Orthodontic Practice US Vol 8 No 3 May/June 2017 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews May/June 2017 – Vol 8 No 3

Which COLOR Moves You & Your Patients?

PROMOTING EXCELLENCE IN ORTHODONTICS Improving quality of life and faces nonsurgically Dr. Steven R. Olmos

Keeping the “special” in the orthodontic specialty: part 1 Dr. John Wise

Making space in your practice: what to do with all those stone models Matt Hendrickson

Corporate profile Introducing Dentsply Sirona Orthodontics

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Reflection: “A frog in a well”

EDITORIAL ADVISORS Lisa Alvetro, DDS, MSD 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

here is an old Japanese expression and similar sayings in other countries, “A frog in a well knows nothing of the great ocean.” Often we get in a routine of doing things the same way over and over again and expecting different results, often described as insanity. Too often it is easy to dismiss evidence-based decisionmaking and inquiry into the quality of evidence by rationalizing, “I am a clinician.” Some evoke possibly 20 years of experience as the validation, but was it 20 years with growth, change, and reflection, or was it 1 year, repeated the same way 20 times? Clinical experience is still very important but in juxtaposition with a more comprehensive approach such as evidence-based clinical practice (EBCP), which considers quality of evidence, particular clinical circumstances, patient-values (autonomy), and clinical experience. If it is only clinical experience, then is the person who is in practice the longest the expert? Hathaway and Long1 quote Dr. David Sackett as saying, “We cannot confidently infer anything about efficacy through the study of patients outside of a trial.” Likewise, Dr. Carl Sagan, the famous astrophysicist, said, “Extraordinary claims require extraordinary evidence,” the Sagan Standard. Have we come far enough since evidence-based dentistry was first described in 2004 by Ismail and Bader in the Journal of the American Dental Association2? Many experience-based orthodontic practices show enough treatment and financial success to tremendously support a practice. Yet some level of treatment success does not necessarily equate to treatment efficiency and effectiveness. At the recent 2017 AAO Annual Session in San Diego, it was gratifying to see many highquality evidence-based presentations, while on the other hand, there were still presentations showing only cases with limited records, no evidence, and personal opinion. The problem may not be solely with the clinician who is resistant or overwhelmed by the challenge that EBCP entails, but more a lack of educational resources to interpret research findings in a friendly and understandable way. There are currently some excellent social media blogs such as those written by Dr. Kevin O’Brien and Dr. Peter Miles that interpret research findings and present clinical implications. There are also two books on evidencebased orthodontics by Huang, et al.,3 and Miles, et al.,4 that can be helpful to the clinician. Also this journal, Orthodontic Practice US, presents some relevant clinical research in an interesting and friendly way, whereas often journals publish esoteric research that has little to no clinical impact or importance. Let’s challenge ourselves to see the great ocean and not be the frog in the well, and reflect on our practices, so they are evolving, embracing change, and the challenges of EBCP. Dr. Dan Rinchuse

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

REFERENCES

Dr. Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-inchief Private Dentistry

2. Ismail AI, Bader JD. Evidence-based dentistry in clinical practice. J Am Dent Assoc. 2004;135(1):78-83.

Dr. Chris Potts BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin

1. Hathaway RR, Long RE Jr. Early cleft management: in search of evidence. Am J Orthod Dentofacial Orthop. 2014;145(2):135-141. 3. Huang GJ, Richmond S, Vig KWL. Evidence-based orthodontics. West Sussex, UK:Wiley-Blackwell;2011. 4. Miles PG, Rinchuse DJ, Rinchuse DJ. Evidence-based clinical orthodontics. Chicago:Quintessence Publishing Co. Inc.;2012.

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 3

Dan Rinchuse, DMD, MS, MDS, PhD, is professor and program director at Seton Hill University graduate program in orthodontics. He is an ABO Diplomate. He received his DMD, MS (pharmacology), MDS (Orthodontics), and PhD (Higher Education), from the University of Pittsburgh.

Orthodontic practice 1

INTRODUCTION

May/June 2017 - Volume 8 Number 3

TABLE OF CONTENTS

Case study The Wilson® 3D® Quad-Helix and maxillary expansion

Corporate profile Introducing Dentsply Sirona Orthodontics

Dr. Nelson Oppermann discusses a technique to correct a narrow maxilla ....................................................... 22

Energies combine, synergies emerge.

Orthodontic insights Keeping the “special” in the orthodontic specialty: part 1

Clinical 10 Effect of low level laser therapy on the rate of canine retraction in orthodontic patients: a split-mouth randomized controlled trial Drs. Mohamed Abd El-Ghafour, Noha Ali El-Ashmawi, Amr Ragab El-Beialy, Mona M. Salah Fayed, and Faten Hussein Kamel Eid investigate the effect of low level laser therapy (LLLT) on the rate of maxillary canine retraction

Dr. John Wise discusses how technology can help specialists to “own” orthodontic treatment ........... 30

ON THE COVER Cover photo courtesy of Matt Hendrickson. Article begins on page 48.

2 Orthodontic practice

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TABLE OF CONTENTS

Continuing education TMJ dysfunction: clicks and trismus Dr. Yad Zanganah explains trismus — an often under-diagnosed and under-treated temporomandibular joint disorder — and offers treatment options............................................44

Continuing education Improving quality of life and faces nonsurgically

Dr. Steven R. Olmos explores how TMJ and airway issues can cause chronic health conditions

Product profile Insignia™ TruRoot™ Insignia — TruRoot data integration and enhanced Approver functionality by Ormco Corporation.................... 50

Practice development The importance of website lead conversion

Technology Making space in your practice: what to do with all those stone models Matt Hendrickson discusses a moneyand space-saving alternative to stone models — going digital....................48

Ian McNickle, MBA, discusses how your website can lead patients to your practice...................................51

Materials & equipment.........................52 Industry news...............56

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CORPORATE PROFILE

Introducing Dentsply Sirona Orthodontics Energies combine, synergies emerge.

he historic merger of DENTSPLY International and Sirona Dental Systems, Inc., was completed in 2016 to bring together two world-class companies with divergent but complementary core competencies. The partnership allows each to both build upon and leverage the other’s respective strengths: DENTSPLY’s leading consumables platform and Sirona’s proven digital solutions and equipment. One of the first synergies to emerge from the union is the new Dentsply Sirona Orthodontics, the orthodontic strategic business unit of the new Dentsply Sirona. Like the corporate merger, the creation of Dentsply Sirona Orthodontics brings together two well-established business entities that also occupy divergent yet complementary spaces within the same area of expertise, DENTSPLY GAC and DENTSPLY Raintree Essix, both known for producing some of the most trusted everyday products in orthodontics, while Sirona is known for the CEREC® system, which includes the CEREC® Ortho software. At a mission level, Dentsply Sirona Orthodontics’ goal is bringing a wide range of innovative orthodontic solutions, spanning from traditional braces and orthodontic supplies, to low visibility braces and clear aligners, in order to meet the needs of the modern dental and orthodontic professional. Doing so will allow the professional to combine treatments into hybrid solutions, personalizing the experience and providing unique benefits to the patient. By providing a full range of services, including best-in-class retainers and continually improving each treatment method within it, the company is empowering dental professionals to create the ideal smile for each patient in the best possible way. The evolving Dentsply Sirona Orthodontics product portfolio includes all of the offerings from GAC and Raintree Essix, including the industry-leading In-Ovation® line of selfligating brackets encompassing In-Ovation® R, In-Ovation® C, In-Ovation® L, In-Ovation® mini, and No•Trace lingual brackets. Joining the flagship line this year will be the new In-Ovation® X bracket. 8 Orthodontic practice

GAC’s In-Ovation X, a new self-ligating bracket system, the latest addition to the In-Ovation line

X marks the spot for innovation In-Ovation X represents the next-generation offering from the system that set the standard for self-ligation performance. The new In-Ovation X bracket retains many of the core design and treatment principles that longtime users of the In-Ovation platform most appreciate. Building this legacy of performance, the In-Ovation X system unites direct input from the orthodontic community with the disciplined approach of Six Sigma product design development, evaluation, analysis, and revision. The result is a worthy

heir to the most successful self-ligating system ever created. The streamlined shape and reduced profile of In-Ovation X is designed to provide a better experience for the patient and the clinician. The occlusal footprint has been reduced without sacrificing any of the interactivity. Plus, a redesigned encased-clip mechanism and closed gingival bracket base have been incorporated to mitigate calculus accumulation that can interfere with clip function. Clinicians will find the In-Ovation X system easy to work with as the clip can be opened and Volume 8 Number 3

CORPORATE PROFILE

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closed with a standard scaler, resists deformation during treatment, prevents unwanted openings, and even delivers a tactile “click” upon closing. Like all the offerings in the In-Ovation platform, In-Ovation X is versatile, allowing for passive interaction for leveling and aligning, expressive interaction for spacing and rotation, or active interaction for detailing and finishing. The new line is manufactured in Dentsply Sirona Orthodontics’ state-of-theart facility in Sarasota, Florida, to deliver the utmost in precision and quality.

Precision PLUS performance The inspiration for Dentsply Sirona Orthodontics’ PLUS line was to reimagine, reengineer, and re-create many of the company’s popular products using technologies not available when the products were first released. Consisting of two key offerings, OmniArch® PLUS and MicroArch® PLUS, the PLUS line has the advantage of being the first product family to be produced in the Dentsply Sirona Orthodontics manufacturing facility in Sarasota, Florida. Utilizing the latest in digital robotic manufacturing, they are produced with an unmatched level of precision for an unbeatable level of performance. This precision manufacturing is at the heart of clinical predictability.

Technology in practice On the technology side, Dentsply Sirona already owns a well-established presence in the orthodontic community. The CEREC® system is the leading CAD/CAM system in dentistry, and orthodontics is no different. Volume 8 Number 3

The virtually undetectable way to align your smile without traditional braces

With the CEREC® Omnicam, a small, powder-free video camera, and the guided scanning process using the CEREC® Ortho software, clinicians can easily and quickly create a digital impression of the entire jaw. The impression can then be used to design and produce orthodontic appliances for clear aligner treatment. This can save a considerable amount of time compared with the conventional methods that require physical models to be fabricated and shipped. The treatment can begin much earlier than usual in many cases. While Dentsply Sirona Orthodontics is uniquely positioned to provide beginning to end care of the orthodontic patient, their area of influence extends well beyond the operatory. According to Vice President of Marketing Andrea Ferencz, “We know that the Dentsply Sirona Orthodontics’ technology and product platforms are well represented in practices. But we’ve also worked hard to extend our presence into areas outside the operatory. This includes expanding the educational access for orthodontic professionals by partnering with the top institutions of learning, promoting the development of new ideas and groundbreaking information, and giving orthodontic practices the tools and techniques they need to drive practice growth.” Dentsply Sirona Orthodontics is dedicated to helping dental professionals attain the knowledge, skills, inspiration, and certification they need to stay up-to-date as well as develop themselves and their practices. As part of the Dentsply Sirona Academy, we are privileged to be a part of the broadest

clinical education platform in the industry. We are committed to supporting orthodontic residents, universities, and faculty members at the top institutions of learning in the world, by promoting the development of didactic and preclinical support materials. The company is also dedicated to transforming how orthodontics is practiced by supporting the Complete Clinical Orthodontics system, a unique, comprehensive process that addresses diagnosis, treatment planning, and treatment delivery in a single, inclusive approach. Research and Development (R&D) plays an integral role in the new Dentsply Sirona Orthodontics. The diverse R&D team is made up of more than 70 professionals working in the Dentsply Sirona Orthodontics research campus in Sarasota, Florida, and around the world. They have facilities in Europe, Japan, and the United States where they can perform innovative mechanical and in vitro testing and then analyze those results through the latest in statistical analysis models. This upstream approach allows the company to develop clinically differentiated, customer-oriented new products for the global orthodontics market while pursuing an aggressive growth plan for bringing new products and solutions to market. For more information about Dentsply Sirona Orthodontics, please visit us online at https://www.dentsplysirona.com/en-us/ products/orthodontics.html. OP

This information was provided by Dentsply Sirona Orthodontics. Orthodontic practice 9

CLINICAL

Effect of low level laser therapy on the rate of canine retraction in orthodontic patients: a split-mouth randomized controlled trial Drs. Mohamed Abd El-Ghafour, Noha Ali El-Ashmawi, Amr Ragab El-Beialy, Mona M. Salah Fayed, and Faten Hussein Kamel Eid investigate the effect of low level laser therapy (LLLT) on the rate of maxillary canine retraction Abstract Objectives: This split-mouth randomized controlled trial investigates the effect of low level laser therapy (LLLT) on the rate of maxillary canine retraction. Materials/Methods: Eligibility criteria included malocclusion that required extraction of the maxillary first premolar and canine retraction, maximum anchorage requirement, good oral hygiene, and medically free patients. Each patient received LLLT on one side during canine retraction, while the other served as the control. NiTi coil springs delivering 150 gm of force retracted the canines. LLLT with active medium indium gallium arsenide (InGaAs). Semiconductor diode and energy density of 29.3 J/cm2 was applied buccally. LLLT was applied every week for the first 4 weeks, then every 2 weeks till the end of the 4-month study. On each visit of laser application, impressions were made to produce dental models to assess the rate of canine retraction. The primary outcome compared the rate of canine retraction between the laser and control sides; the secondary outcome measured molar anchorage loss. Randomization was done by concealed allocation of the computer-generated sequence in opaque sealed envelopes. Blinding to the assessors was performed, which was not Mohamed Abd El-Ghafour, BDS, MSc, is an associate lecturer in the Department of Orthodontics and Dentofacial Orthopedics, Cairo University, Egypt. Noha Ali AlAshmawi, BDS, MSc, is an associate lecturer in the Department of Orthodontics and Dentofacial Orthopedics, Cairo University, Egypt. Amr Ragab El-Beialy, BDS, MOrth RCSEd, MSc, FDSRCSEd, PhD, is a lecturer in the Department of Orthodontics and Dentofacial Orthopedics, Cairo University, Egypt. Mona M. Salah Fayed, BSc, MSc, PhD, Dr.Med.Dent, is a professor in the Department of Orthodontics and Dentofacial Orthopedics, Faculty of Oral and Dental Medicine, Cairo University, Cairo, Egypt. Faten Hussein Kamel Eid, BSc, MSc, PhD, is a Professor in the Department of Orthodontics and Dentofacial Orthopedics, Faculty of Oral and Dental Medicine, Cairo University, Cairo, Egypt.

10 Orthodontic practice

applicable to the patients and operators. Results: Twenty-two patients (19 females and 3 males with mean age of 21.45 (±3.23) years) were randomized with ratio 1:1, and no patients were lost during the 4-month follow-up. The distance traveled by the canine on the laser sides was 3.823 (±1.39) mm, while the control side was 3.832 (±1.91) mm. Molar anchorage loss on the laser side was 1.009 (±1.41) mm and 1.177 (± 1.54) mm on the control sides. No statistically significant difference was found between the two sides in the canine and molar distances traveled. The detected harm was seen in three patients, who had a burn vesicle at the site of laser application, which completely healed after 2 weeks. Limitations: The only considered limitation in this study was the disability to blind both the participants and the operator, but blinding to the assessor was done. Conclusions/Implications: LLLT application was not able to accelerate orthodontic tooth movement according to the protocol used in the present study. Registration: This trial was not registered. Protocol: The protocol was not published before trial initiation. Funding: No funding or conflict of interest to be affirmed.

Introduction One of the disadvantages of orthodontic treatment is the duration of treatment, which averages around 23.5 months.1 Extended treatment increases the risk of white spot lesions, caries,2,3 inflammatory root resorption,4 gingival inflammation, and periodontal breakdown5 as well as decreasing the patients’ compliance.6 Clinicians have used several methods to accelerate orthodontic tooth movement: • Pharmacological approaches using prostaglandins,7 interleukins,8 leukotrienes,9 cyclic adenosine monophosphate,10 vitamin D,11 and platelet-rich plasma12 • Physical approaches such as

applying direct electrical current,13 pulsed electromagnetic field,14 samarium-cobalt magnet,15 and lowintensity pulsed ultrasound16 • Surgical approaches by performing gingival fiberotomy,17 alveolar surgery,18 distraction osteogenesis,19 and corticotomy20 The idea of lasers started in 1917 with Einstein21 and Bohr,22 and then multiple modifications were done till the 1960s when Maiman23 and Goldman24 introduced the laser in dentistry. The versatile properties of lasers encouraged orthodontists to use it for etching, bonding, debonding, pain control, and soft tissue cutting, e.g., gingivoplasty, frenectomy, and exposure of impacted teeth.25 Low level laser offers orthodontists another use.25 LLLT is also known as “soft laser therapy,” “cold laser,” “low energy laser therapy (LELT),” and “low intensity laser therapy (LILT)”26. LLLT provides another physical approach, ostensibly to accelerate orthodontic tooth movement.25 This acceleration claim is based on its biostimulatory effect.27 The orthodontic literature encompasses controversial results regarding the effect of LLLT on acceleration of orthodontic tooth movement. By using variable energy density, application protocol, and sites, some studies28-43 found that LLLT accelerated tooth movement while others44-50 had opposite results. Several systematic reviews51-56 have been published that evaluate its effect on acceleration of tooth movement. No conclusions were reached due to the low and medium quality of the present evidence. All of these systematic reviews recommended a high-quality randomized controlled trial to reach a conclusion regarding the effectiveness of LLLT as a method of accelerated tooth movement. Specific objectives or hypotheses Accordingly, this study aimed to detect the effect of LLLT on accelerated tooth movement via canine retraction as a research model in a split-mouth randomized controlled trial. Volume 8 Number 3

Trial design and any changes after trial commencement The study design provided a split-mouth randomized controlled trial with assessment of the two sides with two parallel groups with an allocation ratio of 1:1. Participants, eligibility criteria, and settings This study selected participants according to the following inclusion criteria: age range from 18 years to 25 years, malocclusion that required extraction of the maxillary first premolars and canine retraction (e.g., bimaxillary dentoalveolar protrusion and Class II Division 1 malocclusion), maximum anchorage requirement, all permanent teeth were present and fully erupted with the exception of the maxillary and mandibular third molars, good oral hygiene and periodontal condition, and medically free subjects with no long-term use of any drugs. Exclusion criteria comprised medically compromised patients, patients suffering from any periodontal disease, patients who had undergone previous orthodontic treatment, and syndromic patients. The study was carried out in the outpatient clinic of the Department of Orthodontics and Dentofacial Orthopedics, Faculty of Oral and Dental Medicine, Cairo University. No changes to methods after trial commencements occurred Interventions Preparatory phase: The 22 recruited participants (19 females and three males with mean age of 21.45 (±3.23) years) received a conventional fixed orthodontic appliance; Roth prescription slot 22 mil × 28 mil (Ormco Mini 2000 brackets). The brackets were bonded to the labial surface of the upper teeth using orthodontic composite resin (Grēngloo™ two-way color change adhesive for metal brackets, Ormco). Ready-made molar bands (Ormco ready-made bands) with two buccal tubes (main and auxiliary) were selected, fitted, and cemented on the maxillary first molars using glass ionomer cement. The archwire sequence in the initial leveling and alignment stage was tailored according to each case until insertion of the stainless steel archwire, 16 x 22 mil (Figure 1). Anchorage preparation and premolar extraction: In order to obtain maximum anchorage, a mini-screw (HUBIT orthodontics, Korea [1.6 × 8 mm]) was inserted between the maxillary second premolar and first molar at the level of the mucogingival junction. Indirect anchorage used an L-shaped 19 × 25 mil stainless steel wire in the auxiliary tube of the maxillary first molar Volume 8 Number 3

band (cinched back) and connected to the mini-screw with a composite ball (Figure 2). The oral surgery department extracted the maxillary first premolars. Canine retraction: Stainless steel ligature ties minimized ligation friction during canine retraction on the active and control sides. ANiTi closed coil spring (Ormco) delivering a force of 150 gm calibrated using Correx tension gauge (Haag-Streit Diagnostics), extending from the hook of the first permanent molar tube to the hook of the canine bracket retracted the canines. The coil was checked every appointment to maintain a constant amount of force. LLLT application: LLLT with active medium InGaAs (indium gallium arsenide) semi-conductor diode (Epic™ 10 Console, Biolase), wavelength of 940 nm, power density of 1.43 W/cm2 and energy density of 29.3 J/cm2 was applied buccally at the level of the middle third of the canine root (Figure 3). LLLT was applied once/week in the first 4 weeks, then once every 2 weeks until the end of the 4-month study. On each visit of laser application, alginate impressions were made to assess the rate of canine retraction.

a Xerox machine with 1:1 proportion after the above landmarks were marked with 0.7 black marker, which produced a flat image upon which the measurements were made between the canine lines and the third rugae lines bilaterally and between the molar lines and the third rugae lines bilaterally. Measurements were made with a digital caliper. A CBCT scan made immediately before canine retraction and after 4 months of active canine retraction captured the three dimensional movement of the canines. The CBCT field of view is restricted to the maxilla, with minimal CBCT machine parameters settings. The distance traveled by the canine cusp tip was measured from the frontal reference plane at the pre-and post- retraction time points (Figure 5).

Data collection The dental models identified the landmarks and lines shown in Figure 4. To overcome the curvature of the palatal vault, the models were 2D scanned using

Figure 1: The end of leveling and alignment stage and insertion of stainless steel archwire 16 x 22 mil

Figure 2: Mini-screw inserted between upper second premolar and first molar. Indirect anchorage was done with L-shaped 19 x 25 mil stainless steel wire cinched back and with composite ball

Figure 3: LLLT application

Figure 4: Landmarks and line on the scanned dental models Orthodontic practice 11

CLINICAL

Materials and methods

CLINICAL Outcomes (primary and secondary) and any changes after trial commencement The primary outcome of this trial was to detect the rate of canine retraction on both the LLLT and control sides and to compare between them. Molar anchorage loss was the secondary outcome. There were no outcome changes after the trials began. Sample size calculation Sample size was calculated using PS-power and sample size calculator. The input data was extracted from a similar study done by Doshi-Mehta and Bhad-Patil42 describing the rate of canine retraction per 3 months for the control and laser applied groups, where The Type I error probability for a two sided test α = 0.05, power = 0.8. A difference in population means δ = 0.32, and for dependent tests σ is within group standard deviation = 0.45. Based on the aforementioned data, sample size calculation yielded 18 subjects, and thus, 22 subjects were selected for the study to avoid attrition bias. Interim analyses and stopping guidelines No interim analyses were performed. The study protocol called for stoppage of the trial if any patient suffered complications such as unusual discomfort. Randomization Randomization was done in three steps: a) Sequence generation: done with computer-generated random numbers using a Microsoft Office Excel 2007 sheet. The first column contained numbers 1 to

Figure 5: CBCT image of the maxilla showing maxillary canine distance travelled to the frontal plane (FP) from sagittal view

20, then the second column select function RAND() generated the randomization number. Sorting these numbers was done according to the randomization number, which randomly distributed the first column numbers. The first 10 random numbers comprised the laser group and second 10 as the control group. b) Allocation concealment: The randomization numbers produced from the sequence generation were written on opaque papers and folded 4 times, sealed in opaque envelopes, and kept in a box till the time of implementation (the day of premolar extractions). c) Implementation: On the day of extraction and first day of laser application, each subject chose one of the envelopes to detect his/her number for the randomization sequence and to select the laser and control sides. The principle operator had the code for each patient’s laser and control sides and had the responsibility for making the laser application and impressions. Blinding Blinding was done for the assessors, where the first assessor carried on the measurements blindly on both sides using each patient’s dental models and then repeated the measurements after 2 weeks to calculate the intraobserver error. The second assessor made the same measurements blindly to calculate the interobserver error. Since patients and operators would know about the laser application, blinding did not occur for them. Statistical analysis (primary and secondary outcomes, subgroup analyses) Statistical analysis was performed by SPSS in general (version 17), while Microsoft Office Excel handled data and graphical presentation. The variables were described by the Mean and Standard Deviation (SD). Kolmogorov-Smirnova, and Shapiro-Wilk tests of normality tested the normality hypothesis of all quantitative variables for further choice of appropriate parametric and non-parametric tests. Paired sample t test and Wilcoxon Signed Ranks Test were used for testing pre–post measurements

Figure 6: Change in canine mean difference of the two sides on the dental model relative to the baseline 12 Orthodontic practice

within the same group while paired t tests and Mann-Whitney U tests were used for comparing the mean changes between the two groups. Significance occured at P < 0.05 (S); while P < 0.01 was considered highly significant (HS).

Results Participant flow Since the design was a split mouth, each group (laser and control) numbered 22. After randomization, no participants dropped from the study. A total of 222 out of 242 laser applications and dental models were made for the recruited subjects. Twenty laser applications and dental models were dropped due to missed appointments. Baseline data The split-mouth design matched the two groups regarding the baseline characteristics: age, gender, malocclusion, periodontal condition, and medical condition. Outcomes and estimation Laser side: The mean differences between each reading and the baseline reading of distance traveled by the canine on the laser side were analyzed (Figure 6). Generally, there was a statistically significant difference between the distances measured from the canine tip to the reference landmark in all the stages of canine retraction. The distances measured from the canine tip to the reference landmark decreased along the path of the canine distally except in 2nd week and 13th week. Along the 4-month trial period, the canine moved distally by 3.823 mm. The daily rate of canine movement on the laser sides is shown in Table 1. The period of the highest rate of canine retraction occurred in the 5th, 7th, 9th, and 11th week. Control side: On the control side, a statistically significant difference occurred between the distances measured from the canine tip to the reference landmark in all the stages of canine retraction (Figure 7). The distances measured from the canine tip to the reference landmark decreased along the path of the

Figure 7: Change in molar distance mean difference of the two sides on the dental model relative to the baseline Volume 8 Number 3

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CLINICAL canine distally except 15th week only. Along the 4-month trial period, the canine moved distally by 3.832 mm. The daily rate of canine movement in the control side is shown in Table 1. The period of the highest rate occurred in the 3rd, 5th, 7th, 9th, and 11th weeks. Laser versus control: By comparing the differences in distances traveled by the canine to the baseline measurement between the two sides, no statistically significant differences occurred between the two sides (Table 2). The difference between the distances moved by the maxillary canines on the laser and control sides to the baseline were the highest at the 3rd week and 15th week. Comparing the distance traveled by the canine via the two measuring modalities; scanned dental models and CBCT, yielded a minimal difference (Table 3). Molar anchorage loss: Molar anchorage loss (Table 4) on the laser side was 1.009 (±1.41) mm and 1.177 (± 1.54) mm on the control sides, which were statistically significant, but no statistical significant difference was found comparing the two sides.

In one session, three patients suffered burn vesicles at the site of laser application, which healed uneventfully in 2 weeks.

Discussion The inability to blind both the participants and the operator provided a limitation, but blinding of the assessor eliminated the detection bias. One might consider the external validity and applicability of this trial’s results limited since it is a single center study. Also, the energy density and protocol of LLLT need more definition to reach values that allow decisive conclusions regarding its effectiveness. Main findings in the context of the existing evidence — interpretation This trial’s protocol was designed according to SPIRIT 2013 explanation and elaboration: guidance for protocol of clinical trials.57 Following the SPIRIT reporting guidelines helps in minimizing the risk of bias and increases the reliability of the results.

The primary outcome assessed the maxillary canine distance traveled along time interval (i.e., rate of canine movement) on both the laser and control sides. Canine movement can be explained from two points of view; Nanda58 offers a mechanical explanation that describes the four phases of canine retraction via sliding mechanics. Burstone,59 Pilon, et al.,60 and van Leeuwen, et al.,61 describe the biological basis of canine retraction when the hyalinized tissue disappears after 30 days. The distance traveled by the maxillary canine was measured as the distance between the canine cusp tips to a line passing through the third rugae. The statistical test compared each dental model to the baseline (first model at the day of extraction). In the laser sides, the distance between the canine and the reference plane significantly decreased along the path of the canine distally except in in 2nd week and 13th week where the canine cusp tip moved mesially. On the control sides, the rate of canine retraction steadily increased from the 1st to

Table 1: The canine measurements on the dental models of the laser side (distance between canine tip and reference to the baseline (in mm)) (paired sample t-test) Laser Mean

1st week

13.186

2.67

zero

13.873

2.59

2nd week

13.245

2.40

zero

13.873

2.59

3rd week

13.223

2.51

zero

13.873

2.59

5th week

12.336

2.33

zero

13.873

2.59

7th week

12.064

2.70

zero

13.873

2.59

9th week

11.614

2.82

zero

13.843

2.65

11th week

11.048

2.75

zero

13.843

2.65

13th week

11.138

2.50

zero

13.775

2.77

15th week

10.320

1.45

zero

13.220

0.87

17th week

10.050

2.56

zero

13.873

2.59

Mean Difference

Std. Deviation

Std. Error Mean

P-Value

-0.686

0.95

0.20

-3.40

0.0027

P < 0.01 Highly Significant

-0.627

0.89

0.19

-3.31

0.0033

P < 0.01 Highly Significant

-0.650

1.09

0.23

-2.79

0.0111

P < 0.05 Significant

-1.536

1.31

0.28

-5.52

0.0000

P < 0.001 Highly Significant

-1.809

1.27

0.27

-6.67

0.0000

P < 0.001 Highly Significant

-2.229

1.16

0.25

-8.79

0.0000

P < 0.001 Highly Significant

-2.795

1.69

0.37

-7.60

0.0000

P < 0.001 Highly Significant

-2.638

1.61

0.40

-6.53

0.0000

P < 0.001 Highly Significant

-2.900

1.30

0.41

-7.07

0.0001

P < 0.001 Highly Significant

-3.823

1.39

0.30

-12.93

0.0000

P < 0.001 Highly Significant

Table 2: Daily rate of canine movement on both sides 1st week

2nd week

3rd week

5th week

7th week

9th week

11th week

13th week

15th week

17th week

Daily rate (laser)

-0.0098

0.0084

-0.0031

-0.063

-0.0194

-0.0321

-0.0404

0.0064

-0.0058

-0.0192

Daily rate (control)

-0.0081

-0.023

-0.0467

-0.026

-0.0331

-0.0224

-0.0374

-0.012

0.0018

-0.0844

14 Orthodontic practice

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CLINICAL Table 3: The canine measurements on the dental models of the control side (distance between canine tip and reference in mm to the baseline) (paired sample t-test) Laser Mean

1st week

13.377

2.19

zero

13.945

2.04

2nd week

13.214

1.95

zero

13.945

2.04

3rd week

12.886

2.28

zero

13.945

2.04

5th week

12.509

2.19

zero

13.945

2.04

7th week

12.045

2.56

zero

13.945

2.04

9th week

11.752

2.44

zero

13.967

2.09

11th week

11.229

2.42

zero

13.967

2.09

13th week

11.106

3.07

zero

14.013

2.27

15th week

10.800

1.82

zero

13.450

0.98

17th week

10.114

2.62

zero

13.945

2.04

Mean

Std.

Std. Error

Difference

Deviation

Mean

P-Value

-0.568

1.06

0.23

-2.50

0.0206

P < 0.05 Significant

-0.732

0.93

0.20

-3.68

0.0014

P < 0.01 Highly Significant

-1.059

0.89

0.19

-5.61

0.0000

P < 0.001 Highly Significant

-1.436

1.05

0.22

-6.42

0.0000

P < 0.001 Highly Significant

-1.900

1.53

0.33

-5.83

0.0000

P < 0.001 Highly Significant

-2.214

1.45

0.32

-7.02

0.0000

P < 0.001 Highly Significant

-2.738

1.77

0.39

-7.10

0.0000

P < 0.001 Highly Significant

-2.906

1.69

0.42

-6.88

0.0000

P < 0.001 Highly Significant

-2.650

1.60

0.51

-5.24

0.0005

P < 0.001 Highly Significant

-3.832

1.91

0.41

-9.41

0.0000

P < 0.001 Highly Significant

Table 4: The canine measurements on the dental models of the two sides (the difference between the distances traveled by the canine in mm to the baseline) (paired sample t-test) Group

1st week

2nd week

3rd week

5th week

7th week

9th week

11th week

13th week

15th week

17th week

Mean

Std. Deviation

laser

-0.686

0.95

control

-0.568

1.06

laser

-0.627

0.89

control

-0.732

0.93

laser

-0.650

1.09

control

-1.059

0.89

laser

-1.536

1.31

control

-1.436

1.05

laser

-1.809

1.27

control

-1.900

1.53

laser

-2.229

1.16

control

-2.214

1.45

laser

-2.795

1.69

control

-2.738

1.77

laser

-2.638

1.61

control

-2.906

1.69

laser

-2.900

1.30

control

-2.650

1.60

laser

-3.823

1.39

control

-3.832

1.91

16 Orthodontic practice

Mean Difference

Std. Error Mean

P-Value

-0.12

0.30

-0.39

0.6990

P > 0.05 Nonsignificant

0.10

0.27

0.38

0.7052

P > 0.05 Nonsignificant

0.41

0.30

1.36

0.1803

P > 0.05 Nonsignificant

-0.10

0.36

-0.28

0.7809

P > 0.05 Nonsignificant

0.09

0.42

0.21

0.8313

P > 0.05 Nonsignificant

-0.01

0.40

-0.04

0.9720

P > 0.05 Nonsignificant

-0.06

0.53

-0.11

0.9152

P > 0.05 Nonsignificant

0.27

0.58

0.46

0.6488

P > 0.05 Nonsignificant

-0.25

0.65

-0.38

0.7055

P > 0.05 Nonsignificant

0.01

0.50

0.02

0.9857

P > 0.05 Nonsignificant

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CLINICAL the 11th week; then it decreased in the 13th and 15th week, then increased again in the 17th week. The phenomenon of rebound of the canine cusp tip occurred in the control side once in the 15th week. This may be due to the faster movement of the canine on the laser sides, where the four phases’ cycle was repeated twice. Comparing the distance traveled, there was no statistically significant difference between the two sides, where the canine in both the laser and control sides traveled 3.8 mm. But by re-examination of the laser sides, it was found that, it passed through by two cycles of four phases mentioned by Nanda,58 while the control side passed through one. Furthermore, the fourth phase of the control sides occurred 2 weeks later than the fourth phase of the second cycle on laser side.

Table 5: Showing the average distance of the canine distance traveled measured in scanned dental models and CBCT Dental Model

CBCT

Group

Mean

laser

-3.823

1.39

-3.48

2.08

control

-3.832

1.91

-3.37

2.62

P > 0.05 Nonsignificant

Our study coincided with the results of Limpanichkul, et al.,47 who found no difference in the rate of canine retraction between the laser and control groups. Similarly, Domínguez, et al.,48 found a insignificant increase in the rate of tooth movement in the laser group as did Altan, et al.,49 and Kansal, et al.50 Conversely, other researchers found that the laser significantly accelerated tooth movement (Cruz, et al.36; Youssef, et al.37; Camacho and Cujar9; Sousa, et al.41; and Doshi-Mehta and Bhad-Patil42). The matched measurements extracted from the model scanning and the CBCT regarding the total amount of canine movement after 4 months of retraction had a consensus of outcome. This validated the poor man’s technique (model scanning) for measuring the rate of canine movement. Molar anchorage loss was measured on the dental models as a distance from the mesiobuccal cusp tip of the first molar to the line passing through the 3rd rugae. In the laser sides, the total anchorage loss was statistically significant as the molar moved mesially by 1.009 mm. On the control sides, similar results and the molars moved mesially significantly by 1.17 mm. However, when comparing the two sides, no significant difference was found between the laser and control sides. This confirms the ineffectiveness of the soft laser used in the current study to

accelerate canine retraction and preserve molar anchorage. The significant amount of anchorage loss occurred using indirect anchorage mini-screws raises a question about its effectiveness. None of the previous studies36,37,40–43,47–50 evaluated the changes in the molar position with laser application. In the current study, LLLT was applied using parameters (energy density), time, and application site recommended by the manufacturer. Concerning the energy density, Goulart, et al.,28 concluded that acceleration of orthodontic movement occurred at an energy density of 5.25 J/cm2 and suggested a higher energy density, 35.0 J/cm2, may retard it. The animal study conducted by Rowan45 who used 50 J/cm2 showed no increase in the rate of tooth movement. A systematic review published by Ge, et al.,55 concluded that a relatively lower energy density (2.5, 5, and 8 J/cm2) was more effective than 20 J/ cm2, and higher, although no one has yet determined the optimal dose. Conversely, several studies using lower energy densitie showed no acceleration in tooth movement. The animal studies conducted by Rowan45 and Seifi, et al.46, both used lower energy densities of 5 J/cm2 and 6 J/cm2 respectively, yet neither showed acceleration of tooth movement. A human study done by Altan, et al.,49 used 5.3 J/cm2 and

Table 6: Parametric test for the molar measurements on the dental models between the two sides (the difference between the distances traveled by the molar in mm to the baseline) (paired sample t-test) Group

1st week

2nd week

3rd week

5th week

7th week

9th week

11th week

13th week

15th week

17th week

Mean

Std. Deviation

laser

0.041

0.98

control

0.232

1.07

laser

0.068

1.35

control

0.086

1.01

laser

-0.345

1.30

control

0.141

1.50

laser

0.255

2.36

control

-0.418

1.04

laser

-0.332

1.65

control

-0.427

1.15

laser

-0.119

2.59

control

-0.110

2.55

laser

-0.857

1.41

control

-0.810

1.53

laser

-1.536

1.87

control

-0.900

1.60

laser

-1.156

2.15

control

-0.622

1.65

laser

-1.009

1.41

control

-1.177

1.54

18 Orthodontic practice

Mean Difference

Std. Error Mean

P-Value

-0.19

0.31

-0.62

0.5412

P > 0.05 Nonsignificant

-0.02

0.36

-0.05

0.9598

P > 0.05 Nonsignificant

-0.49

0.42

-1.15

0.2568

P > 0.05 Nonsignificant

0.67

0.55

1.22

0.2279

P > 0.05 Nonsignificant

0.10

0.43

0.22

0.8249

P > 0.05 Nonsignificant

-0.01

0.79

-0.01

0.9905

P > 0.05 Nonsignificant

-0.05

0.45

-0.11

0.9168

P > 0.05 Nonsignificant

-0.64

0.60

-1.07

0.2947

P > 0.05 Nonsignificant

-0.53

0.90

-0.59

0.5632

P > 0.05 Nonsignificant

0.17

0.45

0.38

0.7078

P > 0.05 Nonsignificant

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CLINICAL found no acceleration of tooth movement. Similarly Kansal, et al.,50 used 4.2 J/cm2, and no acceleration of tooth movement occurred. Futhermore, an animal study by Altan, et al.33 using a high energy density o laser (1717.2 J/ cm2 and 477 J/cm2) concluded that low-level laser irradiation accelerates the bone remodeling process. For now we can conclude that no one has yet determined what the optimal energy density of LLLT might be. This study applied the laser once a week 4 times, then once every 2 weeks until the end of the 4-four month trial. Preceding studies36,37,40–43,48–50 applied the laser on days 0, 3, 7, 14 of each month, while Limpanichkul, et al.,47 applied laser in the first three 3 days of each month, taking in consideration that some of these studies36,37,40–43 resulted in acceleration of tooth movement while others47–50 showed no effect. Unlike the previous studies, Gui and Qu38 applied laser therapy once per week and found acceleration of tooth movement. None of the aforementioned studies offered the rationales for their protocols. Although most of these studies used similar protocols, they achieved different results. We applied the laser tip in the current study on the buccal mucosa above the middle third of the canine’s root. Previous studies36,40,41,43,50 applied the laser on the buccal and palatal surfaces of the canine by the buccal side and five by the palatal side, were carried out, distributed, and ordered as follows, in other studies37,42,47–49 used different application sites. With so many differing opinions regarding LLLT density, site of application, and timing of application, researchers have not come to close to reaching a consensus about a single feature, much less several variables of soft laser application. The results of this split-mouth randomized controlled trial revealed no acceleration of orthodontic tooth movement as assessed by dental models. We recommend further studies with similar designs using different parameters and protocols to elucidate the effect of LLLT on acceleration to discover if LLLT can accelerate tooth movement with any protocol.

Conclusion Within the limitation of this trial, LLLT application did not stimulate tooth movement with an energy density of 29.3 J/cm2 following a recommended protocol from the manufacturer table and the single buccal application site. We found no statistical nor clinical significant differences in the rate of canine retraction or molar anchorage preservation between LLLT exposure and control sides. OP 20 Orthodontic practice

Acknowledgment The authors would like to express their deepest gratitude to Dr. Larry White for his support and efforts in preparing this article for publication. REFERENCES 1. Skidmore KJ, Brook KJ, Thomson WM, Harding WJ. Factors influencing treatment time in orthodontic patients. Am J Orthod Dentofac Orthop. 2006 Feb;129(2):230–8. 2. Bishara SE, Ostby AW. White Spot Lesions: Formation, Prevention, and Treatment. Semin Orthod. 2008 Sep;14(3):174–82. 3. Chen H, Liu X, Dai J, Jiang Z, Guo T, Ding Y. Effect of remineralizing agents on white spot lesions after orthodontic treatment: a systematic review. Am J Orthod Dentofac Orthop. American Association of Orthodontists; 2013 Mar;143(3):376–82.e3. 4. Weltman B, Vig KWL, Fields HW, Shanker S, Kaizar EE. Root resorption associated with orthodontic tooth movement: a systematic review. Am J Orthod Dentofac Orthop. American Association of Orthodontists; 2010 Apr;137(4):462–76; discussion 12A. 5. 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Zur Quantum Theorie der Strahlung. Phys Z. 1917;(18):121–8. 22. Bohr N. The theory of spectra and atomic constitution. Cambridge University Press; 1922. 23. Maiman T. Stimulated optical radiation in ruby. Nature. 1960;187:493–4. 24. Franke EK. Effect of the laser beam on the skin. J Invest Dermatol. 1963;40:121–2. 25. Kang Y, Rabie B, Wong R. A Review of Laser Applications in Orthodontics. Int J Orthod. 2014;25(1):47–56. 26. Hamblin M, Demidova T. Mechanisms of low level light therapy. SPIE. 2006. p. 1–12. 27. Reza F, Katayoun K. Laser in Orthodontics. Principles in Contemporary Orthodontics. 2011. p. 129–80. 28. Goulart CS, Sc M, Roberto P, Nouer A, Ph D, Martins LM, et al. Photoradiation and Orthodontic Movement : Experimental Study with Canines. Photomed Laser Surg. 2006;24(2):192–6. 29. Fujita S, Yamaguchi M, Utsunomiya T, Yamamoto H, Kasai K. Low-energy laser stimulates tooth movement velocity via expression of RANK and RANKL. Orthod Craniofac Res. 2008 Aug;11(3):143–55. 30. Yoshida T, Yamaguchi M, Utsunomiya T, Kato M, Arai Y, Kaneda T, et al. Low-energy laser irradiation accelerates the velocity of tooth movement via stimulation of the alveolar bone remodeling. Orthod Craniofac Res. 2009 Nov;12(4):289–98. 31. Yamaguchi M, Hayashi M, Fujita S, Yoshida T, Utsunomiya T, Yamamoto H, et al. Low- energy laser irradiation facilitates the velocity of tooth movement and the expressions of matrix metalloproteinase-9, cathepsin K, and alpha beta integrin in rats. Eur

J Orthod. 2010 Apr;32(2):131–9. 32. Ibrahim T, Gheith M, Abo-Elfotoh M. The Effect of Soft laser Application on Orthodontic Movement (In vitro study). J Am Sci. 2011;(1991):125–35. 33. Altan BA, Sokucu O, Ozkut MM, Inan S. Metrical and histological investigation of the effects of low-level laser therapy on orthodontic tooth movement. Lasers Med Sci. 2012 Jan;27(1):131–40. 34. Duan J, Na Y, Liu Y, Zhang Y. Effects of the pulse frequency of low-level laser therapy on the tooth movement speed of rat molars. Photomed Laser Surg. 2012 Nov;30(11):663–7. 35. Shirazi M, Ahmad Akhoundi MS, Javadi E, Kamali A, Motahhari P, Rashidpour M, et al. The effects of diode laser (660 nm) on the rate of tooth movements: an animal study. Lasers Med Sci. 2013 Aug 7;published . 36. Cruz DR, Kohara EK, Ribeiro MS, Wetter NU. Effects of lowintensity laser therapy on the orthodontic movement velocity of human teeth: a preliminary study. Lasers Surg Med. 2004 Jan;35(2):117–20. 37. Youssef M, Ashkar S, Hamade E, Gutknecht N, Lampert F, Mir M. The effect of low-level laser therapy during orthodontic movement: a preliminary study. Lasers Med Sci. 2008 Jan;23(1):27–33. 38. Gui L, Qu H. Clinical application of low energy laser in acceleration of orthodontic tooth movement. J Dalian Med Univ. 2008;30:155–6. 39. Camacho AD, Cujar SA. Acceleration Effect of Orthodontic Movement by Application of Low-intensity Laser. J oral laser Appl. 2010;10:99–105. 40. Mahmoud N. The effect of low energy laser on the rate of orthodontic tooth movement, prostaglanin E2 and pain level. A thesis presented to the Faculty of Dentistry, Orthodontic Department, Alexandria University as a partial fulfillment of Master Degree requirements. 2011. 41. Sousa MVDS, Scanavini MA, Sannomiya EK, Velasco LG, Angelieri F. Influence of low- level laser on the speed of orthodontic movement. Photomed Laser Surg. 2011 Mar;29(3):191–6. 42. Doshi-Mehta G, Bhad-Patil W a. Efficacy of low-intensity laser therapy in reducing treatment time and orthodontic pain: a clinical investigation. Am J Orthod Dentofac Orthop. American Association of Orthodontists; 2012 Mar;141(3):289–97. 43. Genc G, Kocadereli I, Tasar F, Kilinc K, El S, Sarkarati B. Effect of low-level laser therapy (LLLT) on orthodontic tooth movement. Lasers Med Sci. 2013 Jan;28(1):41–7. 44. Seifi M, Shafeei HA, Daneshdoost S, Mir M. Effects of two types of low-level laser wave lengths (850 and 630 nm) on the orthodontic tooth movements in rabbits. Lasers Med Sci. 2007 Nov;22(4):261–4. 45. Rowan RC. Low Level Laser Therapy On Orthodontic Tooth Movement. thesis Presented to the Faculty of the Graduate School of Saint Louis University in Partial Fulfillment of the Requirement for the Degree of Master of Science in Dentistry. 2010. 46. Seifi M, Atri F, Yazdani M. Effects of low-level laser therapy on orthodontic tooth movement and root resorption after artificial socket preservation. Dent Res J (Isfahan). 2014;11(1):61–6. 47. Limpanichkul W, Godfrey K, Srisuk N, Rattanayatikul C. Effects of low-level laser therapy on the rate of orthodontic tooth movement. Orthod Craniofac Res. 2006 Feb;9(1):38–43. 48. Domínguez A, Gómez C, Palma JC. Effects of low-level laser therapy on orthodontics: rate of tooth movement, pain, and release of RANKL and OPG in GCF. Lasers Med Sci. 2013 Dec 18; 49. Altan BA, Sokucu O, Toker H, Sumer Z. The Effects of Low-Level Laser Therapy on Orthodontic Tooth Movement : Metrical and Immunological Investigation. JSM Dent. 2014;2(4):1040. 50. Kansal A, Kittur N, Kumbhojkar V, Keluskar K, Dahiya P. Effects of low-intensity laser therapy on the rate of orthodontic tooth movement: A clinical trial. Dent Res J (Isfahan). 2014;11(4):481–8. 51. Carvalho-Lobato P, Garcia VJ, Kasem K, Ustrell-Torrent JM, Tallón-Walton V, Manzanares- Céspedes MC. Tooth Movement in Orthodontic Treatment with Low-Level Laser Therapy: A Systematic Review of Human and Animal Studies. Photomed Laser Surg. 2014 May;32(5):302–9. 52. Gkantidis N, Mistakidis I, Kouskoura T, Pandis N. Effectiveness of non-conventional methods for accelerated orthodontic tooth movement: A systematic review and meta-analysis. J Dent. Elsevier Ltd; 2014 Oct;42(10):1300–19. 53. Long H, Pyakurel U, Wang Y, Liao L, Zhou Y, Lai W. Interventions for accelerating orthodontic tooth movement: a systematic review. Angle Orthod. 2013 Jan;83(1):164–71. 54. Long H, Zhou Y, Xue J, Liao L, Ye N, Jian F, et al. The effectiveness of low-level laser therapy in accelerating orthodontic tooth movement: a meta-analysis. Lasers Med Sci. 2013 Dec 11;23–5. 55. Ge MK, He WL, Chen J, Wen C, Yin X, Hu Z a, et al. Efficacy of low-level laser therapy for accelerating tooth movement during orthodontic treatment: a systematic review and meta- analysis. Lasers Med Sci. 2014 Feb 20;published . 56. Kalemaj Z, Debernardl C, Buti J. Efficacy of surgical and nonsurgical interventions on accelerating orthodontic tooth movement : A systematic review. Eur J Oral Implantol. 2015;8(1):9–24. 57. Chan A, Tetzlaff JM, Gøtzsche PC, Altman DG, Mann H, Berlin JA, et al. SPIRIT 2013 explanation and elaboration : guidance for protocols of clinical trials. Br Med J. 2013;346:e7586. 58. Upadhyay M, Yadav S, Nanda R. Biomechanical Basis of Extraction Space Closure. Esthetics and Biomechanics in Orthodontics. 2015. p. 108–20. 59. Krishnan V, Davidovitch Z. Cellular, molecular, and tissue-level reactions to orthodontic force. Am J Orthod Dentofac Orthop. 2006 Apr;129(4):469.e1–32. 60. Pilon JJGM, Kuijpers-Jagtman AM, Maltha JC. Magnitude of orthodontic forces and rate of bodily tooth movement. An experimental study. Am J Orthod Dentofac Orthop. 1996 Jul;110(1):16–23. 61. Van Leeuwen E, Maltha J, Kuijpers-jagtman AM. Tooth movement with light continuous and discontinuous forces in beagle dogs. Eur J Oral Sci. 1999;(12):468–74.

Volume 8 Number 3

CASE STUDY

The Wilson® 3D® Quad-Helix and maxillary expansion Dr. Nelson Oppermann discusses a technique to correct a narrow maxilla

narrow maxilla is a common problem in orthodontics. Approximately 80% of orthodontic patients need some type of arch expansion.1 The incidence of posterior crossbite is high and is present in more than 50% of the orthodontic cases, with the upper molars being affected in more than 80% of the cases, and the lower molars affected in more than 19% of those cases.2 A narrow upper arch can produce undesired transverse growth changes. In order to intercept abnormal development and properly guide the patient’s growth into a physiological pattern, it is necessary to expand the maxilla. Maxillary expansion will avoid occlusion problems that can produce occlusal and facial disharmony (asymmetries). The crossbite cannot be corrected without treatment, regardless of the etiology and modality of clinical occurrence.3 Early crossbite corrections lead to a stable and normal occlusion pattern and contribute to symmetrical condyle growth, harmonious TMJ, and overall growth in the mandible.4-7 Young patients should start visiting the orthodontist around 4 years of age. Thus, the orthodontist can identify and intercept a narrow maxilla early, avoiding late treatment and the risk of creating a symmetrical occlusion in an asymmetrical skeletal system. Waiting until after 9 years old can lead to TMJ problems and future relapse.8 Correcting the narrow maxilla fostered an increase in the mandibular width measurement and released the mandible to a normal transverse growth. When considering arch expansion, the practitioner should always consider proper diagnosis and planning procedures in the three planes of the space, converting information from the models, comprehensive cephalometrics analysis (lateral and Dr. Nelson Oppermann obtained his Orthodontics Specialty Certificate in 1993 from the Dentist’s Association of Sao Paulo and Master’s Degree in Oral Sciences, focusing in orthodontics from SL Mandic Dental School in 2005. Dr. Oppermann began the Foundation of Modern Bioprogressive Orthodontics. An active and enthusiastic professor and lecturer, Dr. Oppermann has taught orthodontists around the world about Bioprogressive Therapy.

22 Orthodontic practice

Figure 1: Expansion movement possibilities for the maxilla and upper molars

frontal), and divine proportions analysis.29 The posteroanterior radiograph is a very important tool to be used when analyzing the transverse plane. Maxillary expansion procedures can be divided into two major categories, according to previous literature. The first, rapid maxillary expansion (RME), is a procedure that is generally accomplished by using an appliance that incorporates a screw — for example, a Haas or Hyrax. These appliances tend to disrupt the midpalatal suture. The second category for maxillary expansion is the slow maxillary expansion group. These appliances apply slow and continuous forces that do not attempt, as a main objective, to open the midpalatal suture. These appliances include removable expansion plates, the W arch (also known as the Porter arch), and Quad-Helix. The Quad-Helix was developed in 1975 by Robert Murray Ricketts from Porter’s W arch, adding four loops to the appliance, increasing the wire length on 40 mm to 50 mm. The objective was softening the forces and better control molar rotations.32 Many authors have written that the Quad-Helix appliance can deliver sufficient forces to promote skeletal changes on maxillary bone in younger patients (during deciduous and mixed dentitions phases). 2, 7, 10-13, 15, 17-19 Slow maxillary expansion, using the Quad-Helix appliance, is a recommended choice, and it is widely accepted and applied by orthodontists. Many practitioners prefer the Quad-Helix as an expansion device because it is a very versatile appliance, with applications such as molar rotation control, torque, and tipping control. It can also produce advancement in the incisor

region and create greater anterior expansion, resulting in an improved arch form (taking advantage of the anterior arms that deliver a “sweeping action”). Furthermore, the practitioners don’t need the patient’s or parent’s cooperation to reach the set objectives.7,19-21 Transverse maxillary expansion is achieved using a combination of movements, such as (A) buccal tooth version, (B) alveolar bone and molar buccal translation combined with molar torque control, (C) midpalatal suture opening and buccal molar translation, (D) midpalatal suture disrupting, and a combination of two or more of those factors (Figure 1).3 It is possible, when the treatment plan demands, to open the midpalatal suture on a young growing patient from 400 g of transverse pressure applied.10,22 The amount of force delivered by the Quad-Helix depends on two major factors: Quad-Helix construction and amount of activation. Basically, the Quad-Helix is constructed by 4 helicoids on .036 round wire. Dr. Ricketts recommends the use of blue Elgiloy® wire to deliver softer amount of forces and easier bending. In general, using the Quad-Helix for treatment leads to skeletal changes in maxillary bone, when desired by the practitioner and indicated in the treatment objectives. Adjustments are made by simply changing the amount and frequency of the activations. The Quad-Helix can provide a force range from 221 grams to 1,149 grams. The Quad-Helix can rotate the supporting molars, and it can be adjusted to expand the molars and anterior teeth differentially.17 It can also be used to control molar torquing. Volume 8 Number 3

activation strongly depends on the practitioner’s experience to control the amount of force and movements delivered. Due to this situation, it is found in the literature that some authors recommend removing the QuadHelix out of the mouth to place new actions and recement it after these changes. To avoid removing and recementing the bands, many practitioners usually construct the Quad-Helix to be inserted on lingual sheath tubes for horizontal insertion and removing. Also, this kind of Quad-Helix is prefabricated from many ortho manufacturers. In 1983, Wilson and Wilson30 presented to the orthodontics community an inserting/ removing system called the 3D® Fixed/ Removable® System (Wilson®). This kind of insertion brought practitioners versatility and easier inserting/removing procedures due to an innovative vertical insertion. Using the Wilson 3D Quad-Helix, it is possible and much easier to control the molars on the three planes of space during all expansion movements. Its fitting system is composed of two stamped posts laser-soldered to the Blue Elgiloy .038” Quad-Helix (Figure 2) and vertical inserting tubes (Figure 3). The 3D Quad-Helix very precisely allows the orthodontists to control the amount of forces employed and to control molars in the three

Figure 2: Sample of 3D Quad-Helix

Figure 3: Example of bands with Wilson 3D tubes

Figure 4: 3D Quad-Helix adapted to be passive to the malocclusion

Figure 5: Checking the amount of expansion forces

Volume 8 Number 3

planes of the space, strongly increasing movement control. Dr. Wilson recommends installing the appliance at the patient’s first visit in absolute passive to malocclusion, and starting to activate the 3D Quad-Helix on a second visit. New activations should be posted on 40-day periods; in the majority of cases, the activation cannot exceed 1 mm to 2 mm in order to keep cases under control (Figures 4-6). Also, as it is prefabricated on six different sizes, the orthodontists can save time and money, avoiding laboratory steps, and providing the ability to install it chairside with quite a few adaptations. No doubt, the launch of the Wilson 3D Quad-Helix in the market boosts the control of expansion forces, the inserting/ removing system, keeping the molars properly torqued, tipped, and rotated during all the expansion moments. Clinical Case 1, shown in Figures 7 and 8, exemplifies the expansion and molar 3D control using the 3D Quad-Helix. It is noticeable how the upper molars were expanded with complete torque control. In Case 2, it is easy to see the features and possibilities of the 3D Quad-Helix during an expansion treatment. Note the severe transverse problem in the beginning and the high amount of expansion obtained after

Figure 6: Checking the amount of rotation forces Orthodontic practice 23

CASE STUDY

These features make the Quad-Helix a very versatile appliance. It is observed that when correctly employed, the Quad-Helix can produce similar results to the RMEs and also correct all transverse problems in growing patients.8 These findings also coincide with what Cotton concluded after his work with monkeys.26 Hicks reported substantial skeletal changes with slow expansion, especially in younger children.11 Additionally, slow expansion is related to a more physiological reorganization of the maxilla in the three planes of the space, providing more stability and less relapse possibilities than RMEs. We can observe these findings in the works produced by Ohshima26 and Storey.27 Usually, the conventional Quad-Helix is cemented pre-activated with a certain amount of expansion. When the case being treated needs extra amounts of activations, normally the clinicians can do it using a threejaw plier inside the mount. This modality of

CASE STUDY

Figure 7: Expansion Case 1 sample after 4 months â&#x20AC;&#x201D; note molar rotation

Figure 9: Pictures before treatment on Case 2

Figure 8: Superimposition of T1 and T2 tracings on Case 1 for checking changes after expansion â&#x20AC;&#x201D; note the amount of expansion and molar torque control

Figure 10: Occlusal view before treatment on Case 2

Figures 11-12: Model pictures before treatment on Case 2 24 Orthodontic practice

Volume 8 Number 3

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CASE STUDY

Figure 13: Transverse dimension (49 mm molar width) of the maxilla before treatment on Case 2

treatment, noticeable on models measurement, an 8 mm of total molar expansion. The P.A. tracings showed 2.3 mm increasing of J-J width, 8.6 mm on upper molar width, and 3.1mm enlargement on nasal cavity width. Similar to Case 1, the upper molars had the upper molars torque properly controlled. The full 3D system kit also contains other appliances, and the orthodontist can choose, according to needs, the right appliance for each case, and/or exchange the appliance during the treatment without removing the molar bands. Dr. Wilson calls this full kit the Wilson 3D Toolbox. Figure 14: Posteroanterior X-ray image â&#x20AC;&#x201C; T1

Figure 15: Tracing and finds on T1 before expansion on Case 2

Figure 16: Beginning of treatment

Figure 17: After 2 months

Figure 19: Before and after Quad-Helix 3D expansion â&#x20AC;&#x201C; 5 months total time 26 Orthodontic practice

Figure 18: After 4 months

Figure 20: Transverse dimension (57 mm molar width) of the maxilla after expansion on Case 2 Volume 8 Number 3

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CASE STUDY

Figure 21: Posteroanterior X-ray image — T2

Figure 23: Facial changes before and after 3D Quad-Helix expansion treatment

I strongly recommend to orthodontists to use the vertical inserting system developed by Dr. Wilson. We can keep expansions and upper molars fully 3D controlled due to the inventive fitting system and save our precious time cutting off lab steps. Also, it is costeffective. No doubt, a great upgrade on Dr. Ricketts’ invention! OP

REFERENCES 1. Bench RW, et al. Terapia Bioprogressiva. 3a Edição. São Paulo: Editora Santos; 1996.Ia 2. Bench RW, Gugino CF, Hilgers JJ. Bioprogressive Therapy. Part 8. J Clin Orthod. 1978; 12(4): 279-298. 3. Langlade M. Otimização terapêutica da incidência transversal das oclusões cruzadas posteriores. 1a Edição. São Paulo: Editora Santos; 1998.

Figure 22: Tracing and finds on T2 after expansion on Case 2

9. Slavicek R. Dr. Rudolf Slavicek on clinical and instrumental functional analysis for diagnosis and treatment planning. Part 1. J Clin Orthod. 1988;(22)6:358-370. 10. Chaconas SJ, de Albay y Levy JA. Orthopedic and orthodontic applications of the quad-helix appliance. Am J Orthod. 1977;72(4):422-428.

22. Ranta R. Treatment of unilateral posterior crossbite: comparison of the quad-helix and removable plate. ASDC J Dent Child. 1988;55(2):102-104.

11. Hicks EP. Slow maxillary expansion: a clinical study of the skeletal versus dental response to low-magnitude force. Am J Orthod. 1978;73(2):121-141.

23. Mazzieiro ET, Henriques JFC, Freitas MR de. Estudo cefalométrico, em norma frontal, das alterações dento esqueléticas após a expansão rápida da maxila. Ortodontia. 1996; 29(1):31-34.

12. Frank SW, Engel GA. The effects of maxillary quadhelix appliance expansion on cephalometric measurements in growing orthodontic patients. Am J Orthod. 1982;81(5):378-389. 13. Chaconas SJ, Caputo AA. Observation of orthopedic force distribution produced by maxillary orthodontic appliances. Am J Orthod. 1982; 82(6):492-501. 14. Silva Filho OG, Alves RM, Capelozza Filho L. Alterações cefalométricas ocorridas na dentadura mista após o uso de um expansor fixo tipo Quadrihélice. Ortodontia. 1986; 19(1-2): 22-33. 15. Proffit WR, Ortodontia Contemporânea. Pancast Editora Com e Repes Ltda. 1991.

4. Kutin G. Hawes RR. Posterior cross-bites in the deciduous and mixed dentition. Am J Orthod. 1969;56(5):491-504.

16. Ladner PT, Muhl ZF. Changes concurrent with orthodontic treatment when maxillary expansion is a primary goal. Am J Orthod Dentofacial Orthop. 1995;108(2):184-193.

5. Harberson VA, Myers DR. Midpalatal suture opening during functional posterior cross-bite correction. Am J Orthod. 1978;74 (3):310-313.

17. Brin I, Ben-Bassat Y, Blustein Y. Skeletal and functional effects of treatment for unilateral posterior crossbite. Am J Orthod Dentofacial Orthop. 1996;109(2):173-179.

6. Vadiakas GP, Roberts MW. Primary posterior crossbite: diagnosis and treatment. J Clin Pediatr Dent. 1991;16(1):1-4.

18. Sandikçioglu M, Hazar S. Skeletal and dental changes after maxillary expansion in the mixed dentition. Am J Orthod Dentofacial Orthop. 1997;111(3):321-327.

7. Myers DR, Barenie JT, Bell RA, Williamson EH. Condylar position in children with functional posterior crossbites: before and after crossbite correction. Pediatr Dent. 1980; 2(3):190-194. 8. Bell, RA, LeCompte EJ. The effects of maxillary expansion using a quad-helix appliance during the deciduous and mixed dentitions. Am J Orthod. 1981;2(79):152-161.

28 Orthodontic practice

dentition. Am J Dentofac Orthop. 1999;116(3):287-300. 21. Gugino CF. An Orthodontic Philosophy. Denver, CO: RM/ Comunicators; 1977.

19. Boysen B, La Cour K, Athanasiou AE, Gjessing PE. Threedimensional evaluation of dentoskeletal changes after posterior cross-bite correction by quad-helix or removable appliances. Br J Orthod. 1992;19(2):97-107. 20. Erdinç AE, Ugur T, Erbay E. A comparison of different treatment techniques for posterior crossbite in the mixed

24. Siqueira DF, de Almeida RR, Henriques JFC. Estudo comparativo, por meio de analise cefalométrica em norma frontal, dos efeitos dentoesqueléticos produzidos por três tipos de expansores palatinos. R Dental Press Ortodon Ortop Facial. 2002;7(6):27-47. 25. Cotton LA. Slow maxillary expansion: skeletal versus dental response to low magnitude force in Macaca mulatta. Am J Orthod. 1978;73(1):1-23. 26. Ohshima, O. Effects of lateral expansion force on the maxillary structure in Cynomolgus monkey. J Osaka Dent Univ. 1972;6(1):11-50. 27. Storey A. Tissue response to the movement of bones. Am J Orthod. 1973;64(3):229-247. 28. Urbaniak JA, Brantley WA, Pruhs RJ, Zussman RL, Post AC. Effects of appliance size, arch wire diameter, and alloy composition on the in vitro force delivery of the quad-helix appliance. Am J Dentofacial Orthop. 1988;94(4):311-316. 29. Ricketts, MR. The logic and keys to bio philosophy and treatment mechanics. American Institute for Bioprogresive Education; 1996. 30. Wilson W, Wilson Wilson R. Modular 3D lingual appliance. Part I – Quad-Helix. J Clin Orthod. 1983;761-766. 31. Wilson W, Wilson R. Force systems mechanotherapy manual – book 2, Denver: RMO; 1989. 32. Duarte, M.S. O aparelho quadrihélice (quad-helix) e suas variações. R Dental Press Ortodon Ortop Facial. 2006; 11(2):128-156.

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ORTHODONTIC INSIGHTS

Keeping the “special” in the orthodontic specialty: part 1 Dr. John Wise discusses how technology can help specialists to “own” orthodontic treatment

onsider this article a call to action. With the advent of clear aligner technology, the orthodontic profession is facing increased competition from nonspecialists. Although clear aligner therapy has provided an alternative to more traditional orthodontic treatments, it has also caused some patients to overlook the fact that orthodontics is a specialty for a reason — and that moving teeth is serious business. There is no question that clear aligners can move teeth. The question that still remains is whether or not the consumers of orthodontic services in the future will seek out an orthodontist to assist them in that endeavor. Already extensive marketing portrays the general practitioner as capable of delivering a quality service. Add to that the fact that the final plan of roughly 50% of cases submitted to technology companies are accepted without changes by the submitting doctor. The technician designs the aligner sequence, manufactures the aligners, and controls the delivery of care. In the future, will patients think they are able to straighten their teeth without even a GP’s guidance? Can the consumer “do-it-yourself”? Some aligner companies think consumers can since they recently aligned themselves (pun intended) with DIY providers. While “facts are stubborn things,” what’s more important in this discussion is perception — specifically, perception by the consumer. The profession needs to evaluate the long-term effect of $100 million in direct-to-consumer advertising, year after year. How will we counteract this behemoth

John Wise, DDS, is a specialty-trained orthodontist with two locations in growing suburbs near Dallas. Frisco and McKinney, Texas are two of the most overserved towns in the United States with primary care dentists, corporate offices, and specialty care orthodontists on virtually every street corner. Dr. Wise practiced general dentistry for 3 years prior to completing his orthodontic residency program at the University of Texas Health Science Center in Houston, Texas, in 1992. He practices orthodontics exclusively with his partner, Dr. Jessica Lee and his team. Dr. Wise entered the world of virtual orthodontics in 2008 when he began utilizing CBCT scanning and suresmile®. He hasn’t looked back. Ms. Tammy Long became his TechC in 2009, possibly the first such designation in the orthodontic community.

30 Orthodontic practice

Figure 1: 3D-printed models of various materials are used in the modern orthodontic specialty practice. Multiple appliances can be made from each one, and patients can take them home as a very useful parting gift

from Madison Avenue? As an orthodontic specialty practice, you need to be the master at clear aligner therapy. We should all be able to do it efficiently, fast, and cost-effectively. Patients should not even consider allowing their primary care dentist to move their teeth, just like they’d never allow their family doctor to perform heart surgery or a knee replacement. We are specialists. Make sure the consumers in your community know that there is a difference.

“We must all hang together, or most assuredly we will all hang separately.” — Ben Franklin First and foremost, orthodontists and their teams need to be the experts in moving teeth — not only moving teeth in the literal sense but also in the virtual sense. We must all become experts in at least one software product that can allow us to move teeth virtually, print 3D models, and store the final result for our patients’ future. We can no longer rely on technology companies to spoon-feed us their concepts that allow us to become only minimally involved in the process of straightening teeth. We have to be the doctor and the technician to oversee the care delivery system. And we have to be able to deliver

Figure 2: 3D-printed model ready for aligner fabrication. Pressure-forming machine is almost fully automated for ease of use by your staff. Consistency is the key

quality results in a timely fashion all at an affordable price. Numerous companies want to empower orthodontists to treat their own patients. Search out those companies, and support them. Your shopping list needs to include an intraoral scanner (or two or three), a CBCT machine, 3D software with CAD/CAM Volume 8 Number 3

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For the accuracy of a jig with the chairside convenience of a tray, elemetrix IDB delivers new levels of precision performance.

ORTHODONTIC INSIGHTS capability, a 3D printer, a pressure-forming machine, and the tools to trim and smooth aligners. And don’t forget the packaging. Your patients will feel better about your care if they walk out of your office with a nice bag or box for their aligners. You, the orthodontist, need to oversee the quality control of the process from the beginning to the end.

The model makes the case Having treated thousands of clear aligner cases since the late 1990s with various methods, I can tell you with certainty that my favorite way to treat these cases is the way we do them today. It’s hard to describe completely, but I can assure you that a major differentiator for a smooth care cycle is having access to the 3D-printed models. Patient loses an aligner? No problem. Make another one. Aligner material gets distorted? Make another one. Need some modifications to a model to keep the teeth moving? Do it. Patient has special needs for aligner trimming? No problem. Custom trimming is easy. Aligners can be used in unique ways to help you move teeth. Cutouts and buttons for elastics can all be added at various points in the care cycle, but not if you don’t have the models available. I can’t express how valuable it is to have the models for each and every aligner case! These models are extremely durable and capable of being used for several aligners before they get damaged. The final model can be given to the patient as a parting gift with simple instructions on how to bring it in for a new retainer any time (or anywhere) in the future. Patients love this feature. You are the hero, and the only office in town that can do this for them. It makes your office unique.

Figure 3: A pre-restorative case is ideal for clear aligner therapy. Orthodontists are best suited to provide quality, affordable care

In your office (IYO) clear aligners Our protocol starts with a thorough clinical exam. As any specialist knows, not every malocclusion is a candidate for clear aligner therapy. And every parent of a teenager needs to know that their kid probably won’t wear the aligners like they promise they will. You need a full complement of fully erupted teeth to move them with clear aligners. Axial inclination is tough with clear aligners. So is extrusion. Short, small teeth (like upper lateral incisors) are hard to move with clear aligners. Beware of these issues, and be careful to not over-promise. Once you and the patient are feeling good about treatment, finalize the financial agreement. One of the greatest things about in-house clear aligner therapy (other than 32 Orthodontic practice

Figure 4: Ready for ideal restorations after just a few weeks; the patient is thrilled to have avoided braces and achieved a great result

the superior results in my hands compared to all of the outsourced, technician-driven services) is the dramatically lower cost of production. Since you’re not allocating half of the fee toward marketing veiled as “R and D,” you can charge a very reasonable fee and still maintain all of your profitability. Then get an intraoral scan. Don’t let your orthodontic technician stop until it’s perfect. The new scanners can accomplish this in

about 3 minutes per arch. And that’s getting better every day. We use the monochromatic TRIOS® scanner (3Shape) paired with a fully loaded AlienWare laptop and a mobile cart. Your teenage patients will think you are so cool! A quality panoramic film sent over from the GP or captured at your office will suffice for radiographs, in my opinion. Rarely is a ceph required for these cases (unless you just really like cephs for your Volume 8 Number 3

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ORTHODONTIC INSIGHTS liability protection). Get your standard set of intraoral photos along with any special shots that will assist you as you treat the case virtually. Now the fun begins. Your TechC — technology coordinator (yes, your office needs one of these just as we all needed treatment coordinators — TCs — back in the 1990s) uploads the case to your software of choice. We use suresmile® by OraMetrix for both clear aligners and robotically bent wires for conventional care. They also have their elemetrix™ product, which houses only the clear aligner and indirect bracketing capability. There are other software suites out there as well. Buy or lease your own, and learn how to use it. Moving teeth on the computer is fun, and you’ll be amazed at all of the stuff you were missing before. Computers don’t have saliva, lips, or tongues to block your view of the teeth. Let your TechC have a go at the alignment first, and you finalize the result the way you want based on your understanding of the case including any limitations you or the patient placed on the results. Once you have the final result established, you have to put your orthodontic brain in full gear to now design the aligner sequence to accomplish your goals. This is no different from how you sequence your conventional cases today. It’s doctor work. Computer algorithms are great at this, but nothing beats the brain of a well-trained specialist to create an ideal aligner sequence. For the most complex cases, doctor time is about 20-30 minutes. On simple cases, your time will be less than 5 minutes. Once the number of aligners exceeds 20 per arch, the math starts to turn around on you, and using a 3rd party starts to make some sense. For the past 2 years, since I started doing IYO clear aligners, I have not seen one case that I needed to treat with a 3rd-party company. Those are the tougher cases that generally get braces in my office or 3rd-party clear aligners in someone else’s office. For those simple cases where the patient went off to college, forgot her retainers, and her teeth moved a little, IYO aligners are a no-brainer. Industry analysts tell us that there are 20-30 million folks out there who fit this scenario “post braces with minor shifting.” Our specialty must re-commit to treating these cases and stop abdicating their care to the GPs or the DIY crowd. We have to own it! Some tech-savvy doctors are even using IYO clear aligners to finish their conventional cases. The appointment prior to de-banding is used to intraoral scan the patient. In the 34 Orthodontic practice

Figure 5: Post-restoration is a great time to make a final digital scan of the arches to allow the patient to remake clear retainers or bruxism devices from the 3D-printed models. The models can be used over and over with virtually zero damage

Figure 6: Virtual diagnosis and tooth movement is a skill worth learning. Your skill, speed, and comfort will increase with each case treated

Figure 7: The STL files are extremely accurate, and because you can move the teeth virtually, you can fine-tune with ease

software, you can see exactly what is left to finish. Braces are removed virtually, aligners (and retainers) are made from that 3D printed model, patients show up for de-band, and you already have their one or two aligners and their retainer ready for them. No gooey impressions to ruin their big day. Braces, and the final few painful adjustments, are complete, probably ahead of schedule. They love you!

Don’t delay your entry into IYO aligners one more day I’m hopeful that this call-to-action article has opened your eyes to the multitude of benefits that are possible when you, the doctors, are the experts at navigating the virtual world of orthodontics. In the future,

there will be three kinds of orthodontic care providers: 1. GPs who are supplementing their income by offering non-specialty care orthodontics. 2. Orthodontists who only offer braces and 3rd party delivered clear aligners. 3. Tech-savvy orthodontists who took the time and invested the energy and financial commitment to become expert at delivering modern orthodontic treatment with both of their own talented hands firmly on the virtual wheel. You get to decide. I hope you will join the ranks of your peers who have made the virtual leap. It will be good for your practice and really good for your patients. OP Volume 8 Number 3

CONTINUING EDUCATION

Improving quality of life and faces nonsurgically Dr. Steven R. Olmos explores how TMJ and airway issues can cause chronic health conditions

case study featuring a young patient is presented as an example of the airwaycentered philosophy that essentially is defined as a mandibular relationship that produces the optimal orthopedic function of the temporomandibular (TM) joints and prevents or reduces airway collapse (oropharyngeal) in the unconscious state (sleep).

Background In 2016, a study of almost 1,200 patients published in the American Journal of Dentistry found that patients with sleep-related fatigue measured by an Epworth scale greater than 6 were 1.39 times more likely to have jaw locking and primary headaches. This is the first paper to link jaw locking to sleep-related fatigue.1 Sleep-related fatigue (excessive daytime sleepiness) is more often the result of nasal obstruction (mouth breathing) than obstructive sleep apnea (OSA).2 The reason why this journal article is the first is that the intake is the same for both pain and sleep disturbances. In most offices, patients are asked questions about sleep symptoms (if they complain about sleep) and questions about pain symptoms (if they complain about pain). Relationship between OSA and TMD An established relationship exists between OSA and temporomandibular joint disorder (TMD) that is evident in the prevalence rates that are bidirectional. There is increased prevalence of TMD in patients diagnosed with OSA3 and increased prevalence of OSA in patients diagnosed with TMD.4 Two studies5 tested the hypothesis that OSA signs and symptoms were associated with TMD: the OPPERA prospective cohort study of adults 18 to 44 years old at enrollment (n = 2,604) and the OPPERA case-control study of chronic TMD (n = 1,716). Both studies supported a significant association between OSA symptoms and TMD, with prospective cohort evidence Steven R. Olmos, DDS, is an Adjunct Associate Professor, Department of Bioscience Research at the College of Dentistry, University of Tennessee Health Science Center, Memphis, Tennessee. He practices at the TMJ & Sleep Therapy Centre in La Mesa, California. For more information on how to treat adult and pediatric OSA, visit www.tmjtherapycentre.com.

36 Orthodontic practice

Educational aims and objectives

This article aims to discuss TMJ and airway issues that can contribute to chronic health problems.

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: • Realize a connection between sleep-related fatigue, nasal obstruction, and obstructive sleep apnea (OSA). •

Recognize the relationship between bruxism and nasal obstruction in children.

•

Realize the importance of nasal breathing in the treatment of OSA.

•

Understand the significance of forward head posture (FHP).

Figure 1: Aric W. before (left) and after (right) treatment

finding that OSA symptoms preceded first onset of TMD: Patients with two or more signs and/or symptoms of OSA had a 73% greater incidence of first-onset TMD. Patients with OSA often also have a functional breathing problem (nasal obstruction). It is important to define physiologic functional breathing from obstructive sleep apnea (OSA). Proper or physiologic functional breathing is through the nose. Noses are for breathing, and mouths are for eating. Breathing through the nose allows for filtering, warming, and adding moisture to the inspired air. Every nasal breath mixes nitricoxide (NO) gas from the maxillary sinuses that is carried into the lungs. NO is necessary for cilia movement in the sinuses to carry out debris; it is antifungal, antibacterial, and antiviral and also is important in peripheral vasodilation of the blood vessels.6,7-16

It has been recommended that the final endpoint in treating OSA is restoration of nasal breathing.17 Nasal obstruction can result in increased blood pressure. Mouth breathing has none of the physiologic protective mechanisms, so people with this condition are more prone to respiratory infections as well as the dental sequela (gum disease, anterior open bite). Establishing/developing patency of the four points of obstruction (Figure 2) is necessary to prevent orthodontic relapse (anterior or posterior open bite).18 Harvold, in his work with primates, was the first to demonstrate craniofacial deformations and skeletal open bite with silicon obstruction of their noses.19 Bruxism Sleep-related bruxism (SB) — grinding and clenching of teeth — is classified as Volume 8 Number 3

Case study: Aric W. Aric W., the patient, was referred to my office by his chiropractor. Aric W. had been treated with oral appliances (hard and soft) that he described as “mandibular advancement” without relief. The patient presented with the following chief complaints, listed in order of priority: jaw pain; headache; neck, back, facial, and eye pain. In addition, he had the followings sleeprelated breathing symptoms, listed in order of priority: teeth grinding, heavy snoring that affects the sleep of others, teeth crowding, difficulty falling asleep, morning hoarseness, dry mouth upon awakening, and fatigue. Aric W. was only occluding on his anterior teeth (Figure 3), Class 3 dental and skeletal. His vitals were BP 127/87, pulse 70, respirations 13, temperature 96.3°. His neck circumference was 15, height 6’ 2”, weight 178, BMI 22.85. Mandibular ranges of motion were 59 mm vertical, 8 and 7 lateral

Figure 2: Four points of obstruction

Figure 4 Volume 8 Number 3

(left and right), 4 mm protrusion with 2 mm deflection to the right, on opening. Limited cervical ranges of motion were at 55 mm rotation.

Diagnosis i-CAT™ (Imaging Sciences) CBCT demonstrated severe cranial distortions (Figure 4); anteriorly positioned condyles (Figure 5); left middle turbinate pneumatization, conchae bullosa, and a severely deviated septum (Figure 6). My diagnosis was bilateral capsulitis, facial/cervical myositis, physiologic and suspected sleepbreathing disorder.

Treatment Treating chronic pain is a somewhat similar to emergency medicine. During the triage process, structural (orthopedic/ dental), metabolic, breathing (functional and obstructive apnea), infectious, and genetic

Figure 3

Figure 5 Orthodontic practice 37

CONTINUING EDUCATION

a sleep-related movement disorder by the International Classification of Sleep Disorders (diagnosis and coding manual [ICSD3]).20 SB is reported by approximately 15% in the pediatric population and between 8% and 31% in the general adult population, without a difference in prevalence between the sexes.21,22 The characteristic electromyography (EMG) pattern of SB is found in repetitive and recurrent episodes of rhythmic masticatory muscle activity (RMMA) of the masseter and temporalis muscles, which are usually associated with sleep arousals.23 Bruxism is secondary to nasal obstruction (mouth breathing) and explains why oral appliances do not affect it.24 Bruxism and nasal obstruction has been shown to be directly correlated in children.25 Adenotonsillectomy has been shown to significantly reduce bruxism in children with oropharyngeal obstruction.26

CONTINUING EDUCATION mechanisms are evaluated. When patients are unconscious in the emergency room, the airway, breathing, and circulation are evaluated. In the treatment of chronic head pain, we do the same. Phase I goals addressed the patient’s headaches, pain, and sleep symptoms: 1. Decompression appliance therapy (Figures 7 and 8): day and night per my design, sibilant phoneme registration,27 mounted hamular notch-incisive papilla (HIP) (Diamond Orthotic Laboratory, San Diego, California) 2. Medication regimen: NSAIDs, topical cream (ketoprofen, baclofen, ketamine) 3. Physical medicine: MLS laser (Figure 9), trigger-point injections to extension muscles (trapezius splenius capitis) 4. Nutrition/supplementation/diet: consisting of protein, vegetables with limited carbohydrates, omega 3, vitamins B,C, and D, and grapeseed extract as supplements 5. Referral to Board-Certified Sleep Physician for a sleep study 6. Referral to ENT for nasal obstructions Aric W. was treated for 12 weeks. During this time, he had a sleep study and nasal

surgery. The results of his diagnostic sleep study follow: • AHI 18 (moderate obstructive sleep apnea), overall RDI 41 (severe) • Headaches and neck pain resolved 100% • Jaw pain significantly reduced Normally, the patient would be weaned from the day orthotic at this point; however, Aric W. had a significant skeletal discrepancy and open bite, so Phase II is addressing the

open bite. Phase II goals aimed to correct his open bite by skeletal development (orthopedic) and restoration of proper dental alignment (orthodontic) with continued resolution of symptoms. Orthodontic records were taken at the sibilant phoneme position to optimize the orthopedic and airway. This technique has been shown to prevent airway collapse. It is physiologic and produces an orthopedic position of the TMJ that is optimal (Figures 10-13).

Figure 6

Figure 7

Figure 10 38 Orthodontic practice

Figure 8

Figure 9

Figure 11 Volume 8 Number 3

CONTINUING EDUCATION

Figure 12

Figure 13

Figures 14-16: Phase 1 — Maxillary Schwarz and mandibular-positioned Schwarz with screw between the mandibular right tooth Nos. 6 and 7 to distalize tooth No. 7 by 3 mm. Expand maxillary and mandibular arch 6 mm

Every inch the head is forward of the shoulders adds approximately 10 pounds of weight to the cervical and lumbar spine. Figures 17-19: Phase 2 — Transpalatal bar bracket all maxillary teeth. Level, align, and rotate teeth. Bracket all mandibular teeth. Level, align, and rotate teeth. Maxillary positioned ALF with composite buildup on lower 7s. The patient was referred to an oral maxillofacial surgeon for third-molar extraction

Figures 20-22: Phase 3 — Distalize the LR 6 then 5, then 4 with open coils and power chains to rotate the remaining teeth to the right. Level, align, and rotate Volume 8 Number 3

Orthodontic practice 39

CONTINUING EDUCATION

Figures 23-25: Case finish

Figures 26-27: Case finish

Figure 30: Post-orthodontic TMJ

Forward head posture (FHP)

Figures 28-29: Comparing oropharyngeal airway. 28. Pretreatment. 29. Posttreatment 40 Orthodontic practice

Figures 31-33 show that Aric W. is taller at the end of treatment; however, he still has some degree of forward head posture (FHP) due to nasal valve collapse, and left middle turbinate hypertrophy (concha bullosa) also remains (not addressed by his surgeon). Volume and flow has been improved;

however, the nose has not been restored to ideal function as first point of entry (nasal valve) is collapsed (Figures 34 and 35). This contributes to forward head posture. Every inch the head is forward of the shoulders adds approximately 10 pounds of weight to the cervical and lumbar spine. The compressive load can result in osteoarthritis Volume 8 Number 3

Figure 34: Nasal valve collapse

Figure 36: NVivo for Mac software Volume 8 Number 3

CONTINUING EDUCATION

and nerve entrapment.28 Craniofacial pain and internal derangement of the TM joints (temporomandibular joint dysfunction, TMD) manifests in forward head posture.29 The most common symptom of painful jaw joints is occipital cephalalgia at 94%.30 The FHP is secondary to painful swallowing — a postural adaption to injury. The injury described is in the absence/or in addition to a macro-trauma and is the result of repetitive jaw compression (bruxism) originated by sympathetic stimulation during sleep. The patient wakes with temporal headaches and facial pain and jaw joint inflammation that now produces postural compensation. The cantilever strain of FHP, the result of extensor muscles of the neck (trapezius, splenius capititus, semispinalis capititus), produces acute inflammation at their tendon insertions on the occiput. Decompressing inflamed jaw joints utilizing oral appliances, produced with a phonetic technique, has been found to upright the head 4.43 inches on average of a

Figures 31-33: Comparing before-and-after airway and uprighted posture. 31. Pretreatment. 32. 12 weeks. 33. Postorthodontic/nasal therapy

Figure 35: Deviated septum and concha bullosa

population of patients ages 13-74. This relates to relief of close to 45 pounds of weight from the cervical and lumbar spine.31 Uprighting the head can eliminate the need for common therapies for migraine, which include BOTOX® injections for the tendon insertions on the occiput of the skull as well as the mouth-closing muscles (temporalis and masseter), or severing the greater and lesser occipital nerves (often entrapped by the extensor muscle tendons they pass through). FHP has also been found to be related to bruxism and nasal obstruction in children. “Bruxism seems to be related to altered natural head posture and more intense dental wear. A more anterior and downward head tilt was found in the bruxist group, with statistically significant differences compared to controls.”32 Bruxism in children has been found to be related to respiratory Orthodontic practice 41

CONTINUING EDUCATION

Figure 37

effort related arousals (RERA) and OSA.33 Expansion of the maxilla in mouth-breathing children restores proper nasal breathing and uprights the head.34,35 Surgical retrusion of the mandible in prognathic conditions results in significant FHP, perhaps in defense of a compromised oropharyngeal airway.36 Superimposition of the skull via CBCT scans (i-CAT FLX, Imaging Sciences) pretreatment (blue) and posttreatment (bonecolored) demonstrates significant changes. “A” point has been advanced as well as a dramatic shift of the mandible to the left as well as the maxilla (Figure 36). Stabilization has been accomplished with a TMD/mouth-breathing Myobrace™ appliance (Myofunctional Research Co.) (Figure 37). Here are the patient’s vitals at finish: 27 years old, 6’ 2”, 220 lbs, BMI 27.4. A follow-up sleep study (Medibyte, Braebon) demonstrated AHI 9.1 (mild), supine 9.2, non-supine 8.8, and SpO2 mean 94.5%. Long-term stabilization is the final therapy to maintain proper tongue function with the nasal function that must be managed with a nasal dilator (nasal valve collapse) and Xlear® (saline and xylitol) nasal spray (soft-tissue hypertrophy) (Figures 38 and 39). Using this device prevents mouth breathing and helps maintain arch development in a dynamic way utilizing the tongue, which is directed against the palate with this device.

Summary of outcomes A sleep study was performed with the appliance and nasal management utilizing identical equipment demonstrated: AHI 1.1 in all positions and SpO2 97.2%. An FDA-approved oral appliance for the patient’s apnea will be produced after retreatment of his remaining nasal pathology. Now that Aric W.’s obstructive sleep apnea has been reduced to mild (AHI 5-15), appropriate nasal surgery may be effective in reducing AHI.37 Aric W. is symptom-free, and his quality of life has been restored: He can get to sleep, 42 Orthodontic practice

Figure 38

Figure 39

stay asleep, and awakens well rested. He is free of headaches and facial, neck, and back pain. This patient feels and looks like a completely different person. OP

Harvold EP, Tomer BS, Vargervik K, Chierici G. 19. Primate experiments on oral respiration. Am J Orthod. 1981;79(4):359-372.

REFERENCES

21. Carra MC, Huynh N, Morton P, et al. Prevalence and risk factors of sleep bruxism and wake-time tooth clenching in a 7- to 17-yr-old population. Eur J Oral Sci. 2011;119(5):386-394.

1. Olmos Sr, Garcia-Godoy F, Hottel T, Tran NQ. Headache and jaw locking comorbidity with daytime sleepiness. Am J Dent. 2016;29(3):161-165. 2. Hussain SF, Cloonan YK, et al. Association of self-reported nasal blockage with sleep-disordered breathing and excessive daytime sleepiness in Pakistani employed adults. Sleep Breathing. 2010;14:345-351. 3. Cunali PA, Almeida FR, Santos CD, et al. Prevalence of temporomandibular disorders in obstructive sleep apnea patients referred for oral appliance therapy. J Orofac Pain. 2009;23 (4):339-344. 4. Smith MT, Wickwire EM, Grace EG, et al. Sleep disorders and their association with laboratory pain sensitivity in temporomandibular joint disorder. Sleep. 2009;32(6):779-790.

20. Svensson P, Arima T, Lavigne G, et al. Sleep Bruxism: Definition, Prevalence, Classification, Etilology, and Consequences. In: Kryger MH, Roth T, Dement WC. Principles and Practice of Sleep Medicine. 6th ed. Philadelphia, PA: Elsevier Saunders; 2017.

22. Manfredini D, Winocur E, Guarda-Nardini L, Paesani D, Lobbezo F. Epidemiology of bruxism in adults: a systematic review of the literature. J Orofac Pain. 2013;27(2):99-110. 23. Huynh N, Kato T, Rompre PH, et al. Sleep bruxism is associated to micro-arousals and an increase in cardiac sympathetic activity. J Sleep Res. 2006;15(3):339-346. 24. Bektas D, Cankaya M, Livaoglu M. Nasal obstruction may alleviate bruxism related temporomandibular joint disorders. Med Hypotheses. 2011;76(2):204–205. 25. Grechi TH, Trawitzki LV, de Felı´cio CM, Valera FC, Alnselmo-Lima WT. Bruxism in children with nasal obstruction. Int J Pediatr Otorhinolaryngol. 2008;72:391-396.

5. Sanders AE, Essick GK, Fillingim R, et al. Sleep apnea symptoms and risk of temporomandibular disorder: OPPERA cohort. J Dent Res. 2013;92(7)(supp):70-77.

26. Eftekharian A, Raad N, Gholami-Ghasri N. Bruxism and adenotonsillectomy. Int J Pediatr Otorhinolaryngol. 2008;72(4):509-511.

6. Imada M, Nonaka S, Kobayashi Y, Iwamoto J. Functional roles of nasal nitric oxide in nasal patency and mucociliary function. Acta Otolaryngol. 2002;122(5):513–519

27. Singh D, Olmos S. Use of the sibilant phoneme registration protocol to prevent upper airway collapse in patients with TMD. Sleep Breath. 2007;11(4):209-216.

7. Maniscalco M, Sofia M, Pelaia G. Nitric oxide in upper airways inflammatory diseases, Inflamm Res. 2007;56-58. 8. Mancinelli RL, McKay CP. Effects of nitric oxide and nitrogen dioxide on bacterial growth. Appl Environ Microbiol. 1983;46(1):198-202. 9. NathanCF, Hibbs JB Jr. Role of nitric oxide synthesis in macrophage antimicrobial activity. Curr Opin Immunol. 1991;3(1):65-70.

28. Cailliet R. Head and Face Pain Syndromes. Philadelphia, PA: F.A. Davis Company; 1992. 29. An J, Jeon DM, Jung WS, Yang IH, Lim WH, Ahn SJ. Influence of temporomandibular joint disc displacement on craniocervical posture and hyoid bone position. Amer J Orthod Dentofacial Orthop. 2015;147(1):72-79.

10. Fang FC. Mechanisms of nitric oxide-related antimicrobial activity. J Clin Invest. 1997;99(12):2818-2825.

30. Simmons HC 3rd, Gibbs SJ. Anterior repositioning appliance therapy for TMJ disorders: specific symptoms relieved and relationship to disk status on MRI. J Tenn Dent Assoc. 2009;89(4):22-30.

11. Sanders SP, Proud D, Permutt S, et al. Role of nasal nitric oxide in the resolution of experimental rhinovirus infection. J Allery Clin Immunol. 2004;113:697-702.

31. Olmos S, Kritz-Silverstein D, HalliganW, Silversterin ST. The effect of condyle fossa relationships on head posture. Cranio. 2005;23(1):48-52.

12. Sanders SP, Siekierski ES, Porter JD, Richards SM, Proud D. Nitric oxide inhibits rhinovirus-induced cytokine production and viral replication in a human respiratory epithelial cell line. J Virol. 1998;72:934-942.

32. Velz AL, Restrepo CC, Pelaez-Vargas A, et al. Head posture and dental wear evaluation of bruxist children with primary teeth. J Oral Rehabil. 2007;34(9):663-670.

13. Jorissen M, Lefevere L, Williams T. Nasal nitric oxide. Allergy. 2001;56:1026-1033. 14. Runer T, Cervin A, Lindberg S, Uddman R. Nitric oxide is a regulator of mucociliary activity in the upper respiratory tract. Otolaryngol Head Neck Surg. 1998;119:278-287. 15. Jain B, Rubenstein I, Robbins R, Leise KL, Sisson JH. Modulation of airway epithelial cell ciliary beat frequency by nitric oxide. Biochem and Biophys Res Commun. 1993;191(1):83-88. 16. Lindberg S, Cervin A, Runer T. Low levels of nasal nitric oxide (NO) correlate to impaired mucociliary function in the upper airways. Acta Otolarngol. 1997;117(5):728-734. 17. Guilleminault C, Sullivan SS. Towards restoration of continuous nasal breathing as the ultimate treatment goal in pediatric obstructive sleep apnea. Pediatr Neonatol Biol. 2014;1(1):001. 18. Olmos S. CBCT in the evaluation of airway — minimizing orthodontic relapse. Orthodontic Practice US. 2015;6(2):46-49.

33. Ribeiro Ferreira NM, Fernandes dos Santos JF, Fernandes dos Santos, MB, Marchini, L. Sleep bruxism associated with obstructive sleep apnea syndrome in children. Cranio. 2015;33(4):251-255. 34. Tecco S, Festa F, Tete S, Longhi V, D’Atillo M. Changes in head posture after rapid maxillary expansion in mouth-breathing girls: a controlled study. Angle Orthod. 2005;75(2):171-176. 35. McGuinness NJ, McDonald JP. Changes in natural head position observed immediately and one year after rapid maxillary expansion. Eur J of Orthod. 2006;28(2):126-134. 36. Cho D, Choi D, Jang I, Cha BK. Changes in natural head position after orthognathic surgery in skeletal Class III patients. Am J Orthod Dentofacial Orthop. 2015;147(6):747-754. 37. de Sousa Michels D, da Mota Silveira Rodrigues A, Nakanishi M, Sampio ALL, Venosa AR. Nasal involvement in obstructive sleep apnea syndrome. Int J Otolaryngol. 2014; http://dx.doi.org/10.115/2014/717419. Accessed April 18, 2017.

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Improving quality of life and faces nonsurgically OLMOS

1. In 2016, a study of almost 1,200 patients published in the American Journal of Dentistry found that patients with sleep-related fatigue measured by an Epworth scale greater than ______ were 1.39 times more likely to have jaw locking and primary headaches. a. 2 b. 4 c. 6 d. 8 2. Sleep-related fatigue (excessive daytime sleepiness) is more often the result of _______ than obstructive sleep apnea (OSA). a. nasal obstruction (mouth breathing) b. nasal breathing c. bacteria d. teeth grinding 3. Patients with two or more signs and/or symptoms of OSA had a _____ greater incidence of first-onset TMD. a. 25% b. 42% c. 65% d. 73% 4. Breathing through the nose allows for

Volume 8 Number 3

________ the inspired air. a. filtering b. warming c. adding moisture to d. all of the above 5. NO (nitric oxide) is necessary for cilia movement in the sinuses to carry out debris; it is ________ and also is important in peripheral vasodilation of the blood vessels. a. antifungal b. antibacterial c. antiviral d. all of the above 6. Establishing/developing patency of the _______ points of obstruction is necessary to prevent orthodontic relapse (anterior or posterior open bite). a. two b. four c. five d. six 7. The characteristic electromyography (EMG) pattern of _______ is found in repetitive and recurrent episodes of rhythmic masticatory muscle activity (RMMA) of the masseter and

temporalis muscles, which are usually associated with sleep arousals. a. sleep-related bruxism b. jaw locking c. migraine headaches d. increased blood pressure 8. Every inch the head is forward of the shoulders adds approximately _____ of weight to the cervical and lumbar spine. a. 2 pounds b. 5 pounds c. 10 pounds d. 20 pounds 9. _______ seems to be related to altered natural head posture and more intense dental wear. a. Bruxism b. Insomnia c. A Schwarz appliance d. A nasal dilator 10. Expansion of the maxilla in mouth-breathing children _______. a. eliminates migraine headaches b. restores proper nasal breathing c. uprights the head d. both b and c

Orthodontic practice 43

CE CREDITS

ORTHODONTIC PRACTICE CE

CONTINUING EDUCATION

TMJ dysfunction: clicks and trismus Dr. Yad Zanganah explains trismus — an often under-diagnosed and under-treated temporomandibular joint disorder — and offers treatment options

his article aims to explain a symptom called trismus, or lockjaw, so that a clinician can identify it when a patient presents in the clinic and, through an algorithm, reach a diagnosis. In this way, a clinician can have a practical step-by-step approach to treat trismus — a condition that is, in the author’s opinion, both under-diagnosed and under-treated. Many people (adults and teenagers alike) suffer from this condition at some stage of their lives.

Educational aims and objectives

This article aims to explain a symptom called trismus, or lockjaw, so that a clinician can identify it when a patient presents in the clinic and, through an algorithm, reach a diagnosis.

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: • Identify the symptoms of trismus. • Realize what types of questions to ask the patient for accurate diagnosis. • Recognize whether the trismus is muscular or mechanical. • Identify some treatment options for trismus. • Read some tips for creating a bite-raising appliance (bite guard).

Trismus Trismus refers to a reduced opening of the jaws caused by spasm of the muscles of mastication. For patients with a locked jaw, not being able to open the mouth can happen gradually or suddenly. The first point to note is that a dislocated condyle is characterized by the inability to close the mouth into occlusion and confirmed with a radiograph (orthopantomograph/CBCT). This merits a referral to a local hospital to deal with the problem;

however, this is not what we are discussing in the article. Before you diagnose temporomandibular joint (TMJ) dysfunction, make sure the trismus is not caused by an infective process. On rare occasions, neoplasms (tumors) can also cause trismus. Once you have excluded these conditions, you can look into what type of TMJ dysfunction the patient is presenting with.

There are several questions to ask patients: 1. Have they had a click in the TMJ regions in the past? 2. What type of trismus is it? Was there a sudden or gradual onset of symptoms? 3. Pain: Is the pain sharp with each click, or is it more of a dull ache? 4. Is the mouth opening prevented by a rigid mechanic stop, or is it more a painful reactive muscle spasm?

Figure 1: A wax bite for a soft bite guard. Note the thickness

Yad Zanganah, DDS, MFDS, RCPS, graduated in 1999 from Germany and has been based in the United Kingdom since 2001. He is a consultant in oral surgery and has a special interest in dental implants, cosmetic dentistry, and nonsurgical facial esthetics. He is certified in sedation for nervous patients and is a finalist in three of the facial esthetics categories at this year’s Aesthetic Dentistry Awards.

Figure 2: A wax bite for a hard bite guard 44 Orthodontic practice

Volume 8 Number 3

1. Previous clicking If the patient reports a click in the past that suddenly disappeared when the mouth opening is reduced, then measure the mouth opening. Remember the two stages of mouth opening: rotation then translation. A mouth opening of around 25 mm (interincisal) with a rigid mechanical stop indicates a case of anterior displacement of the meniscus without reduction.

2. Reduced opening without rigidity Where the mouth opening is reduced but not rigid, try to gently force the mouth open. If you notice an elastic resistance, with pain clearly in the muscles of mastication (especially the lateral pterygoid), then this could be a sign of muscle spasm. An increase in activity in a muscle can lead to an increase in lactic acid accumulation (due to the Cori cycle) caused by anaerobic glycolysis in the muscles. This makes the muscle painful. (Think about calf pain after the first day of jogging.) A gradual onset of symptoms is an indicator of a gradual increase in lactic acid accumulation. A sudden change can indicate a derangement of the meniscus, like the displacement of the meniscus. (The disc can only displace anteriorly; hence there is no posterior displacement.)

3. Pain A sharp pain alongside a click is an indicator of pain caused by the sudden rapid movement of the disc from its squeezed anterior location (while displaced) into the

fossa once the condyle is inferior anterior enough during the translation part of mouth opening. This is then a case of anterior displacement of the meniscus with reduction. The reduction is reliant on the posterior tendons attached to the meniscus. In my experience, a long-standing anterior displacement of the meniscus without reduction (locked jaw) with trismus (mouth opening with only the rotational stage, up to around 25 mm interincisal distance) is more difficult to treat with conservative methods. The Figure 3: A soft bite-raising appliance, preferably for the lower jaw tendons will more likely lack the ability as it is tolerated more easily to pull the meniscus back into the fossa. Think about this like a spring: If you pull on it and reach the plastic stage, then muscles while examining the patient.) Avoid any pressure with your nails. it is unlikely that the spring will go back to its original state. If the tendon is like a slack spring, then it is likely that the only treatment Treatment options could be surgery — a procedure called meniOnce you have determined what type scopexy, which we will not cover here as it is of trismus this is, you need to look at treatment options. outside the remit of a general dental surgeon. Here I will explain some simple options that have worked well for me, as I see more 4. Trismus type Taking note of the type of trismus — than 700 patients each year with TMJ whether it is muscular or mechanical — can dysfunction syndrome symptoms. again help determine what type of problem One of the first treatment options is as you are dealing with. Each type of dysfuncsimple as reassurance, non-steroidal antition requires a different treatment. inflammatory drugs (NSAIDs), and advising the patient to go on a soft diet. If, on examination, you notice that the muscles of mastication are tender, then take Warm compresses or a microwavenote of which muscles are tender as this will able wheat bag can also help reduce the help follow up your treatment. lactic acid in the muscles. The author has Try to keep the pressure on palpation to not personally seen any significant benefit a gentle pressure of about 50 g. (One way from so-called muscle exercises of the to measure this is to put 50 ml of water in a jaw muscles. plastic cup and feel how heavy it is — that Another option is a simple soft acrylic is the pressure you need to exert on the vacuum-created bite-raising appliance (BRA)

Figure 4A: An upper hard bite-raising appliance with Adams clasps at the first molars Volume 8 Number 3

Figure 4B: Another view of the upper hard bite-raising appliance Orthodontic practice 45

CONTINUING EDUCATION

Now let’s discuss each point in sequence.

CONTINUING EDUCATION

Figure 5A: Step 1 — to determine if a hard bite-raising appliance can help and how thick you need it be, ask the patient to open wide then close up to a dental mirror you keep between the posterior teeth

Figure 5B: Step 2 — ask the patient to open up to 20 mm (rotational stage) and close to the mirror a few times

Figure 5C: Step 3 — ask the patient to open the mouth wide. Observe for a deviation and click. Frequently you will notice that the click disappears. Also you will notice a deviation that might have been present previously had disappeared. The mouth now opens straight. 46 Orthodontic practice

for cases of muscle spasm (pure myofacial pain). This could be provided soon after diagnosis or after a short period of conservative treatment. Remember that patients may have pain from opening the mouth and as such it may be difficult to take good impressions. It is important to distinguish between muscular trismus and meniscus displacement. If you diagnose your patient with an anterior displacement of the meniscus without reduction, then the author suggests a hard acrylic BRA as a first line of treatment — once taking impressions is possible. As you do not know how much clearance you need, start with a gentle 2 mm clearance between the posterior teeth. It is simply a case of ensuring that the lab uses an articulator and clears the occlusal distance by 2 mm, and that all opposing teeth are in contact with the bite guard. Ask the patient to use the hard bite guard for 16 hours a day. If, after a month or two, there is improvement, then the patient can be asked to use it for 22 hours a day. Remember that wisdom teeth need to be covered at least partially, and all teeth need to have a light occlusal contact with the bite guard. There have been cases of over-eruption caused by poorly made bite guards (Chate, Falconer, 2011). Tips for making a bite-raising appliance (bite guard) Good alginate impressions of both upper and lower jaws (regardless of the type of BRA) are essential. Take the bite registration, using wax or a silicone. The important part is the thickness of the material where the teeth meet occlusally. Make sure your bite registration is as thick as your end BRA — this makes it easier for the lab to manufacture it. Figures 1 to 5 illustrate some wax bites and ways to check the thickness. Light pink is sufficient for a soft BRA: You need to see more red and less pink if you are making a hard BRA. This simple test confirms the diagnosis of anterior displacement of meniscus with reduction and the amount you need to open the bite to allow the disc to go back into the fossa. This short video will help show you how to perform the mirror test: www.youtube. com/ watch?v=zx9k5xjZ5f4. OP REFERENCE 1. Chate RA, Falconer DT. Dental appliances with inadequate occlusal coverage: a case report. Br Dent J. 2011;210(3):109-110.

Volume 8 Number 3

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

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TMJ dysfunction: clicks and trismus ZANGANAH

1. A mouth opening of around _____ (interincisal) with a rigid mechanical stop indicates a case of anterior displacement of the meniscus without reduction. a. 15 mm b. 25 mm c. 35 mm d. 50 mm

4. One of the first treatment options is as simple as _______. a. reassurance b. non-steroidal anti-inflammatory drugs (NSAIDs) c. advising the patient to go on a soft diet d. all of the above

7. (For anterior displacement of the meniscus without reduction) Ask the patient to use the hard bite guard for ______ a day. a. 30 minutes b. 2 hours c. 10 hours d. 16 hours

2. Where the mouth opening is reduced but not rigid, try to gently force the mouth open. If you notice an elastic resistance, with pain clearly in the muscles of mastication (especially the lateral pterygoid), then this could be a sign of _________. a. locked jaw b. muscle spasm c. neoplasm d. dislocated condyle

5. Another option is a simple soft acrylic vacuum-created bite-raising appliance (BRA) for cases of ________. a. muscle spasm (pure myofacial pain) b. anterior displacement of the meniscus without reduction c. sudden rapid movement of the disc into the fossa d. slack tendon

8. Good alginate impressions of _______ (regardless of the type of BRA) are essential. a. both upper and lower jaws b. just the upper jaw c. just the lower jaw d. the wisdom teeth

3. An increase in activity in a muscle can lead to an increase in _______ accumulation (due to the Cori cycle) caused by anaerobic glycolysis in the muscles. a. lactic acid b. amino acids c. hydrochloric acid d. lipoprotein

Volume 8 Number 3

6. (When taking impressions for a hard acrylic BRA) As you do not know how much clearance you need, start with a gentle _______ clearance between the posterior teeth. a. 2 mm b. 4 mm c. 6 mm d. 8 mm

9. Take the bite registration, using ________. a. wax or silicone b. alginate c. plaster d. acrylic 10. The important part is the ________ of the material where the teeth meet occlusally. a. strength b. thickness c. flexibility d. removal

Orthodontic practice 47

CE CREDITS

ORTHODONTIC PRACTICE CE

TECHNOLOGY

Making space in your practice: what to do with all those stone models Matt Hendrickson discusses a money- and space-saving alternative to stone models — going digital

n spite of the popularity of intraoral scanners that eliminate the use of alginate and plaster models, traditional impressions continue to be the standard when it comes to taking initial orthodontic records for most practices. And it’s been the standard for years — and years. All those years have added up to boxes of models (Figure 1) tucked away, wasting valuable space. In fact, there’s a minority of practices that have stopped taking impressions as part of the initial record altogether — arguing that it’s simply not worth the hassle of pouring up models only to have them gather dust in a corner. That, of course, is an extreme measure; however, there are other ways for practices to handle their backlog of stone models: digitizing existing models (Figure 2). Orthodontists have been hearing it for a decade now — “go digital.” For some, that might mean using an intraoral scanner. Creating a model as part of the initial record is highly recommended by the American Board of Orthodontics, but it doesn’t make it any less messy or time-consuming. Pouring up models, trimming, and polishing them for patient presentation is a hassle. Digital impressions captured with an intraoral scanner can eliminate those steps. With that in mind, “going digital” seems like common sense, and many orthodontic practices have started to embrace that option. However, it doesn’t undo years of stone models that practices are still obligated to maintain. It varies state by state, but once a stone model becomes part of a patient’s record, the practice must keep it for an average of 7 years after the patient reaches the age of majority. Consequently, if a doctor finishes with a patient when he/she is 13 or 14, the practice will have to maintain the model for at Matt Hendrickson has spent more than 20 years in the industry. He is currently the US&C orthodontic director for Carestream Dental. Prior to joining Carestream Dental, Hendrickson founded and served as president of Integrated Dental Solutions, and he also has held a variety of roles within dental practices.

48 Orthodontic practice

Figure 1

Figure 2 Volume 8 Number 3

TECHNOLOGY

Figure 3

least 10 years. Most offices keep them even longer than required. Herein lies the problem; rooms full of models that must be categorized and documented. Typically, they’ll be put in a box, labeled with a number, and then that number is included in the patient’s records. This leads to storage space and filing issues. Busy or long-standing practices often end up renting an offsite storage facility to save office space, which of course, requires a monthly fee. This brings us back to digitizing stone models. Practices could send models to a lab to be digitized, but there’s a cost involved — $10-$30 per model — as well as the price of shipping and the risk of the models breaking en route. Practices could also purchase their own desktop scanner, but who wants a piece of equipment that takes up counter space and does only one thing? Or they could take advantage of a piece of equipment that’s already in their practices: the extraoral imaging system. These days, as cone beam computed tomography (CBCT) makes its way into orthodontics, an imaging system must do more than just capture pans and cephs. Instead, a multi-functional system, such as the CS 8100SC 3D extraoral imaging system or CS 9300C system, gives orthodontists everything they could need in one unit: 2D imaging, cephalometric imaging, CBCT, and model and impression scanning. In the same way cephs and pans are easily taken, scanning existing models with the CS 8100SC 3D or CS 9300C can be accomplished by any staff member with the push of a button and immediately uploaded to the patient’s file within practice management software. In addition to being able to scan existing models, traditional impressions (Figure 3) can also be scanned, so there’s no need to even pour up a model. If an impression is scanned, software automatically mounts it on a polished base and aligns the occlusion (Figure 4). The model can then be easily manipulated in 3D for analysis and case Volume 8 Number 3

Figure 4

Figure 5

presentation, or even sent digitally to a lab for appliance fabrication. Digital impressions and models not only save on space, but digital files are also easier to pull up if necessary, rather than tracking down a random storage box. Of course, scanning impressions (Figure 5) and models in-office with existing equipment means there’s no cost per scan, and the model can be safely destroyed once it’s digitized. Orthodontics, like all dental specialties, is transitioning more and more toward a digital workflow. Whether doctors fully embrace digital impressions with an intraoral scanner or aren’t quite ready to take the leap,

there’s no denying that the boxes, shelves, and storage units full of stone models aren’t just going to disappear because the march of progress declares the future is digital. Digitizing stone models with a multi-functional extraoral imaging system, such as the CS 8100SC 3D or the CS 9300C, can save storage space in your practice and cut back on the costs of offsite storage or having a lab digitize the models. In addition to saving space, digital models can be quickly pulled up on a computer and impress patients during case presentation. So don’t erase years of stone models, embrace years of stone models in a digital format. OP Orthodontic practice 49

PRODUCT PROFILE

Insignia™ TruRoot™ Insignia — TruRoot data integration and enhanced Approver functionality by Ormco Corporation

ver the past several years, the spotlight on digital orthodontics and associated technologies has become brighter and brighter. As technology continues to evolve, orthodontists and their staff are granted expanded access to advanced patient tools and software systems. To support this digital movement, Ormco has been leading the industry with innovations for over 50 years and pioneering developments in digital technologies, notably with Insignia™. Insignia is a fully interactive, computer-aided treatment planning and custom appliance system designed to give every patient a truly one-of-a-kind smile. It’s a precise, start-tofinish process that can deliver the optimal functional and esthetic outcomes for each unique patient. Earlier this year, Ormco 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. For doctors that do not submit CBCT data with their Insignia cases, Insignia has also improved its existing root library by extending the roots to provide doctors with a full simulation of the entire root position. Displaying long roots provides doctors with a more complete picture of the patient’s

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.

anatomy, enabling them to determine better treatment plans from the start of the case. In addition to the incorporation of improved root data through TruRoot and the updated root library, the latest Insignia upgrade also includes enhanced Approver functionality. The new user experience improvements give doctors exceptional control over macro changes within the Approver software and allow doctors to preview jig design before approving their cases. In addition to exceptional software upgrades and integrations, Ormco has also continued to expand on the number of industry-leading digital scanners from which Insignia can accept files. Of note, effective this year, 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. To learn more about Insignia, visit www. ormco.com/products/insignia-advanced, or speak with your Ormco representative. To learn how your patients can benefit from Insignia, or to find your name in the doctor locator, visit https://insigniasmile.com/. OP This information was provided by Ormco Corporation.

TruRoot allows doctors to better visualize and predict root and tooth movement, making it easier to determine the best treatment plan 50 Orthodontic practice

Volume 8 Number 3

Ian McNickle, MBA, discusses how your website can lead patients to your practice

hat would you say if I told you that by making some changes to your website design, content, and layout you could generate over $100,000 in additional revenue in 12 months? You might think I’m crazy, but I encourage you to take 5 minutes to read this article. You might be very glad you did. To learn how, we need to first take a step back and discuss online marketing. When it comes to online marketing there are two primary objectives: 1. Generate as much “relevant” traffic as possible. 2. Convert that traffic into as many new patient leads and appointments as possible. I frequently lecture at dental conferences and study clubs all over North America, and almost without exception, the clinicians and staff in attendance are not familiar with the performance metric of website lead conversion.

Website traffic To better understand this metric, let’s start with generating traffic. There are many ways to generate traffic to a website such as high search rankings on Google, Bing, Yahoo, etc., which is achieved through effective Search Engine Optimization (SEO). Driving lots of patient reviews to review sites such as Google, Facebook, Healthgrades, and Yelp also have a very positive impact on your search rankings and traffic. Social media activity, engagement, boosted posts, and paid ads can all drive traffic to a website as well. Online directories can drive traffic, and the list goes on and on.

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

Volume 8 Number 3

Lead conversion Once you’ve implemented a robust program to generate traffic, it is equally important to understand how to convert all this traffic into new patient leads. As with traffic, there are many items that affect website lead conversion such as: • having a modern website design with proper layout • the location of the phone number • appointment request buttons or forms • clear calls to action • effective use of videos • compelling offers • online scheduling links • the use of actual photos instead of stock photos • great doctor bio and team pages • patient testimonials (video and written) • helpful and accurate content An experienced online marketing agency with expertise in the dental industry like WEO Media should be consulted for best practices in this area.

How is the lead conversion rate calculated? The lead conversion rate is calculated by dividing the amount of conversion activities (phone calls, appointment requests, etc.) by your website traffic each month. By doing this, you’ll be able to develop a baseline range for how your website typically converts traffic. Consider this example: Let’s suppose your website generates 400 visits (traffic) in a month. You received 30 phone calls from the website and 10 appointment requests through the website. Your conversion rate

would be 40 conversion activities divided into 400 visits for a conversion rate of 10%. If you monitor this rate over time, you’ll be able to understand how your website is actually performing as a marketing tool.

Maximize your Return on Investment (ROI) Where this gets really interesting is when you can improve items on your website that improve your website conversion rate. Even a small improvement can result in tens of thousands or even hundreds of thousands of dollars per year in extra revenue. An average website may generate 500 visits per month with an average conversion rate of around 10%. If you can implement strategies to improve your conversion rate, and it improves to 12%, consider the impact. This slight 2% improvement equates to 10 additional new patients leads per month or 120 per year. If you can convert even 25% of these new patient leads, you’ve now generated an extra 30 patients per year. How much is that worth? The good news is most of the items that improve the website conversion rate do not involve ongoing costs, but rather specific expertise and industry experience to properly design and construct the website.

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

Receive your free marketing consultation today: 888-246-6906 or info@weomedia.com Orthodontic practice 51

PRACTICE DEVELOPMENT

The importance of website lead conversion

M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT DentalXChange announces integrated attachment service

3Shape Orthodontics gets exclusive integration with American Orthodontics Bracket Systems

DentalXChange, the creator of industry-leading electronic claims software, ClaimConnect, has released a new attachment service to optimize the claims process for both payers and providers. The attachment service is fully integrated into the ClaimConnect application, offering enhancements and improved claims management previously unavailable to dental offices. The company’s new attachment service allows dental providers to attach supporting documents such as X-rays, periodontal charts, EOBs, narratives, or any other documentation that may be required by dental insurance companies to adjudicate a claim, without having to open a separate program or mail hard copy documents or films. For more information, visit http://www.dentalx change.com/home/Home.

3Shape announced that its Indirect Bonding application became the first orthodontic software solution to integrate digitally with proprietary American Orthodontics (AO) Bracket Systems libraries. The exclusive integration enables orthodontists and labs using the FDA-cleared 3Shape indirect bonding solution to first plan patient treatment using the virtual American Orthodontics Bracket Systems library and then bond the physical AO brackets using digitally designed transfer trays. Select American Orthodontics Bracket Systems libraries can be accessed directly in 3Shape orthodontic software. Treatment planning and bracket placement of the virtual libraries are made using a digital study model of the patient and/or with the 3Shape Indirect Bonding module. The models are created with a TRIOS® intraoral scan or conventional impression scanned with a 3Shape dental lab scanner. After treatment planning, the real American Orthodontic brackets are placed on the patient using transfer trays also designed with the 3Shape indirect bonding software and printed with a 3D printer. For more information, visit http://www.3shape.com/en/customer +programs/ortho+partner+integrations/bracket+library+integrations.

3Shape orthodontic indirect bonding solution integrates with RMO Bracket Systems 3Shape Indirect Bonding application, an application within 3Shape Orthodontics, announced digital integration with Rocky Mountain Orthodontics (RMO) Bracket Systems. The integration enables orthodontists and labs using the FDA-cleared 3Shape indirect bonding solution to first virtually plan patient treatment using the RMO Bracket Systems libraries and then place the physical RMO brackets using digitally designed and 3D printed transfer trays. Treatment planning and bracket placement of the virtual libraries are made using a digital study model of the patient. The models are created with a TRIOS® intraoral scan or conventional impression scanned with a 3Shape dental lab scanner. After treatment planning, the physical bracket systems are bonded in the patient using transfer trays also designed with the 3Shape indirect bonding software and printed with a 3D printer. The RMO Bracket Systems join more than 200 original bracket libraries and orthodontic solution providers now integrated with the 3Shape orthodontic software. For more information, visit http://www.3shape.com/en/customer +programs/ortho+partner+integrations/bracket+library+integrations.

52 Orthodontic practice

Dentsply Sirona Orthodontics introduces the next generation buccal tubes: GAC Buccal Tubes Dentsply Sirona Orthodontics, a division of Dentsply Sirona announced the introduction of GAC Buccal Tubes, a completely redesigned and reengineered offering that encompasses their entire popular buccal tube line. Uniting an acute understanding of the current clinical landscape with the latest in design and development technology, the new GAC Buccal Tubes are a product of the company’s acclaimed Research, Design, and Manufacturing Campus in Sarasota, Florida. Featuring a patented base that’s been meticulously contoured to match the buccal surface, it delivers a superior fit and outstanding bond strength. The fluted mesial entrance on GAC Buccal Tubes allow the archwire to enter easily and slide freely, while the low profile design, contoured edges, and malleable hook are all engineered to deliver optimal patient comfort. For more information, visit www.dentsplysirona.com.

Volume 8 Number 3

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 3

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

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

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

(Multiple) Doe JF, Roe JP

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Orthodontic practice 53

M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT Planmeca and CephX Technologies LTD launch service for automatic cephalometric tracing and analysis The Finnish dental equipment manufacturer Planmeca has teamed up with CephX Technologies LTD to offer a new service for automatic cephalometric tracing and analysis. Utilizing machine learning technology and artificial intelligence, the service has been designed to help the daily work of orthodontic practitioners. It automatically delivers cephalometric tracing and analyses with a few clicks and in a matter of seconds when integrated into the Planmeca Romexis® dental imaging software. The new service utilizes CephX’s intelligent AlgoCeph algorithm — a sophisticated application of artificial intelligence and machine-learning technology based on thousands of manually traced cephalometric images. The service can also be used directly online from a dedicated website, which has been designed for Planmeca users who have yet to upgrade to the new Planmeca Romexis software version 4.6. For more information, visit https://planmeca.cephx.com today.

OrVance launches the next generation of OrthoDots® OrVance introduced the next generation of OrthoDots®, which offer an easier and more effective application that stays on much longer than dental wax. The new OrthoDots® will provide all the same benefits; plus it works even better, will provide a new easy open packaging, and will be over 50% less expensive than the first-generation product. OrthoDots® is the only product on the market with a moisture-activated adhesive, which is now imbedded within a medical-grade silicone blend. The silicone material used in OrthoDots™ is over 30 times more pliable than the leading brand of dental wax, preventing the crumbling associated with traditional wax products. Additionally, the new OrthoDots® will have an easy open, hygienic packaging feature just like a bandage. Free sample kits are available to all orthodontic practices and resident programs at OrVance.com.

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Dentsply Sirona Orthodontics advances the treatment of minor anterior tooth misalignments Dentsply Sirona Orthodontics announced the expansion of treatment indications for the MTM® (Minor Tooth Movement) Clear•Aligner. The clear aligner combines proven orthodontic techniques with advanced digital modeling to provide dental professionals with a streamlined solution for treating minor anterior misalignments. MTM® Clear•Aligner is uniquely engineered to deliver the space and force needed to accomplish tooth movement. The technology utilizes a proprietary “open pathway” architecture that allows teeth to move easily into the desired positions. Unlike other clear aligners, MTM® Clear•Aligner does not require clinicians to bond unsightly attachments to teeth to accomplish movement. No attachments save practice chairtime and provides for a more esthetically pleasing treatment solution for the patient. To facilitate tooth movement MTM® Clear•Aligner uses integrated “force points,” programmed into the aligner, to provide a greater range of tooth movements while making aligner placement and removal easy for the patient. MTM® Clear•Aligner targets the movement and positioning of the six most visible teeth on both the upper and lower arches. The aligner movements address tooth spacing, tipping, torquing, intrusion, extrusion, and rotation. Ideal candidates are those who are experiencing adult tooth crowding, orthodontic relapse, or those who seek cosmetic enhancements. For more information, visit www.dentsplysirona.com

Productive Practices introduces ErgoPro Motion The ErgoPro Motion is the newest version of Productive Practices’ ergonomically designed operatory stools, which combines unparalleled support with an elegant design. Its unique mechanism is the core of the stool’s ability to adjust to an individual’s personal seating requirements. When set in “free motion,” the back and seat of the stool will hydraulically follow one’s movement. The backrest and entire stool can be individually adjusted for height. Available shoulder support system (Relax and Hydro Armrests) offer relief to the neck and back, while providing full range of motion for both arms. The “Relax” and “Hydro” support Arms swing laterally side-to-side and telescope forward and back. The Hydro adds a third dimension through its tension-adjustable up-and-down motion. For more information, visit www.productivepractices.net, call 1-877-446-8088, or email sales@productivepractices.net.

Volume 8 Number 3

Address the Orthodontic Complexities You Face Everyday with...

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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

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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

Corporate profile MidAtlantic Orthodontics

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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 May/June 2017 – Vol 8 No 3

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

Improving quality of life and faces nonsurgically Dr. Steven R. Olmos

Keeping the “special” in the orthodontic specialty: part 1 Dr. John Wise

Making space in your practice: what to do with all those stone models Matt Hendrickson

Corporate profile Introducing Dentsply Sirona Orthodontics

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

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INDUSTRY NEWS Together Dentsply GAC and Dentsply Raintree Essix are part of the global strategic business unit Dentsply Sirona Orthodontics

Carestream agrees to sell dental digital business to Clayton, Dubilier & Rice and Hillhouse/CareCapital — Carestream Dental to be established as independent company Carestream, working with its parent company, Onex Corporation, has entered into an agreement to sell its dental digital business to funds managed by Clayton, Dubilier & Rice (CD&R), a leading global private investment firm, and CareCapital Advisors Limited (CareCapital), a specialist investment platform focused on dental and consumer health in Asia and part of Hillhouse Capital Management (Hillhouse). The new independent company will be named Carestream Dental. Carestream’s dental digital business, which provides imaging systems and practice management software for general and specialist dental practices globally, has earned leading positions in attractive, high-growth, oral healthcare markets and is well positioned for continued growth and success. CD&R and CareCapital intend to partner with the Carestream Dental team to build on the company’s leading positions and accelerate growth. Dental X-ray film and anesthetics are not included in the agreement and will remain with Carestream. For more information about Carestream Dental, call 800-9446365 or visit www.carestreamdental.com.

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, the firm introduced Dentsply Sirona Orthodontics, a division that includes Dentsply GAC and Dentsply Raintree Essix. The company notes that while this new division represents the evolving scope of the company, the trusted relationship shared between each practice and its respective GAC and Raintree Essix representatives will not change, and customers will continue enjoying the same outstanding service and products they’ve come to expect from these two businesses. Together, GAC and Raintree Essix as Dentsply Sirona Orthodontics can tap into a diverse R&D team made up of more than 70 professionals; a state-of-the-art research, development, and manufacturing campus in Sarasota, Florida; an educational platform committed to investing in education with affiliations in over 40 of the top dental programs across the globe; and one of the most diverse product lines in the market. For more information, visit www.dentsplysirona.com.

Watch for It

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Volume 8 Number 3

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

ÂŠ 2017 Ormco Corporation