Orthodontic Practice US November-December 2016, Vol 7 No 6 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews

Dr. Thomas Wilson

Maintaining clearly defined treatment objectives: part 2 Drs. Domingo Martin and Jorge Ayala

Corporate profile OrthoAccel®

Reframing orthodontics: part 3 Dr. Rohit C.L. Sachdeva

Practice profile Dr. Cooper Callaway

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Drs. John R. “Bob” Smith and Mario Paz

Treating cleft palate with presurgical nasoalveolar molding (PNAM)

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INTRODUCTION

Considering a dual pediatricorthodontic practice?

November/December 2016 - Volume 7 Number 6 EDITORIAL ADVISORS Lisa Alvetro, DDS, MSD Daniel Bills, DMD, MS Robert E. Binder, DMD

s a dual-trained pediatric dentist and orthodontist, it was always my goal to “quarterback” a team of pediatric dentists and orthodontists under one roof. I now operate two such practices, which has become a distinct trend over the last several years. For tenured orthodontists, it seems an effective means of practice growth; and for newly graduated orthodontists with appreciable debt, it is a way to jump-start their careers without more debt; and for the “retiring” orthodontist, it is a means to practice without an owner’s responsibility. Now with an orthodontic partner and three associate pediatric dentists practicing in two towns, my personal goals have been Mike Mayhew, DDS, MS achieved. Coordinating our shared patients and responsibilities of care, however, is an ongoing endeavor. If you are an orthodontist considering the idea of a dual-specialty practice, I offer a few thoughts. First to consider is the difference in patient cultures. Young patients are often apprehensive about going to the dentist and are intensely vocal about their fears. They’re also understandably more dependent on their parents, who also, understandably, are often anxious and inclined to attend to their fretful child chairside. The open-bay concept in orthodontic offices may not lend itself to these circumstances. To any practitioner considering a dual-specialty practice, I suggest physical separation of the two sides of the practice. Another big question is whether other GPs/pedodontists will refer to you lest they lose a patient to your pedodontist. I have very carefully nurtured relationships with our referring general dental and pedodontic practices to be certain they trust our commitment to them. We pledge always to send referred patients back to their general dentist/pedodontist for routine care. We even include a reward for patients who have their teeth cleaned with them. To ensure the dentist/pedodontist is aware of our efforts, we have the dentist return a signed card to us for verification. If you’re considering forming a dual-specialty practice, there’s no better way to explore issues you’ll likely encounter than through connecting with fellow professionals at meetings — regional society meetings, study club groups, and seminars offered by companies such as Ormco. I have enjoyed networking and sharing my knowledge with as well as learning from colleagues at these conferences, including The Ormco Forum. The social and engaging atmosphere at these conferences makes them a perfect place to chat face-to-face with people who’ve already been down this road and can help guide your way. My own journey to a dual-specialty practice took a circuitous route. As a new pediatric dentist having just graduated from UNC-Chapel Hill, I took over the practice of a pediatric dentist who was leaving for an orthodontic residency, planning later for us to work together under one roof. That dream vanished when the new orthodontist decided not to return. It took several years to finalize my decision, hire another pediatric dentist to maintain the practice, then pursue my own dual training and build that practice dream myself. I’m now pleased to have combined the two specialties that share young dental patients in providing comprehensive care. Dr. Mike Mayhew

S. Jay Bowman, DMD, MSD Stanley Braun, DDS, MME, FACD Gary P. Brigham, DDS, MSD George J. Cisneros, DMD, MMSc Jason B. Cope, DDS, PhD Neil Counihan, BDS, CERT Orth Bradford N. Edgren, DDS, MS, FACD 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

Mike Mayhew, DDS, MS, received his dental education at the University of North Carolina with specialty degrees in pediatric dentistry and orthodontics. He is board certified in both specialties and operates a dual-specialty practice in Boone and North Wilkesboro, North Carolina. Dr. Mayhew has lectured nationally and internationally on the Damon™ System, CAD-CAM digital orthodontics, indirect bonding, and office utilization of CBCT. He is on the Sports Medicine Team at Appalachian State University, is an adjunctive clinical professor at the UNC School of Dentistry, has held leadership positions in organized dentistry, and serves as the director of the North Carolina/South Carolina Damon Study Club. He was inducted into the American College of Dentists in 2010 and the International College of Dentists in 2013.

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 6

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TABLE OF CONTENTS

Financial focus Are high 401(k) fees putting your retirement at risk? Tom Zgainer discusses how hidden fees can drain money from your account...........................................18

Case study Maintaining clearly defined treatment objectives: part 2

Practice profile Cooper Callaway, DMD, MS

Striving to be successful and significant

Drs. Domingo Martin and Jorge Ayala illustrate treatment using the FACE concept of orthodontic treatment ........................................................20

Orthodontic insights A Herbst® journey Dr. Bill Dischinger discusses how his personal Herbst experience led to development of a comfortable and efficient appliance............................26

Orthodontic concepts Reframing orthodontics: Designing accelerated orthodontics by managing error — the BioDigital way: part 3 Dr. Rohit C.L. Sachdeva discusses the journey of error management in clinical practice................................ 30

Corporate profile OrthoAccel

Innovating accelerated orthodontic treatment and practice integration

4 Orthodontic practice

14 ON THE COVER Inset photo on cover courtesy of Drs. Domingo Martin and Jorge Ayala. Article begins on page 20.

Volume 7 Number 6

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TABLE OF CONTENTS

Continuing education Using lingual appliances for optimal esthetics and minimal compliance issues

Drs. John R. “Bob” Smith and Mario Paz discuss the development and use of a square-slot, passive self-ligating, straight-wire lingual appliance

Practice management Continuing education Treating cleft palate with presurgical nasoalveolar molding (PNAM) Dr. Thomas Wilson discusses an effective technique that can minimize the extent of surgery to repair cleft palate in newborns..........................42

Designing a dynamic digital team: part 1 Dr. William E. Crutchfield discusses how to design a dynamic digital orthodontic team that is primed for success......................................50

GENERAL MANAGER | Alan Lobock Email: alobock@medmarkaz.com

Product profile

ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkaz.com

Air-Free 90º by Medidenta .......................................................52

Laboratory link 3D printing in orthodontics James Bonham and Arlen Hurt review innovations in 3D-printing technologies ....................................................... 46

Practice development

Product profile Prophy Magic .......................................................54

Book review

What you need to know about online reviews for your practice

Global Diagnosis: A New Vision of Dental Diagnosis and Treatment Planning

Ian McNickle, MBA, discusses the importance of a strong online presence.........................................49

J. William Robbins, DDS, MA, and Jeffrey S. Rouse, DDS ...................................................... 56

6 Orthodontic practice

PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com

EDITOR IN CHIEF | Mali Schantz-Feld, MA Email: mali@medmarkaz.com | Tel: (727) 515-5118 MANAGING EDITOR | Lou Shuman, DMD, CAGS Email: lou@medmarkaz.com

MANAGER – CLIENT SERVICES | Adrienne Good Email: agood@medmarkaz.com CREATIVE DIRECTOR/PROD. MGR. | Amanda Culver Email: amanda@medmarkaz.com WEBSITE MANAGER | Anne Watson-Barber Email: anne@medmarkaz.com E-MEDIA PROJECT COORDINATOR | Michelle Kang Email: michellekang@medmarkaz.com FRONT OFFICE MANAGER | Theresa Jones Email: tjones@medmarkaz.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 www.orthopracticeus.com | www.medmarkaz.com SUBSCRIPTION RATES 1 year (6 issues) 3 years (18 issues)

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PRACTICE PROFILE

Cooper Callaway, DMD, MS Striving to be successful and significant What can you tell us about your background? I have great parents who encouraged my sister and me to be independent thinkers. We both played lots of sports and always seemed to have a job of some sort. She ran track at Millsaps College, and I played tennis at Mississippi State University. She became an artist in New York City, and I chose the dental track. I went to University of Mississippi School of Dentistry and was fortunate enough to go to Baylor College of Dentistry for Orthodontics. I met some amazing people during my time there and attribute whatever success I might have had to the “little things” I picked up.

Why did you decide to focus on orthodontics? In 7th grade, I told my history teacher I wanted to be an orthodontist, and I guess it just stuck. I think I wanted that career because our orthodontist drove a Porsche, and that seemed really cool at the time. Once I was in college, I was playing tennis and having fun and didn’t want to major in one of the “sciences,” so I majored in economics. Once I really got serious about what I wanted to do, it all came down to making a difference. I just couldn’t figure out how there was any way to make as big a difference as improving someone’s self-esteem.

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

Dr. Callaway with a patient

I started three offices from scratch in 2000. I still have the same three offices and have tried virtually every technology that has been introduced to orthodontists since then. However, since the practice has grown, I have had to employ the KISS philosophy more than when I was just starting out. I still employ TADs, Herbst, Carriere®, Forsus™, and surgery to correct Class II’s, so I haven’t become pigeonholed just yet. I did ditch the reverse pull headgear the same year I graduated though. My master’s thesis was on treatment time, treatment quality, and treatment efficiency. So I jumped feet first into self-ligating brackets and used everything that was available. We track our results

monthly for debonds, and on a whim, I decided to try traditional brackets 4 years ago. After seeing the results, I dumped the self-ligating brackets and am all traditional brackets now. My good friend and mentor Dr. Rohit Sachdeva told me years ago that the secret to excellence in orthodontic care lies in developing the right “flight plan.” His words ring true this day and define my approach to patient care.

anything involving i-CAT™ 3D imaging. I was a very early adopter of suresmile® and loved listening to Dr. Sachdeva’s webinars and truly began understanding his concept of developing “empathetic ear-sight” in addressing a patient’s care needs. I was also fortunate enough to go to Wonewok, Minnesota, years ago for a 3M Incognito™ meeting and was very impressed at the results that some of the leading adopters were achieving.

What training have you undertaken?

Who has inspired you?

I try to stay on top of anything new that comes out and usually that involves travel, which I truly enjoy. My favorite courses have been Dr. Jason Cope’s TADs courses and

I guess you could say I have always been very self-motivated and believe inspiration comes from within. However, there have always been people and events along the

8 Orthodontic practice

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PRACTICE PROFILE

way to nudge me along. My favorite quote concerning orthodontics and life and one I live by every day came at my first Baylor alumni event from the founder of the department, Dr. Bob Gaylord. He put his arm around me and said, “Son, I like you; you’re going to do just fine. Always remember, if you treat people right and do a good job, you will always be successful.” And he is entirely correct. I treat every patient as if he/she is one of my own children, and that makes life very easy.

What is the most satisfying aspect of your practice? Well, that is an easy one. Making people smile! The genuine love we receive from patients when their self-esteem is improved because they like the way they look is the reason I continue to do what I do and will have a hard time ever retiring. I believe it was David Phelps who said there is a difference between being successful and being significant. I feel I am a very successful orthodontist, but I enjoy the significance of helping people much more than the monetary reward.

Dr. Callaway with his team

Professionally, what are you most proud of? I’m sure like most orthodontists, my pride comes from changing people’s perceptions about themselves. Sure, as a team we give back a lot to the community from charity walks to donations, to free braces, but at the end of the day, making people feel better about themselves is what it really is all about.

What do you think is unique about your practice? The most unique thing is that we live in rural Mississippi, but our practice employs the best technology available. We have two iTero® scanners and an i-CAT. The Air Force has a training base located in Columbus, Mississippi, and we are always hearing from patients that they never imagined we would be so “high tech.” I guess that just shows you can’t judge a book by its cover!

What has been your biggest challenge? I’m sure I am like a lot of your readers in that managing growth can be a challenge albeit a nice one. As we have continued to grow, scheduling has probably been our biggest challenge since we want each patient to feel as if he/she is the only person in the room at each visit. It seems like once things are nice and smooth, I feel the need Volume 7 Number 6

Dr. Callaway showing patient a 3D image Orthodontic practice 9

PRACTICE PROFILE to tweak our processes to see if we can make our treatment even smoother for our patients. Of course, you could easily say I’ve been my own biggest challenge.

What would you have become if you had not become a dentist? Between my 1st and 2nd year of dental school, I was thinking about changing my course and was working in Washington, DC. I had an informal interview, scheduled at

Shinnecock Hills over a round of golf, with a Wall Street stockbroker. It rained us out, and I didn’t ever look back. So I guess you could say I would be a stockbroker or a farmer, beekeeper, or hunting guide, which is what I truly enjoy doing now.

What is the future of orthodontics and dentistry? I think the future is already here. My thoughts complement those of Dr. Sachdeva, which he discussed in his article, “Reframing Orthodontics 3.0,” published in Orthodontic Practice US July/August 2016 issue. Corporate dentistry, PPOs, advanced technology, dental tourism — it is all changing very rapidly. If you look at the medical model, you have to think expanded duties will come about at some point in time. The insurance companies will look at any way to lower the cost of treatment, and they could justify paying an assistant or hygienist less for a procedure than an orthodontist. I know people don’t want to hear this, but I think that in the future, patients will have the ability to scan their teeth from home or a “scan center” and have aligners shipped to them without ever physically consulting an orthodontist.

What are your top tips for maintaining a successful practice? The famed investor Jim Rogers said the best investment to make is in yourself. That is the philosophy of my team and our office. We try to do fun stuff as a team, and the team also gets together without me. Just this month, they all had a “Day at the Spa,” and we are going skeet shooting this Friday. Also, I believe that consistently tracking results and patient satisfaction is key. That which gets measured gets improved.

What advice would you give for a budding orthodontist? Realize early that you need to be a clinician, manager, and visionary. Figure out what you are good at, and hire someone else to help you with your weaknesses. Dentists have a hard time “letting go” and realizing they cannot do it all. I’m definitely guilty of this. Try your best to avoid the dental handcuffs. From the very beginning, plot out what you want out of life and work to achieve that goal. Otherwise, you might realize 10 years later that although you might have accomplished a lot and have a successful practice, you might not feel happy and fulfilled.

Dr. Callaway with his wife and three children 10 Orthodontic practice

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PRACTICE PROFILE What are your hobbies, and what do you do in your spare time? Well, prior to marriage and children, I loved to travel, play golf and tennis, spear fish, and basically hunt anything that moved, especially bow hunting for elk. A wonderful wife and three children (3, 6, and 7) later, I’m more into spending my free time with them. We have started an apiary with some family friends, called Hardway Honey. The name came about because we don’t do anything the easy way. Both families help out with all aspects of raising and tending to the bees. It’s great for the children to learn about and, of course, they keep all the profits — they call it “honey money.” We live in the country, so whether it’s working in my wife’s garden, tending to her chickens, or hunting and fishing together, we spend as much time as possible with the children. Last year was the first time we have really been able to travel with all three children, and they love snow skiing, so hopefully we can travel more in the future. OP

Top 10 favorites

Top: Dr. Callaway and his kids enjoying a typical summer afternoon after work. Lower left: Dr. Callaway and his wife, Emily Anne. Lower right: Country living with the Callaways — Campbell (7), Swayze (6), and Sawyer (3)

1. Finishing early on a good brusher! 2. i-CAT™ 3D imaging — you don’t know what you don’t know until you know what you don’t know. 3. Itero® Element™ — the ladies in the office love it. 4. Not starting work until 10 a.m. on Mondays. That way when a true Monday comes, it is 25% less painful. 5. Dr. David Phelps and the Freedom Founders — this helped me to achieve freedom to do what I love. 6. Operating a bulldozer, excavator, or a tractor. Nothing says instant gratification like a big boy toy. 7. Beekeeping — nothing slows you down like 60,000 bees in a hive. Come join us anytime you want to try it out. 8. Smoking ribs or brisket. 9. BroadRiver Dental Technology Solutions for IT — keeps me up and running. 10. Of course, my favorite thing is anytime I can spend time with my family. There is nothing more special than the pure joy and laughter of a child.

The Hardway Honey crew 12 Orthodontic practice

Volume 7 Number 6

SMPP587Rev062116

CORPORATE PROFILE

OrthoAccel® Innovating accelerated orthodontic treatment and practice integration

or the past 4 years, OrthoAccel® Technologies, Inc., has been advancing the field of orthodontics by showing orthodontic practices across North America how integrating AcceleDent® into their offices enhances the treatment experience for patients, boosts practice economics, improves predictability of clinical outcomes, and promotes high-quality clinical results. Created and manufactured by OrthoAccel, AcceleDent is the first and only FDA-cleared vibratory orthodontic device that is clinically proven to speed up treatment by as much as 50%. AcceleDent is also clinically proven to relieve discomfort associated with orthodontic treatment. With a strong portfolio of published clinical evidence and a substantial library of successful cases from top clinicians, OrthoAccel has established itself as the leader in accelerated orthodontics. Substantiating OrthoAccel’s leadership position, a Journal of Clinical Orthodontics survey reports that AcceleDent is the most common accelerated treatment technique used by orthodontists.1 Today, AcceleDent is available in more than 3,300 orthodontic locations in North America. OrthoAccel’s innovative culture extends beyond the development and manufacturing of revolutionary medical devices. The company also distinguishes itself through the innovative way it collaborates with orthodontists for shared success. A prime illustration is OrthoAccel’s first-of-itskind, exclusive practice integration program called AcceleDent® NOW™, which provides unprecedented support to orthodontists who want to make accelerated technology an integral part of their practice. OrthoAccel also provides a multitude of high-quality continuing education events for clinicians and staff. Marketing initiatives also include dynamic public relations and social media programs that encourage orthodontists and patients to tell their AcceleDent success stories.

FDA-Cleared Vibratory Orthodontic Device

Proven technology backed by strong clinical evidence OrthoAccel’s president and CEO, Michael K. Lowe, says that science is at the center of AcceleDent’s success. “I’m proud of the strong body of clinical evidence that OrthoAccel has contributed to the field of accelerated orthodontics. We know that orthodontists want and need scientifically sound research and clinical results to be confident that they are providing their patients with safe and effective treatment solutions.” OrthoAccel’s peer-reviewed, published data includes articles proving that

OrthoAccel’s first-of-its-kind practice integration program is called AcceleDent NOW 14 Orthodontic practice

AcceleDent’s patented SoftPulse Technology® delivers micropulses that move teeth faster and more comfortably by accelerating the bone remodeling process. Results of a groundbreaking randomized controlled trial (RCT) recently published in Seminars in Orthodontics showed that AcceleDent’s pulsatile forces significantly accelerate orthodontic tooth movement. This prospective, double-blind, randomized, sham-controlled trial was conducted at the University of Texas Health Science Center at San Antonio and assessed 45 orthodontic patients who were randomized into two groups — the AcceleDent group and a control group. Patients in the AcceleDent group were instructed to use the device for 20 minutes daily. AcceleDent’s SoftPulse Technology delivered the safe and gentle vibrations needed to stimulate tooth movement. The results indicated that the rate of Volume 7 Number 6

“I’m proud of the strong body of clinical evidence that OrthoAccel has contributed to the field of accelerated orthodontics.”

OrthoAccel’s leadership team Volume 7 Number 6

Orthodontic practice 15

CORPORATE PROFILE

OrthoAccel’s president and CEO, Michael K. Lowe

movement was significantly higher for the AcceleDent group versus the control group.2 Dr. Dubravko Pavlin, a professor of orthodontics in the School of Dentistry at University of Texas Health Science Center, authored this study and says that the published data represents an important advancement in orthodontic treatment. “This RCT studied the safety and effectiveness of using pulsatile forces to accelerate orthodontic tooth movement and provided the evidence that adjunct treatment with AcceleDent results in faster tooth movement without compromising patient’s safety.” As the AcceleDent user community has grown, patients have been reporting that the device reduces the discomfort of their orthodontics. Results from a prospective, RCT published in another peer-reviewed article in Angle Orthodontist demonstrated that micropulse vibration, as used in AcceleDent, significantly reduces pain associated with orthodontic treatment. This trial involved 58 orthodontic patients divided into an AcceleDent group and a control group. Both groups were directed not to take any pain medication or use topical ointments. The AcceleDent group used the device for 20 minutes daily and reported that they were

CORPORATE PROFILE in less pain throughout treatment than the patients who were in the control group. At a 0.05 significance level, clear differences in overall pain (P = 0.002) and biting pain (P = 0.003) for the AcceleDent group verses the control group were detected.3 These two peer-reviewed studies published in highly respected orthodontic journals show that AcceleDent is the fast, safe, and gentle solution that resolves two of the most common concerns with orthodontic treatment — length of treatment and discomfort. They also substantiate the clinical findings reported by several of the world’s leading orthodontists, including Drs. Kenji Ojima and S. Jay Bowman. Having treated thousands of aligner cases with AcceleDent, Ojima published results of a complex orthodontic case he treated using AcceleDent in the Journal of Clinical Orthodontics.4 The 26-year-old female patient who was diagnosed as a skeletal Class II with infralabioversion of the maxillary canines and a steep mandibular plane angle used AcceleDent to change aligners every 5 days and completed treatment in 18 months. Dr. Ojima projected that standard treatment for this patient, who had all four third molars removed prior to aligner treatment, would have been 30 months. Dr. Bowman published a peer-reviewed article of a clinical study that evaluated the effects of vibration with AcceleDent on the speed of orthodontic leveling and alignment. This clinical study included 117 consecutively treated Class II non-extraction patients who underwent maxillary molar distalization and concurrent mandibular leveling and alignment. The patients were divided into three groups — the AcceleDent group, the control group, and the pre-AcceleDent group. The results, which were published in the Journal of Clinical Orthodontics, showed that the amount of time required to achieve dental alignment and leveling in Class II non-extraction treatment was reduced by using AcceleDent. The average time to leveling in the AcceleDent group was 48 days less than the control group and 55 days less than the preAcceleDent group. Dr. Bowman concluded that AcceleDent yields a clinically beneficial and statistically significant increase in the rate of tooth movement during orthodontic leveling of the mandibular dentition.5 “The significant results from these welldesigned clinical trials add to the mounting evidence that supports the clinical efficacy of AcceleDent from the scientific and academic communities,” said Dr. Dawei Liu, who is the program director in the Department 16 Orthodontic practice

OrthoAccel’s proprietary AcceleDent technology is the result of applying proven scientific principles and coupling those with a patient-friendly design.

of Developmental Sciences/Orthodontics at Marquette University. Dr. Liu’s research focuses on shortening orthodontic treatment and reducing the risk of root resorption.

Increasing case acceptance and improving predictability of clinical outcomes OrthoAccel’s proprietary AcceleDent technology is the result of applying proven scientific principles and coupling those with a patient-friendly design. In creating a breakthrough product, the company holds 13 patents that protect key design elements and ranges of parameters for AcceleDent. Twelve of the patents were granted by the United States Patent and Trademark Office, and one is held with the State Intellectual Patent Office of the People’s Republic of China. In addition to proven treatment acceleration and reduction in discomfort, another AcceleDent benefit has emerged. Orthodontists report more predictable outcomes when using AcceleDent with either braces or aligners. They report that the tooth movement tracks more precisely with the addition of AcceleDent. A case in point is Dr. Manal Ibrahim of Innovative Orthodontic Centers in Naperville, Illinois. Dr. Ibrahim has been treating patients with AcceleDent for 3 years and says that she will not treat patients without it because of the additional control that the device provides her during the course of treatment. “AcceleDent practically guarantees that all of the control I want and need to achieve the treatment outcomes that I promise patients will actually happen,” said Dr. Ibrahim, a Diplomate of the American Board of Orthodontics and an Invisalign® “Top1%” provider. “AcceleDent works at the cellular level to ensure that the programmed movements in my aligners or my custom suresmile® wires will be expressed more predictably.” An early adopter of technology that enhances the orthodontic treatment experience, Dr. Edward Lin also reports improved clinical outcomes with AcceleDent and aligner wear. Dr. Lin practices at Orthodontic Specialists in Green Bay, Wisconsin, and at Apple Creek Orthodontics in Appleton,

Wisconsin. “In addition to acceleration, AcceleDent is my preferred accelerated treatment modality because of the reduction in patient discomfort, and because it enhances the predictability and precision of my treatment protocol,” he said. Since the technology offered exactly what orthodontists and patients want — accelerated treatment, reduced discomfort and predictable outcomes — OrthoAccel began focusing its corporate efforts on helping practices efficiently integrate AcceleDent into their treatment plans and practice management systems while also ensuring that more patients had the opportunity to experience faster and more comfortable orthodontic treatment. This integration philosophy led to the development of AcceleDent NOW, an exclusive program that enables orthodontists to offer patients a no-risk, 60-day trial of AcceleDent. Orthodontists who are a part of the program report that AcceleDent NOW makes it easier for them to offer all patients the fast and comfortable orthodontic experience they want and deserve. According to customer feedback, 100% of patients in the AcceleDent NOW program are completely satisfied with their accelerated treatment, and 96% of these patients report that it significantly reduced discomfort from their treatment. Drs. Richard Boyd, Fred Garrett, Mart McClellan, and Bart Soper are just some of the highly respected orthodontists who are AcceleDent NOW providers. They report that the program has become a practice differentiator for them by increasing case acceptance rates, elevating patient satisfaction, and enhancing practice management. “The AcceleDent NOW program has been a great differentiator for our practice in the competitive Seattle market,” said Dr. Soper. “We offer AcceleDent to every patient and have achieved a nearly 90% acceptance rate, which significantly improves our practice economics.” Benefits of the AcceleDent NOW program also include preferential pricing to providers with no financial risk to their patients, premier positioning on AcceleDent’s doctor locator, a dedicated practice integration consultant, and marketing materials. Volume 7 Number 6

Additionally, through the online AcceleDent NOW program management system, orthodontists, and staff are able to easily monitor patient’s progress throughout the 60-day trial and collect important patient feedback and demographic information.

Fastest growing company Strategic practice integration initiatives such as AcceleDent NOW have driven OrthoAccel’s growth by increasing the number of orthodontic practice locations that offer AcceleDent and by increasing patient acceptance. Ranked one of the nation’s fastest growing technology companies on the Deloitte 2015 Technology Fast 500™, privately held OrthoAccel is focused on capturing even more of the global market share in accelerated orthodontics. Fueling this growth are OrthoAccel’s institutional equity investors, S3 Ventures, HealthpointCapital, and Piper Jaffray Merchant Banking. The goal now is to further advance the orthodontic industry by increasing

awareness among professionals and consumers of AcceleDent’s proven benefits. Having secured a Program Approval for Continuing Education (PACE) designation by the Academy of General Dentistry, OrthoAccel is enhancing its clinical education program to advance the knowledge and skill set of orthodontists so that they can continue providing the highest quality of service to the public and the profession. With the PACE certification, 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. The American Association of Orthodontists is reporting an all-time high of orthodontic patients, and OrthoAccel has been

REFERENCES 1. Keim RG, Gottlieb EL, Vogels DS 3rd, Vogels PB. 2014 JCO study of orthodontic diagnosis and treatment procedures, Part 1: results and trends. J Clin Orthod. 2014 Oct;48(10):607-630. 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. 2016 Jul;86(4):625-630. doi: 10.2319/072115-492.1. Epub 2015 Oct 23.

Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 9/1/2016 to 8/31/2018. Provider ID# 371902

4. Ojima K, Dan C, Nishiyama R, Ohtsuka S, Schupp W. Accelerated Extraction Treatment with Invisalign. J Clin Orthod. 2014 Aug;48(8):487-499. 5. Bowman SJ. The effect of vibration on the rate of leveling and alignment. J Clin Orthod. 2014 Nov; 48(11): 678-688.

This information was provided by OrthoAccel®.

Volume 7 Number 6

Orthodontic practice 17

CORPORATE PROFILE

OrthoAccel is ranked as one of the nation’s fastest growing technology companies on the Deloitte 2015 Technology Fast 500™

capitalizing on this industry metric through creative social media and public relations campaigns. These initiatives leverage highly satisfied patient testimonials, yielding a 30% increase in Facebook Fans annually and more than $13 million in earned media value in top media markets across the country. “AcceleDent is an adjunct to orthodontic treatment, so it’s important that we provide a true continuum of learning through a diversified clinical education program, while at the same time raising awareness among consumers so that they ask their orthodontist about accelerated treatment with AcceleDent,” said Lowe. “OrthoAccel is the leader of accelerated orthodontics, and the goal of our professional and consumer marketing efforts is to position AcceleDent as the standard of care.” With health clearances in 33 countries, similar marketing initiatives are also being implemented to support OrthoAccel’s global expansion. A dedicated Europe, Middle East, and Africa (EMEA) sales team headquartered in Essen, Germany, has established market leadership in Europe as several key opinion leaders in the United Kingdom and Italy tout AcceleDent’s safety and effectiveness. “The rapid market adoption, high-quality clinical outcomes, and high patient satisfaction scores that we’re seeing domestically and internationally show me that OrthoAccel’s future is bright,” said Lowe. Lowe added that the company’s growth is a testament to the dedicated and hardworking employees who are passionate about maintaining OrthoAccel’s market leadership. “We’ve proven that AcceleDent is the fast, safe, and gentle way to accelerate tooth movement effectively, so now we want every orthodontist and every patient to experience the benefits,” said Lowe. OP

FINANCIAL FOCUS

Are high 401(k) fees putting your retirement at risk? Tom Zgainer discusses how hidden fees can drain money from your account

f you contribute to a 401(k) plan, you’re one of more than 88 million Americans who invest in workplace retirement savings programs — many of whom will rely on the savings from those plans to support them financially in retirement.

In 2015, the Obama administration announced that hidden fees in retirement plans were costing Americans $17 billion per year. HBO’s John Oliver sounded the alarm in a great segment on “Last Week Tonight.”

So what? According to research from the nonprofit National Association of Retirement Plan Participants, approximately 60% of people don’t know they’re paying any fees at all in their 401(k) plan. But they’re wrong! We all pay fees, and over time, those fees can eat away at investments, leaving plan participants with far less money to live on in retirement than if there really were no fees involved. Low-cost index funds like Vanguard charge between 0.10% and 0.20% in fees. Vanguard’s fees are 0.13% on average, according to their website. That works out to $13 for every $10,000 you invest. But the dominant providers in the retirement plan space, including many brandname insurance and payroll companies, often charge 7 to 10 times as much for the same or comparable investments. The difference goes into their pockets — and they get away with it because most of us never bother to do this math. Compounded over many years of investing, a fee that looks small — for example, 2% of investments — can reduce your total potential nest egg by as much as two-thirds. If two people have the same 7% return over time but one pays 1% in fees while the other pays 2%, the latter will run out of money 10 years earlier.

Tom Zgainer is CEO and founder of America’s Best 401(k) 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.

18 Orthodontic practice

Last year, the Obama administration announced that hidden fees and backdoor payments were costing Americans $17 billion per year. And that’s not counting the excessive “out-in-the-open” fees that are draining our retirement accounts. “The corrosive power of fine print and buried fees can eat away like a chronic illness at a person’s savings,” said U.S. Secretary of Labor Thomas E. Perez.

Why are the fees so high? Many retirement plans are plagued with huge commissions, very high expense ratios, and a laundry list of other — often hidden — layers of fees. They might be labeled “assetmanagement charges” or “contract asset charges.” They often add up to 1% or more and are buried in the fine print of plan disclosures. On top of that, the majority of retirement plan providers accept payments from the mutual funds offered in the plans they sell to businesses. This is called “revenue sharing” (or, more aptly, paying to play). As a result, the investments you have to choose from in your 401(k) plan are usually the funds that pay the provider the most — these are rarely the best-performing options out there, and they are almost never the lowest in cost. For example, in a recent 401(k) plan I reviewed, one of the leading payroll companies in the United States receives 0.40% annually in revenue sharing from the company whose mutual funds are included in the plan they offer. This means the payroll company makes 135% more than the actual 0.17% cost of the fund — thanks to its revenue-sharing agreement. Finally, retirement plan providers often restrict low-cost funds to plans that exceed a certain dollar amount of assets. Since the providers don’t make much of a profit on these lower-cost funds, they mark them up.

One major insurance company is offering an S&P 500 index fund for more than 1% annually, when the actual cost is .05%. That’s a 2,000% markup. And because of the aforementioned minimum asset requirements, employees of smaller companies are often forced to invest in funds with higher fees.

What can I do about it? Often a 401(k) provider is chosen as a matter of convenience — integration with a payroll provider’s offering, for example. More often it is through an introduction, via a colleague or friend who “knows a guy.” Not enough due diligence may have been completed to see the long-term ramifications of the choice or providers, or even related to their expertise. Even though employers have good intentions, they are deeply focused on running their businesses. And they are probably not experts in investing for retirement, or in the 401(k) industry. So it’s up to you, the employer who sponsors the 401(k) plan, to educate yourself on how your plan works and where your money is going. Look closely at your paperwork. Compare the expense ratios and other fees in your plan documents to those charged for similar investments from other providers. This is tedious, but important. If you’re concerned about the fees you’re paying, start by completing a thorough benchmark of your plans’ fees to alternatives. You have a legal responsibility to make sure that your 401(k) plan puts your participants’ best interests FIRST, and this benchmark will help you clearly see if a near term change might be in the best interests of all those participating in your plan. Take action — your financial future, and those of your employees and their families, may depend on it. OP

Take control, start here: http://americasbest401k.com/fee-checker-medmark. Volume 7 Number 6

The future of Class II correction is here. The Jasper Vektor is the ONLY appliance that utilizes gentle, intrusive force vectors – just what is needed for efficient Class II correction. • Produces gentle, curved force vectors since the appliance flexes in 25-45% of its overall length • Robust nickel titanium design • Easy installation • Free from the “food zone” • Allows natural lateral mandibular movement for patient comfort

Other appliances produce extrusive tipping forces on the maxilla and anterior teeth, which is always contraindicated for the over erupted Class II patient. Since the vector control module (VCM) is made from nickel titanium, the appliance is break-resistant and force values of only 3.5 ounces are produced. Provide your patients the latest Class II correction alternative with the Jasper Vektor appliance.

See why the Jasper Vektor appliance is in a class of its own. Call or visit us online:

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CASE STUDY

Maintaining clearly defined treatment objectives: part 2 Drs. Domingo Martin and Jorge Ayala illustrate treatment using the FACE concept of orthodontic treatment

n the September/October 2016 issue of Orthodontic Practice US, we introduced the FACE (Functional and Cosmetic Excellence) concept of orthodontic treatment and its importance in achieving function and esthetics. We also explained the treatment goals and the key factors that make up the goals. After the introduction to the FACE treatment philosophy, we explained that the FACE Evolution bracket* was developed by some of the key members of the FACE group. This bracket was developed by clinicians for clinicians. In the article, we gave the many reasons for the development of a new bracket system. In retrospect, the main reason was the need for a bracket system that took function into account, and this is the first of its kind. In the second part of the article, we will further explain the necessity for changing the original Roth prescription. The rationale for the many changes in the prescription makes sense to experienced clinicians. We also introduce the concept of “working tube,” something that many clinicians will like, and more importantly, the need for this type of bracket in our toolboxes. We also announced the “working bracket” and its multiples uses, and why we need this in many instances to obtain our functional and esthetic occlusal goals.

Prescription for work and prescription for finish FACE Evolution incorporates a new concept into orthodontic biomechanics:

Figures 11A-11B: Clinical examples of the use of 11A. FACE work and 11B. finish prescription

Figures 12A-12C: Three vertical guides enable the placement of the tube more mesially, more distally, and a central framework to achieve three different anchorages (14°, standard, and –6° of rotation) with the same tube

working prescription and finishing prescription. The work prescription consists of using specific tubes and brackets for their temporary use in certain situations with the purpose of attaining certain aims (Figure 11A). The prescription for finish is obtained with the use of the standard FACE Evolution prescription — a good finish in a high percentage of cases — without needing to bend the arches. In some situations, because of minor anatomic variations, the necessary adjustments should be performed (Figure 11C).

Working tubes By varying the mesiodistal position of the tubes, we can modify the rotation values and the anchorage values to tackle

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 has a diploma in orthodontics by the FACE/Roth Williams Center for Functional Occlusion 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 Maxillar 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: Drs. Martin and Ayala are consultants for Forestadent.

20 Orthodontic practice

cases of minimum, medium, and maximum anchorage. Therefore, the tube will have three vertical guides (Figure 12) that enable us to locate the tube more mesially for cases of maximum anchorage, or more distally, for cases of minimum anchorage, and a central framework for cases of medium anchorage and finishing stage. These guidelines will coincide with the main vestibular sulcus as indicated. Tubes with markings became available in 2016 (Figures 12A-12C). With the same tube, we can therefore attain three different anchorages (standard, +4°, and –4°), simply and efficiently; the necessary inventory is also simplified, so this is like having three different prescriptions in the same tube. As its name indicates, the prescription for work is the one with which we can perform specific actions — for example, distalization or retrusion of the six anterosuperior teeth or mesialization of the posterior segments — by increasing or reducing the anchorage. Once the required aim is obtained, in this case closure of the spaces, we will switch to the prescription for finish by positioning the tubes in the usual way.

Working brackets For cuspids, the working bracket with 20° positive torque will enable us to place Volume 7 Number 6

Active system and hybrid system It is difficult to come to an agreement in regard to which self-ligating system has more advantages and less disadvantages.

Table: Working brackets and working tubes for FACE Evolution system

Various papers conclude that sliding mechanics are favored for the use of passive self-ligating brackets, but control of the root position could be comprised. They also confirm that the sliding resistance (SR) is necessary when we have to produce torque and correctly position the root for correct finishing. The wish to minimize resistance to friction should be moderated because of the need to control movement of the teeth. In the new FACE Evolution, we have opted to take the advantages of both parts by means of two versions: the active system and the hybrid system. The active system gives us more control: During subsequent treatment stages, sliding resistance (SR) increases along with the size of the arch. This provides better threedimensional control and fills the sulcus to

produce a torque force that correctly positions the root and the crown. The hybrid system provides the clinician with the best combination of low friction and control, especially in cases with extractions. A recent study performed by Dr. Douglas Knight on 400 finished patients concluded that the duration of treatment and number of appointments of 200 patients treated with the hybrid system reduced by 15%.

Clinical cases Case 1 by Dr. Domingo Martín (Figures 14–22) A 13-year-old female presented with severe space deficiency, and with her skeletal anatomy, we decided to extract four bicuspids and close spaces, maintaining her upper teeth forward, not retruding the upper lips, and obtaining a good functional occlusion.

Figures 14A-14C: Pretreatment facial pictures

Figures 15A-15C: Pretreatment intraoral photos before extractions

Figures 13A-13B: 13A. Before and 13B. after correction with working bracket; the apex is seen inside the bone Volume 7 Number 6

Figures 16A-16C: After extractions of first bicuspids, we let the teeth fully erupt and the molars come forward and, thus, lose anchorage since it is a low anchorage case. Once the teeth are fully erupted, we will begin orthodontic treatment Orthodontic practice 21

CASE STUDY

these teeth in the required position to be subsequently replaced with the standard torque bracket or bracket with the final prescription. For the mandible, the molar torque of –30° operates efficiently in most cases, although at times not in the case of second molars. Indeed, in a lower percentage of cases, the second lower molar “tips” toward the lingual region, especially in those cases with an accentuated curve of Spee. The explanation appears to reside in the fact that when attempting to access these molars and given that the apices are in relation to the compact bone of the external oblique line, this undesired effect would occur, which is difficult to resolve. Therefore, FACE Evolution proposes a working tube with 0° of torque, which once the molar torque has been corrected, should be replaced with the prescription’s standard finishing tube.

CASE STUDY

Figures 17A-17C: We start the aligning and leveling phase in the upper arch with a .020” x .020” BioTorque® archwire

Figures 18A-18C: We are still in the aligning and leveling phase in the upper and lower arch with a .019” x .025” BioTorque® in the upper and lower arch.We are closing spaces in the upper and lower arch preparing for the working phase. We place a transpalatal bar for vertical control

The rationale for the many changes in the prescription makes sense to

Figures 19A-19B: We are now in the working phase in the upper and lower arch with a .019” x .025” TMA T-LOOP Double keyhole loop archwire that gives us torque control, creates a moment for incisor control, helps us loose anchorage, controls the canine in the three dimensions, and will correct the curve of Spee — all with one archwire

experienced clinicians. Figures 20A-20C: We are now in the finishing stage with the curve of Spee aligned, spaces almost completely closed, torque of the upper anteriors achieved, and good arch form in the lower and upper arch. We can resort to Class II elastics in this phase if necessary

Figures 21A–21C: Posttreatment facial pictures

Figures 22A-22F: Posttreatment intraoral pictures 22 Orthodontic practice

Volume 7 Number 6

CASE STUDY

Case 2 by Dr. Jorge Ayala (Figures 23–27)

Figures 23A-23C: Pretreatment intraoral pictures

Figures 24A-24C: Initiation of treatment in the maxilla with .014” BioStarter®

Figures 25A-25C: .019” x .025” upper BioTorque and .018 lower BioStarter®

Figures 26A-26C: .019” x .025” upper and lower braided wire

Figures 27A-27C: Posttreatment intraoral pictures Volume 7 Number 6

Orthodontic practice 23

CASE STUDY Case 3 by Dr. Jorge Ayala (Figures 28–31)

Figures 28A-28C: Pretreatment intraoral pictures

Figures 29A-29C: .014” upper and lower BioStarter®

Figures 30A-30C: .019” x .025” upper and lower braided wire

Figures 31A-31C: Posttreatment intraoral pictures

* Fa. FORESTADENT OP

24 Orthodontic practice

Volume 7 Number 6

FACE Evolution System

"An appliance system designed for function and facial esthetics!" - The FACE Group

Dr. Domingo MartĂn , Dr. Jorge Ayala, Dr. L. Douglas Knight and Dr. Straty Righellis.

www.forestadent.com

ORTHODONTIC INSIGHTS

A Herbst® journey Dr. Bill Dischinger discusses how his personal Herbst experience led to development of a comfortable and efficient appliance

had a Herbst® as a teenager. How are my memories of that time in my life? Well … not exactly great. Although as an adult, I look at the results it gave me compared to the upper bi extraction cases that were the norm back then, and I know it was worth it. But … The second Dischinger to have a Herbst was none other than Terry Dischinger himself. We treated him when he was in his late 50s. He had always been a Class II open bite that would have required surgery. Eventually, he developed a modified Herbst appliance that intruded the maxillary molars while the Herbst was correcting the Class II. The results are similar to what we see in today’s technology using TADs to intrude the maxillary molars and autorotate the mandible. He claims his experience was an easy process, but my dad is kind of that way. It sure beat surgery though, but in watching from the other side, it didn’t look all that comfortable. Shortly after finishing his treatment, we decided to see if we could make a smaller Herbst appliance. Our purpose in attempting this design change was to improve the comfort of orthopedic Class II treatment for our patients. I was two boys into my now current four-boy family, and it was obvious they were following the Dischinger growth pattern and would require Class II correction. Selfishly speaking, I wanted my kids’ experience to be better than mine, my dad’s, and all my previous and current patients. So we set off on a journey, and let me tell you, it was

a journey much harder and more frustrating than we had dreamed. When I was in my residency, I had a classmate that sat down at the bar with me one night, grabbed a napkin and pen, and said, “Let’s invent an appliance.” Well, it isn’t quite that easy. We had the design idea, but making that work from an engineering perspective is a little harder than most people would think. Thanks to the hard work of some amazing engineers at Ormco, we slowly started putting out some prototypes. We worked with these prototypes for a few years until we felt we had a design that worked consistently with great results. AdvanSync™ was launched shortly thereafter. Early on, it was widely adopted by many based on the features that other doctors also recognized were beneficial to their practices and patients. Like many initial concepts, once the product was

Bill Dischinger, DMD, of Lake Oswego, Oregon, received his dental degree from Oregon Health and Science University School of Dentistry in 1997 and his certificate in orthodontics at Tufts University in Boston in 1999. His B.S. degree is from Oregon State University. In private practice with his father, Dr. Terry Dischinger, Dr. Bill Dischinger has taught at their in-office comprehensive courses and used the Damon® System for over 15 years. He is an Adjunct Professor in the Orthodontics Department at the University of the Pacific in San Francisco and one of 12 certified Damon instructors who has taught and lectured extensively on passive self-ligation with the Damon System. He has also lectured nationally and internationally on a variety of subjects, including functional jaw orthopedics, indirect bonding, and practice management from a team approach. Dr. Dischinger has written articles published in Orthodontic Products, Orthotown, and Ormco’s Clinical Impressions and is actively involved in national study clubs that address the latest treatment techniques. He is also a member of the American Association of Orthodontists, Pacific Coast Society of Orthodontists, the American Dental Association, and orthodontic professional associations that enable him to actively participate in continual education and remain current on advances in orthodontic treatment. Dr. Dischinger has been married to his wife, Kari Lynn, for over 20 years, and together they have four sons.

26 Orthodontic practice

mass-produced, we began to see several flaws surface. We then went to work on the second generation with manufacturing and design changes that would resolve the issues. Thus came AdvanSync 2 with modified enhancements, and this is the product we are still using today and have been for nearly 5 years. As stated, our goal was to improve the comfort of orthopedic Class II treatment for our patients. AdvanSync™ 2 is almost half the size of the miniscope appliance that we had been using and half of the size of the flip-lock design we used prior to that. It is well over half the size of what I had as a kid, which I can assure you. Because of the smaller size, it fits more in the posterior of the mouth. Most of the sores we saw patients experiencing were in the lower premolar area from the screw housings. This has been minimized with the enhancements of AdvanSync 2. The appliance also does not show in the mouth like previous Herbst designs, so patients are more accepting to wear it. A bonus that came out of the smaller design was the ability to bracket every tooth forward of the appliance. In the past, we were unable to bracket the lower premolars, and at times, we would not bond the maxillary premolars either. With this new design, we bond all the teeth, and sometimes the mandibular second molars as well. When we are finished with the Class II correction and the appliance is removed, most of the Class I orthodontics has been accomplished Volume 7 Number 6

Class II Correction with

Improved Patient Comfort Simple. Fast. More Efficient.

AdvanSync 2 offers a compact solution that provides the ability to bracket 5-5 while simultaneously correcting CL II malocclusions. This combination has the potential to increase Tx efficiencies by reducing overall treatment time. Its size also provides a benefit to both patient comfort as well as being more aesthetic than other CL II appliance options. Class II correction in Class I time Engineered for efficient correction Available as a custom appliance or chairside kit

For more information, call 800.262.5221, or visit aoalab.com.

ORTHODONTIC INSIGHTS

Taylor Dischinger initial phase 1

Taylor Dischinger initial phase 1 occlusal upper

Taylor Dischinger final occlusal upper

as well, which allows us to quickly move to the end of treatment making our orthopedic Class II cases much more efficient. Since moving to the AdvanSync 2 appliance, we have dropped our average treatment time by over 6 months. Over the years of using the AdvanSync, I have modified my treatment protocols on most of my patients. I used to place the crowns, place the braces, and hook up the AdvanSync arms on every new patient the first day of his/her treatment. Today, with most of our current patients, I am waiting 2 to 4 months before hooking up the arms. For younger patients, this helps them ease into treatment with less to adjust to. For some patients, I like to get the lower arch leveled, particularly in Class II, division 2 patients. Although this postpones the Class II correction by 2 to 4 months, the end result is that less orthodontics needs to be done after removal of the appliance. Because of this, the Class II correction occurs smoothly without vertical issues, and thus, the overall treatment time is lessened. Since starting my Herbst journey over 35 years ago, I have seen a great progression in the comfort and efficiency of treating skeletal Class II patients. It has been rewarding to see my patients, especially my own children, go through a better experience than I did. OP HerbstÂŽ is a registered trademark of Dentaurum, Inc., and AdvanSyncâ&#x201E;˘ is a trademark of Ormco Corporation.

Taylor Dischinger final 28 Orthodontic practice

Volume 7 Number 6

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ORTHODONTIC CONCEPTS

Reframing orthodontics: Designing accelerated orthodontics by managing error — the BioDigital way: part 3 Dr. Rohit C.L. Sachdeva discusses the journey of error management in clinical practice The road to wisdom? Well, It’s plain and simple to express: “Err Err And err again but less and less and less” — Piet Hein from Grooks “The Road to Wisdom”

Introduction The key dimensions of quality care that drive the philosophy and practice of BioDigital Orthodontics are patient centeredness, patient safety, and clinical effectiveness.1-2 Errors committed during the delivery of care have the highest potential of negatively impacting these quality measures and, as a result, treatment time. Strategic approaches to error management in clinical practice have been substantially neglected by the orthodontic professionals in their pursuit of the holy grail of accelerated orthodontic care. A culture of patient safety cannot be practiced without confronting the causes of orthodontic errors and their appropriate management. This journey of error management in clinical practice can only begin by recognizing 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.

30 Orthodontic practice

the various types and sources of errors and then finding ways to prevent them or, at a minimum, to develop appropriate barriers to arrest their propagation. I have found that errors in clinical practice commonly manifest around what I term the 7 M’s: 1. Miscommunication 2. Misdiagnosis 3. Misplanning 4. Misprescription 5. Mismanagement 6. Misadministration 7. Misaction The root cause of these is grounded in deficits of knowledge, inadequate skills, and the violation of rules. The objective of this paper is to familiarize the reader with the principles, the tools, and the clinical practices that I use and have

developed in the service of error-proofing the care of my patients with a focus on managing the 7 M’s. These practices have resulted in shorter treatment times and, more importantly, enhanced patient safety.

Principles and practice of error proofing “We can’t solve problems by using the same kind of thinking we used when we created them.” — Albert Einstein The strategic and tactical practices to error-proofing patient care against the 7 M’s that I present are based on a bedrock of sound biomechanical principles and, when appropriate, are enabled with the use of 3D-imaging technologies such as CBCT, OraScan (Figure 1), and CAD/CAM technologies offered by the suresmile® total

Figure 1: Various types of images used for care design and planning. Note the CBCT provides information regarding bone, crown, and roots. The OraScan is limited to the crowns and gingival tissue. suresmile® offers the service of merging the CBCT image with the OraScan and 2D extraoral frontal images Volume 7 Number 6

A) Error-proofing against Misdiagnosis A major thrust of orthodontic diagnosis involves the understanding and delineation of the complex spatial interrelationships between the various anatomical components of the craniofacial complex. Misdiagnosis in orthodontics commonly occurs as a result of perceptual, measurement, and judgment errors. By using 3D images and 3D virtual models of a patient for simulations, such errors may be minimized. Clinical examples of the use of these tools follow. High-fidelity 3D diagnostic imaging 2D images of patients, such as photographs or the panorex, are commonly used as aids in diagnosis. Unfortunately, such images lack depth and are also prone to projection errors.4 This limits the doctor’s ability to perform a thorough diagnosis for his/ her patient. Misdiagnosis leads to incorrect treatment decisions and, as a result, treatment time is negatively impacted. 3D imaging helps overcome these issues. Examples of both the clinical “misses” resulting from 2D images and the benefit of using 3D images in these situations are shown in (Figure 3). Autoanalytics Many of our diagnostic decisions rely upon accurate and precise measurements of the dentition. We are often hampered both by the limitations of the tools we use and our perceptual biases. This is primarily due to a lack of operational definitions for the region of interest and having no common plane of reference to measure against. This leads to inaccurate, unreliable (inter- and intra-operator) measures that result in the incorrect diagnostic assessment of a patient. Autoanalytic tools overcome such limitations and allow for more reliable diagnosis.5 (Figure 4). Interactive diagnosis with simdiagnostics Currently, we measure the degree of severity of a malocclusion by measuring against a normative age/sex/ethnic-based sample. However, it is equally important to measure the degree of severity of a malocclusion based upon the amount and nature of tooth displacement required to achieve the treatment objective (Figure 5). Assessing this measure with conventional tools is difficult. For instance, the assessment of the severity of crowding is affected by a Volume 7 Number 6

Figure 2: suresmile cloud-based total patient management system. Note: suresmile provides 3D printing services. Also STL files of models are available for remote printing at the practice or a laboratory

Figures 3A-3C: 3A. Note the CBCT image detects the bone fenestrations around the canines but not the gingival recession that can be seen on both the intraoral or OraScan image. 3B. 3D images can be navigated to allow the viewer to see multiple perspectives of the image and gauge depth. As a result, the “hidden” can be seen. Note that the second bicuspid is extruded. This is not seen on the intraoral visible in the intraoral images or from the occlusal perspective of the 3D OraScan. It is clearly visible from the lingual perspective of the OraScan. 3C. The panorex image does not show the dilaceration at the apex of the lower left central incisor. This is seen with the CBCT image

Figure 4: Autoanalytic tools offered by suresmile technology allow the automatic measure of various features of interest. Also feature points such as marginal ridges are automatically detected. The doctor can override their location and relocate the points. Also, the ABO discrepancy index and the Bolton tooth size discrepancy index are automatically measured Orthodontic practice 31

ORTHODONTIC CONCEPTS

patient care management platform3 (Figure 2). These approaches are discussed below.

ORTHODONTIC CONCEPTS multiplicity of boundary conditions such as arch form, nature of tooth movement, midline, and anatomical constraints. Accounting for all these variables is beyond the capacity of the clinician. The ability to run multiple simulations on a patient’s virtual models and impose upon these models varying boundary conditions provides an elegant solution to this problem (Figure 6). I term this practice simdiagnostics. It is performed quickly and, most importantly, does not put the patient at risk as all the simulations are done virtually. An accurate assessment of the nature and type of planned orthodontic tooth movement allows the operator to design the appropriate appliance system that delivers

the appropriate force system to move the teeth. This minimizes “round tripping,” which invariably adds to treatment time.

B) Error-proofing against Misplanning Misplanning is commonly a result of misdiagnosis and a misguided understanding of the impact of a doctor’s treatment measures on the course and outcome of care. I use two approaches to overcome these limitations. Proactive care prototyping with simplanning Prior to beginning active treatment on a patient, I run simulations that model different

treatment scenarios to critically evaluate and validate the best “care flight plan” for the patient. This avoids wayfaring or midcourse retractions during the patient’s care journey, allowing for the promotion of patient safety and less wasteful practices. As a result, treatment time is compressed (Figure 7). Simprognostics A very important aspect of care planning resides in a doctor’s ability to determine the prognosis of treatment. This requires that the clinician be skilled in forecasting the potential “fault lines” or risks associated with the treatment measures and the likelihood of a successful treatment outcome. Simulations provide a very useful method to assess

Figure 5: Simdiagnosis. This patient demonstrates a significant shift (asymmetry) of the mandible to the left. The severity of the dentoalveolar compensation in the lower left buccal segment is difficult to assess with conventional intraoral images. The nature of compensation can be the CBCT when compared to the right side. Quantifying its extent and the nature of the tooth movement to correct it require the ability to both simulate and measure the movement of the tooth to the desired state. In this situation, the lower right first molar was controlled tipped 15° with a center of rotation at the left of the crown tip. This is a difficult movement to accomplish and will take time to correct and require the creative design of a force-driven appliance. Recognition of this patient need can only be done with the aid of simdiagnosis

Figure 6: Simdiagnostics. Simulations allow a quick way to understand the impact of various boundary conditions on the resolution of crowding. In this situation, the impact of choosing the natural arch form (Figure 6A) versus the Damon arch form (Figure 6B) is being considered. Note the amount of intersections, a measure of crowding when using both arch forms, is similar. However, more tooth movement will be required to achieve the desired Damon arch form especially in the molar areas. The use of the Damon versus a natural arch form may well be driven by the esthetic needs of the patient but not by efficiency or stability of treatment 32 Orthodontic practice

Figures 7A-7E: Simplanning. 7A.This patient would have benefited from simplanning prior to the start of treatment. 7B. Note the simulation depicting the non-extraction approach to care clearly demonstrates that such a treatment would result in an bimaxillary protrusion with an anterior open bite This treatment strategy would not be in the best interest of the patient. 7C. Note the similarity between the non-extraction simulation and the clinical result. 7D.An extraction approach to treatment would have been a better approach to treatment. 7E. Mid-treatment the four first bicuspids were extracted. Although the bimaxillary protrusion is resolved, it is apparent that space closure has not been well controlled, resulting in forward tipping of the buccal segments and, especially, the lower right buccal segment. Practicing orthodontic care by a “fly of the wheel” approach is not right patient care and adds to treatment time as well Volume 7 Number 6

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ORTHODONTIC CONCEPTS

Figure 8: High-fidelity diagnosis. 2D OraScan and the panorex images are inadequate in demonstrating the exact position of the roots. Note the upper right mesiolingual resides between the distobuccal and lingual root of the upper first molar root. On the panorex, the lower first bicuspid appears to show a root proximity problem with respect to the lower second bicuspid. However, when seen from multiple perspectives of the CBCT image, it is apparent that this is not the case

Figure 9: Simplanning and simprognostics. Correction of the rotation of upper second right molar at the crown level appears to be innocuous. However at the root level, one can clearly see that root collision will be a consequence of the derotation of the molar and put the patient at risk. Patient A.Z. clearly demonstrates that correct diagnosis, planning, and prognostics needed to be integrated in a sequential manner to serve safe patient care

the prognosis of treatment (Figures 8-10). Accurate prognostics again saves treatment time since it allows the doctor to proactively recognize the impact of his/her treatment regiments and design appropriate solutions to better manage patient care and therefore shorten the care cycle.

C) Error-proofing against Miscommunication It is not uncommon to observe a disconnect between the voice of the patient and that of the doctor in terms of treatment needs. Furthermore, this disconnect commonly extends into the larger concentric circle of the care team and interprofessional care collaborators. This leads to conflicting treatment goals and measures, placing the patient at risk, compromising the patient’s care experience, delaying treatment, and potentially hindering the quality of treatment outcomes. One common source of this angst lies in the high signal-to-noise of information shared orally or in the form of abbreviated text in the patient’s notes. Visual communication with simulations, complemented with both the oral and textual mediums, provides a realistic solution to overcome miscommunication.6 A brief description of the approach I use to better communicate among all the stakeholders is provided below. Participatory communication with simcomm To break the walls of miscommunication between the patient and the care team, a shared “blue space” for all the stakeholders is created. Real-time simulations are used to both design and explain treatment to the patient. This draws the patient into a “show and share” versus “show and tell” mode of 34 Orthodontic practice

Figure 10: Simprognostics. Alignment of the lower incisors leading to the appearance of black triangles was forecast prior to the start of treatment and discussed with the patient. She declined any more interproximal reduction than that which was required to correct the crowding between the incisors and accepted the black triangles. However, she was very satisfied with the results as she was made aware of this occurrence using simulations at the beginning of treatment and made a personal choice to accept the black triangles

Figure 11: Simcomm. Creating a shared interactive environment around the “blue space” gives the doctor the ability to actively input the patient’s preferences in the design of his/her occlusion. Additional tools for planning the surgical and restorative needs of a patient are used. This facilitates interprofessional communication. I often perform these consult sessions with webinars over the Internet

communication with the doctor(s). Thinking out loud encourages both the patient’s “buyin” in terms of his/her care needs and adherence to future requests made by the doctor, such as the wearing of elastics (real time).

The virtual visual treatment plan established for the patient is accessible to all members of the care team, bringing concurrence in understanding the goals of care to all stakeholders involved in the care process (Figure 11). Volume 7 Number 6

D) Error-proofing against Mismanagement and Misaction Continuous active participatory care management with checklists, clinical pathway guidelines and patient care navigation maps with simtracking A common challenge in managing patient care through the care cycle is that the care team loses sight of treatment goals, leading to clinical inertia or thematic vagabonding7 (Figure 12). This is commonly seen in practices that are busy, where work stress and intensity are high, and where the environment encourages safety violations8 (Table 1). As a result, treatment is delayed, and greater opportunities for failure emerge. Such unwanted practices are contained with the use of checklists and clinical pathway guidelines (Figure 13). Checklists are also

Figure 12: Thematic vagabonding. Patient has been in treatment for 16 months and shows little progress in treatment over this period

These practices have resulted in shorter treatment times and, more importantly, enhanced patient safety.

Table 1: Practice violations High levels of diagnostic uncertainty High decision density High cognitive load Narrow time windows Multiple transitions of care Multiple interruptions/distractions Low signal-to-noise ratio Surge phenomena Circadian dysynchronicity Fatigue Novel

Table1: Some factors that can enhance safety violations in an orthodontic practice. (Adapted from Croskerry and Wears, 2002) Croskerry P, Wears RL. Safety errors in emergency medicine. In: Markovchick VJ and Pons PT (eds.) Emergency Medicine Secrets, 3rd Edn..; Hanley and Belfus: Philadelphia, PA, 2002:29-37. Safety violations in practice Volume 7 Number 6

Figure 13: Checklists and clinical pathway guidelines are used to contain errors and prevent clinical inertia Orthodontic practice 35

ORTHODONTIC CONCEPTS

Orthodontic literacy with patient decision aids Communication with patients is further facilitated by ensuring they have access to current disease-specific literature that is context-sensitive and caters to cultural diversity.

ORTHODONTIC CONCEPTS used to minimize errors of omission and active participation in his/her own care. their superior performance. Furthermore, in commission9 (Figure 14). Indeed, patient cooperation is vital to achieve my opinion, these claims are accentuated Another solution to care inertia involves a successful outcome. by marketing tactics that create an echo the creation of patient care navigation maps chamber populated by “the believers” whose (PCNMs). These visual simulations show a Conclusions ammunition consists of a few isolated clinical temporal sequence of the milestone-driven Orthodontic Misdiagnosis, Misplanning, patient histories with insufficient documentagoals of the patient’s care journey. The care Miscommunication, and Misaction impact tion. Added justification comes from quoting team and patient can use PCNMs to track the care cycle and, more importantly, put research whose strength is justified by the fact that it was published by “independent” treatment progress (Figure 15). I term this the patient at risk. Unfortunately, as a profesapproach to care management simtrack. I sion we have neglected to understand the researchers from an academic center rather also use simtracking to manage patient visits. influence of these care processes on the than on what really matters — the design of the study and cross validation of the results Patients are provided their PCNMs and asked duration of orthodontic care and develop from multiple centers. to self-monitor and assess their care progapproaches to mitigate these “misses” ress against the map. Patients then schedule consistently. Instead, the current orthodontic On the other hand, the “nonbelievers” also their care visits based upon the attainment of marketplace has addressed the problem of need to be held to the same standards as the the planned milestones, allowing for just-inreducing the care cycle by inundating the “believers” and subject to the rigors of scientific time care scheduling. Simtracking results in profession with promises of transformascrutiny. It is not enough for the nonbelievers just to dismiss the other side without holding fewer unnecessary patient visits, opening the tional technologies that claim to accelerate doctor’s schedule up, decreasing the “busyorthodontic tooth movement. Many of themselves accountable. It is my hope that the ness” in the clinic, and, in turn, minimizing these technologies are sold on the basis of profession of orthodontics imposes upon itself the risk of operator-induced errors due to a having a “biological” foundation to explain the habit of self-reflection and recognizes that decline in workload intensity. Patients are also encouraged to use PCNMs to detect any untoward or spurious tooth movement and may schedule an appointment immediately to rectify the presenting problem. Such care management practices help contain errors and, most importantly, encourage Figure 14: Forgetting to engage an archwire is an error of omission. Not engaging an archwire properly is an error of commission. Checklists are used to engage such errors the patient’s enthusiastic and

Figure 15: Simtracking. A patient-care navigational map is shown. Patients are encouraged to self-monitor their treatment progress by taking images of their own teeth during the course of treatment and matching it against the map. Care team members also have access to these maps to monitor treatment progress. Such practices create a flat-bed structure, allow for open communication between all stakeholders, and minimize errors 36 Orthodontic practice

Volume 7 Number 6

REFERENCES 1. Sachdeva R. Novus ordo seclorum: a manifesto for practicing quality care - part 1. EJCO. 2014;2(3):71-76. 2. Sachdeva R. Novus ordo seclorum: a manifesto for practicing quality care - part 2. EJCO. 2015;3(1):2-14. 3. Sachdeva R. Integrating digital and robotic technologies: diagnosis, treatment planning, and therapeutics, In: Graber ML, Vanarsdall RL, Vig KWL, eds. Orthodontics: Current Principles and Techniques. 5th ed. Philadelphia, PA:Elsevier/ Mosby; 2012. 4. Bouwens DG, Cevidanes L, Ludlow JB, Phillips C. Comparison of mesiodistal root angulation with posttreatment panoramic radiographs and cone-beam computed tomography. Am J Orthod and Dentofacial Orthop. 2011;139(1):126–132. 5. Grünheid T, Patel N, De Felippe NL, Wey A, Gaillard PR, Larson BE. Accuracy, reproducibility, and time efficiency of dental measurements using different technologies. Am J Orthod and Dentofacial Orthop. 2014;145(2):157–164. 6. Almog D, Sanchez Marin C, Proskin HM, Cohen MJ, Kyrkanides S, Malmstrom H. The effect of esthetic consultation methods on acceptance of diastema-closure treatment plan: a pilot study. J Am Dent Assoc. 2004;135(7):875-881. 7. Aujoula I, Jacquemin P, RietzscheE, et al. Factors associated with clinical inertia: an integrative review. Adv Med Educ Pract. 2014;5:141–147.

ORTHODONTIC CONCEPTS

its sustainability will be driven by focusing on finding the problem first and then the solution rather than trying to fit a solution to a problem. This will also require that the opposing camps refrain from debating each other with the sole purpose of proving the other faction wrong and engage in meaningful conversation that seeks the truth supported by the bedrock of scientific evidence. Only then will we able to practice what I call authentic orthodontics where the interests of the patient supersede personal opinion. In my next article, I will discuss how I manage errors related to orthodontic therapeutics. OP

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

8. Croskerry P, Cosby K, Schenkel SM, Wears R, eds. Patient Safety in Emergency Medicine. Philadelphia, PA: Lippincott Williams & Wilkins; 2008. 9. Gawande A. The Checklist Manifesto: How to Get Things Right.London: Profile Books; 2010. 10. Cash AC, Good SA, Curtis RV, McDonald F. An evaluation of slot size in orthodontic brackets — are standards as expected? Angle Orthod. 2004; 74(4):450-453. 11. Balut N, Klapper L, Sandrik J, Bowman D. Variations in bracket placement in the preadjusted orthodontic appliance. Am J Orthod Dentofacial Orthop. 1992;102(1):62-67. 12. Eerkens JW. Practice makes within 5% of perfect: visual perception, motor skills, and memory in artifact variation. Current Anthropology. 2000;41(4):663-668. 13. Sachdeva R, Bantleon H. Cantilever based orthodontic— biomechanical and clinical considerations. In: Sachdeva RCL, ed. Orthodontics for the Next Millennium. Glendora, CA: Ormco Publishing; 1997. 14. Fontenelle A. Challenging the boundaries of orthodontic tooth movement. In: Sachdeva RCL, ed. 14. Root Cause Analysis. Patient Safety World Health Organization. doc:1.10.A http://www.who.int/patientsafety/education/ curriculum/course5a_handout.pdf 15. Vaughan D. The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. London: The University of Chicago Press; 1996.

FREE LIMITED 6 CASE When you sign up for free at clearcorrect.com/doctors using promo code OPRAC3 Offer available for new providers only. Expires December 31, 2016.

Volume 7 Number 6

Orthodontic practice 37

CONTINUING EDUCATION

Using lingual appliances for optimal esthetics and minimal compliance issues Drs. John R. “Bob” Smith and Mario Paz discuss the development and use of a square-slot, passive selfligating, straight-wire lingual appliance

onsidering the evolution of lingual orthodontics, it is worth noting that the lingual technique gained limited popularity in the United States and Canada during the early 1980s. In the intervening years — partly due to the clinical difficulties associated with it during its early development and the success of esthetic alternatives — lingual therapy has languished in North America. Educated later with improved techniques, clinicians in Europe and Asia had greater success with lingual therapy where its use has become much more common. An October 2013 AAO survey, entitled “The Economics of Orthodontics,” found that the number of orthodontic starts in the U.S. and Canada increased 20% between 2010 and 2012 with a 14% increase in the number of adult patients over the age of 18 during that same period.1 Certainly, the tremendous growth of Invisalign® is testament to the demand for esthetic appliances and is what adults and even teens come into offices asking for. While aligners enable us to perform suitable corrections for many patients, there are times when fixed appliances are a better choice. And the conversation moves considerably in favor of fixed appliance treatment when we introduce lingual therapy. Lingual offers a high level of care with optimal esthetics and minimal compliance issues. It can serve as an important strategy for sustained practice growth since it’s a

Educational aims and objectives

This article aims to discuss the use of the Alias™ lingual appliance passive self-ligating, square-slot lingual bracket system.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 45 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Identify instances for which fixed appliance treatment would be a more appropriate choice than removable appliances.

•

Identify instances where lingual systems would be more appropriate than labial systems.

•

Identify some characteristics of the Alias™ lingual appliance.

•

Recognize some benefits of using this system for certain patients.

Figures 1A-1C: Difficult case in treatment for approximately 3.5 years with removable appliances

Figures 1D-1F: The patient switched to lingual appliances with the final result achieved in approximately 2 years

John R. “Bob” Smith, DDS, MSD, received his dental degree from Emory University. He earned a MSD in Dental Science at the University of Washington, winning the coveted Milo Hellman International Research Award for research which established that implants could be used for stable anchorage. Such research was the precursor for the development of TADs, so important to today’s orthodontic treatment modalities. Dr. Mario Paz, DDS, MS, completed his General Dental Residency at Eastman Dental Center, Rochester, New York, earning an MS in Dental Science from the University of Rochester and a certificate of proficiency in orthodontics with special training in lingual treatment. Both Drs. Smith and Paz have published on the lingual technique and have trained orthodontists on the methodology throughout the world for many years. Over the past 9 years, Dr. Smith has been involved in the development of Insignia™ Advanced Smile Design™, part of the Ormco™ Custom digital suite of products. Since 1990, Dr. Paz has focused on lingual therapy, having established one of the largest lingual orthodontic practices in the U.S. He is known internationally for his expertise and is the Past President of the American Lingual Association of Orthodontists (ALOA). Disclosure: Drs. Smith and Paz served on the international evaluation team that participated in the development of the Alias™appliance system. Both Drs. Paz and Smith have treated patients with the Alias bracket.

38 Orthodontic practice

specialist’s treatment modality, not something a GP would likely adopt. Moreover, the adult segment of the market offers tremendous growth opportunity since the penetration of it currently stands at a mere 5%. While Invisalign has driven a demand for esthetic orthodontic treatment in the adult and teen population, in some circumstances, a removable appliance is not able to achieve the level of care as reliably as a fixed treatment alternative (Figures 1A-1C). In such cases, if metal or clear labial braces will not satisfy the patient esthetically, lingual treatment is a powerful tool to have at the clinician’s disposal (Figures 1D-1F). Volume 7 Number 6

Volume 7 Number 6

Table 1: Lingual straight-wire facilitates easier sliding. 018 x .018 Archwire Slot for Enhanced Rotational and Torque Control2

Figures 2A-2C: The small size and low profile of Alias lingual brackets means less interference with speech and greater comfort

Figures 3A-3C: Notice the alleviation of crowding and increase in arch width in 1 and 4 months. A. Pretreatment. B. 1 month C. 4 months

In terms of additional advantages, vertical wire insertion improves visualization of the wire-slot interface and simplifies wire placement. The small bracket dimensions provide more comfort with less occlusal and speech interference compared with numerous options on the market. Self-ligation appreciably reduces clinical chair time compared with steel ligation or double over-tie elastomers. There are also the inherent advantages of “straight wire”— simplified protocols with no or fewer wire bends to disrupt sliding mechanics, and easier archwire coordination and finishing. While in some cases the wire may not be a “perfectly straight wire in appearance,” it will not have sharp bends like the typical lingual mushroom archwire that greatly inhibits sliding mechanics. The goal is to maintain the straight-wire shape. Additionally, the square slot offers important advantages over the typical rectangular lingual slot — better tip control and appreciably better rotational control. Patients have reported the considerable comfort of Alias, which boasts rounded edges, a small shape and noticeably low profile (Figures 2A-2C). The passive aspect of

this self-ligating bracket also means clinicians will see many of the same benefits associated with passive self-ligating labial appliances — better sliding mechanics with less friction for faster arch unraveling and transverse width development (Figures 3A-3C). Effective tooth translation with better mesial-distal root tip control has also been reported. For patients, treatment length has always been of the utmost importance. Judging this bracket against time spent ligating conventional lingual twin brackets, these selfligating lingual brackets offer tremendous time savings. While there are no studies yet on ligation time of lingual self-ligating versus other lingual bracket systems that require traditional ties, the studies of labial brackets, self-ligation versus twin brackets, have demonstrated considerable time savings. We would think the magnitude of improvement should be comparable.3,4 In our hands, it’s shown almost 50% improvement in time, which is much appreciated by the staff. Also, the use of passive self-ligating brackets forces staff to stay in arch wires until they’ve been fully expressed. Staff can’t proceed to the next larger wire unless the case is ready for it because they can’t close the brackets Orthodontic practice 39

CONTINUING EDUCATION

Additionally, patients who originally come in seeking clear removable therapy, when apprised of its compliance aspect, will often opt for lingual treatment instead. If a fixed appliance is more appropriate for their particular case, their decision for lingual is reinforced. Friends, co-workers, and spouses of our lingual patients who had clear removable treatment and struggled with compliance or learned later that fixed appliance treatment would likely have given them a superior result admit that they wish they had been given the option of lingual treatment. Being able to propose lingual treatment — the ultimate esthetic option — gives clinicians a needed and now efficient tool to fulfill these patients’ expectations cosmetically without compromising the finish. The new Alias™ lingual appliance (Ormco) is the profession’s first passive selfligating, square-slot lingual bracket system. Specifically, if we were to take a look at the patented .018 x .018 square slot of the Alias PSL lingual appliance, there are a number of benefits for doctors. With passive labial selfligation, the standard .022 x .028 rectangular slot does not facilitate rotational control until placing .014 x .025 Cu Ni-Ti wires. Given the greater inter-bracket width and the .018 x .018 square slot — exclusive to the Alias PSL lingual appliance — clinicians can realize the benefits of early rotational and torque control with smaller diameter, more flexible arch wires. Because of the tight wire-bracket interface tolerances, there is less wire spin and play. The 016 x .016 Cu Ni-Ti wire is an excellent wire to gain both rotational and the first stage of torque control. The slot provides improved torque control when reaching full-sized wires. It’s always been difficult to insert a .018 x .025 stainless steel wire in a standard lingual slot without the risk of debonding the bracket — even when the case is fully aligned and ready for this size wire. The full-size wire for the appliance is the much smaller .018 square wire, which makes insertion easier yet maintains vertical root control during final torque refinements near the end of treatment. Moreover, the solid fourth wall of the bracket maintains torque control when retracting posterior teeth and closing spaces with a power chain. The wire can’t pull out of the slot as it can with a conventionally ligated bracket. In part, it is the way the wires insert in the posterior — going in vertically. Plus the snug fit of the .018 square wire in the .018 slot (when the self-ligating door is closed) maintains axial inclination, fostering tooth translation rather than tipping.

CONTINUING EDUCATION to secure the wire properly. This standardizes archwire progression, which they appreciate because it takes the guesswork out of it and keeps treatment on track. When patients are happy, staff is happy, and we have noticed fewer patient complaints about soreness and speech interferences with the smaller size bracket. Our staff also reports that there is a huge improvement in ease and time savings for wire changes with it because of the way the brackets open. Long-tenured staff members, especially those who have suffered from (or even have had surgery for) carpal tunnel syndrome appreciate the ease of self-ligation. Tying steel ties or attaching elastics onto conventional lingual brackets is even more straining than it is with labial brackets. The biggest surprise with this system was the velocity of tooth movement both in nonextraction and extraction cases — even though I’ve had considerable experience with the Damon™ System passive self-ligating labial bracket with similar results (Figures 4A-4B). We’re sure to cinch back the early archwires or leave them shorter, so they have room to move distally without irritating tissue. Clinicians unfamiliar with passive self-ligation will need to be careful to use Ormco-supplied lingual archwires and follow the prescribed wire progression in order not to overpower the system and thus over-expand arches. Because it’s a straight-wire system, we’re also able to use packaged lingual wires and shape them ourselves to duplicate a wire, if needed. While we seldom need to resort to this option, it’s a real timesaver when we do. There is considerable added expense and potential treatment delay to order and receive a replacement wire with appliance systems that provide technique-sensitive, robotically shaped wires. For case presentations, as professionals, we educate our patients about the best approaches to solve their orthodontic challenges. Our case presentation schools patients about their condition and its degree of treatment difficulty. Through the discussion phase of the presentation, we come to agreement about the best appliance, timeline for treatment, and cost. If the patient has very high esthetic demands and rejects labial clear brackets, the choices are either clear aligners or lingual braces. The difficulty and odds of success with clear aligners steers the conversation from that point. If I feel I need a fixed appliance, then the lingual appliance is my recommendation. 40 Orthodontic practice

Figures 4A-4B: Notice rapid space closure in only 4 months. A. Beginning of retraction stage. B. 4 months later

Figures 5A-5G: Using Alias in the upper arch and Damon Clear in the lower arch satisfies fee-sensitive patients. A-B. Pretreatment. C-D. Bonding. E-G. 9 months

Lingual therapy gives us the full capability of a fixed appliance that avoids the possible compromises with removable appliance therapy.

We offer lingual treatment as an option in all teen and adult case presentations — even for selected Phase I treatment. Lingual therapy gives us the full capability of a fixed appliance that avoids the possible compromises with removable appliance therapy. With lingual treatment, we have the same force capabilities and treatment control as labial therapy, so we never have to settle for a compromised treatment result. To increase patient comfort and lessen speech interferences in patients with restricted lower arches and/or considerable lower arch crowding, we sometimes recommend lingual appliances for the upper arch and esthetic labial brackets (Damon™ Clear) on the lower arch (Figures 5A-5G). We price this option more affordably than full lingual; so if the fee is a major consideration for particular patients, this combination can be quite satisfactory.

Conclusion Being able to offer efficient lingual treatment in lieu of an esthetic labial option is vital to competing in today’s competitive

market that has become extremely insistent on esthetic treatment. While patients in Southern California are certainly demanding of esthetic solutions, we don’t feel that they’re appreciably more demanding than most people across the U.S. In fact, even years ago, Dr. Jack Gorman had more lingual patients in Marion, Indiana, than doctors in larger metropolitan areas. With the recent modifications made to the Alias appliance, we are continuing to notice the speed and reliability of movement. Archwire sequence used on the case described below has been as follows: • 014CN, 016CN as initial wires • 16 x 16 CN • 18 x 18 CN • 016 TMA to be used for finishing stage We noticed decreased speech interference due to small bracket design and diminished initial discomfort from initial light forces. Excellent torque control is due to precise fit of the square archwire in the square bracket slot. Also, know the efficiency of self-ligating Volume 7 Number 6

CONTINUING EDUCATION

Figures 6A-6B: A. Class III patient being treated nonsurgically with UL Alias using Cl 3 mechanics. B. Fifteen months into treatment and approaching completion of treatment

mechanics with its resulting freedom of movement. With this bracket system, thereâ&#x20AC;&#x2122;s no need to settle for a non-fixed treatment alternative in cases where doing so could compromise treatment. Because we make this option readily available, it is rare that an esthetically demanding teen or adult patient will choose a labial option over lingual. Combine the indirect bonding setup and an efficient reliable bracket, there is no better time than now to incorporate lingual therapy into your practice. OP

REFERENCES 1. AAO study finds adults are seeking orthodontic treatment in record numbers. Orthodontic Products. Published October 30, 2013. http://www.orthodonticproductsonline.com/2013/10/aao-study-finds-adults-are-seekingorthodontic-treatment-in-record-numbers/. Accessed October 17, 2016. 2. Scuzzo G, Takemoto K, Takemoto Y, Scuzzo G, Lombardo L. A new self-ligating lingual bracket with square slots. J Clin Orthod. 2011;45(12):682-690.

Figure 7: Teen sisters and patients. The patient on the left is wearing STb, an earlier lingual appliance from Ormco. The patient on the right had previously worn clear removable appliances but switched to Alias when it became available. Patients interested in esthetics will rarely choose a labial option over lingual when given the opportunity Volume 7 Number 6

3. Turnbull NR, Birnie DJ.Treatment efficiency of conventional vs self-ligating brackets: effects of archwire size and material. Am J Orthod Dentofacial Orthop. 2007;131(3):395-399. 4. Chen SS, Greenlee GM, Kim JE, Smith CL, Huang GJ.Systematic review of self-ligating brackets. Am J Orthod Dentofacial Orthop. 2010;137 (6):726.e1-726.e18.

Orthodontic practice 41

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Treating cleft palate with presurgical nasoalveolar molding (PNAM) Dr. Thomas Wilson discusses an effective technique that can minimize the extent of surgery to repair cleft palate in newborns

ne of the most challenging conditions confronting the craniofacial healthcare team is treatment of cleft lip and palate. The many functional, esthetic, psychological, and sociological issues resulting from clefts and related craniofacial anomalies require a team approach using the expertise of professionals in many healthcare disciplines. A successful treatment result will depend on a combination of surgical, orthodontic/ orthopedic, and restorative care, as well as speech therapy and ongoing maintenance of the dentition. Treatment approaches and timing for cleft conditions remain a matter of debate even in our current era of advanced technology and knowledge. The basic goal of any approach to cleft lip, alveolus, and palate repair is to restore normal anatomy. Ideally, deficient tissues should be expanded, and malpositioned structures should be repositioned prior to surgical correction. This provides the foundation for a less invasive surgical repair. Historically, the use of presurgical infant orthopedic (PSIO) appliances or molding plate therapy has helped reduce the size of clefts of the alveolus and hard palate prior to surgery. Since its introduction by McNeil (McNeil, 1950), various techniques have been described for bringing the intraoral alveolar segments closer together in unilateral and bilateral cleft patients (Mylin 1969; Latham 1980). In 1997, Drs. Barry H. Grayson and Court B. Cutting at the Institute of Reconstructive Plastic Surgery at New York University Medical

Thomas Wilson, DDS, is a graduate of the University of Iowa College of Dentistry. He completed his residency in pediatric dentistry at the University of Florida and his residency in orthodontics at Emory University. Dr. Wilson is board certified in both pediatric dentistry and orthodontics. He maintains a private practice in pediatric dentistry and orthodontics in Des Moines, Iowa. Dr. Wilson also holds an adjunct position at the University of Iowa College of Dentistry.

42 Orthodontic practice

Educational aims and objectives

This article aims to discuss presurgical nasoalveolar molding for treatment of cleft palate in newborns.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 45 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Discuss some accepted treatment approaches for cleft conditions. • Identify the technique using presurgical nasoalveolar molding (PNAM). • Recognize some appliances needed for the PNAM procedure. • Recognize some clinical procedures for correction of the unilateral cleft using the NAM appliance. • Identify some physical reactions to look for during treatment to ensure that the infant is reacting well to the technique.

Center developed a new approach of presurgical nasoalveolar molding (PNAM). PNAM includes not only reduction of the size of the intraoral alveolar cleft through the molding of the bony segments, but also the active molding and positioning of the surrounding

soft tissues affected by the cleft, including the deformed soft tissue and cartilage in the cleft nose. This is accomplished through the use of a nasal stent that is based on the labial flange of a conventional oral molding plate and enters the nasal aperture. The stent provides support and gives shape to the nasal dome and alar cartilages. Presurgical nasoalveolar molding may be successfully employed in the early management of both the unilateral and bilateral cleft anomalies in newborns. These

Figure 1A: 2.5 weeks old

Figure 1B: NAM in place with taping

Figure 1C: 10 days before surgery

Figure 1D: 4 years posttreatment Volume 7 Number 6

Clinical procedures for correction of the unilateral cleft using the NAM appliance As soon as possible after birth, the infant is scheduled for an exam, and an impression of the cleft is made using a polyvinylsiloxane material. The impression is obtained with the infant awake and without any anesthesia. Care is taken to ensure that the material has reproduced the borders as well as the cleft area. The infant should be able to cry during the impression procedure. If no crying is heard, the airway is blocked. The impression is then poured in stone and trimmed. The cleft region of the palate and the alveolus can be filled with wax or silly putty to approximate the contour of an intact arch prior to fabrication of the molding appliance. The appliance is then made using clear orthodontic resin with a thickness of 3 mm to 4 mm. The appliance is mainly retained through extraoral facial tape and elastics. Also, no acrylic material should project into the cleft areas, as this will block the intended movement of the alveolar segments into their desired presurgical positions. The infant must be able to easily feed without gagging or struggling. If gagging is noted, the posterior extent of the appliance should be reduced. At the second appointment, if the infant is doing well, the appliance is modified to begin molding the alveolar cleft segments. This is accomplished through selective removal of acrylic from the area where the alveolar bone is to move. At the same time, a soft denture reline material is added to the area where bone is to be moved. These minor adjustments are made weekly. The ultimate goal of this sequential addition and selective grinding away of material is to reduce the size of the cleft gap and to have the two segments of alveolus contact with proper maxillary form. At this same appointment, an external retentive button is added at the site of the cleft. This retentive button helps seat the appliance and secure the retentive lip tapes and elastic bands (Figure 3). The taping of the cleft lip segments also serves to improve the alignment of the nasal base region by bringing the columella toward the midsagittal plane and improving the symmetry of the nose. Volume 7 Number 6

Figure 2A: Pre NAM 4 weeks old

Figure 2B: Nasoalveolar molding (NAM) appliance with stent

Figure 2C: NAM in place with taping

Figure 2D: After 3 months treatment with NAM, pre-surgery

Figure 2E-2F: 7 days post-surgery

Figure 3: Force vectors with NAM Orthodontic practice 43

CONTINUING EDUCATION

new techniques greatly improve upon the results usually achieved through traditional cleft palate appliances. The result is an overall improvement in the esthetics of the nasolabial complex, while minimizing the extent of surgery and the overall number of surgical procedures.

CONTINUING EDUCATION

Figure 4B: NAM with stent in place with taping

Figures 4C-4D: 3 months treatment with NAM

Figure 4A: Pre NAM, 1 week old

The infant is checked, and the appliance is modified every 7 to 10 days. When the cleft gap has been reduced to approximately 6 mm or less, a nasal stent is added, and active nasal cartilage molding begins. The nasal stent is a wire and acrylic projection that is placed inside the nasal dome on the cleft side of the nose. When properly placed and taped, blanching of the tissue overlying the tip of the nasal stent can be observed. The nasal stent also exerts a reciprocal intraoral molding force against the alveolar segments. The goal of the intraoral molding has the gingival tissues contact on either side of the alveolar ridge. Successful surgery can result even when a small cleft remains between the alveolar ridges. At the conclusion of intraoral molding and nasal stenting, the alveolar segments should be aligned and the nasal cartilages, columella, and philtrum should be properly repositioned to facilitate the first surgical procedure. This first surgery is usually performed between 3 and 4 months of age. The infant wears the appliance continuously up to the time of surgery. Following surgical repair of the lip, the lip is taped, and no intraoral appliance is used. The palate repair, if 44 Orthodontic practice

indicated, is usually performed at approximately 11 to 13 months of age. Cleft lip and palate patients pose special challenges for the treating dentist and require a team that involves several healthcare disciplines. An early coordinated team provides an accurate diagnosis, preventative and treatment regimens, ongoing evaluation and maintenance and can produce results that vastly improve the function, esthetics, and overall quality of life for patients. OP

Acknowledgment Dr. Wilson appreciates the skill and expertise of craniofacial and children's reconstructive surgeons, Samuel Maurice, MD, and W. Dale Franks, DDS, MD. These individuals are dedicated to the health and well-being of children with craniofacial anomalies and seek to promote an optimal surgical outcome for these children.

REFERENCES 1. McNeil CK. Orthodontic procedures in the treatment of congenital cleft palate. Dent Rec. 1950;70(5):126-132. 2. Mylin WK, Hagerty RF, Hess DA. Modern concepts in the treatment of unilateral cleft lip and palate. South Med J. 1969 Feb;62(2):171-174.

Figure 4E: 2 years post surgery

3. Latham R. Orthodontic advancement of the cleft maxillary segment: a preliminary report. Cleft Palate J. 1980;17(3):227-233. 4. Grayson BH, Santiago PE, Brecht LE, Cutting CB. Presurgical nasoalveolar molding in infants with cleft lip and palate. Cleft Palate Craniofac J. 1999;36(6):486-498.

Volume 7 Number 6

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

REF: OP V7.6 SMITH/PAZ REF: OP V7.6 WILSON

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

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Using lingual appliances for optimal esthetics and minimal compliance issues

Treating cleft palate with presurgical nasoalveolar molding (PNAM)

SMITH/PAZ

WILSON

An October 2013 AAO survey, entitled “The Economics of Orthodontics,” found that the number of orthodontic starts in the U.S. and Canada increased 20% between 2010 and 2012 with a _______ increase in the number of adult patients over the age of 18 during that same period. a. 5% b. 14% c. 30% d. 50%

Lingual offers a high level of care with ________. a. more GPs offering this option b. optimal esthetics c. minimal compliance issues d. both b and c

In such cases (when a removable appliance is not an option), if _________ will not satisfy the patient esthetically, lingual treatment is a powerful tool to have at the clinician’s disposal. a. metal labial b. clear labial c. STb d. both a and b

Additionally, patients who originally come in seeking clear removable therapy, when apprised of its compliance aspect, __________. a. continue to pick that option b. often opt for lingual treatment instead c. decide against orthodontic treatment d. seek another orthodontist’s opinion on treatment options

With passive labial self-ligation, the standard .022 x .028 rectangular slot does not facilitate rotational control until placing ________ wires. a. .018 x .025 Ni-Ti b. .019 x .025 Ni-Ti

Volume 7 Number 6

c. .014 x .025 Cu Ni-Ti d. .016 x .025 stainless steel 6.

Given the greater inter-bracket width and the .018 x .018 square slot — exclusive to the Alias PSL lingual appliance — clinicians can realize the benefits of early rotational and torque control with ________ archwires. a. smaller diameter b. more flexible c. larger diameter d. both a and b

The _____ wire is an excellent wire to gain both rotational and the first stage of torque control. a. .016 x .016 Cu Ni-Ti b. .018 x .025 Ni-Ti c. .016 x .025 stainless steel d. .017 x .025 stainless steel

According to the authors, self-ligation ________ clinical chair time compared with steel ligation or double over-tie elastomers. a. has no appreciable effect on b. increases c. appreciably reduces d. is equal to

Lingual therapy gives us __________ a fixed appliance that avoids the possible compromises with removable appliance therapy. a. the full capability of b. a fraction of the capability of c. less movement than d. a less painful alternative to

10.

We noticed decreased speech interference due to _________ and diminished initial discomfort from initial light forces. a. round bracket design b. small bracket design c. archwire sequence d. robotically controlled wires

(To restore normal anatomy) Ideally, deficient tissues should be expanded, and malpositioned structures should be repositioned _______ surgical correction. a. prior to b. after c. simultaneously with d. to avoid Historically, the use of presurgical infant orthopedic (PSIO) appliances or molding plate therapy has ________ the size of clefts of the alveolus and hard palate prior to surgery. a. interfered with b. helped reduce c. helped increase d. had no effect on

The stent _______________. a. provides support b. gives shape to the nasal dome c. gives shape to the alar cartilages d. all of the above

The result is an overall improvement in the esthetics of the nasolabial complex, while _________________ . a. minimizing the extent of surgery b. minimizing the overall number of surgical procedures c. totally eliminating the need for surgery d. both a and b

As soon as possible after birth, the infant is scheduled for an exam, and an impression of the cleft is made using _______ material. a. zinc-oxide eugenol b. impression plaster

c. a polyvinylsiloxane d. an alginate 6.

The impression is obtained with the infant awake and _______ anesthesia. a. with b. without any c. with local d. under heavy

The infant _________ during the impression procedure. a. should be able to cry b. should not be able to cry c. should be completely under sedation d. none of the above

When the cleft gap has been reduced to approximately _____, a nasal stent is added, and active nasal cartilage molding begins. a. 6 mm or less b. 8 mm c. 9 mm d. 10 mm

This first surgery is usually performed between _____ of age. a. 6 and 8 weeks b. 3 and 4 months c. 6 and 7 months d. 8 and 9 months

10. The palate repair, if indicated, is usually performed at approximately _____ of age. a. 5 to 6 months b. 7 to 9 months c. 10 months d. 11 to 13 months

Orthodontic practice 45

CE CREDITS

ORTHODONTIC PRACTICE CE

LABORATORY LINK

3D printing in orthodontics James Bonham and Arlen Hurt review innovations in 3D-printing technologies

D printing continues to march forward in what many experts call the next industrial revolution. Also known as additive manufacturing, 3D printing is the process for making a physical object from a three-dimensional digital model file by laying down successive thin layers of a material. 3D-printing technology is changing the way products and prototypes are produced in every industry, including advancements in the dental industry. The purpose of this article is to review several common 3D-printing technologies used in today’s dental market. 3D printers rely on 3D scanners and CAD software to create and manipulate printable data files. 3D scanners can be direct or indirect. Direct scanners are in contact with the object, while indirect scanners gather information with the scanner away from the object. Most dental scanners use the indirect capture technique. All scanners are prone to missing data and rely on CAD software to fill the voids of missing data. It is always important to carefully review your dental scans for accuracy prior to starting the printing process. After the scan data has been captured, the 3D model files need to be sealed and identified before it can be sent to the 3D printer. A third-party additive printing software such as Netfabb® is used for printer preparation. The 3D printer’s software then slices the model file into very small layers. These thin layers are then reconstructed during the printing process. Printers vary in their resolution capabilities. High-resolution printers will lay thinner layers and produce

a surface that is smoother than low-resolution printers. There are multiple additive printing technologies available, including Vat Photopolymerization (light polymerization), Material Jetting, Binder Jetting, Material Extrusion, Powder Bed Fusion, Sheet Lamination, and Directed Energy Deposition. At Specialty Appliances laboratory, we currently use three different 3D-printing technologies to fabricate dental models. Each technology has strengths and weaknesses that we will discuss.

VAT Polymerization

SLA is the most common form of VAT Polymerization printing

The first type of light polymerization that we use is stereolithography (SLA or SL). Stereolithography is an additive manufacturing process that works by focusing an ultraviolet (UV) laser on to a vat of photopolymer resin. This process creates parts when a laser passes over the resin, using photo polymerization to cure each layer. SLA advantages include a relatively fast print

speed. Printed models are strong and make great master molds. Disadvantages of SLA printing include a higher cost of ownership, and post-processing requires a chemical bath before being placed in a UV curing oven. Another VAT Polymerization technology is Digital Light Projection (DLP). DLP technology is used in cinemas, classrooms, and

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. As Vice President and partner at Specialty Appliances, Arlen Hurt, CDT, has dedicated the past 30 years to orthodontic appliance innovation. Mr. Hurt is recognized as an award-winning inventor, published author, and national orthodontic speaker. He is best known as one of the most dependable resources for orthodontists everywhere.

DLP has the fastest print speeds and a low cost of ownership for in-office use 46 Orthodontic practice

Volume 7 Number 6

LABORATORY LINK in rear projection televisions. In 3D printing, this energy source is projected onto a photo polymer to create 3D models. DLP technology exposes one complete layer in a single shot, creating much faster print times compared to point-by-point technologies. The layer thickness is adjustable to sub-50 Îźm resolution on the image plane. DLP printing shares the same advantages as SLA printing, but it is faster and offers a lower cost of ownership. Disadvantages of DLP technology include the same chemical bath and UV curing for post-processing as with SLA technology.

Material Jetting This process is very similar to an inkjet printer, but the print head drops photopolymers instead of ink. Two materials are used in this process. A build material is accompanied by a filler material to help create difficult geometries. A UV light cures both materials as their layers are dropped. Post- processing involves soaking the model, then using a high-powered water jet station to remove the fill material. Material jetting has advantages such as consistent accuracy, and no chemicals are necessary for post-processing. Multiple materials can also be incorporated in a single print job. Disadvantages include a noisy and technique sensitive pressure washer for post-processing. The material cost is higher than any other 3D-printing technologies covered in this article.

Material Jetting is a reliable form of 3D printing and is great for high volume print jobs

3D-printing technology is changing the way products and prototypes are produced in every industry, including advancements in the dental industry.

Material Extrusion Material Extrusion is also referred to as FFF (Fused Filament Fabrication). Parts are produced by extruding small beads of melted material, which harden immediately to form object layers. A spool of hermoplastic filament is unreeled to supply material to an extrusion nozzle head. The nozzle head heats the material and turns the flow on and off. Typically stepper motors are used to move the extrusion head and adjust the flow of material as the layers are placed. Advantages include a wide range of materials and the lowest cost of ownership. There is also no post-processing required for FFF printers. Disadvantages include visible layer lines and longer build times compared to other printing technologies. Temperature fluctuations during production can cause issues like delamination. To learn more about 3D printing for your orthodontic office, contact Specialty Appliances. OP 48 Orthodontic practice

No post-processing is required with FFF printers. The resolution can be as high as 10 microns Volume 7 Number 6

PRACTICE DEVELOPMENT

What you need to know about online reviews for your practice Ian McNickle, MBA, discusses the importance of a strong online presence

magine you’ve just arrived in a city you’re not very familiar with, and it’s dinnertime. What do you do? Well, if you’re like most people these days, you’ll pull out your smartphone and search online review sites such as Yelp for nearby restaurant reviews. In fact, over 90% of consumers now read online reviews to help them decide where to go and what to buy.* While it is true the most commonly searched category for online reviews are restaurants, most people don’t realize the second most commonly searched category for online reviews is dentists/doctors.* The days of ignoring your online reviews are over.

Why do reviews matter? There is a major trend toward patients researching their healthcare providers before visiting an office, even if they were referred by a friend or another healthcare provider. In fact, recent surveys have found that 80% of consumers trust online reviews just as much as personal recommendations from someone they know.* For many people, this is an amazing statement, but the reality is our society is changing at a rapid pace, and dental practices simply must focus on their online reviews and online reputation.

The “Big Four” review sites for dentistry In the dental industry, the most important review sites are Google+, Yelp, Healthgrades®, and Facebook®. 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” 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 WEO Media online at www.weodental.com.

Volume 7 Number 6

Google represents about 65% of all online search traffic and features its own reviews from Google+, so those reviews will generally attract more readers than other review sites. Reviews on Google+ have the added benefit of helping your website SEO perform better in online searches related to dentistry. Yelp has become one of the leading review sites in the country and regularly ranks highly in local search results when people search for dentists. In addition, the Bing search engine displays Yelp reviews as its primary reviews shown in search results. Healthgrades is the largest healthcare directory and review site in North America and has over 1,000,000 visitors per day. As with Google+ and Yelp, a solid Healthgrades profile helps both online reputation and website SEO. Over the last few years, Facebook reviews have become increasingly important since Facebook is the dominant social media site. Facebook has over 1.7 billion regular users, and most of them look at reviews on Facebook business pages when researching a business.

What can you do for your dental practice? To get the maximum benefit from these review sites, we recommend the following strategies:

1. Completely fill out your review site profile pages with business information, photos, videos, office hours, specials, and any other relevant information about your practice. 2. Link to your review sites from your website to encourage existing patients to write reviews, and potential new patients to read your reviews. 3. Implement a proactive strategy to generate more patient reviews on these review sites. However, we highly recommend you contact your state dental association or Dental Board to make sure you understand the rules for soliciting reviews from patients in your state. 4. Embed your positive patient reviews directly into your website.

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

REFERENCE *

Bright Little Light, Ltd. Local consumer review survey 2015. BrightLocal. https://www.brightlocal.com/learn/localconsumer-review-survey/. Accessed September 22, 2016.

Receive your free marketing consultation today: 888-246-6906 or info@weomedia.com Orthodontic practice 49

PRACTICE MANAGEMENT

Designing a dynamic digital team: part 1 Dr. William E. Crutchfield discusses how to design a dynamic digital orthodontic team that is primed for success

have been practicing orthodontics for 30 years. For the first 20 years, everything seemed to be the same. Maybe some of the things got a little sexier and maybe a little sleeker like braces, elastics, etc., but it was still the same. Then the wonderful world of digital and three-dimensional orthodontics and the digital orthodontic office came onto the scene. What a leap to a higher plateau. We are now able to diagnose and treat our patients more efficiently and better as well as delegate more functions to our team. There is not one position in the orthodontic office that is the same as it was, even 2 years ago. The paradigm has certainly shifted, and staff knowledge and skills have evolved. I am so glad that I chose technology to be my new associate 10 years ago. But, what about our team? Where do they fit in? What personnel and what skills do we need in the digital office in order to be successful in the digital orthodontic world? Your new digital team will need to have a broader and more sophisticated working knowledge. It is up to you, the digital orthodontist, to design your dynamic digital orthodontic team that is primed for success. Designing a dynamic digital orthodontic requires attention to the following five areas: 1. Identifying the needs of the office 2. Assessing your current team and identifying their skills 3. Hiring team members to address the team needs 4. Training the team members 5. Leading and managing the team Two points to remember during the designing process: The digital team will be dynamic and in constant motion. It will also be

Orthodontics by Crutchfield (OBC) staff

synergistic. The power of team members together is greater than the individual team members alone. In order to have a functionally efficient team, all five areas must be a constantly evaluated and modified to improve your team. It is your responsibility as team leader, not as boss, to keep the team progressing by broadening their scope and expanding their skills. Assessing the needs of your office is the critical first step. This requires a little dreaming. Wave the magic wand. In your ideal world, without regard to money, space, etc., consider your vision of an ideal office. How would it operate and with what personnel? All team members should have input on this. From the collective information gleaned, identify your office’s ideal team tasks, and identify the skills that an ideal team member would possess in each position. Now, you have a rough profile of the ideal employee(s). So what skills do your team members need? This is hard to answer since every team is different. However, at the very least, your team needs to have a good working knowledge of the Microsoft® Office Suite, basic computer functions, skills, and IT, as well as Internet and social media skills. This is all in addition to the skills needed for specific office and orthodontic clinical tasks. Your current team members, of course, have the inside track to the new digital office

William E. Crutchfield, DDS, is a Diplomate of the American Board of Orthodontics and and received his dental degree from Virginia Commonwealth University, Medical College of Virginia. He is on the suresmile® Clinical Advisory Board. Dr. Crutchfield is in private practice in Chantilly, Virginia, a suburb of Washington, D.C. As a 100% suresmile user, he often speaks on the digital team, digital orthodontic care, and digital team delegation. Dr. Crutchfield may be reached at drcrutchfield@gmail.com. Disclosure: Dr. Crutchfield does not have any financial interest in suresmile or any other product mentioned in this article.

50 Orthodontic practice

concept. There are skills and talents that some of your current team members possess that can benefit your team design and work in your digital office — “Mad skills” if you will. For example, some of your team may be great at Photoshop, social media, Excel, or IT. Other members may have better people skills than other team members. Having the right attitude to acquire new skills and not being afraid of change are critical to team success. The key is to have a team that is eager to learn and is not averse to change. This must be the team ethos. I always tell our team, “I don’t care how much you know, but do care how much you learn.” This also applies to you, the team leader. If you do not believe, your team will not believe. And here is an unsettling thought, doctor — you probably are not and will not be the best digital performer on the team. That is why effective delegation is important. You have to have team members who are up for the challenge. When hiring new team members, you need to look outside of the dental or orthodontic world. Placing an ad in the traditional “dental” areas of the traditional media may not be fruitful. There are plenty of people who have been burned by the corporate world. They are looking to make a change. You offer something very unique: a chance to make a difference in someone’s life. This is a powerful concept. We orthodontists cannot usually compete on the corporate pay scale. However, you do offer a clean, fun, and rewarding career with consistent hours and a happy environment. Therefore, using today’s online job placement sites and placing your job notice in non-dental areas may be more productive. For instance, there may be a receptionist, hairdresser, massage Volume 7 Number 6

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PRACTICE MANAGEMENT

therapist, etc., looking to make a change. conventional team. Your leadership needs dear doctor, must get out of the way, and let Your goal is to find these people and have to be more supportive than directive. You them do it. You have to trust in their skills and programs in place to effectively place them have hired these people to do a job. You, my you have to trust in your training. With digital and their skills into your digital office. orthodontics and a skilled team, you also Training for the digital team is different have the opportunity to delegate more from the conventional orthodontic skills tasks. Therefore, as head of this great training. Yes, the basic orthodontic team, it is important that “situational” terms and techniques need to be leadership is brought into play (Figure 1). You must work to learn what motivates taught. However, other skills are needed. Team members need to know how to all team members, how they like to learn, maneuver in the computer world easily and how they like to do their own jobs. and freely. For instance, everyone in the The days of being highly directive are clinic should know how to scan patients, over. As one of my friends, a principal in digitally analyze cases, align teeth digia well-known company, told me, “I hire tally, do treatment simulations, order thoroughbreds and let them run.” Not bad customized orthodontic wires, and virtuadvice. Hire, train, and get out of the way. ally bend or modify orthodontic wires. Digital orthodontics is an exciting Since digital orthodontic information, new world. However, it can be very frustrating without the proper personnel. As products, and techniques are evolving leader of this exciting venture, you, the at a faster rate, it is a lot of information for your team to absorb. Therefore, it is doctor, as leader need to generate the important that team training be consisenthusiasm and have systems in place tent, frequent, and interactive to keep the to select, train, manage, and promote team sharp, focused, and progressing. the team you design. Productivity will Managing your new dynamic digital increase, and your stress will decrease. Enjoy the ride! OP team is different from managing a Figure 1: Leadership styles (source: K. Blanchard and P. Horsey, 1960)

PRODUCT PROFILE

Air-Free 90º by Medidenta

he story behind the origination of the one-of-a-kind Air-Free handpiece series is interesting. The idea actually originated from you, the doctor. While attending many of the dental trade shows and exhibitions, we have had many orthodontists inquire about our surgical highspeeds. We took notice and started asking why an orthodontist is paying more money for a surgical handpiece — something designed specifically for oral surgery. We soon found out that the doctors were seeking a highspeed that did not expel any air onto the working site because the air caused increased sensitivity to the patient. While the 45° angle of the surgical handpiece was cumbersome to use, especially for debonding procedures, the doctors were still committed to providing the best dentistry they could and ensuring the most comfort for their patients. This gave us an opportunity to provide a perfect solution for these dedicated practitioners. We designed a 90° highspeed that does not expel any air out the head of the handpiece — one better than the typical surgical handpiece that expels air from the rear headcap on the head of the unit. All the air is redirected and exited through the dedicated pilot holes in the rear of the handpiece. This gave birth to the Air-Free 90º and the rest of the Air-Free Series. The Air-Free 90º not only reduces the sensitivity for the patient but also empowers the orthodontist with many other advantages. For instance, since there is no air to the procedure site during debonding, there is no longer any adhesive residue flying around the patient’s mouth creating the “powdered donut” effect. In addition to that, since the residue isn’t being displaced all over the patient’s mouth, the remaining adhesive on the surface turns to what looks like frost, which can act as an indicator that there is still adhesive that needs to be removed. With all of the aforementioned advantages, along with 20 watts of power and a titanium coated body, this handpiece line can benefit all types of practices. Whether it be Orthodontics, Pediatrics, Periodontics, Oral Surgery, Endodontics, or even General Use — the Air-Free can be a great addition to your practice. Visit www.medidenta.com, or call 800-221-0750 for more information. OP This information was provided by Medidenta.

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Volume 7 Number 6

PRODUCT PROFILE

Prophy Magic

rophy Magic is your direct source for high-quality products at factory-direct prices. We specialize in disposable prophy angles and offer free incentives with EVERY purchase such as our hygiene handpiece or disposable air/water syringe tips. Prophy Magic is committed to Excellent Customer Service paired with exceptional offers that will save your practice money. We at Prophy Magic understand the challenges of today’s tough economic times and thrive to keep the costs low, quality high, and to build a lifetime relationship with you and your practice. Prophy Magic prophy angles are very smooth running with no stalling or overheating. Our prophy angles provide less splatter and better flaring for better subgingival access. All of our prophy angles are all made 100% latex-free. Our standard prophy angles come in three different cup variations — soft, hard, and our signature Mystic cup. Our Mystic cup prophy angle has unique, diamond-shaped bumps on the external surface to help improve interproximal and lingual cleaning. Their internal webbing has counterclockwise, turbine-like fins that impel the prophylaxis paste to polish more quickly

Prophy Magic prophy angles

and effectively. This configuration also greatly reduces the splatter of paste and saliva. For our orthodontic patients, Prophy Magic is pleased to offer two new prophy angle types. We now offer a tapered brush and a pointed polisher. The tapered brush is ideal for heavy stain removal and is great for orthodontic cleanings and applications. The tapered brush also provides exceptional access to occlusal pits and fissures. Our pointed polisher is also great for heavy stain removal and orthodontic cleanings, providing hard-to-reach access under ortho wires and around brackets. For pediatric patients, Prophy Magic has added our KiDDOZ Prophy Angles. The 100%

latex-free prophy angles are available in five fun designs that greatly help to reduce young patients’ anxiety. The young patient can pick from a bird, pig, panda, fish, or a seahorse. These fun angles have a soft webbed/ribbed cup design for maximum splatter control and are available in 100-count assorted boxes. Our hygiene handpiece is the ideal handpiece for doing prophylaxis. It is ergonomically balanced and designed with a weight less than 3 ounces greatly reducing fatigue. It has a detachable friction-grip nose cone that allows you to easily insert and remove prophys without having to turn and lock. The motor itself is actually a standard “E-type” motor and also allows for other attachments, such as contra angles or straightnose cones, making it extremely versatile. This handpiece is offered as a FREE incentive with your prophy angle purchase. For more information, visit www. prophymagic.com, or call 866-54-MAGIC (62442). OP This information was provided by Prophy Magic.

Prophy Magic motor

Prophy Magic brush and pointed polisher 54 Orthodontic practice

Volume 7 Number 6

$500 $500 $500

prophy angles

BOOK REVIEW

Global Diagnosis: A New Vision of Dental Diagnosis and Treatment Planning J. William Robbins, DDS, MA, and Jeffrey S. Rouse, DDS 232 pages, 563 photos, tables and illustrations, $148.00 Quintessence Books, 2016

r. Welden Bell, the quintessential orofacial pain and TMD diagnostician, once presciently declared that dentists, by training and patient expectations, were therapists, not diagnosticians. Unfortunately, for dentists and their patients, that dental defect has existed far too long. For that reason, this new Quintessence publication by Robbins and Rouse offers a welcomed beginning for the antidote to that embarrassing defect in the dental curriculum. This sensible and complete diagnostic regimen did not spring full-grown from a single inspired insight; rather it has evolved from years of experience, close observations, and professional collaborations these remarkable clinicians have had. As befits such a comprehensive subject, the authors have marshaled the expertise of 19 other clinicians and technicians with their skills, practice, and knowledge to answer the five CORE questions of the Global Diagnosis: 1. What are the facial proportions and skeletal relationships? 2. What is the length and mobility of the upper lip? 3. What is the relationship between the gingival line and the horizon? 4. What is the length of the maxillary central incisor? 5. Is the CEJ palpable in the gingival sulcus? The traditional dental diagnostic regimen has been one of several regional diagnoses rather than a “global” or inclusive one that determines where the teeth fit in the mouth and face and what techniques could combine to make that happen; hence, the facially generated diagnosis. The authors have devoted chapters to explaining the analysis they use and then adding sections regarding methods that allow 56 Orthodontic practice

them to implement the Global Treatment Plan such as crown lengthening, tissue grafting, dentoalveolar intrusion and extrusion, forced eruption, orthognathic surgery, and even a chapter on dentofacial plastics via BOTOX® and dermal fillers. The final sections concern sequencing the treatment plan, explaining the CORE Template, which has an attached CD that contains its forms and messages, and a final chapter of patient treatments. Esthetically, the book displays features readers typically associate with Quintessence

publications — e.g., succinct but clear narratives, thick durable pages, elegant colored photographs, and pleasing page layouts. The authors provide ample bibliographies to support their beliefs. Clearly, a more comprehensive text on dental esthetics does not exist. This book not only belongs in every dentist’s library, but also needs inclusion in every dental school’s curriculum. OP

Review by Larry White, DDS, MSD

Volume 7 Number 6

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This advertisement accompanied the mailing of the November/December issue of Orthodontic Practice US. It did not appear within the pages of the magazine. The views, opinions and statements within this advertisement are solely those of Propel Orthodontics.