Orthodontic Practice US Vol 8 No 2, March-April 2017 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews

PROMOTING EXCELLENCE IN ORTHODONTICS Early treatment of anterior open bites Dr. Bradford N. Edgren

A review of suresmile®: efficiency and effectiveness Dr. Rohit C.L. Sachdeva

Drs. Amy H. Hoch, Gerald Hoch, Analia Veitz-Keenan, Olivier Nicolay, and George J. Cisneros

Corporate profile MidAtlantic Orthodontics

Two-step retraction versus en masse retraction during maxillary space closure

30% LESS TREATMENT TIME? PRECISELY.

March/April 2017 – Vol 8 No 2

Practice profile Dr. Marc Olsen “What can be accomplished is often nothing short of amazing.” Jeff Johnson, DDS, MS Dallas, TX

Go to page 31 to learn more.

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OPTIMAL AESTHETICS. PROVEN PERFORMANCE. The Inspire ICE monocrystalline bracket features crystal-clear sapphire finishing for optimal aesthetics and unparalleled strength1 that provides clinical performance during treatment while also offering safe, easier, single piece removal.2

To learn more, visit ormco.com, call 800-854-1741, or speak with your Ormco representative. 1. Fracture Strength of Ceramic Bracket Tie Wings Subjected to Tension Gerald Johnson, DDS; Mary P. Walker, DDS, PhDb; Katherine Kula, DDS, MSc Angle Orthodontist, Vol 75, No 1, 2005 2. Angle Orthodontist, Vol 85, No 4: 651-656, 2015

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EDITORIAL ADVISORS Lisa Alvetro, DDS, MSD

Digital orthodontics is changing everything

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

© FMC 2017. 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 8 Number 2

recall how proud I was as a boy when I was “mature” enough to own a Swiss Army knife. After seeing it, I remember wondering why they even called it a “knife.” With all its other capabilities, simply calling it a knife somehow diminished its true usefulness. After 8 years in the digital orthodontic world, I’m feeling the same way about technology. In 2009, I chose to move to a digital technology platform, which would help me finish my cases to within fractions of a millimeter-precision that I was unable to achieve otherwise. I overcame the initial financial commitment, a significant learning curve, and a server-based technology that limited my mobility. Over the past 8 years, I’ve seen so many improvements that technology touches nearly every area of my practice. I can’t imagine going back to “the way things used to be.” To characterize this transition as simply a way to bend finishing wires absolutely diminishes the capabilities it gives me. Adios, servers! Where I used to be tethered to a local server, most of my technology is now cloud-based. With no server, my financial commitment dropped to near zero. My cases are now accessible anywhere I have Internet access. What this means is that now I have unprecedented opportunities for collaboration. My virtual “team” is always with me. I can share files electronically with referring doctors or an out-of-town parent. I can show patients why elastic wear is critical and help them to understand why. I can collaborate with mentors across the planet and teach new users remotely. Superpowered diagnostics Where I used to align crowns of teeth, I am now able to see crowns, roots, and bone. I can “try out” different scenarios easily — extraction/non-extraction, surgical/nonsurgical. I can even determine how much molar intrusion is necessary to close an open bite. I have a Bolton analysis on every patient, and I can discuss restorative needs or determine IPR before I start. I can also see the occlusal relationships from the lingual, a huge benefit not available before. Targeting precision with IDB One of the best ways to reduce treatment time and minimize unwanted movement is bonding brackets in optimal positions. I build an ideal digital setup with great tools. I don’t have to guess at smile arc — I can see the upper anteriors and how they overlay the lower lip. I can see roots and bone and how they relate, and I plan final positions safely. I see the occlusion from all positions, and I can plan where I want to put contacts. Before we bond, I plan IPR and restorations, all with precision. After I’ve built the ideal setup, ordering the custom IDB is just one click. (By the way, this system is “bracket-agnostic” in that I can use whatever bracket set I like — I’m not limited to one manufacturer.) Lingual with ease Lingual braces are so difficult to position and manage that most orthodontists shy away from offering them. Using our technology, I can do an ideal setup and IDB brackets, and order all custom wires at the get-go. The company I work with even provides a mentor for consultation. Clear aligners Not all aligners are the same. Now I can do an ideal setup (with or without roots/bone), add virtual “bumps” to the teeth, and then, with one click, have a series of custom models with incremental changes. I determine the limits of movement, and the models are printed and delivered to the office, so we can fabricate clear aligners. I can also print them on my new 3D printer, all for a ridiculously low lab fee. It changes my “clear aligner” game! Jump in! I’m sure you’ve heard or maybe even thought that using digital technology providers like suresmile® (the one I use) is simply a more precise way to make finishing bends. (I’ve even heard an orthodontist say, “It’s for orthos who don’t know how to bend wires.”) This is far from the truth. In my office, while it does bend a wonderful finishing wire, it is much more than that. Whether improving visualization, allowing tryout of different treatment plans, allowing me to precisely bond whatever brackets I like on an ideal setup, making lingual orthodontics predictable and manageable, or supporting in-house clear aligner therapy, digital technology is truly the Swiss Army knife of orthodontics. If you haven’t jumped into the digital world, I encourage you to do so right away. The cost and learning curve to entry have dropped to where you’ll have an “easy button” to success.

Louis G. Chmura, DDS, MS, PC, an ABO Diplomate, received his MS in orthodontics from the University of Michigan in 1987 and has been in private practice in Marshall, Michigan, since 1991. Dr. Chmura has a special interest in systems and incorporating new technology (suresmile®, TADs, laser, cone beam CT, home sleep testing) and diagnostic considerations, including smile design and sleep apnea, into the orthodontic practice. Dr. Chmura is the first orthodontist to complete Advanced Laser Proficiency, as well as the first Orthodontic Fellow of the Academy of Laser Dentistry. He is a member of the American Academy of Dental Sleep Medicine and is on the Schein Orthodontic Sleep Advisory Board.

Orthodontic practice 1

INTRODUCTION

March/April 2017 - Volume 8 Number 2

TABLE OF CONTENTS

Financial focus Is your retirement plan tax savvy?

Practice profile Marc Olsen, DDS

Building an authentic practice

Tom Zgainer discusses the impact of taxes on your financial future ....................................................... 15

Clinical case study Management of facial asymmetries — true skeletal or functional shift Drs. Jamie Y. Kim, Chung How Kau, and Ahmet A. Celebi show a patient’s progress through treatment............ 18

Orthodontic insights Orthodontics is moving forward Dr. Richard P. McLaughlin discusses current trends in orthodontics .......................................................24

Orthodontic concepts A review of suresmile®: efficiency and effectiveness — sprinkled with a dose of self-reflection Dr. Rohit C.L. Sachdeva reviews the benefits of suresmile .......................28

Corporate spotlight

MidAtlantic Orthodontics ON THE COVER Photo on cover courtesy of Dr. Bradford N. Edgren. Article begins on page 36.

2 Orthodontic practice

Volume 8 Number 2

Find GAC and Raintree Essix at AAO BOOTH #2414

Dentsply Sirona Orthodontics

Changing the Face of Orthodontics Together Recently DENTSPLY and Sirona united to form the world’s largest manufacturer of professional dental products and technologies—Dentsply Sirona. With the formation of this new company, we are proud to introduce Dentsply Sirona Orthodontics, a division that includes DENTSPLY GAC and DENTSPLY Raintree Essix. Dentsply Sirona Orthodontics is empowering professionals by enhancing diagnosis and treatment capabilities, expediting case progression and improving oral health worldwide. While this new division represents the evolving scope of the company, one thing that will not change is the trusted relationship shared between each practice and their respective GAC and Raintree Essix representatives. So while you will see the new face of Dentsply Sirona Orthodontics on our packaging, print ads, brochures, and more, you can be confident that you will continue enjoying the same outstanding service you’ve come to expect. Find out more on dentsplysirona.com

TABLE OF CONTENTS

Continuing education Two-step retraction versus en masse retraction during maxillary space closure Drs. Amy H. Hoch, Gerald Hoch, Analia Veitz-Keenan, Olivier Nicolay, and George J. Cisneros discuss multiple factors that contribute to whether clinicians select one technique over another................... 44

Continuing education Early treatment of anterior open bites

Dr. Bradford N. Edgren discusses effective treatment to achieve stable results for anterior open bites

Product profile Air-Free 90º from Medidenta Dr. David A. Chenin discusses a handpiece that is beneficial to the orthodontic practice........................ 56

AAO preview Maximize your potential at 2017 Annual Session of the American Association of Orthodontists .......................................................48

Practice development Top five dental marketing scams Cory Roletto, MBA, discusses some marketing tactics to avoid................52

Technology Remote monitoring of treatment — less time, more control Dr. Terry Sellke discusses a smartphone-driven technology to increase efficiency ..........................54 4 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

Book review Competing Against Luck by Clayton M. Christensen, Taddy Hall, Karen Dillon, and David S. Duncan ....................................................... 58

ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkaz.com NATIONAL SALES DIRECTOR | Kristin Sammarco Email: kristin@medmarkaz.com CLIENT SERVICES/SALES SUPPORT | Adrienne Good Email: agood@medmarkaz.com CREATIVE DIRECTOR/PROD. MGR. | Amanda Culver Email: amanda@medmarkaz.com

Materials & equipment.........................60 Small talk Truth and fact Dr. Joel C. Small discusses the need to develop critical thinking as a means to defining and creating our preferred future...............................................63

Industry news...............64

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

Marc Olsen, DDS Building an authentic practice

Dr. Olsen treating a patient

What can you tell us about your background, and why you decided to become an orthodontist? I grew up in Bountiful, Utah, which is just north of Salt Lake City. I never planned to be an orthodontist, or even go into the dental industry for that matter. My father had an orthodontic practice, and my two older brothers were also entrenched in learning the industry. I was convinced it wasn’t for me. Instead, I was planning to study veterinary medicine. I’ve always had a love for animals and had been working for a horse trainer in California at the time. My career goal changed, however, when someone very wise once told me, “If you want to own a healthy horse, don’t become a veterinarian because you are always working on other people’s animals, and won’t have time for your own.” For some reason, this stuck, so I applied to the University of Utah and went from there. After completing my undergraduate degree at the University of Utah, I continued on to the University of Iowa where I earned my 6 Orthodontic practice

Doctor of Dental Surgery degree. Funny side story about my time at Iowa, actually. I met my wife, Janine, there while completing my dental degree, and we came to find out that we grew up just five blocks away from each other in Utah. Talk about a small world! From there, I went on to receive my Orthodontic Certificate at Indiana University. I completed Indiana’s dual-specialty program for orthodontics and prosthodontics. What’s cool about this is that I was the first to complete this dual program at Indiana; typically students complete each degree one at a time. Today, I operate my practice, Olsen Studio Ortho, out of Billings, Montana, and Lander, Wyoming, and my passion for what I do is second to none. We have a total of six locations, the two main offices and four satellite locations; and my wife, Janine, helps steer the ship at all offices.

How long have you been practicing, and what appliances do you use? I have been practicing orthodontics for

more than 16 years, and love the opportunity it’s given me to make a positive difference in the lives of the people in my community. One of the flagship products that my staff and I use is the Damon™ System by Ormco™. In fact, in April of this year, I’ll be celebrating my practice’s 10-year anniversary of using the Damon System. This advanced, efficient, esthetically pleasing orthodontic Volume 8 Number 2

PRACTICE PROFILE

treatment system has been instrumental in the growth and success of my practice. It’s interesting how I came to be such a believer in the Damon System. As I began looking for a new system to use in my practice, I knew one thing for certain: I wanted to subscribe to a treatment philosophy that I could really and truly be passionate about. In 2007, I attended an industry meeting at the Montana State Orthodontic Society Meeting where Dr. Derick Tagawa was speaking about the Damon System. I remember looking around the room and thinking to myself, There are orthodontists in this room approaching retirement — in their mid to late 60s — but they’re operating with the passion and excitement of doctors who just opened their practice. Their excitement for the industry and the Damon System blew my mind. You’d think that at that age, they’d be focused on retirement, eventually settling down, or travel, but their passion about Damon was contagious and got me excited about the potential of what could be accomplished with the system. After that meeting, I watched lectures by Drs. Dwight Damon and Alan Bagden. Once again, the passion they exuded for the industry and the Damon System was something I knew I could fully support. I studied Dr. Damon’s cases extensively and am now a proud Damon provider. Additionally, in 2011, my practice began to offer Insignia™ Advanced Smile Design™, also by Ormco.

Dr. Olsen and his team work out of six locations, with two main offices (Billings, Montana, and Lander, Wyoming) and four satellite locations Volume 8 Number 2

Dr. Olsen with one of his satisfied Damon System patients Orthodontic practice 7

PRACTICE PROFILE

Top 10 favorites 1. My wife, Janine (married 24 years), and my three daughters, Emmalee, Kaitlin, and Jillian 2. Damon™ System and Insignia™ Bracket Systems from Ormco™ 3. Automatic alginate mixers 4. Towel-warming oven (white) 5. BBQ ribs (a full rack, of course) 6. Big Thunder Mountain Railroad at Disney World 7. Classic country music 8. Dogs (basset hound, German shepherd, and English golden retriever) 9. Utah Jazz basketball team 10. My dad The Olsen Studio Ortho team

What is the most satisfying aspect of your practice, and what makes it unique? The most satisfying thing about my practice and profession is the daily interaction I have with my staff, patients, and their families. Being an orthodontist is a social profession, and the opportunity to do this on a daily basis makes my 9-to-5 more enjoyable. Seeing my hard work reflected on the faces and smiles of those individuals who walk through my office door makes even the tough days exceptional. I think the geographic footprint of my practice and the areas we serve — northern Montana to southern Wyoming, northeast Wyoming to central Montana — and the fact that the practice is serviced by just one orthodontist makes us rather unique. We have about 30 staff members, and every day we strive to boast an impeccable presence, exceptional timeliness, and make every appointment impactful.

continue to be adopted as well. In terms of what I’d like to see, given my dual disciplines, it would be nice to see more interdisciplinary practices emerge. Maybe more dental practices will come together with orthodontics to treat patients holistically and secure a true 360 degrees of the patient. While the industry will continue to be price driven — this will always exist to some degree — the industry will always remain steadfast in its servicebased and customer-service business model.

realize YOUR potential and live up to it to the best of your ability. Additionally, find a mentor whom you trust and respect. They will soon serve as your “safe place,” where you can ask questions and find answers to your challenges. Continue to be a student as well, not just of orthodontics but of business and entrepreneurism.

What advice would you give to an aspiring orthodontist?

Lots of things! I don’t have any sons — I have three daughters — but I’m involved in the local Boy Scouts, serving as a mentor and leader. I love working with young men to help them find their passion and build their skill sets. I also enjoy being outside, fishing, hiking, and being with my wife and daughters. I also have a knack for building and constructing things (I guess you could say I found the right profession after all). OP

Plain and simple: You have to be passionate about what you do. You should also be comfortable with limiting yourself to what you are good at and what you are zealous about. Hone in on your craft and become really good at something versus being mediocre at many things. Don’t try to live up other people’s success. Instead,

What are your hobbies, and what do you do in your spare time?

What are your top tips for maintaining a successful practice? 1. Hire great team members. Don’t be afraid to use a lengthier hiring process to ensure a good hire. 2. Be willing to embrace change in products, theory, protocols, and processes. It’s bound to happen, so embrace it! 3. Know your numbers, and stay in tune with key practice indicators. 4. Be authentic, and strive to live up to your God-given potential each and every day.

What is the future of orthodontics? It goes without saying that technology is going to continue to drive everything. The larger, more robust practice model will 8 Orthodontic practice

Dr. Olsen with his family at his daughter’s recent wedding Volume 8 Number 2

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With a .020x.026 Slot, A New Vision of Passive Self-Ligation Efficiency Is Realized If you love passive systems for the leveling and aligning phase of treatment, but wish they offered better control for finishing, you need to get FiT.20, the new passive self-ligating system from MidAtlantic Ortho. By slightly reducing the width and depth of the slot, FiT.20 all but eliminates bracket â&#x20AC;&#x2DC;slopâ&#x20AC;&#x2122;, delivering an unmatched combination of free-sliding performance and fine-tuned precision. This degree of control can end the need for multiple prescriptions, auxiliaries, repositioning and bracket swapping at the end of treatment. For full control without compromise, get FiT.20 from MidAtlantic Ortho, and exercise control of every case.

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CORPORATE SPOTLIGHT

MidAtlantic Orthodontics

idAtlantic Orthodontics is a family-owned company with a culture that derives directly from our core values. These values drive our policies and business practices. They are the foundation of our relationships with our customers and, in turn, the community that we are all contributing members towards. Since our inception, these principles have served to make MidAtlantic Orthodontics the reputable, full-service provider of quality products and services we have been known for and is consistent with the vision Mr. Tony Prusich had when starting the company.

Vision for the future MidAtlantic Orthodontics is committed to bringing those same core values and spirit into the future as we develop a new Vision that will define even greater goals for us to achieve moving forward. That vision is to connect with you, in a progressive new way, so that your practice is empowered like never before, with the convenience and efficiencies necessary for you to both treat and compete in today’s competitive marketplace.

CONVENIENCE THROUGH means that no matter what device or time of day is most convenient for you, we’ve made it possible to connect with us. In fact, research from a leading media company showed that 80% of dental professionals use their smartphones for business purposes. However, we took this statistic a step further by integrating all popular means of communication into our E-Commerce site, such as phone, desktop, tablet, or live chat. Whether you prefer to speak with a live person or interact on your own remotely, MAO has a channel through which to contact us. VISION STATEMENT

“To lead innovations in supply that increase the demand for orthodontic healthcare solutio around the world.” MISSION STATEMENT

However, connectivity and communica“To deliver convenience and tion does not stop there. MidAtlantic efficiency Ortho in a way that impro has also developed fresh new media the social bottom line of every one o sites and blog pages forour youcustomers.” to access and exchange information, perspectives, ideas, and testimonials meant to not only improve the relationships we share within

At MidAtlantic Ortho, we believe empowering your practice begins with putting you in command of your supply. As a result, we have innovated an E-Commerce platform unlike any other in our marketplace that will serve as an on-command resource for all of your practice supply needs. More than just online ordering, MAO now provides a user-friendly way to place, track, and store your purchase and ordering history with just a click of a button. With MidAtlanticOrtho.com, there is no more waiting for a visit from your sales representative, no more buying more than you need from a stock-up promotion, and no more figuring out the true cost of a complicated buying group program. All of the materials, information, and historical data you need to run and grow your practice is now available 24/7. 12 Orthodontic practice

Volume 8 Number 2

Your practice is your business, and your supplies are a critical component of your business’ value — the value you ultimately provide to your patients. At MidAtlantic Ortho, we understand that attracting, starting, and treating more patients is most important to our customers. The time that it takes to source, stock, and account for any errors in your supply is time away from growing your practice. That is why we developed our E-Commerce platform, to assist you in improving your workflow efficiency by eliminating the waste that often exists as part of traditional ordering processes. With MidAtlanticOrtho.com, your ordering can be more convenient, accurate, recorded, and accessible like never before. Your practice can run “leaner,” a standard objective across all businesses that correlates with higher profits. More time and higher profits mean greater capacity to do the things most important to you. In these ways and others, MAO represents Supply That Supports Your Bottom Line.

in treating with leading passive self-ligating systems, along with his background in mechanical engineering. Together, he was able to identify both the physical attributes and clinical shortcomings of competitive appliances, and determine which design elements would most benefit today’s practicing orthodontist. The result is a true twin, passive self-ligating appliance system having a reduced slot dimension of .020 x .026, combined with a series of extra broad arch form wires.

Brackets (.020 x .026) Control over torque and tip has eluded clinicians for years and has been compensated for in various ways from specifying additional degrees in programming, to repositioning, to wire sequencing. However, between ranges in manufacturing tolerances and quality control, an inherent amount of “slop” within the bracket slot is virtually unavoidable. This is particularly true in passive bracket systems as the reduced friction, free-sliding benefit is unable to utilize a ligation method that at least seats a wire firmly in place. Whether it has been an effort

to preserve existing economies of scale, or a reluctance to break from tradition on the part of the manufacturing community, a movement towards the ultimate solution of reducing the slot dimension has yet to occur — until now. MidAtlantic Orthodontics, consistent with our new vision for meaningful solutions in today’s marketplace, is proud to support Dr. Robert “Tito” Norris in the development and supply of this exciting transformative system. Not only did we look to collaborate on the premise of a reduced slot dimension, but we also sought to incorporate best-in class features that would be further appreciated by many, such as four true tie-wings with undercuts that can accommodate popular colored ligature ties; biocompatible, cobaltchromium composition for nickel-free use by allergy-sensitive patients; a flawless clip mechanism for consistent reliability; injection molded manufacture for strength integrity, smooth comfortable surfaces, and increased hygiene; and a mechanical base for troublefree bonding. Also available in the form of molar tubes, FiT.20 is a complete molar-tomolar system.

Solutions for the future The ability to innovate is one thing, but how those innovations translate into practical solutions is another. At MidAtlantic Orthodontics, we possess the expertise as part of our Leadership Team to understand your business — both clinically and commercially — so that we deliver the innovative solutions necessary for you to be successful. This has just been evidenced in a major way through the development and description of our E-Commerce platform, meant to provide increases in practice efficiency through supply. Now, we are equally proud to introduce an MAO exclusive in the area of treatment efficiency through advanced appliance systems.

The FiT.20 system is a new dimension in treatment efficiency, as it is the most advanced progression in passive self-ligation and arch form technology to date. Conceived by Dr. Robert “Tito” Norris, it is the culmination of his years of experience Volume 8 Number 2

Orthodontic practice 13

CORPORATE SPOTLIGHT

our immediate network, but to enhance the experiences of many others throughout the entire orthodontic community as well.

CORPORATE SPOTLIGHT

Wires (extra broad) As with FiT.20 brackets, FiT.20 wires are a break from convention and take what we know about expanded arches and esthetic expression to a whole new level. Once again, Dr. Robert “Tito” Norris learned from observation, learned from trial and error, and synthesized what he experienced from the use of existing broad arch forms into the extra broad arch form we have now developed. A non-coordinated arch makes it possible to treat both the maxilla and mandible with the same form. Thirty percent broader than the broadest arch on the market, this extra broad arch achieves a number of key efficiencies and effects: it affords maximum space as it expresses each tooth to its full outermost potential; it gains maximum leveling and alignment as the teeth are afforded a greater range of motion; it influences the musculature of the surrounding soft tissue earlier in preparation for subsequent desired reprogramming; and it introduces a collaborative dynamic sooner between the bracket and the wire. Throughout the later working and finishing stages of treatment, a “Rounded” rectangular (19x25) arch wire is introduced (yet another MAO exclusive) that makes insertion, clip closure, and seating smoother than ever. FiT.20 Wires are the perfect compliment in how they fully express the torque and tip of the bracket over existing passive systems, yet without the binding of other higher frictional systems. Most importantly, however, is how they both FiT to produce broader, more expressive smiles than anything else available today.

Dr. Robert “Tito” Norris Dr. Norris attended University of Texas at Austin where he received his bachelor’s degree with honors in Biology, and a minor in Mechanical Engineering. He was salutatorian of this dental school class at the University of 14 Orthodontic practice

At MidAtlantic Ortho, we possess the expertise to understand your business — both clinically and commercially — so that we deliver the innovative solutions necessary for you to be successful.

Texas Health Science Center at San Antonio Dental School. He completed a General Practice Residency at the Washington DC VA Medical Center. He completed his orthodontics specialty training at Howard University, and graduated as valedictorian with the highest GPA in the Orthodontic Department’s 25-year history.

Instruments and handpieces are an integral part of your practice. At MidAtlantic Orthodontics, we recognize that the condition and performance of these tools can have a direct impact on your overall treatment and practice efficiencies as well. That is why we have developed a dedicated department of our business specific to instrument sales, repairs, and services. The service center has received a brand of its own named Revive, and through it you have a convenient and reliable way to ensure that all of the critical hand tools you need to be in smooth, sharp, and clean working condition will be properly maintained. The process is easy and cost effective. Just contact us directly, or visit our website for more information.

MAO value proposition At MidAtlantic Orthodontics, we are committed to providing the solutions that are indicated to expand the specialty of orthodontics and improve the vitality of its care providers. Whether it is in the form of technological platforms meant to increase your operational efficiencies through novel means of supply, or in the design of materials meant to increase treatment efficiencies and quality outcomes, MAO will deliver the highest level of value in the friendliest, most convenient manner for your complete satisfaction. We welcome you to join our community of customers and partners, and experience our numerous other quality brands and services, as we grow into the future — together. OP

See how your supply chain supports your bottom line.

This information was provided by MidAtlantic Orthodontics.

Volume 8 Number 2

FINANCIAL FOCUS

Is your retirement plan tax savvy?

Tom Zgainer discusses the impact of taxes on your financial future

hat’s your retirement plan? Do you have a pension? A 401(k)? Do you think this will be enough for you to live comfortably on? While millions of Americans have a retirement account in place, the scary truth is they have not considered the impact that taxes have on how much of their money they will actually keep. If you haven’t noticed already, our government has some serious spending habits. They’ve racked up not only more than $17.3 trillion in debt, but also $100 trillion in unfunded liabilities with Social Security 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/feecheckermedmark.

Volume 8 Number 2

and Medicare as well. So what do you think this means for taxes? Will taxes be higher or lower in the future? You have probably been taught to maximize your 401(k) or IRA contributions for tax purposes because each dollar is tax deductible. This, of course, means that you don’t have to pay tax on that dollar today, but instead will defer the tax to a later day. Here is the problem: It’s impossible to know what tax rates will be in the future. So you have no idea how big of a bite taxes will take out of your retirement fund. Most experts will tell you that over time, the only logical direction for taxes to go is up. After all, someone has to pay for those staggering levels of debt the government has accumulated. What does this mean for your retirement plan? In short, it means that what you actually get to keep could be a lot less than you anticipated.

To help you determine which retirement plan is right for you, we help answer some of the most important questions you may have about the impact of taxes on your financial future.

Q: Should you participate in your 401(k) plan? A: The bottom line is that you have to do something. But you have to be smart about it. The 401(k) can be a great piece of tax code that, if structured right, can fuel your retirement for years. But, as we see in most of today’s plans, many 401(k) plans are chock-full of fees and unseen costs. In 2012, service providers became required by law to disclose these fees, but despite this change, the majority of employees still aren’t aware of how much they’re paying — and really, how much they’re losing. Orthodontic practice 15

FINANCIAL FOCUS Just be sure to know how your company’s plan stacks up. Go to http://Americasbest401k.com/401k-fee-checker, and click on “Fee Checker” to assess your company’s plan.

Q: What should you do if you think taxes are going up? A: If you think that taxes will go up in the future, then you may want to consider a Roth retirement plan. A Roth IRA, and more recently the addition of the Roth 401(k), is often overlooked but is actually one of the most tax-efficient solutions to retirement out there. With a Roth account, we pay taxes today, then deposit the after-tax amount, and never have to worry about taxes again. So our money grows tax-free, and we don’t have to worry about taxes when we take our money out. You are completely protected if the government decides to raise taxes in the future. And most importantly, you will know with absolute certainty how much money you will actually have when you decide to start making withdrawals. Most of today’s 401(k) plans allow you “check a box,” and your contributions will

receive the Roth tax treatment. This means you can pay tax today and let your growth and withdrawals steer clear of the tax man. And while a Roth IRA is limited to a $5,500 annual contribution, the Roth 401(k) allows you to deposit $18,000 every year. Just remember, if you decide to check the box and make your 401(k) contributions Roth eligible, you will still be investing in the same list of funds. The only difference will be that you are paying taxes on the income today, while securing your money from taxes in the future.

Q: Is there anything you can do with your traditional IRA? A: Yes, there is. If you think taxes will be going up in the future, then you may want to consider a Roth conversion. With a Roth conversion, the government will allow you to pay the tax on your IRA today (because they could use the money now), and you will never have to pay tax again. Confused? Take John, for example. John has an IRA with $10,000 and is in the 40% tax bracket. This means he would pay $4,000 today and allow the remaining $6,000 to grow and be withdrawn tax-free!

You must learn how to protect your money from unforeseen changes in the environment, particularly taxes.

Some people are automatically turned off from the idea of paying tax today. But remember, you will have to pay taxes eventually. And by doing it now, you are protecting yourself and your nest egg from future tax hikes.

Q: Are there any additional options to save? A: Small business owners or highincome earners who have a steady income and want to reduce their taxes today can find big benefits by coupling a cash-balance plan with their 401(k) plan. A cash-balance, or CB plan, is basically a pension plan that happens to have elements of a 401(k). Like a pension, you won’t be investing any of your own money into the plan. You also don’t have control over the investment choices. But rather than your overall benefits being based on a specific formula that considers how long you’ve worked at the company or what your average salary has been, the CB plan simply takes a set percentage of your salary each year, plus a set interest rate, and adds it into your account. The best part is that you can max out your 401(k) plan and a profit-sharing plan and then still add a CB plan to create some substantial — and fully deductible — contributions. A cash-balance plan starts to get very exciting when you get older, as you can put a more substantial amount of money away while reducing your tax liability. A cash-balance plan essentially allows you to squeeze 20 years of savings into 10 years. Remember, it’s not enough to just protect your nest egg from the unscrupulous fees and costs that some 401(k) plans impose; you must learn how to protect your money from unforeseen changes in the environment, particularly taxes. Whether this means selecting a plan in which you pay your taxes today, or one that allows you to defer your taxes until later, you must find a way to optimize your growth and be fully aware of how much you will get to keep. Don’t be blindsided by the hit the tax man will take on your nest egg. Protect your nest egg, and protect your road to retirement because by doing so, you are ultimately protecting your financial future. OP

Is your plan tax savvy? Find out here: http://americasbest401k.com/fee-checker-medmark. 16 Orthodontic practice

Volume 8 Number 2

SMPP587Rev062116

CLINICAL CASE STUDY

Management of facial asymmetries â&#x20AC;&#x201D; true skeletal or functional shift Drs. Jamie Y. Kim, Chung How Kau, and Ahmet A. Celebi show a patientâ&#x20AC;&#x2122;s progress through treatment

he presentation of a unilateral posterior crossbite is usually accompanied by a mandibular shift producing a lower midline deviation toward the crossbite side.1,2 Bilateral posterior crossbites often involve true basal skeletal discrepancies in the transverse relationships of the maxilla to the mandible that usually reflect a severe maxillary skeletal constriction rather than mandibular enlargement. Generally, there are no dental midline and facial midline discrepancies in full-occlusion and at-rest positions with any obvious functional deviations observed upon closure in bilateral posterior crossbites.3 Mandibular asymmetries have been the source of multiple debates and significant research. A question frequently addressed in the literature is the source of the asymmetry: Is it predominantly skeletal, dento-alveolar, or a combination of both? Many causes of fa-

cial asymmetry have been reported in the literature, as genetics, condylar fractures, condylar hyperplasia or hypoplasia, tumors or ankylosis in the temporomandibular region, prepubertal asymmetries, and asymmetric condylar positioning.4

Asymmetric condylar positioning and asymmetric mandibular growth Many studies have reported that asymmetric condylar positioning associated with mandibular shifts can be demonstrated on tomograms and transcranial radiographs in the majority of posterior crossbite patterns that present in children.5,6 In the skeletally immature patient with severe asymmetry, the option to treat with maxillary expansion appliances might be the most appropriate choice. In a study, 22 children with a functional posterior crossbite were corrected with maxillary expansion

at a mean age of 8.5 years. The condyle on the non-crossbite side was positioned more anterior prior to treatment and moved posteriorly and superiorly after treatment.7 In another study, authors compared condylar and ramal asymmetries in 81 patients with unilateral posterior crossbites to 75 normal occlusive subjects. The results showed patients with unilateral posterior crossbites had more asymmetric condylar positions than the controls. Moreover, the condylar, ramal, and condylar-ramal heights on the crossbite side were smaller than the noncrossbite side.7 Asymmetric malocclusions can be complicated and challenging to correct, especially when there is an underlying skeletal component.4 Orthodontic treatment alone is a difficult choice in this situation.8 The treatment of patients with an asymmetry that is moderate to severe and with

Jamie Y. Kim, DMD, MS, received her degree in Doctor of Dental Medicine at the Medical College of Georgia. She completed the Certificate of Orthodontics and Master of Science at the University of Alabama-Birmingham. Dr. Kim is currently practicing in Atlanta, Georgia. Chung How Kau, BDS, MScD, MBA, PhD, MOrth, FAMS, FDSGlas, FFD (Ortho), FDSEdin, FAMS, FICD, is Chairman and Professor at the Department of Orthodontics, The University of Alabama at Birmingham. He is a Diplomate of the American Board of Orthodontics and enjoys practicing clinical orthodontics. He is a researcher with a keen interest in three-dimensional and translational research. Currently, he is Principal Investigator on a number of grants and has a research involvement in excess of $4 million dollars. He actively contributes and publishes in the orthodontic literature and has over 300 peer-reviewed publications, conference papers, and lectures. He was also made the King James IV Professor by the Royal College of Surgeons in Edinburgh, Scotland, in 2011. Ahmet A. Celebi, BDS, MSc, PhD, graduated from Marmara University School of Dentistry, Turkey, with a BDS degree. He had completed an MSc degree in Physiology and a PhD in Orthodontics in Kirikkale University, Turkey. Currently, Dr. Celebi is a Postdoctoral fellow in the Department of Orthodontics, The University of Alabama at Birmingham.

Figure 1: Pretreatment intraoral and extraoral photographs 18 Orthodontic practice

Volume 8 Number 2

Figure 2: Pretreatment dental cast models

Case report

Figure 3: Pretreatment cephalometric and panoramic radiographs

Table 1: Pretreatment and posttreatment cephalometric measurements Measurements

Pretreatment

Posttreatment

SNAº

79.4

79.2

SNBº

81.9

ANBº

-2.5

-2.7

SN-MPº

35.9

36.2

FMAº

22.9

24.5

U1-NA mm

7.2

11.4

U1-SNº

105.9

111.9

L1-NB mm

6.2

5.8

L1-MPº

90.2

88.6

Upper lip to E plane (mm)

0.5

2.5

Lower lip to E plane (mm)

5.3

3.2

Volume 8 Number 2

Diagnosis and etiology The patient was a 13-year-old AfricanAmerican male who visited Department of Orthodontics in The University of Alabama at Birmingham for orthodontic consultation. The chief complaint was posterior crossbite on the right side. No specific medical problems or temporomandibular joint symptoms were observed. The clinical exam revealed that he had a Class I molar on the right and a half-step Class III molar on the left. The upper incisors were in negative overjet. In addition, the upper dental midline was deviated 2 mm to the left while the lower dental midline was deviated 4 mm to the right from the midsagittal plane (Figures 1 and 2). Even though a CR-CO shift was suspected, it was impossible to de-program the patient fully at the clinical exam. A CBCT radiograph (Carestream 9500) was taken to verify if a true skeletal mandibular asymmetry was present. A mildly retrusive maxilla and a prognathic mandible contributed to a Class III skeletal relationship (ANB = -2.5). His mandibular plane angle was normal (SN-MP = 35.9°) (Figure 3 and Table 1). The maxilla was skeletally narrow in the transverse dimension. Mild crowding of less than 3 mm existed in the maxillary and mandibular arches. There was Bolton discrepancy with large upper lateral incisors. His facial profile was slightly concave with a normal chin-throat distance and normal nasolabial angle. He showed mild facial asymmetry with deviation of mandible to the right side. Treatment objectives The treatment objectives for the dentition were correction of the right posterior crossbite, to make the maxillary, mandibular, and facial midlines coincident. The treatment objectives for the skeleton and soft tissue were to improve the facial asymmetry, Orthodontic practice 19

CLINICAL CASE STUDY

no significant functional limitations may be delayed until skeletal maturity is reached for a definitive orthodontic and/or surgical correction. Despite this, an attempt can be made to control and modify asymmetric growth in patients with active growing time.9 An attempt at early treatment is always the choice as functional shifts establish malocclusions and musculo-skeletal function. Often, the latter is difficult to unestablish. In this report, we present the orthopedic and orthodontic treatment of a facial asymmetry and unilateral posterior crossbite with severe midline discrepancy in a growing patient.

CLINICAL CASE STUDY

Figure 4: Intraoral photographs during first phase

including the deviation of the chin, to correct the transverse discrepancy, and to improve the facial profile by reducing the lower lip protrusion. Thus, facial symmetry, normal overjet and overbite, and Class I canine-tomolar relationships could be obtained. Treatment progress The treatment plan included two phases. During the first phase of treatment, a removable diagnostic bite plate was used. The design included maxillary first molar clasps, no labial bow, an anterior bite ramp, and an acrylic plate covering the palate with an expansion screw embedded in the acrylic. The anterior bite ramp disoccluded his dentition for deprogramming of the jaw. The patient was instructed to wear the appliance full time for 23 days without any expansion. Upper metal brackets from canine-to-canine were bonded, and the expansion was initiated (1 turn/day). A 5.5 mm expansion was achieved by 22 turns, and the posterior crossbite was successfully corrected. The remaining upper and lower teeth were bonded. After 5 months of treatment, the anterior bite plate was removed, and the mandible appeared to be in the new position (Figure 4). During the second phase, treatment continued with fixed orthodontic treatment. The upper archwire progressed to 0.016 x 0.022 Niti, and the lower archwire progressed to 0.020 SS wire. At this time, Class III elastics were worn full time. The wire progression continued to 0.019 x 0.025 SS upper archwire and 0.017 x 0.025 SS reverse Curve of Spee wire on the lower arch to level the Curve of Spee. After 16 months of total treatment, appliances were removed. Maxillary and mandibular retention was performed with fixed retainers.

Results Intraoral photographs obtained after the first phase of treatment are presented in (Figure 4). The final records show that the unilateral posterior crossbite was resolved, and dental midlines were coincident with each other and with the facial midline. (Figures 5 and 6). The skeletal facial 20 Orthodontic practice

Figure 5: Posttreatment intraoral and extraoral photographs

Figure 6: Posttreatment dental cast models

asymmetry was corrected by the correction of mandibular shift. Intraorally, a Class I canine and molar relationship with optimal overbite and overjet was achieved. In the comparison of the dental casts before and after treatment, maxillary inter-molar widths increased by 4 mm. Cephalometric superimposition showed A point moved back slightly due to upper anterior lingual torque. Maxillary incisors were proclined and moved forward. Mandibular incisors were slightly retroclined (Figures 7 and 8). A straight profile was achieved with improvement of lower lip to

E-line. As shown in the CBCT, deviation of the mandible asymmetry resolved after treatment (Figure 9). Diode laser (NVÂŽ Microlaser, DenMat) was used to recontour hyperplastic gingiva (Figure 10). Posttreatment panoramic radiographs showed acceptable root parallelism and developing third molars (Figure 11).

Conclusion Facial asymmetry with a unilateral crossbite and functional shift of the mandible was treated in a growing patient, due to the expansion of the maxilla and symmetrical Volume 8 Number 2

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

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

CLINICAL CASE STUDY

Figure 7: Posttreatment cephalometric radiograph

Figure 8: Cephalometric superimposition before and after treatment

Figure 10: Removing hyperplastic gingiva using a diode laser

Figure 9: Pretreatment and posttreatment CBCT

repositioning of the mandible. Consideration of a hidden functional shift is important for treatment planning for these patients. Orthognathic surgery may not be necessary in growing patients with functional asymmetries. Minimally invasive treatment can be treatment planned for patients exhibiting unilateral posterior crossbites possessing transverse discrepancies. OP Figure 11: Posttreatment panoramic radiograph

REFERENCES 1. Bell RA. Functional posterior crossbites in children. J Pediatric Dent Care. 2005;11(1):28-31. 2. Piero AC. Interceptive orthodontics: The need for early diagnosis and treatment of posterior crossbites. Med Oral Patol Oral Cir Bucal. 2006;11:E210-214. 3. Bell RA, Kiebach TJ. Posterior crossbites in children: Developmental-based diagnosis and implications to normative growth patterns. Semin Orthod. 2014;20(2). 4. Anhoury PS. Nonsurgical treatment of an adult with mandibular asymmetry and unilateral posterior crossbite. Am J Orthod Dentofacial Orthop. 2009;135(1):118-126. 5. Santos Pintos A, Buschang PH, Throckmorton GS, Chen P. Morphological and position asymmetries of young children with functional unilateral posterior crossbite. Am J Orthod Dentofacial Orthop. 2001;120:513–520. 6. Vitral RW, Fraga MR, Oliveira RS, Vitral JC. Temporomandibular joint alterations after correction of a unilateral posterior crossbite in a mixed-dentition patient: a computed tomography study. Am J Orthod Dentofacial Orthop. 2007;132(9):395-399. 7. Hesse KL, Artun J, Joondeph DR, Kennedy DB. Changes in condylar position and occlusion associated with maxillary expansion for correction of functional unilateral posterior crossbite. Am J Orthod Dentofacial Orthop. 1997;111(4):410-418. 8. Bishara SE, Burkey PS, Kharouf JG. Dental and facial asymmetries: a review. Angle Orthod. 1994;64:89-98. 9. Proffit WR. Treatment of orthodontic problems in preadolescent children. In: Reinhardt RW, ed. Contemporary Orthodontics. 2nd ed. St. Louis, MO: Mosby; 1993.

22 Orthodontic practice

Volume 8 Number 2

QUALITY, MEET CONVENIENCE. You wonâ&#x20AC;&#x2122;t want to miss this introduction.

AAO Booth

#713

ORTHODONTIC INSIGHTS

Orthodontics is moving forward Dr. Richard P. McLaughlin discusses current trends in orthodontics What do you think will be the next big trend in orthodontics? Orthodontics is always evolving, and there are some exciting trends. CBCT imaging and digital models â&#x20AC;&#x201D; CBCT imaging is a great help for accurately locating impacted tooth positions, as well as the evaluation of temporomandibular joint and airway issues. It is helpful in locating the correct location for TAD and plate positioning. It is also becoming a most exciting area in the diagnosis and treatment planning of surgical orthodontic cases, and for allowing this information to be shared by the orthodontist and surgeon. Intraoral scanning of the dentition is becoming a very accurate method of creating study models and removable appliances and using them for a variety of applications, just as we have done with study models in the past. It is a great timesaver in this area (for example, in the area of indirect bonding) and will work well in many special situations. TADS and plate technology â&#x20AC;&#x201D; TADS and plates have been used in orthodontics for some time. The need for, the location of, and the percentage of failure of these devices continues to be an issue. However, when these issues are worked through, TADS and plates become a very effective method of controlling anchorage and moving teeth in ways that were previously very difficult or

Richard P. McLaughlin, DDS, completed his orthodontic training at the University of Southern California in 1976. Since then he has been in full-time orthodontic practice in San Diego, California. He has lectured extensively in the United States as well as internationally. He is a member of the Pacific Coast Society of Orthodontists, the American Association of Orthodontists, and a Diplomate of the American Board of Orthodontics. He is the Past Component Director of the Southern California Component of the Edward H. Angle Society of Orthodontists and Past President of the National Angle Society. He is the recipient of the 2009 American Board of Orthodontics Dale Wade Award as well as the 2010 Pacific Coast Society of Orthodontists Award of Merit. In addition, Dr. McLaughlin is a clinical professor at the University of Southern California, Department of Orthodontics in Los Angeles, California, and an associate professor at Saint Louis University, Department of Orthodontics. He has written more than 30 journal articles and co-authored five textbooks.

24 Orthodontic practice

Dr. McLaughlin leading a case review with a group of attendees in the 2-Year McLaughlin Program in San Diego

impossible. Much improved control of the vertical dimension can be achieved with these devices.

How has the use of aligners changed orthodontics? The development of the aligner concept and all of the marketing being done has resulted in more individuals presenting for orthodontic evaluations. In this way, it has created a greater interest in orthodontic treatment. Aligner treatment is a good option for those patients who have a good posterior occlusion and malalignment of their front teeth. In this situation, aligners allow for effective control of posterior teeth, while improving the position of the anterior teeth. Since they are generDr. McLaughlin during a new patient evaluation discussing treatment ally less effective in moving posterior alternatives with the patient teeth than fixed orthodontic appliances, there can be compromises in the overall So, overall with the significant variations in treatment result. It is beneficial to explain malocclusions that present, a differential to patients that occasionally it is benefidiagnosis is critical in determining whether cial to have a short phase of fixed orthaligners of fixed appliances are the best odontic appliances, after the aligners, to choice for treatment. fully correct some malalignment difficulties. Volume 8 Number 2

The McLaughlin Program A t w o - y e a r, p o s t g ra d u at e o r t h o d o nt i c co u r s e

Dr. McLaughlin’s treatment philosophy is to treat as many patients as possible to the American Board of Orthodontic Standards in the most efficient way possible. He has dedicated his career, and most of his life, to this cause. Over the years, Dr. McLaughlin has created and fine-tuned systems not only in treating malocclusions , but all systems in the office. Over the two-year course, you will learn the basic mechanics of Dr. McLaughlin’s treatment goals, as well as how to incorporate them into your own practice. You will have the opportunity to hone your skills to achieve better efficiency, more predictable finishes, and learn about new techniques. You will learn how to streamline systems in your own practice, benefitting not only you and your staff, but your patients as well.

Dr. Richard McLaughlin

THIS COMPREHENSIVE PROGRAM CONSISTS OF SIX SESSIONS, OVER TWO YEARS . Each session lasts three days except course one, which lasts five days. This includes presentations, discussions, and hands-on segments. COURSE 1 – June 23-27, 2017 - Ortho Treatment Mechanics and the Pre-adjusted Appliance COURSE 2 – September 30 - October 2, 2017 - Inter-Arch Treatment Mechanics, Part I IDB COURSE 3 – February 17-19, 2018 - Inter-Arch Treatment Mechanics, Part II COURSE 4 – June 9-11, 2018 - Management of the Dentition COURSE 5 – December 1-3, 2018 - The Occlusion, the TMJ, and Orthodontic Treatment COURSE 6 – March 30 - April 1, 2019 - Surgical Treatment TO REGISTER FOR THE McLAUGHLIN PROGRAM,

Call: 619-225-1611 Visit: McLaughlinCE.com

Forestadent USA · 2315 Weldon Parkway · St. Louis, MO 63146 · TOLL FREE 1-800-721-4940 Fax 314-878-7604 · info@forestadentusa.com · Internet: http://www.forestadentusa.com

ORTHODONTIC INSIGHTS

Continued leveling and aligning with .019 x .025 heat-activated archwires

On bracket manufacturing, what have you learned over the years, and what do you feel is necessary to make an ideal bracket? From an orthodontic standpoint, the most important part of the bracket is the interaction between the bracket slot and the archwire. With the edgewise appliance, the initial bracket slot used was .022. As treatment proceeded, a rectangular wire was used for the major tooth movements. The wire sizes ranged from .017 x .025, .018 x .025, .019 x .025, or .021 x 025. A slot size bracket .018 was later added with the edgewise appliance. The major archwires used with this appliance were the .016 x .022 and .017 x .025. Edgewise brackets were machine milled. Archwires were adjusted for three-dimensional movements: tip, torque, and in-out dimension. Andrews created a significant change in orthodontic appliances by developing the Straight Wire Appliance™. Tip, torque, and in-out dimension were built into each bracket. Archwires were shaped to fit the arch form without the above wire bending. This significantly reduced the time spent with each patient. The “straight-wire” brackets were cast in stainless steel, much like gold crowns. In time, other variations of straight wire appliances were developed. In the mid to late 1980s, most companies made brackets using a technique called metal injecting molding (MIM). Powdered stainless steel was heated to a high temperature and then was poured into the molds for each bracket. The metal cooled in the mold, and there was a slight amount of shrinkage during this process. To prevent brackets from being undersized during the shrinkage process, tolerances above the size of the traditional .022 and .018 slot sizes were used. Archwires were developed with varying sizes and varying amounts of contour on their edges. The brackets were still sold as .022 and .018 sizes, despite the variations in the slot size. 26 Orthodontic practice

Enjoy the opportunity to create stable occlusions, beautiful smiles, and improve the quality of life for so many people.

More recently, brackets were made with accurate milling machines out of bars of solid metal. The technique was referred to computer numerical control (CNC), and the brackets were closer to the .022 and .018 dimensions. They also had a greater stiffness than the MIM brackets. Adjustments in technique were required with the CNC bracket system, as opposed to the more frequently used MIM bracket system. The choice that is

selected by the orthodontist requires awareness of this important difference.

What advice would you give the current graduating orthodontic residents concerning how they should approach their career in orthodontics? I always recommend that young orthodontists set goals to continue to improve on the quality and efficiency of their treatment. Developing a systematic approach to every aspect of diagnosis, treatment planning, and treatment mechanics is most helpful. Educating your staff to implement this process is essential. Participating in orthodontic study clubs and interdisciplinary study groups will keep you current, and stateof-the-art thinking is very advantageous. All the above factors are important in developing a successful practice. Lastly, enjoy the opportunity to create stable occlusions, beautiful smiles, and improve the quality of life for so many people. Orthodontics is a wonderful career! OP

Resident course in San Diego with the 2nd- and 3rd-year residents from USC in September 2016 Volume 8 Number 2

ORTHODONTIC CONCEPTS

A review of suresmile®: efficiency and effectiveness — sprinkled with a dose of self-reflection Dr. Rohit C.L. Sachdeva reviews the benefits of suresmile

n all-digital CAD/CAM solution — suresmile® — offers the orthodontist a total solution for managing patient care.1 This technology has evolved over the past 2 decades and enables the doctor to perform 3D-image guided diagnosis, care planning, and also the ability to design personalized therapeutic devices, including indirect bonding trays,2 aligners,3 and archwires. suresmile’s value proposition to the clinician is based upon shorter treatment times and better patient outcomes. This is achieved by providing tools that enable the management of reactive care processes during orthodontic care.1 The aim of this article is to present a summary of the results of various studies that

have been conducted over the last decade to understand both the efficiency and effectiveness of suresmile. Furthermore, the present discussion is limited to reporting treatment results in response to the use of suresmile® customized archwires.

suresmile® efficiency and quality To date, five clinical studies4-8 have been conducted to evaluate suresmile efficiency and quality of treatment outcomes. The results are summarized in Figures 1 and 2 and Table 1. Although these studies are

Figure 2: Shows a summary of the results from studies of suresmile versus conventional: Average treatment time, initial DI (ABO Discrepancy Index), CRE (ABO Cast Radiograph Evaluation ), OGS (ABO Orthodontic Grading System), n (sample size) from various studies

Figure 1: Shows a summary of the results from studies of of suresmile versus conventional: average treatment time

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 rcsorthocoach@gmail.com to access information.

28 Orthodontic practice

Table 1: Shows additional findings of interest from studies on efficiency and effectiveness of suresmile versus conventional Volume 8 Number 2

Accuracy of suresmile

Figure 4: suresmile versus Incognito: Accuracy of translational movements (average) for all maxillary teeth in three planes of space — central incisor (CI),lateral incisor (LI), canine (C), first premolar (FPM), second premolar (SPM), first molar (FM), second molar (SM)

Figure 5: suresmile versus Incognito: Accuracy of rotational movements (average) for all maxillary teeth in three planes of space — central incisor (CI), lateral incisor (LI), canine (C), first premolar (FPM), second premolar (SPM), first molar (FM), second molar (SM) Volume 8 Number 2

The promise of suresmile technology is based upon a “What you see is what you get” user interface. This means that the design of the 3D virtual target setup provides the input for the personalized archwire, which in turn drives the correction of the malocclusion to its final position — i.e., the preplanned target state (Figure 3). Under the ideal circumstances, the final outcome should provide a 100% match against the virtual target setup. Therefore, a number of investigations7-9 have been conducted to study the accuracy of the final treatment outcome against the virtual target setup. Larson, et al.,10 and Müller-Hartwich, et 11 al., used “best fit” superimposition techniques of scanned final models of dental casts against the virtual target setup to evaluate tooth positional discrepancies in all three planes of space. Larson, et al.,10 studied a sample size of 23 patients treated with suresmile. They arbitrarily defined translational and rotational discrepancies between the final results and the virtual target setup of 0.5 mm and 2˚ for final tooth position as being clinically ”ideal.” Based upon their definition of the ideal, they found that the mesio-distal positions of all teeth except for the lateral incisors and second molars were on target. When considering the buccal (facial)-lingual tooth positions, they found that all teeth except for the maxillary central incisors, premolars, and molars, and mandibular incisors and second molars met their conditional standards of “ideal.” Vertical tooth positions were clinically ideal for all teeth except mandibular second molars. Larson, et al.,10 also found that crown torque, tip, and rotation discrepancies did not meet their standard for “clinically ideal.” The exceptions were for crown torque on mandibular second premolars and crown tip of mandibular second premolars and first molars. A summary of the results of their study is shown in Figures 4, 5, 6, and 7. Müller-Hartwich, et al.,11 studied 26 patients and found that the median deviations for translational tooth movements were Orthodontic practice 29

ORTHODONTIC CONCEPTS

Figure 3: Accuracy: the discrepancy between the virtual target model (VTM) and the final model

retrospective in nature and are limited in their design and methodology, it should be noted that the general trend of the results of these studies strongly suggest that treatment time with suresmile is reduced between 25%-40%. Furthermore, the treatment outcomes measured in three studies using the ABO-OGS and ABO-CRE9 indicate an improvement in treatment outcomes in a range of 10%-18%.

ORTHODONTIC CONCEPTS 0.19 mm – 0.21 mm and for rotational 1.77°– 3.04°. They noted that the anterior teeth more precisely matched the virtual planned (target) position than the posterior teeth. Smith12 evaluated the mesio-distal tip and facio-lingual torque outcomes on 40 consecutively treated patients by a single operator with suresmile. Final CBCT images were evaluated against the virtual target setup using “best fit” superimposition. He found that the overall mean discrepancy of the SS target models to the outcome CBCT were within ±2.5˚ and generally speaking were beyond the ±2.5˚ for the maxillary and mandibular second molars for tip, and the maxillary second molar and mandibular central and lateral for torque. Also, second-order outcomes were closer to target than torque outcomes for most tooth types. Of interest was that the mandibular teeth in general showed deviations greater than 2.5˚ of the plan. Table 2 provides a summary of the results of this study.

Figure 6: suresmile versus Incognito: Accuracy of translational movements (average) for all mandibular teeth in three planes of space — central incisor (CI), lateral incisor (LI), canine (C), first premolar (FPM), second premolar (SPM), first molar (FM), second molar (SM)

Discussion and conclusions Efficiency and effectiveness Current research is a first step in demonstrating the efficiency and effectiveness of suresmile. Rangawala,7 using a Chi-squared test and assuming a passing ABO-CRE score of 20, demonstrated a significant difference in pass rates for suresmile® (73% ) versus conventional treatment (45%). Expressed in terms of an odds ratio, this investigator suggested that patients treated with suresmile were 3 times more likely to achieve an ABO-CRE passing grade than those treated with conventional treatment. A valid concern to the reader should be some of the studies presented were based on a limited patient sample and could be suspect to selection bias. However, it is important to note that the study by Sachdeva, et al., was based on a study population of 9,350 suresmile and 2,945 conventionally treated patients from 142 practices nationwide. These records were gathered from the suresmile database with the doctors’ approval. Furthermore, the doctors had no input in their selection. By the sheer volume of the patients studied and the number of practices represented, little opportunity for patient selection bias presented itself. In fact to this day, this study represents the largest-ever sample of patients studied to determine treatment efficiency of competing orthodontic treatments. The results of this study may be considered more compelling. The studies presented here are a first step in better understanding the benefits 30 Orthodontic practice

Figure 7: suresmile versus Incognito: Accuracy of rotational movements (average) for all mandibular teeth in three planes of space — central incisor (CI), lateral incisor (LI), canine (C), first premolar (FPM), second premolar (SPM), first molar (FM), second molar (SM)

Table 2: suresmile: Accuracy of mesio-distal tip (second order). CBCT-based virtual target setup versus final CBCT model Volume 8 Number 2

LESS TIME

29.6

26.3 23.0 15.8 CRE

Jeff Johnson, DDS, MS Dallas, TX

MOS.

suresmile

20.8 20.0 18.5

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conventional

CRE- Case Report Examination

PROVEN RESULTS, FASTER. Studies show that the suresmile Treatment Management System achieves better or equal quality finishes in 30% less time while effectively accomplishing desired tooth movements.*

OGS- Objective Grading System

*Details available upon request from suresmile.

For more information, call suresmile at 877.787.7645 or visit suresmile.com

suresmile.com

to be sure.

30.7

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“When people are given the proper tools and motivation, what can be accomplished is often nothing short of amazing.”

ORTHODONTIC CONCEPTS of suresmile. Future studies from multiple academic/research centers with better designed methodologies are needed to further clarify suresmile’s impact on treatment outcomes. As alluded to earlier, suresmile studies on efficiency and effectiveness are entirely based on the use of the customized archwires to deliver the target outcome. The question that remains unanswered to this day is whether the addition of customized brackets and indirect bonding may contribute to further gains in efficiency and effectiveness in patient care. A recent study by Brown, et al., sheds some light on this question. They investigated the clinical effectiveness and efficiency of three different appliance systems. Three patient groups were selected and treated as follows: • Group 1 was treated with CAD/CAMcustomized orthodontic appliances (i.e., brackets, indirect bonding trays, and archwires were all customized). • Group 2 was treated with direct techniques. • Group 3 was treated with indirect bonded techniques. The two latter groups used, “off-theshelf” orthodontic brackets. Patients treated with the fully customized appliance systems demonstrated the shortest treatment time of 13.8 ±3.4 months. They found the total treatment time for the CAD/CAM group was on average 8 months shorter than for the direct bonded group, and more importantly, only about 3 months shorter than for the indirect bonded group. Furthermore, they found no statistically significant differences between the three treatment groups (P = 0.13) in terms of ABO-CRE scores. These results are very interesting from a clinical vantage point and underscore the importance of initiating in-depth studies to better understand which elements of CAD/CAM-generated appliances truly add value to patient care and the clinical practice. Is it the customized archwire, brackets, or the indirect bonding tray? Furthermore, it raises the question of whether a CAD/CAM-customized indirect bonding tray has merit over an analog manufactured tray, or can just processing improvement through better planning mitigate the need for elaborate technology? Accuracy Studies presented in this article suggest that with suresmile, translational movements in 3D space can be achieved within ±0.5 mm and rotational movements (torque, tip, etc.) within 2.5˚ of the plan. 32 Orthodontic practice

Table 3: suresmile: Accuracy of torque (third-order). CBCT-based virtual target setup versus final CBCT model

However, the results of these investigations also indicate that accuracy is diminished in the first and second molar region. A host of reasons may contribute to these discrepancies in the posterior region. These may include the use of auxiliaries, e.g., elastics, the slot archwire slop, and what I call clinical-virtual setup dissonance. This phenomenon is a result of a doctor’s overconfidence in achieving a desired outcome by planning tooth position on a virtual setup that cannot possibly be achieved biologically — simply put, unreasonable treatment goals. For comparison purposes I have also included accuracy studies conducted by Grauer and Proffit11 on the Incognito® system for lingual orthodontic care (Figures 4-7). This system uses a platform similar to that of suresmile. The accuracy results on Incognito are based on the use of the customized bracket, indirect bonding tray, and archwire. The comparative data certainly suggests the relatively superior performance of suresmile in comparison to Incognito. Furthermore clinicians need to be cognizant of the fact that the accuracy of a single-tooth position does not reflect upon its relative position to an adjacent tooth in an arch that determines the “fit and the look of the dentition.” To better understand this issue, let us consider the example of an upper right incisor and its neighboring tooth, the left central incisor. Let us also postulate that each of these teeth can be positioned independently within a target of ±0.5 mm in the vertical direction. As a result, there is a possibility that at the culmination of treatment, one of the incisors may be intruded by

0.5 mm, while its neighbor may be extruded by the same amount. This would result in a relative vertical discrepancy of 1 mm between the teeth, which by all standards would be considered clinically unacceptable. And herein lies the enigma in relying on the accuracy of single-tooth positions in determining the merit of a technology. To gain better understanding of the quality of treatment outcome, investigators need to measure both tooth position accuracy in conjunction with the ABO-CRE scores for the population sample under study. In addition, better methodologies to evaluate tooth-position accuracy need to be developed. Currently, the best fit superimposition techniques used rely upon internal references. This results in an “averaging effect,” which leads to both false positive and negative results for the displacement measures. As more studies to understand accuracy of the virtual target setup emerge, it is important that the clinical and academic community work together to establish some conditional standards for both the accuracy of tooth modeling and target response. If not, we will in time fall into the abyss of competing products with little understanding of their performance, just as we currently do with brackets whose prescriptions and slot tolerances remain unchecked. In fact even to this day, scientific evidence has yet to validate either the efficiency or effectiveness of the straightwire against standard edgewise therapy. Yet it has become the defacto gold standard for fixed appliance therapy. Maybe we are entrapped with the metaphor of the “Emperor’s New Clothes” when it comes to the straightwire appliance. Volume 8 Number 2

ORTHODONTIC CONCEPTS A time for reflection “Magic mirror, on the wall, who is the fairest of them all?” — Evil Queen in “Snow White and the Seven Dwarfs” I have been very fortunate to have been directly involved in the development of suresmile®. Furthermore, over nearly the past 20 years, I have had the opportunity to serve well over 12,000 patients in multiple practices worldwide. Therefore, I feel reasonably qualified to share some of my practical learning in the deployment and use of this system in the practice. “The first rule of any technology used in a business is that automation applied to an efficient operation will magnify the efficiency. The second is that automation applied to an inefficient operation will magnify the inefficiency.” — Bill Gates I do not believe that this technology or others similar to it have any value unless the clinician has a succinct answer to the following questions: “What is the problem I face in the care of my patients (in other words finding the problem first), and why?” and “How can the technology solution help?” This requires deep self-reflection, which is painful. Without the answer to this question, one is liable to fall into the trappings of “solutioneering.” “Most of the problems in life are because of two reasons: We act without thinking, or we keep thinking without acting.” — Unknown One should resist the temptation of jumping onto the technology bandwagon before making a needs assessment. “The real problem is not whether machines think but whether men do.” — B. F. Skinner The notion that “smartness” or “intelligence” is embedded in the technology is far from the truth. In other words, this technology just as all others does not offer the holy grail of effortless “push button,” “cruise control” orthodontics. “Observe, record, tabulate, communicate. Use your five senses. Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone, you can become expert.” — William Osler Proper diagnosis, planning and appropriate patient management remain the bedrock of clinical skills required to achieve desirable treatment outcomes. suresmile 34 Orthodontic practice

technology relies on human cognition as input to achieve its promise of performance and reliability. “Every person is in certain respects like all other people, like some other people, and like no other person.” — Clyde Kluckhohn and Henry A. Murray, Personality in Nature, Culture, and Society Yes, this technology is unique in that it offers a plethora of tool sets that enable computer-aided planning, interactive communication, and computer-aided manufacturing of appliances, such as customized archwires for labial and lingual orthodontics, indirect bonding trays, and aligners. The skill the clinician needs to develop is to recognize where the value of each of this offerings lies for a particular patient and intent. To believe that there is a one-way approach in successfully using this technology for all patients is unreasonable and unrealistic. “Plans are nothing; planning is everything.” — Philip Kotler “We are what we repeatedly do. Excellence, then, is not an act, but a habit.” — Aristotle I personally believe that the value of this technology cannot be fully extracted and provide meaningful care for a patient without developing the primary skill set for 3D design and planning. This task cannot be delegated and requires perseverance by the clinician through deliberate practice to achieve expertise. And this is where the enigma lies for the busy clinician —finding the time to learn and reflect. Change in habits is difficult! “A superior leader is a person who can bring ordinary people together to achieve extraordinary results.” — Unknown “What gets measured gets improved.” — Peter Drucker Success in the use of such technologies requires a sincere effort by the leadership to evoke change in habits and skills for the entire care team. Energy, time, and motivation are vital ingredients to enable this transformation. The metaphor of Sisyphus is very applicable in describing the challenges associated with this transformation. The only way to overcome this biting challenge is to develop a much disciplined self-governed program that institutes timelines and performance metrics to measure progress. “It’s not what you a pay a man, but what he costs you that counts.” — Will Rogers Also, the impact on the cost of deploying

such technologies and its cascade effects on the practice and patient fees requires deep appreciation. It is my hope that by recognizing some of these issues that you, my colleagues, do not become the victims of the Icarus Paradox, a phenomenon described by Danny Miller in his book by the same name. This term refers to the sudden failure of organizations after a short run with apparent success followed by failure, which is brought about by the very elements that initially contributed to the success. “Do as much as possible for the patient and as little as possible to the patient.” — Dr. Bernard Lown Fiat justitia et pereat mundus. (Do the right thing, come what may.) OP

REFERENCES 1. Sachdeva RC. SureSmile technology in a patient-centered orthodontic practice. J Clin Orthod. 2001;35(4):245-253. 2. Sachdeva RCL. BioDigital Orthodontics: Design and use of suresmile® customized 3D-printed indirect bonding trays: part 20. Orthodontic Practice US. 2016;7(2):20-34. 3. Sachdeva RCL, Kubota T. BioDigital Orthodontics: suresmile® aligners, part 21. Orthodontic Practice US. 2016;7(3):26-31. 4. Saxe AK, Louie LJ, Mah J. Efficiency and effectiveness of SureSmile. World J Orthod. 2010;11(1):16-22. 5. Sachdeva RC, Aranha SL, Egan ME, et al. Treatment time: SureSmile vs conventional. Orthodontics (Chic.). 2012;13(1):72-85. 6. Alford TJ, Roberts WE, Hartsfield Jr JK, et al. Clinical outcomes for patients finished with the SureSmile™ method compared with conventional fixed orthodontic therapy. Angle Orthod. 2011;81(3):383-388. 7. Rangwala T. Treatment outcome assessment of SureSmile compared to conventional orthodontic treatment using the American board of Orthodontics grading system [thesis]. Bronx, New York: Albert Einstein College of Medicine, Department of Dentistry; 2012. 8. Groth C. Compare the quality of occlusal finish between SureSmile and Conventional [thesis] Ann Arbor: University of Michigan; 2012. 9. The American Board of Orthodontics Grading System for Dental Casts and Panoramic Radiographs https://www. americanboardortho.com/media/1191/grading-systemcasts-radiographs. pdf. Accessed February 3, 2017. 10. Larson BE, Vaubel CJ, Grünheid T. Effectiveness of computer-assisted orthodontic treatment technology to achieve predicted outcomes. Angle Orthod. 2013;83:557–562. 11. Müller-Hartwich R, Jost-Brinkmann PG, Schubert K. Precision of implementing virtual setups for orthodontic treatment using CAD/CAM-fabricated custom archwires. J Orofac Orthop. 2016;77(1):1-8. 12. Smith, TL. Mesio-distal tip and facio-lingual torque outcomes in computer-assisted orthodontic treatment [thesis]. https:// indigo.uic.edu/bitstream/handle/10027/9911/Smith_Tharon. pdf?sequence=1. Accessed February 3, 2017. 13. Grauer D, Proffit WR. Accuracy in tooth positioning with a fully customized lingual orthodontic appliance. Am J Orthod Dentofacial Orthop. 2011;140(3):433-443. 14. Brown MW, Koroluk L, Ching-Chang Ko, Zhang K, Chen M, Nguye T. Effectiveness and efficiency of a CAD/CAM orthodontic bracket system. Am J Orthod Dentofacial Orthop. 2015;148(6):1067–1074.

Volume 8 Number 2

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

Submitting articles Orthodontic Practice US requires original, unpublished article submissions on orthodontic topics, multidisciplinary dentistry, clinical cases, practice management, technology, clinical updates, literature reviews, and continuing education. Typically, clinical articles and case studies range between 1,500 and 3,000 words. Authors can include up to 15 illustrations. Manuscripts should be double-spaced, and all pages should be numbered. Orthodontic Practice US reserves the right to edit articles for clarity and style as well as for the limitations of space available. Articles are classified as either clinical, continuing education, technology, or research reports. Clinical articles and continuing education articles typically include case presentations, technique reports, or literature reviews on a clinical topic. Research reports state the problem and the objective, describe the materials and methods (so they can be duplicated and their validity judged), report the results accurately and concisely, provide discussion of the findings, and offer conclusions that can be drawn from the research. Under a separate heading, research reports provide a statement of the research’s clinical implications and relevance to implant dentistry. Clinical and continuing education articles include an abstract of up to 250 words. Continuing education articles also include three to four educational aims and objectives, a short “expected outcomes” paragraph, and a 10-question, multiple-choice quiz with the correct answers indicated. Questions and answers should be in the order of appearance in the text, and verbatim. Product trade names cited in the text must be accompanied by a generic term and include the manufacturer, city, and country in parentheses. Additional items to include: • Include full name, academic degrees, and institutional affiliations and locations • If presented as part of a meeting, please state the name, date, and location of the meeting • Sources of support in the form of grants, equipment, products, or drugs must be disclosed • Full contact details for the corresponding author must be included • Short author bio • Author headshot Volume 8 Number 2

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

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

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

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

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

Orthodontic practice 35

CONTINUING EDUCATION

Early treatment of anterior open bites Dr. Bradford N. Edgren discusses effective treatment to achieve stable results for anterior open bites Introduction Effective treatment of anterior open bite malocclusions is both challenging and frustrating. An anterior open bite (AOB) occurs when the maxillary and mandibular permanent incisors lack incisal contact and vertical overlap when the posterior teeth have maximum intercuspation. Proper classification of anterior open bites requires appropriate training and clinical experience (Ngan 1997). Effective treatment resulting in stable results is difficult. Malocclusions with a significant vertical skeletal component that possess an anteroposterior discrepancy require the pinnacle of clinical diagnosis and skill (Ellis 1985).

Prevalence In a study of 489 children in the early mixed dentition by Keski-Nisula, an open bite was recorded in 4.6% of patients (KeskiNisula). Cozza, et. al., reported that the prevalence of anterior open bites was 17.7% in mixed dentition subjects (Cozza 2005). Transient anterior open bites do occur during the transitional dentition, between the deciduous and mixed dentitions, and are considered normal as the permanent incisors erupt into the oral cavity. These pseudo open bites can last between 1 to 2 years (Ngan 1997). Transitional open bites lasting longer than this time period warrant further investigation, and clinicians should consider them abnormal.

Etiologies Etiologies of anterior open bites are often multifactorial in nature ranging from dentoalveolar development to vertical skeletal growth patterns (Sassouni 1969, Nahoum 1975, Schudy 1965, Nielsen 1991), complications from upper airway obstruction and oral breathing (Linder-Aronson 1983, Vig

Educational aims and objectives

This article aims to discuss effective treatment for early treatment of anterior open bites.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 43 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify some characteristics of anterior open bites. • Realize the prevalence of anterior open bites. • Realize the multifactorial causes of anterior open bites. • Recognize etiologies of patients with significant risk for this condition. • Identify some fundamental objectives of early interceptive treatment.

1998), oral habits (Cozza 2005), adaptive tongue posture (Takada 1985), traumatic injuries, and/or congenital anomalies/ abnormalities. Strictly dental AOB malocclusions generally result from the persistent undereruption of the maxillary and/or mandibular permanent incisors and have no obvious skeletal component (Ngan 1997). Orthodontic treatment of patients with normal cephalometric facial heights with dental open-bite malocclusions is more successful than with those malocclusions that have a significant vertical skeletal component. Dental open bites as a result of finger or thumb habits will often self correct with cessation of the habit and no appliance therapy (Subtelny 1964). However, patients who possess hyperdivergent facial characteristics and prolonged sucking habits are at significant risk for developing an anterior open bite in the mixed dentition (Cozza 2005). Consequently, patients with AOB and skeletal open-bite malocclusions can require a more demanding early diagnosis and treatment plan than those with more normal facial heights. Cephalometric analysis is vitally important in diagnosing these types of malocclusions. Note that Dung and Smith found that patients with a cephalometric analysis suggesting an excessive vertical

Bradford Edgren, DDS, MS, FACD, earned both his Doctorate of Dental Surgery, as valedictorian, and his Master of Science in Orthodontics from the University of Iowa, College of Dentistry. He is a Diplomate, American Board of Orthodontics, and a director of the Southwest Component of the Edward H. Angle Society. Dr. Edgren has presented nationally and internationally to numerous orthodontic groups on the importance of orthodontic diagnosis, early interceptive orthodontic treatment, CBCT, and upper airway obstruction. He has been published in the American Journal of Orthodontics and Dentofacial Orthopedics, the Angle Orthodontist, the American Journal of Dentistry, as well as other orthodontic publications. Dr. Edgren currently has a private practice in Greeley, Colorado.

36 Orthodontic practice

skeletal relationship is not indicative that the patient will possess an anterior open bite (Dung 1988). In fact, most patients with AOB possess a combination of traits, including both dentaoalveolar and increased vertical skeletal components (Cangialosi 1984, Richardson 1969, Nahoum 1971). Thus, anterior open bites can exist in both normal and long-faced individuals, and conversely, normal overbites can exist in the same type of patients (Ngan 1997). Early traumatic injuries to the dental alveolus can result in the ankylosis of anterior teeth preventing their full eruption and resulting in open bites. Fixed-appliance treatment to extrude ankylosed teeth can result in poor outcomes from the intrusion of adjacent teeth, further complicating the pre-existing open-bite malocclusion. Initial diagnosis of ankylosed teeth is important in preventing adverse effects from fixed appliances. Maxillofacial jaw fractures, especially condylar fractures that can affect future mandibular growth (Proffit 1980), may result in AOBs. The condylar neck is the weakest part of the mandible, and it is not surprising then that condylar fractures constitute the most common maxillofacial fracture, accounting for 29% to 52% of all mandibular fractures (Ellis 1985, Motamedi 2003). Actively growing patients under 12 years of age can have complete regeneration of the condyle with little or no residual deficit (Proffit 1980). Proffit stated that approximately 25% of children with early condylar fractures will have some deficits in growth (Proffit 1980). Early interceptive treatment in these patients is of benefit by establishing a normal Volume 8 Number 2

corrections of vertical discrepancies requiring adaptations made by favorable growth of the mandible and the alveolus of both jaws (Worms 1971).

Case reports Case 1 As previously stated, effective treatment resulting in stable results is difficult, and patients with both a significant vertical skeletal component and an anteroposterior discrepancy require extraordinary clinical diagnosis and skill (Ellis 1985). This 8-year 2-month-old Caucasian female presented

clinically with an end-on Class II malocclusion and severe anterior 3 mm open bite (Figure 1). Her parents did not report a history of a digit habit. The maxillary and mandibular permanent incisors were both undererupted. Her CBCT scan, taken on an i-CAT速 Next Generation CBCT (Imaging Sciences International), revealed the potential of upper airway obstruction from an enlarged adenoid pad (Figures 2 and 3). Cephalometric analysis by Rocky Mountain速 Orthodontics Data Services速 (RMODS速) revealed a severe dental and skeletal open bite due to the maxilla and mandible (Figure 4). A skeletal Class II anterior posterior discrepancy due

Figure 2

Figure 1

Figure 3

Figure 4 Volume 8 Number 2

Orthodontic practice 37

CONTINUING EDUCATION

occlusion (Proffit 1980), thereby potentially reducing the severity of the deformity and degree of surgery at a later date. Examples of congenital anomalies possessing anterior open bites include craniofacial syndromes such as Crouzon's, Apert's, and Mandibulofacial Dysostosis (Treacher Collins Syndrome). Treatment of these types of patients requires surgical intervention. A fundamental objective of early interceptive treatment is to normalize the dentofacial skeleton. Normalization at an early age can result in the improvement of occlusal function and skeletal discrepancies. The goals of early treatment of AOB patients include

CONTINUING EDUCATION to both jaws was also present. Her anterior nasal spine was tipped up, possibly indicative of micro rhino dysplasia, and lower anterior facial height was excessive. Ricketts future facial growth analysis, without treatment, revealed the potential for excessive vertical growth. Early interceptive treatment included maxillary expansion with a bonded acrylic expander with occlusal coverage from first molars to deciduous canines. After 6 mm of active expansion, the maxillary central incisors were bonded and attached via a .016 NiTi archwire to tubes placed on the buccal aspects of the expander. The mandibular

dentition was fully bonded at this appointment as well. The expander was left in situ for 61â &#x201E;2 months as the open bite closed and the mandibular dentition leveled out. The

Figure 5

remaining maxillary mixed dentition was bonded after removal of the expander. Closure of the open bite is apparent in the CBCT scan taken on the day of expander removal (Figure 5). The maxillary lateral incisors were bonded 1 year after the initiation of treatment. Total treatment time was 31 months resulting in closure of the open bite (Figures 6-8). The occlusal plane rotated counterclockwise and the mandibluar plane angle reduced (Figure 9). One year post-op the anterior open bite correction is stable. Control of the vertical skeletal dimension is an important factor in successful treatment (Cozza 2005).

Figure 7

Figure 6

Figure 8

Figure 9 38 Orthodontic practice

Volume 8 Number 2

Case 2 The following patient presented with an instance of an anterior open bite malocclusion with a mild brachyfacial dentofacial skeleton. This 8-year-old Caucasian female presented clinically with a significant open bite, Class II malocclusion, and severe crowding (Figures 10-12). She had a previous history of a digital sucking habit. Cephalometric analysis showed a Class II malocclusion due to the lower molar, significant mandibular retrognathia, bimaxillary protrusion, severe open bite, and a skeletal lingual crossbite due to both jaws (Figure 13). Her future growth forecast without

treatment revealed the potential for positive horizontal, mandibular development. A bonded expander with full occlusal coverage for maxillary expansion and fixed appliances was treatment planned. After 4.0 mm of maxillary expansion, the maxillary and mandibular dentitions were bonded. The expander was removed 6 months later, and the remaining maxillary arch was bonded. At this point, the open bite closed significantly requiring the placement of occlusal stops on the mandibular first molars to avoid anterior interferences. The maxillary lateral incisors were bonded 18 months after the start of treatment.

Figure 11

Figure 10

Figure 12

Figure 13 Volume 8 Number 2

Orthodontic practice 39

CONTINUING EDUCATION

Early treatment substantially benefited this patient. Closure of the anterior open bite and changes in the oral cavity prevented the adaptation of a resting tongue posture that would have maintained the open bite. She now possesses a normal occlusion resulting in proper mastication. Removable Hawley retainers are worn full time until the eruption of the remaining permanent teeth. Full-time Hawley wear during this transitional period into the permanent dentition supports the expansion of the maxilla and early fixedappliance therapy. Comprehensive treatment after the eruption of the permanent dentition will finalize the occlusion.

CONTINUING EDUCATION

Figure 15

Figure 14

Figure 16

Figure 17

Total early interceptive treatment time was 28 months (Figures 14-16). The anterior open bite fully closed. During the course of treatment, significant anterior growth of the mandible compared to the maxilla occurred, resolving the anterior-posterior component of the open bite. Incisor protrusion also improved with treatment (Figure 17). The current result is being maintained with 24-hour wear of removable maxillary and mandibular Hawley retainers until the remaining permanent teeth erupt. Following the eruption of the permanent dentition, 40 Orthodontic practice

comprehensive orthodontic treatment to finalize the occlusion is planned. This case is an excellent example of utilizing mandibular growth to facilitate correction of malocclusions. Case 3 This 10-year 7-month-old Caucasian male presented with an early mixed dentition, unerupted maxillary lateral incisors, and a persistent anterior open bite (Figure 18). He had a previous thumb habit. A CBCT scan revealed ectopically developing maxillary

canines (Figures 19 and 20). A cephalometric analysis of the facial skeleton showed a mesofacial facial pattern with an anterior open bite and skeletal lingual crossbite due to the mandible (Figure 21). Future facial growth analysis predicted significant anterior growth of both jaws, especially that of the mandible. Phase I treatment composed of maxillary expansion with a complete coverage bonded expander and fixed appliances. A total of 6 mm of expansion was achieved with the expansion appliance. The maxillary Volume 8 Number 2

CONTINUING EDUCATION

Figure 19

Figure 18

Figure 20

Figure 22

Figure 21 Volume 8 Number 2

incisors were bonded 6 weeks after expander delivery and attached to the expander with a .016 Niti archwire via tubes attached to the buccal aspect of the expander at the level of the deciduous canines. The mandibular dentition was bonded at the same time. Expander removal occurred 5.5 months after initial delivery. Appliances were removed after 26 months to await the eruption of the remaining permanent dentition, to be followed up with comprehensive treatment (Figure 22). The Orthodontic practice 41

CONTINUING EDUCATION

Figure 23 Figure 24

Figure 25

persistent anterior open bite closed, and space was created for the erupting maxillary canines (Figures 23 and 24). Significant horizontal growth of both jaws occurred during treatment, especially the mandible (Figure 25). The patient has been instructed to wear removable Hawley retainers full time until the remaining permanent teeth erupt and finalization of the occlusion with future fixed appliances. Various treatment modalities have been recommended for the early treatment of AOB malocclusions including chin cup therapy, lingual spurs, headgear, multi-bracket techniques, bite blocks, and functional appliances. Maxillary expansion, with a complete coverage bonded expander, combined with fixed appliances in the mixed dentition successfully corrected anterior open-bite malocclusions in these patients. Maxillary expansion offers one more effective treatment modality in AOB malocclusions. OP 42 Orthodontic practice

REFERENCES 1. Ngan P, Fields HW. Open bite: a review of etiology and management. Pediatr Dent. 1997;19(2):91-98. 2. Ellis E 3rd, McNamara JA Jr, Lawrence TM. Components of adult Class II open-bite malocclusion. J Oral Maxillofac Surg. 1985;43(2):92-105. 3. Keski-Nisula K, Lehto R, Lusa V, Keski-Nisula L, Varrela J. Occurrence of malocclusion and need of orthodontic treatment in early mixed dentition. Am J Orthod Dentofacial Orthop. 2003;124(6):631-638. 4. Cozza P, Baccetti T, Franchi L, Mucedero M, Polimeni A. Sucking habits and facial hyperdivergency as risk factors for anterior open bite in the mixed dentition. Am J Orthod Dentofacial Orthop. 2005;128(4):517-519. 5. Sassouni V. A classification of skeletal facial types. Am J Orthod. 1969;55(22):109-123. 6. Nahoum HI. Anterior open-bite: a cephalometric analysis and suggested treatment procedures. Am J Orthod. 1975;67(5):523â&#x20AC;&#x201C;521. 7. Schudy FF. The rotation of the mandible resulting from the growth: its implications in orthodontic treatment. Angle Orthod. 1965;35:36-50. 8. Nielsen IL. Vertical malocclusions: etiology, development, diagnosis, and some aspects of treatment. Angle Orthod. 1991;61(4):247-260. 9. Linder-Aronson S. The relation between nasorespiratory function and dentofacial morphology. Am J Orthod. 1983;83(5):443-444.

10. Vig KW. Nasal obstruction and facial growth: the strength of evidence for clinical assumptions. Am J Orthod Dentofacial Orthop.1998;113(6):603-611. 11. Takada K, Lowe AA. A comparison of tongue posture in control and open-bite subjects. J Dent Res.1985. 12. Subtelny JD, Sakuda M. Open-bite: diagnosis and treatment. Am J Orthod.1964:50(5):337-358. 13. Dung DJ, Smith RJ. Cephalometric and clinical diagnoses of open bite tendency. Am J Orthod Dentofacial Orthop. 1988;94:484-90. 14. Richardson A. Skeletal factors in anterior open-bite and deep overbite. Am J Orthod. 1969;56(2):114-27. 15. Nahoum HI. Vertical proportions and the palatal plane in anterior open-bite. Am J Orthod. 1971;59:273-282. 16. Cangialosi TJ. Skeletal morphologic features of anterior open bite. Am J Orthod. 1984;85(1):28-36. 17. Proffit WR, Vig KW, Turvey TA. Early fracture of the mandibular condyles: frequently an unsuspected cause of growth disturbances. Am J Orthod.1980;78(1):1-24. 18. Ellis E 3rd, Moos KF, el-Attar A. Ten years of mandibular fractures: an analysis of 2,137 cases. Oral Surg Oral Med Oral Pathol. 1985;59(2):120-129. 19. Motamedi MH. An assessment of maxillofacial fractures: a 5-year study of 237 patients. J Oral Maxillofac Surg. 2003;61(1):61-4 20. Worms FW: Open bite. Am J Orthod. 1971;59(6):589-595.

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Early treatment of anterior open bites EDGREN

1. An anterior open bite (AOB) occurs when the maxillary and mandibular permanent incisors lack _______ when the posterior teeth have maximum intercuspation. a. incisal contact b. vertical overlap c. anterior interferences d. both a and b 2. Transient anterior open bites do occur during the transitional dentition, between the deciduous and mixed dentitions, _______ as the permanent incisors erupt into the oral cavity. a. and are considered normal b. but are considered abnormal c. and are extremely dangerous d. and are painful 3. These pseudo open bites can last between _______ years. a. 1 to 2 b. 3 to 4 c. 4 to 6 d. 7 to 8 4. Etiologies of anterior open bites are often multifactorial in nature ranging from dentoalveolar development to vertical skeletal

Volume 8 Number 2

growth patterns, _________, traumatic injuries, and/or congenital anomalies/abnormalities. a. complications from upper airway obstruction and oral breathing b. oral habits c. adaptive tongue posture d. all of the above 5. Orthodontic treatment of patients with normal cephalometric facial heights with dental open bite malocclusions ________ than with those malocclusions that have a significant vertical skeletal component. a. is more successful b. is no more successful c. is more dangerous d. is more painful 6. _______ is/are vitally important in diagnosing these types of malocclusions. a. 2D X-rays b. Visual examination c. Cephalometric analysis d. Digital photographs 7. Initial diagnosis of ________ is important in preventing adverse effects from fixed appliances. a. carious teeth

b. ankylosed teeth c. teeth with Class I mobility d. periodontal disease 8. Proffit stated that approximately _______ of children with early condylar fractures will have some deficits in growth. a. 6% b. 25% c. 46% d. 60% 9. Various treatment modalities have been recommended for the early treatment of AOB malocclusions, including chin cup therapy, _____ bite blocks, and functional appliances. a. lingual spurs b. headgear c. multi-bracket techniques d. all of the above 10. Maxillary expansion, with a complete coverage bonded expander, combined with fixed appliances in the mixed dentition _______ anterior open bite malocclusions in these patients. a. was unable to correct b. only partially corrected c. successfully corrected d. was a short-term correction for

Orthodontic practice 43

CE CREDITS

ORTHODONTIC PRACTICE CE

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Two-step retraction versus en masse retraction during maxillary space closure Drs. Amy H. Hoch, Gerald Hoch, Analia Veitz-Keenan, Olivier Nicolay, and George J. Cisneros discuss multiple factors that contribute to whether clinicians select one technique over another Abstract: The intent of this article was to review the literature to determine whether canine retraction followed by incisor retraction is more efficient than en masse retraction of the six anterior teeth during extraction space closure. Methods: Specific keyword phrases such as “anchorage loss in orthodontic space closure,” “en masse retraction in orthodontics,” and “two-step retraction in orthodontics” were used to search Google Scholar, PubMed, Embase, and Cochrane Ovid for published articles. No language restrictions were placed when searching for articles. In addition, the authors’ hand-searched related articles as well. Results: Over 41 articles were obtained and reviewed. All articles were categorized according to the following subtitles: anchorage, overjet reduction, duration, adolescents versus adults, mechanics, lingual versus

Educational aims and objectives

This article aims to determine whether canine retraction followed by incisor retraction is more efficient than en masse retraction of the six anterior teeth during extraction space closure.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 47 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Realize the role of anchorage when trying to achieve space closure. • Identify different types of retraction devices that should be used. • Realize the role of overjet and crowding in anchorage loss. • Realize the differences between primary anchorage and secondary anchorage.

buccal appliances, etc. Within each category, subcategories were created: TADs, NiTi closing coils, power chains, headgear, etc., to further catalog the articles. Conclusion: There is no strong evidence supporting one method over the other. Both techniques can

be effective along with the use supplemental materials such as TADs, NiTi closing coils, retraction archwires, and more. Closing first premolar extraction spaces usually requires practitioners to select one of the two following strategies: retraction of

Amy H. Hoch, DDS, earned her undergraduate degree at the University of Michigan in Ann Arbor and went on to attend dental school at New York University (NYU) College of Dentistry. After graduating NYU, Dr. Amy Hoch went on to complete a 1-year general dental residency at St. Barnabas Hospital in the Bronx. In August 2010, she started a 3-year orthodontic residency at New York University College of Dentistry. Dr. Amy Hoch is a Diplomate for the American Board of Orthodontics.

Gerald Hoch, DDS, received his undergraduate education at Rutgers University in New Brunswick, New Jersey. He graduated New York University (NYU) College of Dentistry with high distinction and went on to complete his orthodontic residency there as well. At NYU, he was elected to OKU, the Dental Honors Fraternity. Dr. Gerald Hoch has been teaching at NYU since 2007 as a postgraduate orthodontic attending.

Analia Veitz-Keenan, DDS, is a practicing general dentist. She holds the position of Clinical Associate Professor in the Department of Oral Maxillofacial Pathology, Radiology and Medicine, and is currently the Director of Evidence-Based Dentistry in the Department of Epidemiology and Health Promotion at NYU College of Dentistry. She teaches to undergraduate and postgraduate students, as well as coordinates and teaches activities for faculty.

Olivier Nicolay, DDS, MMSc, is Acting Chair and Clinical Associate Professor – Department of Orthodontics at NYU College of Dentistry. He has a DCD from the Universite Paris Descartes in France, a DDS from Columbia University, and a Certificate in Orthodontics, Masters in Medical Sciences from Harvard. After graduation, Dr. Nicolay joined the Ohio State University where he taught postgraduate students and was involved in research. In 1989, he assumed the position of Program Director at Columbia University, pursuing his interests in research and teaching orthodontics. He has been member of the NYU College of Dentistry since 2002. He is a Diplomate of the American Board of Orthodontics, a Member of Angle East, component of the Angle Society of Orthodontists, the American Association of Orthodontists, and the American Dental Association. George J. Cisneros, DMD, earned his dental degree from the University of Pennsylvania School of Dental Medicine and a specialty certification in both Pediatric Dentistry and Orthodontics, as well as a Master of Medical Science degree (MMSC) in Oral Biology at Boston’s Children’s Hospital Medical Center, the Forsyth Dental Center, and the Harvard School of Dental Medicine, respectively. He developed and established Postgraduate Training Programs in Orthodontics at Albert Einstein College of Medicine/Montefiore Medical Center and Saint Barnabas Hospital in New York, and served as Chair of Orthodontics at New York University College of Dentistry. He is a Diplomate of the American Board of Pediatric Dentistry (ABPD) and the American Board of Orthodontics (ABO), and has served as an ABO board examiner and on the ABPD Advisory Committee. He also was elected to and served on the American Academy of Pediatric Dentistry Board of Trustees. For nearly 20 years, he was the Dental Director for the Craniofacial Disorders team and was a consultant with the SleepWake Disorders Center at Montefiore Medical Center/Einstein College of Medicine. A recipient of the Milo Hellman Award from the American Association of Orthodontists, Dr. Cisneros’ main research interests include the evaluation of facial growth and development using nuclear medical techniques, the diagnosis and treatment of patients with obstructive sleep apnea, the impact of fixed orthodontic appliance design upon the efficiency of tooth movement, and the study of various computer-imaging techniques. Other research interests are related to the use of speech appliances in children with velopharyngeal insufficiency, the relationship between malocclusion and speech sound production, patient self-image and perception of need for orthodontic care, the impact of fixed and removable orthodontic appliances on periodontal health, the impact of demineralized white spot lesions on the dentition and their prevention using dental varnishes and sealants, and enhancing doctor/patient interaction and communication. He has published more than 100 scientific peer-reviewed articles, book chapters, and abstracts.

44 Orthodontic practice

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retraction is more efficient than en masse retraction or vice versa.

Material and methods Our review used specific key phrases such as “anchorage loss in orthodontic space closure,” “en masse retraction in orthodontics,” and “two-step retraction in orthodontics” to search Google Scholar, PubMed, Embase, and Cochrane Ovid for published articles. We placed no language restrictions when searching for articles. In addition, the authors hand-searched for related articles. Through these search methods, over 41 articles were obtained and reviewed. Each article was categorized according to the following subtitles: anchorage, overjet reduction, time, adolescents versus adults, mechanics, lingual versus buccal appliances, etc. Within each category, subcategories were created: TADs, NiTi closing coils, power chains, headgear, etc. to further catalog the articles. When reviewing the articles, we grouped them based on retraction methodology, anchorage, mechanics, and materials used. The retraction method was grouped into en masse retraction versus two-step retraction, en masse retraction, and two-step retraction. In terms of anchorage, the techniques used were posterior teeth as anchorage, implant anchorage, transpalatal arch as anchorage, and headgear. Many articles compared the following materials when it came to efficiency of closing space with Class I mechanics: NiTi closing coils, elastic modules, such as power chains, and power thread.

Results with discussion Anchorage can be broken into primary anchorage and secondary anchorage. Geron, S., et al. (2003), describe primary anchorage loss factors as crowding and mechanics and secondary anchorage loss factors as extraction sites, age, and overjet. When comparing primary anchorage loss factors, severe crowding was less conducive to anchorage loss than mechanics. When comparing secondary anchorage loss, extraction sites were more critical than age and overjet. However, it was shown that including the second molar in the anchorage system along with low retraction forces and reduced friction-filled mechanics could be considerably more efficient when controlling and establishing absolute anchorage. Extraction sites can contribute to anchorage loss, e.g., first premolars versus second premolars. Even though some articles refer to second premolar extraction

leading to greater anchorage loss than first premolar extraction patterns, this particular study stated that not enough evidence existed to make it statistically significant.3 Growing and non-growing patients demonstrate differences in anchorage loss. Adults experience greater anchorage loss than adolescents, but the difference between the two groups was not statistically significant. Most likely, this is why growth has been considered a secondary factor when it comes to anchorage loss. Overjet and crowding are also factors of anchorage loss. Studies have shown that the greater the crowding is in the mandibular arch, the more likely anchorage loss will occur, thus making it a primary factor of anchorage loss. Although biomechanically speaking, it requires less anchorage to unravel crowding than to reduce overjet. Kawakami and co-workers4 used implants as anchorage with lingual appliances after second premolar extractions and showed that with implant-supported anchorage, little anchorage loss occurred when retracting the six anterior teeth en masse. Temporary anchorage devices (TADs) and miniscrew implants are now more common in the orthodontic mechanotherapy. Studies have shown that TADs and microscrews offer effective anchorage control in patients that require maximum anchorage.5-15 Even though headgear has been widely used over the years and has been valued as a useful anchorage device, issues like patient compliance and the negative side effects the headgear may have on the patient’s occlusion limits its use. Thiruvenkatachari, et al.,9 compared the rate of canine retraction with conventional molar anchorage and titanium implant anchorage. In that study, there was a significant difference in retraction with implant anchorage and molar anchorage. They observed approximately 0.35 mm – 0.60 mm more retraction with implants than with conventional molar anchorage. Moreover, Kuroda, et al.,11 conducted a study comparing headgear use and the use of miniscrews to help retract the canines and incisors. Both treatment modalities had acceptable results; however, using miniscrews helped improves the patients’ profiles by providing more effective anchorage. Force delivery taxes anchorage, and the type of force used during treatment matters. Studies have researched the different types of materials used to achieve this movement. Nickel-titanium (NiTi) closing coils, elastic modules, and closing loop archwires are Orthodontic practice 45

CONTINUING EDUCATION

the canines first, followed by retraction of the incisors thereafter or retraction of the six anterior teeth all at once, otherwise known as en masse retraction. It is yet unclear whether a practitioner’s preference is based on anchorage requirement, orthodontic mechanotherapy, esthetics, or mere habit. Although extraction of premolars may be indicated for cases with crowding, severe overjet, etc., an individual’s parameters will help determine the extent and limits of the dental movements within each dental arch. Clearly, there are multiple factors that contribute to whether clinicians select one technique over another, or whether one is necessarily better than another. Anchorage loss is multi-factorial, making the issue more complex than it appears. The concept of anchorage control is rooted in Newton’s Third Law of Motion: “For every action, there is an equal and opposite reaction.”1 However, with some of the therapeutic advances we have today, different treatment approaches are revisited. Practitioners may prefer to retract the canines first in the belief that retraction of two teeth, then of four teeth may be more effective to maintain anchorage, while others prefer to retract all six anterior teeth at once. All are still trying to achieve the same goal — space closure obtained efficiently with minimal anchorage loss. There have not been many studies comparing the two aforementioned techniques, but there have been many publications referring to aspects of space closure. Throughout our search of the topic, we found that while canine retraction versus en masse retraction might be a simple question, many factors play a role in its methods. The most persistent question is, How do we maintain anchorage to use the extraction space for retraction of the anterior teeth? Do we need a transpalatal arch, perhaps with a Nance button to help achieve anchorage? Should we use headgear, mini-implants, tooth-borne anchorage, etc.? As we found more information, more questions surfaced. For instance, what type of retraction devices should we use? For example, there are power chains, nickel-titanium closing coils, retraction archwires with T-loops, retraction archwires with mushroom button loops, etc. When using different methods, there can also be variations between labial appliances and lingual appliances. There can be differences between first premolar extractions and second premolar extractions and much more. This paper proposes to review the literature and determine whether either two-step

CONTINUING EDUCATION among some of the most popular approaches in the retraction of the anterior dentition. However, NiTi closing coils seem to be the most efficient and effective modality.16-21 In summary, little difference was found between the two retraction techniques — en masse versus canine retraction — in maintaining molar anchorage and duration of treatment, however, there were variations in the methodology used for retraction of the anterior teeth.22 NiTi coils with 150 grams of force were the most efficient retracting modality with the least amount of unwanted side effects. Moreover, TADs appear to be

the most effective in maximizing anchorage during extraction space closure. Transpalatal arches with a Nance button can also offer effective anchorage as well as headgear; however, headgear is dependent on patient compliance. Orthodontic practitioners have multiple techniques for treating patients, especially with extractions. Several opinions exist about whether two-step retraction or en masse retraction is the most effective method. This review has found that both techniques will produce similar outcomes. However a few items clinicians consider when treating

extraction patients are the type of anchorage used, the materials used to retract the anterior teeth, and the amount of force applied to the teeth.

Conclusion There is no difference between en masse and two-step retraction. When closing extraction spaces with either method, the most efficient way to retract the anterior segment is with 150-gram NiTi closing coils. In both retraction methods, clinicians should consider additional anchorage devices to reduce anchorage loss. OP

Table 1: Review of articles Retraction Method

Articles

Anchorage Method

Mechanics Used

En Masse Retraction vs. Two-Step Retraction

Tian-Min Xu, et al., 2010

Headgear and transpalatal arch

Elastic modules

Wook Heo, et al., 2007

Posterior teeth

Open-type vertical loops on an 0.019x0.025SS – activated 1 mm to produce a force of 150g/side.

En Masse Retraction

R. H. A. Samuels, et al., 1998

Second premolars and first molars

Light and heavy NiTi closing coils (150 grams vs. 200 grams)

R. H. A. Samuels, et al., 1993

Second premolars and first molars

NiTi closing coils and elastic modules (split mouth technique)

Masayoshi Kawakami, et al., 2004

Titanium screws

Elastic thread was used to retract the anterior six teeth on lingual appliances with reinforced anchorage

Jason A. Yee, et al., 2009

No specific anchorage system reported

NiTi closing coils

Badri Thiruvenkatachari, et al., 2008

Molar anchorage and titanium implant anchorage

NiTi closing coils

Kazuo Hayashi, et al., 2004

Osseointegrated midpalatal implants incorporated into a transpalatal arch

Canine retraction with sliding mechanics vs. canine retraction with a Ricketts retraction spring

Two-Step Retraction

REFERENCES 1. Kuhlberg AJ, Priebe DN. Space closure and anchorage control. Semin Orthod. 2001;7(1):42-49. 2. Peck S. A biographical portrait of Edward Hartley Angle, the first specialist in orthodontics, part 1. Angle Orthod. 2009;79(6):1021-1027. 3. Geron S, Shpack N, Kandos S, Davidovitch M, Vardimon AD. Anchorage loss — a multifactorial response. Angle Orthod. 2003;73(6):730-737. 4. Kawakami M, Miyawaki S, Noguchi H, Kirita T. Screw-type implants used as anchorage for lingual orthodontic mechanics: a case of bimaxillary protrusion with second premolar extraction. Angle Orthod. 2004;74(5):715-719. 5. Thiruvenkatachari B, Ammayappan P., Kandaswamy R. Comparison of rate of canine retraction with conventional molar anchorage and titanium implant anchorage. Am J Orthod Dentofacial Orthop. 2008;134(1):30-35. 6. Cope JB. Temporary Anchorage devices in orthodontics: a paradigm shift. Semin Orthod. 2005;11(1):3-9. 7. Upadhyay M, Yadav S, Patil S. Treatment effects of mini-implants for en-masse retraction of anterior teeth in bialveolar dental protrusion patients: a randomized controlled trial. Am J Orthod Dentofacial Orthop. 2008;134(1):18-30. 8. Basha AG, Shantaraj R, Mogegowda SB. Comparative study between conventional en-masse retraction (sliding mechanics) and en-masse retraction using orthodontic micro implant. Implant Dent. 2010;19(2):128-132. 9. Thiruvenkatachari B, Pavithranand A, Rajasigamani K, Kyung HM. Comparison and measurement of the amount of anchorage loss of the molars with and without the use of implant anchorage during canine retraction. Am J Orthod Dentofacial Orthop. 2006;129(4):551-554.

Results • No significant difference between the two methods in anchorage loss. • Average 1 mm loss of anchorage for every 4 mm of retraction. • Difference found between the two methods is time – en masse takes less time. • With NiTi coils, more retraction with 150 grams than 100 grams of force, no difference between 150 and 200 grams. • 200 grams of force cause unwanted side effects on the canine. • Less anchorage loss with implant anchorage.

• Heavy forces retract canines faster (7.34 mm vs. light forces at 3.51 mm over a 12-week period) with unwanted side effects, anchorage loss and canine rotations. • Significant differences in retraction with implant anchorage and molar anchorage, more retraction with implant (0.35-0.65 mm). • No statistical significance between two retraction techniques with mm per month or crown tipping. • Significant canine rotation with a Ricketts spring than with a NiTi closed coil.

12. Yao CC, Lai EH, Chang JZ, Chen I, Chen Y. Comparison of treatment outcomes between skeletal anchorage and extraoral anchorage in adults with maxillary dentoalveolar protrusion. Am J Orthod Dentofacial Orthop. 2008;134(5):615-624. 13. Benson PE, Tinsley D, O’Dwyer JJ, Majumdar A, Doyle P, Sandler PJ. Midpalatal implants vs. headgear for orthodontic anchorage — a randomized clinical trial: cephalometric results. Am J Orthod Dentofacial Orthop. 2007;132(5):606-615. 14. Upadhyay M, Yadav S, Nanda R. Vertical-dimension control during en-masse retraction with mini-implant anchorage. Am J Orthod Dentofacial Orthop. 2010;138(1):96-108. 15. Garfinkle JS, Cunningham LL Jr, Beeman CS, Kluemper GT, Hicks EP, Kim MO. Evaluation of orthodontic mini-implant anchorage in premolar extraction therapy in adolescents. Am J Orthod Dentofacial Orthop. 2008;133(5):642-653. 16. Samuels RH, Rudge SJ, Mair LH. A clinical study of space closure with nickel-titanium closed coil springs and an elastic module. Am J Orthod Dentofacial Orthop. 1998;114(1):73-79. 17. Nightingale C, Jones SP. A clinical investigation of force delivery systems for orthodontic space closure. J Orthod.2003;30(3):229-236. 18. Dixon V, Read MJF, O’Brien KD, Worthington HV, Mandall NA. A randomized clinical trial to compare three methods of orthodontic space closure. J Orthod. 2002;29(1):31-36. 19. Samuels, RH, Rudge SJ, Mair LH. A comparison of the rate of space closure using a nickeltitanium spring and an elastic module: a clinical study. Am J Orthod Dentofacial Orthop. 1993;103(5):464-467. 20. Nattrass C, Ireland AJ, Sherriff M. The effect of environmental factors on elastomeric chain and nickel titanium coil springs. Eur J Orthod.1998;20(2):169-179.

10. Park HS, Kwon TG. Sliding mechanics with microscrew implant anchorage. Angle Orthod. 2004;74(5):703-710.

21. Nattrass C, Ireland A, Sherriff M. An investigation into the placement of force delivery systems and the initial forces applied by clinicians during space closure. Br J Orthod.1997;24(2):127-131.

11. Kuroda S, Yamada K, Deguchi T, Kyung H, Takano-Yamamoto T. Class II malocclusion treated with miniscrew anchorage: comparison with traditional orthodontic mechanics outcomes. Am J Orthod Dentofacial Orthop. 2009;135(3):302-309.

22. Heo W, Nahm DS, Baek SH. En masse retraction and two-step retraction of maxillary anterior teeth in adult Class I women. A comparison of anchorage loss. Angle Orthod. 2007;77(6):973-978.

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Two-step retraction versus en masse retraction during maxillary space closure HOCH, ET AL.

1. Geron, S., et al. (2003), described primary anchorage loss factors as crowding and mechanics and secondary anchorage loss factors as __________. a. extraction sites b. age c. overjet d. all of the above 2. When comparing primary anchorage loss factors, __________. a. severe crowding was less conducive to anchorage loss than mechanics b. mechanics was less conducive to anchorage loss than severe crowding c. mechanics and severe crowding were equally as conducive to anchorage loss d. none of the above 3. Adults experience _________ than adolescents, but the difference between the two groups was not statistically significant. a. greater anchorage loss b. less anchorage loss c. more moderate d. a greater amount of growth 4. Kawakami and co-workers used implants as anchorage with lingual appliances after second premolar extractions and showed

Volume 8 Number 2

that with implant-supported anchorage, _________ occurred when retracting the six anterior teeth en masse. a. considerable anchorage loss b. infection c. little anchorage loss d. negative side effects 5. Studies have shown that _________ offer effective anchorage control in patients that require maximum anchorage. a. clear aligners b. TADs c. microscrews d. both b and c 6. Thiruvenkatachari, et al., observed approximately ________ more retraction with implants than with conventional molar anchorage. a. 0.20 mm – 0.25 mm b. 0.35 mm – 0.60 mm c. 0.65 mm – 0.70 mm d. 80 mm 7. Nickel-titanium (NiTi) closing coils, elastic modules, and closing loop archwires are among some of the most popular approaches in the retraction of the anterior dentition. However, _______ seem to be the most efficient and effective modality.

a. elastic modules b. NiTi closing coils c. closing loop archwires d. microscrews 8. NiTi coils with _______ of force were the most efficient retraction modality with the least amount of unwanted side effects. a. 100 grams b. 125 grams c. 150 grams d. 175 grams 9. Moreover, _______ appear to be most effective in maximizing anchorage during extraction space closure. a. TADs b. transpalatal arches alone c. Nance buttons d. microscrews 10. Transpalatal arches with a Nance button can also offer effective anchorage as well as headgear; however, headgear is dependent on _________. a. the age of the patient b. patient compliance c. the size of the patient d. the cost restrictions for the treatment plan

Orthodontic practice 47

CE CREDITS

ORTHODONTIC PRACTICE CE

AAO PREVIEW

AAO

Maximize your potential at 2017 Annual Session of the American Association of Orthodontists

alifornia, here we come! From April 21-25 at the 2017 Annual Session of the American Association of Orthodontists, clinicians will explore the art, science, and business of orthodontics. With business and clinical technologies evolving so rapidly, keeping up with the latest trends and techniques can positively impact the future of your practice. It’s time to learn a new subject, see and touch innovative equipment and materials, and network with other specialty practitioners. Educated, talented, and motivational speakers will discuss topics including anchorage modalities and TADs, sleep-disordered breathing, Class II correction, risk management, and mega-trends for this dynamic specialty. Besides these enlightening sessions, the AAO is a great opportunity to discuss possibilities with vendors. With more than 350 exhibitors under one roof at the San Diego Convention Center, you will be able to see firsthand products that can make your practice life easier, improve workflow for your team, offer you more treatment options, and provide optimum care to your patients. Orthodontic Practice US is excited to showcase some of these powerful and versatile products to whet your appetite and welcome you to these booths. Increased practice efficiency and profitability await your practice, and these Visit Orthodontic Practice US at Booth No. 1247 companies are awaiting your visit!

Diagnose, Design & Achieve with suresmile®

Meditorque Elite 3-piece kit from Medidenta

Get into digital with suresmile®, elemetrix™ and fusion™ lingual technology. Established in 1998, OraMetrix developed the suresmile system, a revolutionary digital Treatment Management System that redefines patient care through patient-specific wire sequences and hybrid appliance modalities. suresmile brings together integrated labial and lingual treatment options, including surgical design, an array of restorative planning tools, an innovative approach to indirect bonding, and fully coordinated aligner design. suresmile not only allows visualization of alternate treatment plans, it also advances the ability to plan smile esthetics, consult with the referring GP over the Internet, and share design plans with the patient and parents during consultation. Based on proven suresmile technology, the recently introduced suite of digital applications, elemetrix, makes digital aligner design, IDB, and advanced diagnostics available on a case-by-case basis. suresmile fusion lingual brings together the precision of suresmile treatment planning software, digitally-designed indirect bonding, robotically-bent archwires, and the efficiency a self-ligating, low profile bracket system. For more information, visit suresmile.com or call 877-787-7645.

The Meditorque Elite 3-piece kit provides your office with consistent power and performance over a longer period of time. With 25% more speed than most conventional motors, the Meditorque Elite is sure to exceed your expectations, thanks to its superior build. It will offer you all the power and versatility you need for your chairside procedures. We are running a “Buy 1, Get 1 60% OFF” offer at the AAO, Booth No. 522.

Visit suresmile/OraMetrix at Booth No. 2937

48 Orthodontic practice

Visit Medidenta at Booth No. 522

Volume 8 Number 2

American Orthodontics Empower® 2 Self Ligating Brackets

American Orthodontics’ Empower® 2 Self Ligating metal brackets and molar tubes feature micro-etched Maximum Retention™ bonding pads, which increase bond strength 15%-30% over non-micro-etched pads. A modified clip, which is 20% thicker and stronger than previous generations, helps seat wire into the slot during clip closure and increases wire-seating force while reducing clip deformation. A chamfered slot entrance also reduces friction from wire binding. The Empower family gives you the most features, prescription choices, and treatment possibilities all in one quality, unified system. Multiple bracket options include metal, clear, and molar tubes, and system choices include a fully interactive system, a fully passive system, or the innovative Dual Activation™ system. Learn more about Empower 2 and the entire Empower family by visiting www.americanortho.com/Empower.

Visit American Orthodontics at Booth No. 2337

AcceleDent® — patented SoftPulse Technology® AcceleDent® is the first noninvasive, FDA-cleared Class II medical device that employs patented SoftPulse Technology® clinically proven to speed up bone remodeling during orthodontic treatment by enhancing physiological bone turnover. Leading orthodontists from around the world report increased mechanical efficiency with orthodontic appliances and improved predictability of clinical outcomes when using AcceleDent. Visit acceledent.com to learn how doctors are incorporating AcceleDent into their treatment protocols.

Visit AcceleDent at Booth No. 3037

CS 8100SC 3D by Carestream Dental

Great Lakes Brackets

The CS 8100SC 3D extraoral imaging system is the newest solution from Carestream Dental that offers panoramic imaging, cephalometric imaging, cone beam computed tomography, and additional 3D applications in one versatile unit. In addition to highresolution, low dose 3D imaging, the system includes the fastest scanning cephalometric module on the market — as little as 3 seconds.1 Carestream Dental’s exclusive software recognizes anatomical structures and traces them automatically; in fact, it can go from scanning to tracing within 90 seconds.2 The system can also scan patients’ traditional impressions or plaster models to create digital models for easier storage or for analysis using CS Model software. Plus, at just 72.5 inches wide, the CS 8100SC 3D is compact enough for almost any practice.

Great Lakes’ full line of quality fixed appliances is valuepriced for practice profitability and offers maximum versatility and reliability. The brackets offer easy placement, a low profile, secure bonding, and patient comfort. EasyClip+® can be used as fully passive, fully interactive, or a combination of both and features a unique planar NiTi clip that locks securely and will not deform or degrade. BioTru® Classic straight-wire stainless steel brackets have a .080 contoured mesh pad for excellent bond strength, rounded tie wings for patient comfort, and a compound, contour base for easy, accurate placement. BioTru® Ceramic brackets offer a unique combination of esthetics, function, and strength. BioTru® Sapphire brackets are incredibly transparent, will not stain, and are strong and fracture resistant. For more information, contact Great Lakes at 800-828-7626, and ask to speak with a brackets specialist, or visit our website, GreatLakesBrackets.com.

1. For an 18x24 cm image in fast scan mode 2. For an 18x24 cm image

Visit Carestream at Booth No. 3417

Volume 8 Number 2

Visit Great Lakes at Booth No. 1305

Orthodontic practice 49

AAO PREVIEW

PREVIEW

AAO PREVIEW

AAO

Ormco Corporation — Damon™ Clear2

Propel Orthodontics — Your one-stop shop Propel Orthodontics is a leading innovator, manufacturer, and worldwide seller of orthodontic devices, providing in-office and at-home offerings for orthodontists and patients. Propel offers the Excellerator™ Series Drivers, a line of advanced orthodontic devices allowing clinicians to perform quick in-office treatments during regularly scheduled visits. The VPro5™, a vibratory device used to assist in properly seating clear aligners in just 5 minutes a day, allows patients to participate in treatment at home or on the go! Propel Orthodontics — Your one-stop shop for both in-office and at-home options. Stop by AAO Booth No. 713 for exciting promos, exclusive discounts only available at the show, and Q&A sessions with Propel experts. Visit Propel Orthodontics at Booth No. 713

You can efficiently treat all of your patients to a beautiful result with Damon™ Clear2. With a completely clear body and door that is resistant to staining, Damon™ Clear2 brackets provide the control and performance needed to treat a wide range of cases with exceptional results. Eliminating the need for elastomerics, the self-ligating bracket design with innovative SpinTek™ slide ensures quick and comfortable wire changes. Doctors treating with Damon Clear have access to My Smile Consult™, Ormco’s interactive online consultation tool designed to educate patients on the benefits of orthodontics and the Damon™ System, including Damon Clear. Visit our website at ormco.com, or call 800-854-1741.

Visit Ormco at Booth No. 2637

Rocky Mountain Orthodontics The orthodontic world is changing rapidly, and technology is leading the way to improved quality, profitability, and practice efficiency. Don’t get left behind! Join us for the 2017 seminar series where you’ll hear from Dr. Terry Sellke and Dr. Neal Kravitz on how to incorporate office efficiency through technology even in the busiest orthodontic offices! Learn more at rmo-seminars.com, or call 1-800-525-6375.

Visit Rocky Mountain Orthodontics at Booth No. 1821

50 Orthodontic practice

Volume 8 Number 2

Address the Orthodontic Complexities You Face Everyday with...

clinical articles • management advice • practice profiles • technology reviews

VISIT www.orthopracticeus.com

PROMOTING EXCELLENCE IN ORTHODONTICS Early treatment of anterior open bites Dr. Bradford N. Edgren

A review of suresmile®: efficiency and effectiveness Dr. Rohit C.L. Sachdeva

EMAIL subscriptions@medmarkaz.com

Two-step retraction versus en masse retraction during maxillary space closure Drs. Amy H. Hoch, Gerald Hoch, Analia Veitz-Keenan, Olivier Nicolay, and George J. Cisneros

Corporate profile MidAtlantic Orthodontics

CALL 1.866.579.9496

Practice profile Dr. Marc Olsen “What can be accomplished is often nothing short of amazing.” Jeff Johnson, DDS, MS Dallas, TX

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clinical articles • management advice • practice profiles • technology reviews January/February 2017 – Vol 8 No 1

Dr. Maurizio Cannata

Esthetic preferences regarding the anteroposterior position of the mandible Drs. Jeffrey H. Lee, Daniel Rinchuse, Thomas Zullo, and Lauren Sigler Busch

24 continuing education credits per year Clinical articles enhanced by high quality photography Analysis of the latest groundbreaking developments in orthodontics

Educator profile Dr. Frank Spear

Practice management advice on how to make orthodontics more profitable Real-life profiles of successful ortho practices Technology reviews of the latest products

Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 12/1/2016 to 11/30/2018 Provider ID# 325231 CONTINUING EDUCATION BROUGHT TO YOU BY

Reframing orthodontics: part 4 Dr. Rohit C.L. Sachdeva

Practice profile

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Dr. Gerry Ahrens

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The use of Kilroy Springs in the disimpaction of upper canines

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PRACTICE DEVELOPMENT

Top five dental marketing scams Cory Roletto, MBA, discusses some marketing tactics to avoid

e have all received the letters, seen the emails, and may have even answered a call from a company claiming something that is not true or promising something too good to be true. Over the past 7 years working with dental offices, we have seen our share of less than reputable marketing practices. In this article, we will talk about the top five dental marketing scams. 1. You receive a letter that your domain is expiring and needs to be renewed. This letter may look very official, and many have the word domains in the company name. The form asks you to fill out information about your domain, give your approval to renew the domain, and send payment. The payment request is often $100 or more. With rules established by The Internet Corporation for Assigned Names and Numbers (ICANN), the governing body for domain purchase and transfer, you are unlikely to actually lose control of your domain, but you may not even notice your money didn’t go to pay for domain renewal. If you are in doubt, you can verify the domain registrar by doing a WHOIS lookup on your website domain; most domain registrars have this feature. Here is a link to the WHOIS lookup page on Network Solutions: https://www.networksolutions.com/whois/index-res.jsp 2. You receive an email that they have evaluated your website, and it has not been SEOed. These emails are often automated spam emails with wording that makes it sound like they have evaluated your website, but upon closer inspection don’t give any specifics about what they found — because no one actually evaluated your website. They will often make nonsensical statements such as your website is not web

Cory Roletto is partner and co-founder of the dental marketing firm WEO Media, www. weodental.com, where he leads the operations team. He holds a MBA and BS in Chemical Engineering from the University of Washington.

52 Orthodontic practice

Avoid marketing scams. Receive your free marketing consultation today: 888-246-6906 2.0 compliant and have a link to test your site, or one of the following blanket statements: a. You have low online presence for many competitive keyword phrases. b. Your social media accounts are unorganized. c. You have many bad back links to your website. d. Your website is not compatible with all mobile devices. e. Your website is being penalized by Google. These types of spam emails have become more sophisticated often using search scrapers to pull some easy-toobtain data about your website that is added to the email to make it appear legitimate. They may also have a graph showing made-up metrics; for example, social media completeness. One other obvious red flag that is the email will not have any information on the company that supposedly evaluated your website, giving just a callback number or a Gmail email to respond. 3. A review directory representative states he/she can get negative reviews removed or make your positive reviews show up more, if you sign up for an advertising package. We have actually had salespeople for a very large, well-known review directory system state this to us and many of our clients. This is always stated over the phone, and they have never put it in writing — because it is flat-out not true. I am sure the directory involved would not condone this type of sales tactic, but

we have seen it so many times, it had to be mentioned. The truth is any reputable directory does not let advertising dollars influence what reviews do or do not show up when searching for a service. 4. They say they have a special relationship with Google. In this instance, the claim is that due to a special relationship, they can do things others cannot, such as getting special pricing on Google payper-click (PPC) campaigns or obtaining a No. 1 ranking on Google search. They may also misuse Google Partner to imply special treatment. Being a Google Partner means that personnel at the company have passed one or more Google certification tests showing they are proficient in some aspect of SEO or PPC. Being a Google Partner is a good thing, but it does not provide any special privilege or advantage other than the fact that the company has taken the time to be certified. 5. They assert that your Google PPC campaign is showing up in Europe because it is using the default settings. This was one of the most outlandish claims we have seen. To start, Google requires the region for the PPC campaign be set as part of the creation of the PPC campaign. Second, there is no way for someone to accurately detect Google PPC campaign settings. Also, if someone guarantees a No. 1 ranking in Google, they can only be referring to Google PPC where the No. 1 ranking can be bought by paying more per click, which is less than optimal. If a salesperson makes any of these claims, run. OP Volume 8 Number 2

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MESSAGE FROM YOUR ORTHODONTIST

Hi Julia, Your treatment is progressing well, keep wearing your Energy Pak Elastics! Hope the vacation is going well, no appointment is needed until next month! Dr. Anderson

TECHNOLOGY

Remote monitoring of treatment — less time, more control Dr. Terry Sellke discusses a smartphone-driven technology to increase efficiency

lecture worldwide on the business of orthodontics. We live in an ever more competitive, ever more regulated, and ever more price-controlled world. Importantly, the patients we serve seek convenience as well as quality. The practice that can master both of these aspects will surely be the winning orthodontic practice of the future. I was intrigued to read the AAO Tech Blog by Dr. Domenico Dalessandri of Italy (March 11, 2016) entitled, “Smartphonebased orthodontic monitoring: the big brother in our patient’s mouth.” In it he discussed app-based monitoring systems offered by various vendors. He asked, “Could these systems become important tools allowing us to improve our treatment quality and efficiency?” Following that blog was another, entitled “eOrthodontics,” by Dr. Anthony Puntillo (July 20, 2016) where the author also explored remote monitoring of patient care. Both authors mention a smartphonedriven technology called Dental Monitoring (DM). At the time of these blogs, I too was contemplating the benefits and rewards of remote monitoring. If it could work, and if it was accurate, remote monitoring offered orthodontists the chance to monitor treatment MORE frequently yet with FEWER patient visits. The potential to the practice would be better results in fewer visits and in fewer months. This should translate to more profit per case, and in this world of cost control by third parties, that is truly an exciting consideration.

Terry Sellke, DDS, MS, graduated with his Doctorate of Dental Surgery in 1971. Two years later, he achieved a specialty degree in orthodontics. In 1974, he received a Master’s degree in orthodontics, the same year that he opened the first office of what was to become Drs. Sellke and Reily, Ltd. In 1980, Dr. Sellke became a Diplomate of the American Board of Orthodontics. He taught orthodontics at the University of Illinois College of Dentistry for more than 35 years, where he earned the titles of full professor, master clinician, co-clinic director, and master’s thesis advisor. Dr. Sellke lectures domestically and internationally on clinical orthodontics as well as another of his passions, applying business principles to the practice of orthodontics.

54 Orthodontic practice

There are also advantages for the patients and parents with remote monitoring. In addition to those outlined previously for the practice, patients and parents want convenience. Parents don’t want to take kids out of school. Even after-school appointments compete with sports and other activities while complicating the lives of busy parents. If there was a way, therefore, for patients to be treated remotely, and at the same time enhance (not compromise) quality, this would be a boon to any practice. It would represent a win-win-win proposition sure to be a practice builder. Following these blogs, my practice began the use of remote monitoring. We wanted to test if quality monitoring was possible, if enhanced patent communication could be achieved, and if this could lead to fewer and shorter visits with treatment in fewer months. I understood that remote monitoring is not new at all. How long have pacemakers been placed, for example? In medicine, there are myriad examples of patient monitoring done remotely that enhance patient care and treatment outcomes. Why would we NOT expect this medical concept to have applications to orthodontics? Our office now has several hundred patients being remotely monitored using DM. We have developed systems for use of this tool. We have found it works far better than expected, and patients and parents love the benefits. I would like to give just one example of how remote monitoring can change your practice. I have included two photographs from DM dated 11/30/16 (Figure 1) and 12/13/16 (Figure 2). We were prompted by DM after the latter set of photos that this Invisalign® patient was experiencing failure in the fit of her aligners. Please note how much we had lost control of tooth No. 7. This was during a period of only 2 weeks. Our office, like most using Invisalign, tends to see patients every 6 to 8 weeks. We use Propel to help seat aligners, and patients are instructed to change aligners every week. Imagine, in a world where this patient would have gone

Figure 1

Figure 2

through possibly four more aligners before she returned to the office, what the status of our treatment would be? It would have required ordering new refinement aligners! Instead we were able to remotely intercept a serious problem, react and go back 2 aligners, recapture tooth No. 7, and finish this patient without further incident. Align Technology has recently revised its Invisalign change protocol to a 1-week aligner change — but with an important proviso — the need to monitor the patient closely. With any removable appliance, once the patient has left your practice, then compliance in wearing it is totally in the patient’s control, and as the orthodontist you do not know how the treatment is tracking. I am sure all my professional colleagues have experienced Volume 8 Number 2

Volume 8 Number 2

Remote monitoring with DM will be the next significant leap in how orthodontics is practiced in the 21st century.

They change the aligners themselves. Now with DM, the orthodontist can take back control of the clinical decision of changing out of one active appliance into another. In a challenging world, we need to seek out cost-effective methods to improve our care and also differentiate our practices. Similar to the Invisalign example, DM remote monitoring also delivers similar benefits with fixed appliances. Now you can pick up very quickly when a bracket debonds, a wire breaks, or oral hygiene needs to be improved. In more than 30 years of practicing as an orthodontist, I have seen how technology

and systems can improve orthodontics — giving efficiencies and control that lead to better patient outcomes and improved profitability for the orthodontist. Remote monitoring with DM will be the next significant leap in how orthodontics is practiced in the 21st century. Over the next year, I will be conducting a series of 1- and 2-day workshops for orthodontists and staff to show how to easily integrate remote monitoring into the orthodontic practice. For more information, go to http://rmo-seminars.com. OP This article was provided by Rocky Mountain Orthodontics.

Orthodontic practice 55

TECHNOLOGY

many instances where patients come back for their next appointment, and things are nowhere near where they should be. The patient is disappointed — a longer treatment is necessary, and the aligners are now highly visible. The orthodontist is disappointed in the appliance — the aligner doesn’t fit, and a new scan or impression is needed. And more appointments are necessary, and profitability is reduced. Remote monitoring with DM is the way to address these concerns. If you can’t fix the problem, you can at least reduce its incidence significantly as described in the previous patient example. You should change the aligner when it has expressed all its force, and the teeth have moved into the desired position that warrants moving into the next aligner — not after 1 week or 2 weeks. This depends on many variables, but patient compliance is the major one. Think of an aligner similar to an archwire. With braces, the orthodontist determines when it is appropriate to move to the next wire. With Invisalign and other aligners, we have given away control of this decision point to patients.

PRODUCT PROFILE

Air-Free 90Âş from Medidenta Dr. David A. Chenin discusses a handpiece that is beneficial to the orthodontic practice

he story behind this one-of-a-kind patent-pending Air-Free handpiece is very interesting. It actually originated from the needs of practicing orthodontists. As an exhibitor of many orthodontic conferences over the years, Medidenta had consistent inquiries about surgical handpieces. Medidenta soon found out that doctors were looking for a handpiece that did not blow air on the working site, which is a source of sensitivity. This sensitivity in traditional handpieces is especially true in orthodontics where the teeth are not anesthetized, have enlarged PDLs, and are more cold-air reactive with sensitivity caused by recent orthodontic tooth movement. Although I have used 45-degree angled surgical handpieces to reduce the cold air being expelled on the teeth, I found them very cumbersome. This was a great opportunity for someone to develop a better solution for my orthodontic needs. Finally, Medidenta came through and created a 90-degree handpiece that did NOT expel air from the head

David A. Chenin, DDS, MSD, is a Diplomate of the American Board of Orthodontics, a member of the Schulman Study Group, and an Adjunct Orthodontic Faculty Member at the University of the Pacific School of Dentistry. He can be reached at DrDave@CheninOrtho.com. Disclosure: Dr. Chenin is a beta-test doctor for Medidenta and received no compensation for this article.

56 Orthodontic practice

of the handpiece. Instead, the air is directed out of the rear of the handpiece away from the patient. Thus, the Air-Free 90 degree has quickly become the hottest item ever sold by Medidenta. While the main benefit is almost no sensitivity to the patient, another benefit is less adhesive flash powder being blown all over and around the patient because it can be suctioned away much more easily. Itâ&#x20AC;&#x2122;s also important to note that the handpiece is built rock solid and generates an ultra-smooth high-speed polishing action. As a result, vibrations on the tooth surface are eliminated, making for a more comfortable experience when compared to generic handpieces. Significant timesaving has been seen during my braces removal appointments because of fewer pauses due to sensitivity issues. This 20-watt titanium-coated handpiece has benefits not only in orthodontics, but can also be applied for uses in pediatrics, periodontics, endodontics, oral surgery, and general dentistry. OP Volume 8 Number 2

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BOOK REVIEW

Competing Against Luck by Clayton M. Christensen, Taddy Hall, Karen Dillon, and David S. Duncan Harper, New York

layton Christensen, best known for his theory and subsequent book, Disruptive Innovation, has combined his skill, knowledge, and expertise with three of his protégés to produce this new Theory of Jobs to Be Done, which concentrates on understanding customers’ struggles for progress. Rather than offer ivory tower speculations, they draw illustrations from real-world insights and experiences of people and companies that use Jobs Theory to make innovation a reliable engine of growth. Christensen explains how innovation transforms an existing market by introducing simplicity, convenience, accessibility, and affordability, but cautions that disruptive innovation doesn’t tell one where to look for new opportunities, explain how to innovate, where to create new markets, or how to avoid hitand-miss innovation that leaves your fate to luck. But the Theory of Jobs to Be Done will. At its core, Jobs Theory explains why customers hire others to resolve unsatisfied jobs that arise in their lives. Ultimately, customers don’t buy products or services; they pull them into their lives to make progress, i.e., the job they are trying to get done. And those jobs have an inherent complexity in that they have not only functional features but also social and emotional dimensions. The authors offer one particular example that has particular resonance for dentists as people attempt to have a smile that will make a good first impression, and the circumstances, obstacles, and imperfect solutions they face in achieving that goal. For dentists, these three or four pages may make the cost of the book worthwhile.

In a large way, these authors are reemphasizing profound insights popularized decades ago by Ted Levitt, who said, “People don’t want to buy a quarter-inch drill. They want a quarter-inch hole.” The late Peter Drucker also warned that customers rarely buy what the company thinks it sells. Therein lies the messy task of discovering what jobs people want done, and what has to get fired for your products and services to get hired. They list and explain how several wellknown companies whose brands are synonymous with the jobs they do achieve their results, e.g., Uber, TurboTax®, Disney, Toyota®, Amazon, Mayo Clinic, OnStar,

IKEA®, Google, Xerox®, and Netflix among many others. Conversely, they also offer examples of companies that by emphasizing processes unaligned with customers’ jobs simply got better and better at doing the wrong things and ultimately failed — some spectacularly like Kodak. Aside from regressing into needless repetition — a minor failing — this book offers an antidote to relying on luck and serendipity to help entrepreneurs and companies discover what jobs people want done and how they might go about doing them. OP Review by Dr. Larry White

Ultimately, customers don’t buy products or services; they pull them into their lives to make progress, i.e., the job they are trying to get done. 58 Orthodontic practice

Volume 8 Number 2

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M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT 3M Partners with BlueLight Analytics to offer the checkMARC® Curing Light Testing service 3M has partnered with BlueLight Analytics to offer checkMARC®, a professional service (NIST3-traceable) for validating curing light performance and determining the required curing times for each curing light and material combination in a dental clinic. With the checkMARC system, 3M will test and identify the efficacy of a dental office’s curing lights. Based on the results, 3M will review the lightcuring protocols currently in practice and work together with the dental clinic to identify evidence-based opportunities to improve clinical outcomes and patient satisfaction. For more information, call 1-800-634-2249 to set up an appointment to have your curing lights tested and light-curing protocols reviewed. Visit 3M.com/curinglights for more information.

PreXion, Inc., announces change in business model and launch of new PreXion Excelsior CBCT PreXion, Inc., global provider of advanced CBCT equipment in the dental industry, has announced that it will no longer be selling directly but will begin selling through dealer distribution. This change in business model will coincide with the launch of the new PreXion Excelsior 3D CBCT. Still having the smallest focal point in the industry, PreXion has also advanced all other core CBCT technologies, including the X-Ray tube and the Flat Panel Detector (FPD). The new Excelsior CBCT couples the smallest focal spot (0.3 mm) with the following: a voxel size of 0.1 – 0.2, 1024 volume size, 360° gantry rotation, and advancements in the PreXion software. Because of these advances, PreXion can deliver 30% lower radiation exposure without compromising the image quality. The PreXion software flawlessly integrates into the customer’s network without any specialized hardware. The PreXion3D Viewer can be installed on any Windows PC on the network, allowing scans to be viewed from any computer (with no additional or annual viewer licensing fees). For more information, email info@prexion.com.

3Shape orthodontic software integrates with Ormco Damon System Brackets 3Shape announced that its Indirect Bonding solution now integrates with the Damon™ System Bracket library by Ormco Corporation. The indirect bonding solution is a function within the 3Shape orthodontics software for practices and laboratories. The Damon System Bracket library joins more than 150 original bracket libraries and orthodontic solution providers now integrated with the 3Shape orthodontic software. Using 3Shape’s FDA-cleared indirect bonding functionality, orthodontists and lab technicians can now digitally plan and place the Damon System brackets based on a digital model. The digital models are created with an intraoral scan produced by TRIOS or by scanning a conventional impression in a 3Shape lab scanner. The indirect bonding functionality enables users to optimize fixed-appliance installation and ensure precise bracket positioning with the help of real-time collision detection tools. The software then allows the accurate placement of the Damon System brackets on the patient using 3D printed transfer trays. All managed digitally. Damon™ Clear2, Damon™ Clear and Damon™ Q brackets as well as Snaplink™ and Accent™ Mini tubes are now available in the 3Shape software. For further information, see http://www.3shape. com/en/customer+programs/ortho+partner+integrations/ bracket+library+integrations.

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News from Ormco Ormco announced Insignia is now compatible with the Carestream Dental CS 3600 intraoral scanner, effective as of January 30, 2017. Clinicians utilizing Carestream Dental CS 3600 scanners will now be able to take advantage of the clinical excellence, precision, and efficiency that Insignia can provide. Orthodontists using Carestream Dental CS 3600 intraoral scanners can submit digital impression .STL files to Insignia through OrmcoDigital. com. The CS 3600’s unique continuous scanning capabilities make it faster than ever to acquire a patient scan. It allows the user to scan in a smooth, uninterrupted manner, greatly reducing the time it takes to capture a digital impression while increasing accuracy. In addition, Ormco Corporation announced TruRoot™ data integration for Insignia™. Ormco’s proprietary TruRoot process precisely combines cone beam computed tomography (CBCT) data and intraoral scanner or impression data for uncompromising accuracy in the representation of patient anatomy in the Approver software. The incorporation of TruRoot technology allows doctors to better visualize and predict root and tooth movement, making it easier to assess and determine the best treatment plan for each patient at the start of an Insignia case. Insignia cases can now be submitted with Align’s iTero Element, Carestream Dental’s CS3600, and 3Shape Desktop scanners, in addition to previously accepted scanners. For more information, visit www.ormco.com.

Volume 8 Number 2

M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT HydroKleen AF Hand Sanitizer effective on most frequent illness causing germs HydroKleen AF Hand Sanitizer is 99.9% effective against the most frequent illness causing germs. This hand sanitizer features an alcohol-free, antibacterial formulation that’s highly effective, yet gentle on hands. HydroKleen contains Benzalkonium Chloride (BZK), an antibacterial antiseptic compound, proven safe and effective in reducing bacteria on the skin. This type of alcohol-free sanitizer formula is absorbed rapidly into the skin with little impact on the skin’s natural barrier function and is predicted to be more useful and effective as a rinse-free hand sanitizer than alcohol-containing formulas. This hand sanitizer was FDA-approved for use in 1992. This can be found in hospitals, clinics, physicians’ offices, and dental practices nationwide. Visit the website at www.productivepractices.net, or call 1-877446-8088, or email sales@productivepractices.net.

New software solution gives doctors a boost with easy access to clinical, practice management information With CS Boost, doctors have in- and out-of-office web and mobile access to their clinical information. This new software solution for Carestream Dental cloud users gives doctors secure, fast access to appointments, patient searches, and clinical information through a modern web app on traditional computing devices or via a native mobile application on iOS and Android devices. Doctors can easily access their schedules and filter them by provider and/or location. When viewing the schedule, appointment details can be accessed to view notes, alerts, provider, and even chair location. Doctors can also search by patient name for quick access to patient contact information and clinical history. The Clinical Snapshot allows for easy viewing of contact information, appointment history, recently completed procedures, and all clinical notes. When viewed on a smartphone, the doctor can even contact the patient’s pharmacy or find the closest one in an emergency from within the app. The app is HIPAA-compliant, with built-in audits and logs to protect practices, and adheres to data viewing, storage, and disposal. For more information, call 800-944-6365, or visit www. carestreamdental.com.

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Orthophos SL: now with 3D I-X Low Dose mode. Coming soon. The 3D I-X mode offers diagnostic optimization for a large number of indications, is intuitively selectable for an efficient workflow, and provides intelligent technical realization and optimal clinical results. In addition to existing High Definition (HD) and Standard Dose (SD) modes, the 3D I-X with Low Dose mode gives users access to 3D information for specific clinical issues with significantly reduced dose. This expands the application area of 3D imaging in the fields of implantology, orthodontics, and for dentists who treat a large number of children, including SICAT Air users who use 3D images to display the upper airways and treat obstructive sleep apnea. Visit www.dentsplysirona.com for more information about Dentsply Sirona.

3M Oral Care adds Tip Bar feature to 3M™ Incognito™ Appliance System brackets, enhancing precision and adding stability during treatment Unlike traditional metal brackets, which are placed on the front of teeth, Incognito™ Brackets follow the lingual contour of teeth for better comfort and esthetics. Located behind the teeth, the 100% customizable brackets help give patients the best smiles possible — from start to finish. Available February 2017, 3M™ Incognito™ Brackets with Tip Bar enhance the Incognito Appliance System with extensions on the mesial and distal sides of the lingual bracket, increasing the bracket slot width to give better angulation control, when used in combination with 3M™ AlastiK™ Lingual Ligatures. Now, Incognito Brackets with Tip Bar set a new standard for completely esthetic, comfortable, and individually customized orthodontic options. The extended slot innovates upon the Incognito Lingual Appliance system, a revolution in customized appliances that combine accurate mechanics, patient comfort, and esthetic treatment. The new “tip bar” enhancement improves angulation control, when used in combination with AlastiK lingual ligatures. Incognito Brackets with Tip Bar support increased demand from orthodontists for more controlled appliances and techniques, while meeting patient demand for invisible, comfortable, and convenient orthodontic care. Learn more at 3M.com/dental or 3M.com/orthodontics.

Volume 8 Number 2

SMALL TALK

Truth and fact Dr. Joel C. Small discusses the need to develop critical thinking as a means to defining and creating our preferred future “Average performers tend to believe truth and fact are the same. The world class knows there is a difference. Champions use their critical thinking skills to make clear distinctions between truth and fact. Fact is reality. Truth is our perception of reality, and perceptions are subjective.” ~Steve Siebold Secrets of the World Class We have all seen this scenario — it’s a hot summer day, and we see a fly beating its wings against a window pane in a futile effort to get outside. The fly sees where it wants to go, but the glass serves as an invisible barrier that ultimately frustrates and defeats the fly. The fact, or reality, is that the glass is impenetrable, but the truth, as the fly perceives it, is that the invisible barrier is blocking the fly’s only path to freedom. Our initial response to this scenario is to acknowledge that the fly lacks the necessary mental capacity to visualize the obvious alternative paths to freedom that we see so clearly. We say, “How unfortunate. If only the fly was smart like us.” And yet we exhibit the same behavior as the fly on a regular basis. Albert Einstein famously stated, “We can’t solve problems using the same kind of thinking we used when we created them.” This quote has meaning at so many levels. Take the profession of dentistry for example. Over the past 20 years, we have needed to evolve from the cottage industry that defined our past. We can no longer assume, Joel C. Small, DDS, MBA, FICD, is a practicing endodontist and the author of Face to Face: A Leadership Guide for Health Care Professionals and Entrepreneurs. He received his MBA, with an emphasis in healthcare management, from Texas Tech University. He is a graduate of the University of Texas at Dallas postgraduate program in executive coaching and limits his coaching practice to motivated healthcare professionals. He is a nationally recognized speaker on the subjects of leadership and professional development. Dr. Small is available for speaking engagements and for coaching healthcare professionals who wish to experience personal and professional growth while taking their practices to a higher level of productivity. Dr. Small can be reached at jsmall@ntendo.com.

Volume 8 Number 2

as in years past, that simply putting out a sign and practicing in a secluded environment will guarantee our comfortable retirement. Too much has changed, and it has immutably altered the environment in which we practice. We are being challenged on many fronts, and yet we have been slow to respond to these critical challenges. Why? I would submit that we choose the course of inaction because we remain with the same mindset that prevailed from years past. In reality, change is inevitable and necessary. We are, however, hindered by our perceived truth that the same process from the past, one that required little thought or action on our part, will somehow bring us the same results in the future. We are like the proverbial frog in hot water. Our truth is the water is warm. The fact is the water will soon boil and cause our demise. Marshall Goldsmith, author of the bestselling book, What Got You Here Won’t Get You There, would say that dentists are highly superstitious. Superstition, according to Goldsmith, is simply the confusion of correlation and causality. As a result of this confusion, we tend to repeat any behavior that is followed by positive reinforcement whether or not the positive reinforcement occurred as “a result of” or ”in spite of” the behavior. So if we are able to experience a degree of success in spite of our habitual inaction and mindlessness, we tend to assume that the same behavior will provide future success. This is our truth, but as Goldsmith states, our reality is that what got us here won’t get us there. When I started my endodontic practice 38 years ago, “Yelp” was something that happened when you stepped on a dog’s tail, and defending our reputation was something that took place after school at the bike rack, not online. What was “online” anyway? So much has changed that has altered our existence. Even this old dog has had to learn new tricks. The time has come for dentistry and dentists to develop the necessary critical

thinking skills that will allow us to distinguish between truth and fact. It is time for us to align our truth with the facts, so we can see our world as it truly exists. Is feefor-service a dying concept? Will corporate dentistry overwhelm traditional dentistry? Solutions to these and other critical issues will require a different type of thinking. The solutions require action as opposed to our habitual inaction of years past. I truly believe that creating dentistry’s preferred future depends on our willingness and ability to develop our critical thinking skills. If dentistry as we know it is to survive, future dentists must be true entrepreneurs with the same, or better, critical thinking skills as those possessed by corporate non-dentists who seek to forever change our profession to meet their own needs. Once we discard our old way of thinking and learn new critical thinking skills, we will begin to see the alternative paths that take us where we need to be. So how do we acquire these vital skills? One obvious way would be to include this training as part of the dental school curriculum, but I fear that we are a long way from seeing this become a reality. Another way would be to create a highly skilled team of professional advisors and use their counsel as a guide for entrepreneurial endeavors and decision-making. Some dentists have even chosen to return to school to study business and organizational development. In conclusion, learning how to think is just as important as learning what to think. This is a process of challenging our truths and aligning them with facts. By removing barriers that diminish our clarity, we are able to see and deal with reality at a whole new level. With the help of advisors or professional coaches, we can learn to cast away subjective self-limiting beliefs and assumptions that keep us tied to the status quo and prevent us from finding the alternative paths to success. OP Orthodontic practice 63

INDUSTRY NEWS Ultradent receives Medal of Honor from French university

LED announces transformative transaction and private placement financing LED Medical Diagnostics Inc. has entered into a definitive purchase agreement to acquire 100% of Apteryx, Inc., a profitable, software development company with well-established applications for the dental-imaging market with strong brand recognition across the dental industry. LED expects this transaction to be immediately accretive, allowing the company to reach profitability prior to the end of 2017. Apteryx, Inc., was founded in 1995 to create and develop software applications and systems, including XrayVision® and XVlite®, an imaging suite of applications that digitizes X-rays and other images for dental practitioners; XrayVision DCV DICOM software for the institutional dental market; XVWeb®, a cloud-based PACS and DICOM server; and other Windows-based applications and utilities. For additional information visit the Apteryx website at www. apteryx.com.

Clinical Study demonstrates effect of vibration on molar distalization using AcceleDent OrthoAccel® Technologies, Inc., announced that the Journal of Clinical Orthodontics (JCO) has published “The Effect of Vibration on Molar Distalization,” a study that focused on adolescent patients. Conducted by Dr. S. Jay Bowman, this prospective, peer-reviewed clinical study concluded that when treating Class II malocclusions, AcceleDent’s SoftPulse Technology® speeds up molar distalization rates in the apex and crown while also reducing the number of days to move the upper molars into a normal Class I relationship. Bowman found that there was 71% more movement of the molar root apex (2.9 mm versus 1.7 mm per month) and a modestly significant 27% increase in crown movement (1.1 mm versus 0.9 mm per month) in the AcceleDent group than the control group. Additionally, the desired Class I molar relationship was achieved an average of 27 days faster in the AcceleDent group. The article can be viewed here: https://www.jco-online.com/ archive/article-view.aspx?year=2016&month=11&articlenum=683. For more information about AcceleDent, visit AcceleDent.com.

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The University of Montpellier in Dardilly, France, presented the Medal of Honor, the university’s highest recognition, to Dr. Dan Fischer, founder and CEO of Ultradent Products, Inc., who received the award on behalf of the company. The dean of the University of Montpellier, Philippe Gibert, called the award a “mark of gratitude for the involvement of Ultradent in the training of future dentists at Montpellier, and, overall, for their important contribution to the teaching of dentistry.” Since 2009, Ultradent has been involved in the University of Montpellier’s dental program, helping provide practical training to students in tooth whitening, adhesions, veneers, and even management and leadership through product support, training, and lecturing. Additionally, Ultradent supported the creation of a postgraduate diploma by Dr. Bruno Pelessier in esthetic and restorative dentistry, which has become the most widely recognized and reputable professional diploma for working dentists in France. Ultradent has also helped the university develop a master class on posterior restorations that is not only available at the University of Montpellier’s main campus in France, but also at outposts on the islands of Réunion, Guadeloupe, and Martinique. To learn more, visit ultradent.com, or call 800-552-5512.

Smile for a Lifetime national board elects new president Smile for a Lifetime (S4L) announced the election of a new national board president, Dr. Donald Montano of Montano & Cardall Orthodontist Specialists. Dr. Montano has served in his local chapter in Bakersfield, California, and as a national board member since 2009 and awarded over 100 orthodontic scholarships. He has been involved with S4L from the time of its inception, having created one of S4L initial chapters. Dr. Montano is also an active member of the American Dental Association, American Association of Orthodontists, Pacific Coast Society of Orthodontists, California Association of Orthodontists, California Dental Association, Kern County Dental Society, Omicron Kappa Upsilon, Rotary International Bakersfield West, and Founder of the Kern County regional chapter of Smile for a Lifetime. For more information, visit http://www.s4l.org/.

Volume 8 Number 2

Breakthrough in Class II Treatment

New!

Carriere® Motion CLEAR ™ Class ll Appliance Unlike any other Class II appliance on the market, the Motion CLEAR Appliance is ideal for even the most aesthetically demanding patients. Whether it’s the simplicity of use, the sleek patient-friendly design, or the remarkable speed and predictability of how it works, the Motion CLEAR Appliance is truly your clear choice for Class II correction.

Initial

12 Weeks Class l Occlusion achieved

11 Months

11 months total treatment time: Motion CLEAR Appliance (3 months) + SLX Brackets (8 months)