises, 3Shape users can simply send the lab scanner to any of the six local repair centers in the Americas, Asia, and Europe for a free repair during the 5-year after-purchase period. The 5-year warranty is an addition to the services already provided by the 3Shape LABcare™ customer program. LABcare members also receive special discounts on scanner trade-in programs and select deals on new scanner and software purchases. To learn more about the 3Shape dental lab scanners, visit www.3shape.com/new+products/dental+labs/lab+scanners.

The recent suresmile® 7.3 release features an improved MACROS user interface that is easier to follow and more efficient, with less navigation and fewer clicks required. Other enhancements include: • The addition of Bracket Placement orientation lines added to IDB straight wire simulation. Now vertical and horizontal lines are placed on each tooth to help users visualize bracket placement. The intersection of the lines is set to the FA (Facial Axis) point. • Occlusal rests for non-bonded teeth added to IDB tray design. Fit and stiffness of the trays are improved. • New bracket height set placement measurement options. Two viewing options have been added for adjusting IDB bracket heights: by the actual bracket height (mm) or to the FA point (mm). • Email notification and preference for shipments. Shipping notification by email is now available when wires, IDB trays, or printed models are shipped; shipping preferences can also be indicated. For more information, contact suresmile at 877-787-7645 or 972-728-5500, or visit suresmile.com.

Registration is now open for The Forum 2017 Ormco has announced that registration is now open for The Forum 2017, the largest privately sponsored orthodontic event in North America. Now in its 16th year, the annual conference will take place February 22-25, 2017, at the combined properties of JW Marriot and Ritz-Carlton Orlando, Grande Lakes in Orlando, Florida. The conference will feature impactful clinical presentations, interactive discussions, round table lunches, clinical mentoring sessions, practice management sessions, and abundant networking opportunities. Practices can register for The Forum 2017 by visiting forum. ormco.com.

Volume 7 Number 5

Great Lakes Orthodontics named 2016 Silver ESOP Award Winner Great Lakes Orthodontics, Ltd., was recently named a 2016 Silver ESOP Award Winner by The ESOP Association (employee stock ownership plans). The Silver ESOP Awards recognize companies for their work in sustaining their ESOP and Association memberships for 25 years or more. The ESOP Association is the leading voice in America for employee ownership. Based in Tonawanda, New York, Great Lakes Orthodontics is an employee-owned company specializing in 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.

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INDUSTRY NEWS

New suresmile® 7.3 release simplifies workflow, increases efficiency

INDUSTRY NEWS i-CAT™ introduces i-CAT FLX V-Series, the first line of upgradable dedicated 3D CBCT machines with the full award-winning i-CAT FLX technology i-CAT™, a brand of the KaVo Kerr Group, launched the i-CAT FLX V-Series, the industry’s first fully upgradable solution. This dynamic system offers three fields of view (FOV), enhanced lowdose and ultra-low dose 3D imaging, and dedicated 2D traditional panoramic capabilities at a price point starting at under $90,000. The i-CAT FLX V-Series enables clinicians to support current or incorporate new treatment offerings, such as airway analysis, with an imaging solution that can grow as their practice evolves. i-CAT FLX V-Series provides the option of upgrading the field-ofview based on the types of procedures performed today and in the future, such as i-CAT FLX V8 – 8x8, 2D Pan; i-CAT FLX V10 – 10x16, 2D Pan; and i-CAT FLX V17 – 17x23, 2D Pan. Enhanced low-dose and ultra-low dose scanning, which is easily achieved using i-CAT QuickScan and QuickScan+ protocols, allows practitioners to take complete 3D images at a radiation dose comparable to a 2D panoramic image. The i-PAN™ feature allows technicians to take a quick 2D pan using the same high-quality sensor that is used to acquire 3D scans. For more information, visit http://info.i-cat.com/flxvseries_vbpr.

OrthoAccel receives program approval for continuing education (PACE) by Academy of General Dentistry OrthoAccel® Technologies, Inc., announced it has received a Program Approval for Continuing Education (PACE) designation by the Academy of General Dentistry (AGD). According to the AGD, PACE was established to create, improve, and promote quality dental continuing education (CE) and to assist professionals with identifying appropriate CE opportunities. As an approved PACE provider, OrthoAccel has demonstrated its commitment to creating and delivering continuing education programs that support the rigorous standards established by PACE. These standards ensure that premier educational organizations from across the world follow generally accepted best practices in offering CE programs. OrthoAccel will now provide CE hours directly to orthodontists, staff members, and other professionals who attend OrthoAccel educational programs, including webinars, live-instructional events, case study presentations, online independent study courses, and other learning opportunities. Presenters will also receive CE hours for delivering these types of educational programming through OrthoAccel’s PACE providership. For information about OrthoAccel’s continuing education opportunities, visit acceledent.com/orthodontists.

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Tess Oral Health helps dentists give back while buying back this Halloween Once again, Tess Oral Health is proud to sponsor the Halloween Candy Buyback program in which thousands of dentists across the nation buy back excess Halloween candy, then donate the candy to U.S. troops via Operation Gratitude. Tess Oral Health is supporting the program by not only making a monetary donation, but also sending one toothbrush to U.S. troops for every box of toothbrushes sold. For more information call 715-832-7271 or 800-762-1765, or visit www.tessoralhealth.com.

3Shape co-founder and CTO, Tais Clausen, named one of the 10 most influential people in dental technology As 3Shape CTO, Clausen plays an essential role in developing the company’s groundbreaking scanning technology and software applications. He is a driving force, serving as both its strategic product development-leader as well as a hands-on engineer. Recent disruptive 3Shape product launches such as the D2000 lab scanner, which scans two dental models simultaneously, and the TRIOS intraoral scanner are considered category leaders by the dental industry. The D2000 lab scanner recently won a Red Dot Design Award. The TRIOS named the industry’s number one intraoral scanner by the Cellerant “Best of Class” Technology Awards. Clausen and his partner, 3Shape co-founder, Nikolaj Deichmann, started the company more than 15 years ago. The two have since grown 3Shape to more than 750 employees, including 275 plus on-staff developers. For more information, visit http://www.3shape.com

Danaher Corporation awards scholarships to children of dental platform associates The 2016 Danaher Scholarship Program was honored to present a total of $225,000 to students this year. Nearly 400 students applied to the program this year. Of the 36 universitybound women and men selected — chosen based on a combination of academic achievement, extracurricular activity involvement, and moral character — three are children of Danaher dental platform associates. Administered by Scholarship Management Services on behalf of Danaher, each student will receive between $5,000 and $8,000 to put toward tuition. Since its inception more than a decade ago, the Danaher Scholarship Program has awarded more than $2 million in scholarship dollars to deserving students. Visit www.kavokerrgroup.com for more information.

Volume 7 Number 5

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