Orthodontic Practice US November/December 2017 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews

Combining temporary anchorage devices with accelerated orthodontics to treat transposition Dr. David Alpan

An unusual orthodontic therapy Drs. Pat Brady, Carina Dabney, and Hilton Israelson

Corporate profile OrthoAccel®

forum.ormo.com

CALIFORNIA

Dr. Ricky E. Harrell

FEBRUARY 14-17

Tooth substitutions in orthodontic treatment

PALM DESERT

PROMOTING EXCELLENCE IN ORTHODONTICS

November/December 2017 – Vol 8 No 6

Company spotlight SleepArchiTx™

PAYING SUBSCRIBERS EARN CONTINUING EDUCATION CREDITS PER YEAR!

THE FORUM 2018

Featured Damon patients treated by Dr. Todd Bovenizer.

ONE AESTHETIC APPLIANCE FOR ALL YOUR PATIENTS Canâ&#x20AC;&#x2122;t treat all of your patients with a clear aligner? You can efficiently treat all your patients to a beautiful result regardless of their age or malocclusion with the Damon Clear2 bracket that offers 100% clear aesthetics, improved rotational control and variable torque options for patient-specific mechanics.

Visit ormco.com/damonwebinar to view the new Damon Clear2 webinar! ÂŠ 2017 Ormco Corporation

EDITORIAL ADVISORS

Creative financing for unrealized growth opportunity

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 John Voudouris (Hon) DDS, DOrth, MScD Neil M. Warshawsky, DDS, MS, PC John White, DDS, MSD Larry W. White, DDS, MSD, FACD CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day BDS, VT Julian English BA (Hons), editorial director FMC Dr. Paul Langmaid CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-inchief Private Dentistry Dr. Chris Potts BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon

© FMC 2017. All rights reserved. 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.

o thrive and grow in a competitive business landscape, orthodontists must be able to pivot — to think more broadly about the patient problems they solve and to reimagine ways of operating. For me, Jamie Reynolds, the pivot resulted from working in the Detroit area that found itself on the leading edge of the economic meltdown in 2007. At the time, I believed that if my partner and I became the best orthodontists in town, business would follow; so we spent the first 10 years becoming great finishers, among other Drs. Jamie Reynolds and Jeff Kozlowski undertakings, attending Ormco’s annual Forum and learning from the best clinicians in the world. But we still weren’t growing. When the recession hit, we needed to pivot, to make some onthe-fly decisions to keep the business alive. So I started contacting my most successful orthodontic friends. Jeff Kozlowski was my first call. For me, Jeff Kozlowski, my initial eye-opener came during the transition from group practice to running my own show. I had the unique opportunity to conduct an extensive evaluation of Insignia™, Ormco’s comprehensive digital treatment solution. Through it, I learned the importance of efficient clinical mechanics and measuring what happens after treatment starts. As soon as I began in solo practice, I started tracking detailed metrics and, like Jamie, worked to be the best orthodontist around with high-quality finishes, thoughtful patient care, and imperatively, case management efficiency. Using state-of-the-art appliances brought significantly faster treatment times. The dilemma then became patient financing, especially after the recession hit. My gut reaction was to decrease fees, but people, especially parents, are willing to pay more for optimal care. Monthly payments just needed to be affordable. Extending payments beyond end of treatment made sense, but how could I cover overhead — especially using advanced, higher-cost appliances that require upfront payment — and still manage cash flow if some patients couldn’t put 25% down? I needed to pivot. So we (Jamie and Jeff) put our heads together and formed a company to share our solutions with other practitioners looking for unrealized growth opportunities. It almost doesn’t matter whether you’re the most qualified practitioner around if you’re not starting patients because your financing doesn’t work. Success comes not only from doing phenomenal work but also from opening your doors to as many patients as possible. We learned to regard our patient pools in the aggregate to leverage those who pay in full or to put more money down so more patients can elect treatment. Then, hitting the sweet spot, we could add more patients without adding to fixed costs. And we were surprised with how few issues we had with extended payments. Of late, we’ve been offering seminars (ormco.com/education) to share the results of collecting and mining data and our success with creative financing. Our businesses are growing; they’re profitable, and we and our teams maintain amazing personal and practice lives. We encourage doctors to take advantage of the collective knowledge of our specialty at conferences, courses, and study clubs and to capitalize on what the latest practice and patient management and appliance technologies provide. The answers are there. Drs. Jamie Reynolds and Jeff Kozlowski Jamie Reynolds, DDS, MS, Novi, Michigan, and Jeff Kozlowski, DDS, New London, Connecticut, manage separate private practices. Well regarded for employing advanced technologies for effective clinical and practice management solutions and collecting and mining practice data, they lecture together, keeping course participants engaged with their stimulating material. They co-founded OrthoFi to assist clinicians in making treatment affordable for the greatest number of patients possible. Dr. Reynolds earned his DDS at the University of Michigan and MS from the University of Detroit-Mercy. He is a Diplomate of the ABO. Dr. Kozlowski earned his degree in economics from Syracuse University before receiving his DDS and orthodontic specialty certificate from the State University of New York at Buffalo.

ISSN number 2372-8396

Volume 8 Number 6

Orthodontic practice 1

INTRODUCTION

Nov/Dec 2017 - Volume 8 Number 6

TABLE OF CONTENTS

Banding together An unusual orthodontic therapy

Company spotlight SleepArchiTx™ — building your dental sleep practice A leadership team second to none .......................................................16

Drs. Pat Brady, Carina Dabney, and Hilton Israelson helped a patient uncover her smile through orthodontics

Clinical insight In my practice: aligner therapy with added high-frequency vibration Dr. David R. Boschken discusses a combination of therapies that can lead to more efficient orthodontic treatment ....................................................... 20

Corporate profile New OrthoAccel CEO leads company through next stage of growth

Orthodontic tips Low-cost assessment of UV sensitive adhesive Drs. Roberto Soares da Silva Júnior, Lídia Parsekian Martins, Larry W. White, and Renato Parsekian Martins offer advice for removing residual adhesives on debonding day...........24

2 Orthodontic practice

Volume 8 Number 6

LET YOUR ORTHODONTIC WORK SPEAK FOR ITSELF

WORKFLOW INTEGRATION I HUMANIZED TECHNOLOGY I DIAGNOSTIC EXCELLENCE

Carestream Dental orthodontic solutions give you fast, safe and efficient results worth sharing With an integrated orthodontic solution, planning, treating and consulting come together seamlessly—resulting in confident diagnoses, enhanced patient understanding and increased case acceptance. When that solution includes CS OrthoTrac Cloud, you can add “peace of mind” to your list of benefits, because all of your patient data and images are safe with HIPAA-compliant protection. And you can access your files anytime, anywhere—from almost any device.*

© Carestream Health, Inc. 2017. OrthoTrac is a trademark of Carestream Health. 16379 OR OrthoTrac AD 1017 Carestream Dental 3D images are available the next day. Radiological images displayed on digital handheld devices are not intended for diagnostic use.

For more information, call 800.944.6365 or visit carestreamdental.com

Take a Good Look at Great

Enclosed Clip Channel Enclosed clip mitigates calculus build-up

Opening Mechanism Easy opening with no dedicated instrument

Low-Profile Reduced overall profile

Reduced Curvature Improves clip strength and increased wire retention forces

Presenting In-OvationÂŽ X by GAC Crafted in collaboration with the orthodontic community, the new In-Ovation X bracket gives you the precision you want, the control you need and the confidence you deserve. For better, safer and faster outcomes, take a good look at great with GACâ&#x20AC;&#x2122;s In-Ovation X from Dentsply Sirona Orthodontics. Put the future of self-ligation at your fingertips with the new In-Ovation X. (800) 645-5530 www.inovationx.com

TABLE OF CONTENTS

Continuing education Tooth substitutions in orthodontic treatment Dr. Ricky E. Harrell discusses how to manage space for teeth that are either congenitally missing or lost due to disease or trauma............................32

Continuing education Combining temporary anchorage devices with accelerated orthodontics to treat transposition

Dr. David Alpan discusses alternatives to extractions, implants, and orthognathic surgery

Product profile Technology Artificial Intelligence (AI) and orthodontics — can you imagine where we will be in the very near future? Dr. C. William Dabney discusses computer systems’ ability to perform tasks normally requiring human intelligence......................................38

For new updates to CS OrthoTrac, it all starts with the users Kris Kinlen, Uriyah Robinson, Rick Alfieri, and Jerry Dickens discuss achieving absolute comfort with this practice management software .......................................................42

SEO: Scam or critical marketing service? part 2 Ian McNickle, MBA, discusses strategies to rank highly on Google and other search engines................40

6 Orthodontic practice

EDITOR IN CHIEF | Mali Schantz-Feld, MA Email: mali@medmarkmedia.com | Tel: (727) 515-5118 MANAGING EDITOR | Lou Shuman, DMD, CAGS Email: lou@medmarkmedia.com ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkmedia.com NATIONAL SALES DIRECTOR | Kristin Sammarco Email: kristin@medmarkmedia.com

Product profile Great Lakes offers a complete 3D digital orthodontic solution The ultra-fast 3Shape TRIOS® Ortho System™ streamlines impression taking, improves practice workflow, and increases patient satisfaction .......................................................44

Practice development

PUBLISHER | Lisa Moler Email: lmoler@medmarkmedia.com

Industry news...............46 Materials & equipment.........................48

NATIONAL ACCOUNT MANAGER Celeste Scarfi-Tellez Email: celeste@medmarkmedia.com CLIENT SERVICES/SALES SUPPORT | Adrienne Good Email: agood@medmarkmedia.com CREATIVE DIRECTOR/PROD. MGR. | Amanda Culver Email: amanda@medmarkmedia.com OFFICE MANAGER/EXECUTIVE ASST. | Mystey Helm Email: mystey@medmarkmedia.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 www.orthopracticeus.com | www.medmarkmedia.com SUBSCRIPTION RATES 1 year (6 issues) 3 years (18 issues)

$149 $399

Volume 8 Number 6

BANDING TOGETHER

An unusual orthodontic therapy Drs. Pat Brady, Carina Dabney, and Hilton Israelson helped a patient uncover her smile through orthodontics

n August 20, 2014, a 13-year-old patient presented to our office for orthodontic treatment with this chief complaint: “I don’t want to smile because I don’t have any front teeth.” Her mother further confided that her daughter’s education has been severely impeded as she refused to attend school because of her appearance. The initial examination revealed a Class I posterior occlusion, and teeth Nos. 6, 8, 9, 10, and 11 were impacted, while No. 7 was partially erupted and lying parallel to the floor of the nose (Figure 1). The treatment plan called for the exposure and bonding of attachments to all of the impacted teeth and bonding the remaining teeth in the maxillary and mandibular arches. Initially, the plan was to use distraction osteogenesis to advance the maxilla and hopefully stimulate growth of alveoli for the impacted teeth. Such surgical distraction proved unnecessary, however, as treatment progressed. Simply uncovering, extrusion, and advancing the teeth with their alveoli eventually provided the much needed support for the upper lip. A CT scan provided both orthodontist and oral surgeon enough additional data to

Figure 1: Initial photos and panoramic X-ray

Pat Brady, DDS, MS, has more than 40 years of experience as an orthodontist. He is a past president of the Greater Dallas Association of Orthodontists and has had academic appointments at the Baylor College of Dentistry and UT Southwestern School of Medicine. He is a former Captain of the United States Air Force and is certified by the American Board of Orthodontics. Dr. Brady also did original research on nitinol wire.

Carina Lynn Schwartz-Dabney, DDS, MD, PhD, has 14 years of experience as an oral surgeon. Dr. Dabney’s practice includes extractions, pre-prosthetic services, biopsies, expose and bond, frenectomies, orthodontic anchorage, bone grafts, and implants. Dr. Dabney attended both the University of Dallas, Irving, and the University of Illinois, Champagne-Urbana, before earning her Doctor of Dental Surgery degree from Baylor College of Dentistry in 1993 and her PhD in Craniofacial Biology in 2001. Dr. Dabney has previously served as an assistant professor at the University of Texas Southwestern Medical School. Her current professional memberships include the AAOMS, North Texas Society of Oral and Maxillofacial Surgeons, Texas Society of Oral and Maxillofacial Surgeons, Omicron Kappa Upsilon, and Tripartite ADA, TDA, and Dallas County Dental Society. Dr. Dabney has also been published in numerous books and journals. Hilton Israelson, DDS, MS, is a periodontist who specializes in treating the soft tissues and bone surrounding the teeth and in placing dental implants. In addition to private practice, he has been an educator to other dentists for over 40 years and has participated in numerous periodontal research studies. He is a Diplomate of the American Board of Periodontology, the highest status awarded to a periodontist for knowledge and clinical expertise. A native of South Africa, Dr. Israelson received his degree as a general dentist in 1973 from the University of the Witwatersand, Johannesburg, School of Oral Health Sciences. He then came to the United States for his periodontal specialist training and residency and graduated from Tufts University School of Dental Medicine in Boston with a certificate in periodontology.

8 Orthodontic practice

formulate an eruption plan for the impacted teeth. The surgeon channeled the bone to expedite the eruption of each impacted tooth, while the forced eruption of the exposed teeth was achieved by using as anchorage the inner bow of a maxillary headgear appliance from which the outer bows were removed. The inner bow fitted into the headgear tubes of the molar bands and was tied in place with ligature wires. The anterior part of the adapted headgear bow was notched to accommodate elastic threads that tied to the uncovered, impacted teeth. A continuous edgewise maxillary arch wire consolidated the rest of the maxillary dentition to minimize reciprocal effects from the extrusion of the impacted teeth (Figure 2). As treatment progressed and the teeth continued to erupt, brackets were added allowing more control. At this time tooth No. 8 was now discovered to be rotated 180° Volume 8 Number 6

BANDING TOGETHER

Figure 2: Modified headgear inner bow and exposed impacted teeth

Figure 3: Exposed teeth erupted enough to receive brackets

On February 1, 2017, after a period of 2 years and 6 months, treatment was completed, and the patient no longer hesitates to smile, and she attends school regularly.

and possessed a dilacerated root. It was decided by mutual agreement between the orthodontist and oral surgeon to leave the tooth in its unrotated position (Figure 3). As the teeth erupted, the headgear bow was advanced downward and forward. The headgear bow was discarded once the teeth had sufficiently erupted to use anterior box elastics to the maxillary and mandibular incisors. A vertical elastic was applied to the impacted maxillary canine to aid its eruption. As soon as the maxillary arch had been aligned, anterior box elastics were used to close the bite. At this point, the patient was referred to a periodontist for sulcus deepening amid concerns regarding the attached gingiva over the maxillary central incisors. Once the periodontal tissue had stabilized, the orthodontic therapy was completed, and tooth No. 8, which remained unrotated, was reconstructed by filling in the lingual surface of the tooth with composite to give the appearance of a normal incisor facial surface (Figure 4). On February 1, 2017, after a period of 2 years and 6 months, treatment was completed, and the patient no longer hesitates to smile, and she attends school regularly. In addition to its general dentists and specialty teams, Bear Creek Family Dentistry of Dallas, Texas, donated their staff, facilities, and services to make this treatment possible. OP

Figure 4: Treatment outcome photographs. Note the temporarily composite-augmented lingual surface of the maxillary left central incisor that awaits further periodontal and cosmetic intervention Volume 8 Number 6

Orthodontic practice 9

with elemetrix IDB & Aligner Design

Take the guesswork out of bracket placement elemetrix IDB provides 3D automation for rapid digital evaluation and adjustment of bracket placement. Choose elemetrix IDB for: > Precision bracket placement > Completely adjustable bracket and tooth position > Simulations of projected tooth movement > Control over tray segmented design > Access to all elemetrix diagnostic tools “elemetrix IDB affords me all the benefits of

Reduced training costs On-site Training fee is now $1,250 (elemetrix registration fee also required). Once training is completed, you’ll receive a $550 product credit following your first order!

indirect bonding without the encumbrance of old-fashioned lab techniques. The set-up is completely virtual and allows me to visualize the final tooth alignment based on how I’ve positioned the brackets, which I can then adjust accordingly. Bottom line, it’s an affordable solution that takes the guesswork out of bracket positioning.”

To learn more, call 888.672.6387 (U.S. and Canada) or 972.728.5902 or visit elemetrix.com.

elemetrix.com

Cory Costanzo, DDS, MSD Fresno, CA

Double Bonus Savings!

Design your own aligners cost-effectively

Choose elemetrix Aligner Design for cases requiring moderate tooth movement, including: > Aligner-only treatment > Aligner treatment in conjunction with braces, either to start or finish cases > Clear retainers at the end of treatment with braces — the scan can be performed before removal of braces, eliminating an office visit and becoming the start of a practice retention program > Order 3D printed models or export staged models for printing

“I use elemetrix Aligner Design for cases requiring moderate tooth movement, often in hybrid cases when I am treating with aligners in conjunction with braces at the beginning of treatment. Aligner Design is also very cost-

An even better value than ever! The elemetrix registration fee is just $500 (reduced from $1,750) and includes complimentary Aligner Design training. Even better, you’ll receive a $500 product credit once training has been completed!

efficient, while providing notably excellent precision.”

J. Peter Kierl, DDS, MS Edmond, OK

Not only is elemetrix Aligner Design fully adjustable — allowing customization of aligners as needed throughout each case — it consistently delivers outstanding precision and value.

CORPORATE PROFILE

New OrthoAccel CEO leads company through next stage of growth

rthoAccel® Technologies, Inc. launched noninvasive accelerated orthodontic treatment with the creation of AcceleDent®, the first and only vibratory treatment device clinically shown to speed up orthodontic treatment by as much as 50% and reduce patient discomfort. The prescription-only device is used in conjunction with braces or aligners, and its patented SoftPulse Technology® produces gentle pulsating forces that are shown to speed up bone remodeling during orthodontic treatment. Since introducing AcceleDent in the United States in 2012, OrthoAccel has grown to become the market leader in accelerated orthodontic treatment technology, has amassed a substantial portfolio of clinical cases that demonstrate the merits of its technology, and continues to introduce new innovations that enhance its device and the patient experience. On the heels of launching its thirdgeneration device AcceleDent® Optima™, OrthoAccel named David Josza, an orthodontic and dental industry senior executive with more than 25 years of experience, to assume the role of CEO and lead the company’s next phase of growth and innovation. Throughout his career, Josza has held executive level positions at dental implant and medical device companies where he was responsible for providing strategic oversight, executing new product launches, and developing creative sales initiatives that yielded business growth. After recently completing his first quarter with OrthoAccel, Josza is enthusiastic about the opportunity to further strengthen the company’s leadership position in accelerated orthodontics. “Throughout my career I’ve been fortunate to build long-term business success around new and disruptive technologies, and I’m excited to repeat that success at OrthoAccel,” said Josza. Josza’s first priority? Traveling across the U.S. and Canada with OrthoAccel’s regional territory managers and sales directors to meet orthodontists and their staff, listen to their feedback about OrthoAccel, and reaffirm the company’s commitment to the orthodontic industry. While he met several doctors in their practices, Josza also had the opportunity to meet with AcceleDent providers and 12 Orthodontic practice

David Josza, president and CEO of OrthoAccel® Technologies, Inc.

Manufactured by OrthoAccel®, AcceleDent®Optima™ is the company’s third-generation, vibratory orthodontic device that is clinically shown to speed up orthodontic treatment by as much as 50% and reduce patient discomfort

industry influencers at the regional orthodontic trade shows this fall. “The reoccurring theme I’m hearing is that AcceleDent Optima is the best-in-class accelerated treatment technology that orthodontists and patients have been waiting for,”

said Josza. “That’s just one piece of the puzzle though. Another piece represents the various clinical education and marketing programs needed to support orthodontists who want to offer this innovative technology to as many patients as possible. And of Volume 8 Number 6

Best-in-class innovation: AcceleDent Optima The priority for Josza and his team is introducing AcceleDent Optima to orthodontists and patients in North America and Europe. In addition to receiving FDA clearance, AcceleDent Optima has been cleared by Health Canada and received the CE Mark that makes it commercially available in Europe. Powered by the same SoftPulse Technology as its predecessors, AcceleDent Classic and AcceleDent Aura, AcceleDent Optima is a smaller and lighter device. Having listened to patient feedback, OrthoAccel designed many of the device’s new features with enhanced patient convenience in mind. Optima is waterproof, and its small charging case enables patients to wirelessly charge the activator, which has a 5-to-7 day battery life.

AcceleDent Optima is the first and only orthodontic device that directly connects patients and practices through usage monitoring, direct messaging, and virtual awards via the state-of-the-art AcceleDent App. The app, which can be downloaded via the Apple App Store and Google Play, uses Bluetooth® connectivity to enable Optima to sync with smartphones and tablets. HIPAA-compliant, the AcceleDent App was designed to increase practice efficiency for orthodontists and their clinical teams while also using unique virtual awards to encourage patient compliance in a positive, engaging way. To receive the benefits of accelerated treatment, it is important for patients to use the device daily for 20 minutes. The app allows patients to track their usage, set reminder notifications, and compare their treatment progress to other AcceleDent Optima patients across the world. Parents who have adolescents in orthodontic treatment with AcceleDent can also download the app to monitor their child’s usage. Patients who maintain optimal daily usage of AcceleDent will earn awards on the app’s Achievements Screen. This added

motivation is similar to badges that users earn on popular fitness tracking apps. Orthodontists, treatment coordinators, and other practice staff can log into a customizable web portal to view real-time usage data for each of their AcceleDent patients. Access to this data enables the clinical team to compliment patients who are excelling with compliance and to encourage low-compliant patients. Additionally, the availability of this data allows for more proactive case management, including more informed scheduling and an overall increase in practice efficiency. Orthodontists, such as Drs. Fred A. Garrett and Richard W. Boyd Jr. of Garrett and Boyd Orthodontics, have reported that integrating AcceleDent Optima and the new web portal into practice has been a seamless transition.

The HIPAA-compliant AcceleDent App allows patients to track their AcceleDent Optima usage, set reminder notifications, earn virtual awards, and compare their treatment progress to other AcceleDent patients across the world. Orthodontists, treatment coordinators, and other practice staff can log into a customizable web portal to view real-time usage data from the AcceleDent App Volume 8 Number 6

Orthodontic practice 13

CORPORATE PROFILE

course, the third piece is being responsive to the pulse of the industry so that we continue innovating to enhance the orthodontic treatment experience. This is how we’ll continue to grow and help orthodontists grow their practices as well.”

CORPORATE PROFILE

The OrthoAccel case gallery includes more than 40 cases from 24 orthodontists and shows the wide range of diagnostic conditions that doctors are clinically confident in treating with AcceleDent. View the case gallery at AcceleDent.com/orthodontist/case-studies

Since introducing AcceleDent in the United States in 2012, OrthoAccel has grown to become the market leader in accelerated orthodontic treatment technology, has amassed a substantial portfolio of clinical cases that demonstrate the merits of its technology, and continues to introduce new innovations that enhance its device and the patient experience. “AcceleDent Optima enhances motivation and buy-in from patients so much so that it translates into increased efficiency and profitability from the practice standpoint and increased satisfaction among patients,” said Boyd.

Evidence of superior clinical results with AcceleDent Since orthodontists have requested more clinical data supporting AcceleDent, OrthoAccel has coupled its clinical library with an online case gallery to share a broader depth of clinical results. The clinical library includes 14 peer-reviewed articles — including two randomized controlled trials — that demonstrate AcceleDent’s effectiveness in clinical applications. Building upon this research, the online case gallery now includes more than 40 cases from 24 orthodontists. These cases show the wide range of diagnostic conditions that doctors, using varying treatment approaches and mechanics, are clinically confident in treating with AcceleDent. 14 Orthodontic practice

Highly respected orthodontists and international lecturers provide details in these cases of how difficult or advanced movements become easier to achieve in the planned amount of time with AcceleDent’s SoftPulse Technology. The cases include wire sequencing protocols as well as examples of different tray change protocols for aligner cases. “We know that orthodontists place a high value on continuing education, especially as they are evaluating emerging technologies such as AcceleDent,” said Farley. “That’s why the OrthoAccel case gallery is so important. It gives orthodontists the opportunity to study real-world patient cases to determine best practices when incorporating AcceleDent into treatment.”

New value pricing brings AcceleDent a step closer to standard of care With the launch of AcceleDent Optima, OrthoAccel introduced new value pricing and the continuation of two marketing programs that have made it even more attractive for

orthodontists to offer AcceleDent as standard of care to all of their patients. Now in its third year, AcceleDent NOW is an exclusive program that allows orthodontists to offer patients a no-risk, 60-day trial of AcceleDent. To date, nearly 10,000 patients have been enrolled in the program, and on average, orthodontists report a 90% acceptance rate. OrthoAccel also offers orthodontists the opportunity to engage in an annual purchasing agreement to lock in preferred AcceleDent Optima pricing for a calendar year.

Predictable growth OrthoAccel has won numerous business, design, and industry awards, including being named to the Deloitte 500 list of North America’s fastest growing technology companies as well as being selected as the preferred accelerated orthodontic technique in the Journal of Clinical Orthodontists survey and in the annual Orthotown Townie Choice Awards. As Josza looks to double and maybe even triple the business, in part with entrance to the Latin America market, he leans on the strength of the brand and the ongoing desire of orthodontists to increase predictability of outcomes to elevate OrthoAccel to its next level of success. “We’re not yet done revolutionizing the orthodontic industry through innovation,” added Josza. “It’s our time. We have a new product, the demand is apparent, and the market opportunity is great.” For more information about OrthoAccel and AcceleDent, visit AcceleDent.com. OP This information was provided by OrthoAccel®.

Volume 8 Number 6

Beyond Acceleration: Driving Predictable Outcomes AcceleDent® Optima™ is an affordable, FDA-cleared accelerated orthodontic vibratory device. Clinically proven to accelerate tooth movement by up to 50%* & reduce pain and discomfort by up to 71%* Practices incorporating AcceleDent reported a significantly higher number (36% greater) of case starts than non-users Pulsating forces, like those AcceleDent produces, are clinically proven to stimulate cellular activity in orthodontic treatment, both in fixed appliances and aligners FIND OUT MORE ABOUT ACCELEDENT OPTIMA US: sales@orthoaccel.com International: sales.emea@orthoaccel.com

acceledent.com

*Based on randomized control trials

COMPANY SPOTLIGHT

SleepArchiTx™ — building your dental sleep practice A leadership team second to none

From left to right: Marco Navarro, DDS, MS; Jerald Simmons, MD, D.ABPN, D.ABSM, D.ABCN; Payam Ataii, DMD; Alice Limkakeng, SleepArchiTx CEO; Lou Shuman, DMD, CAGS; Rob Veis, DDS; Sal Rodas, SleepArchiTx Chief Product Officer

nowing the complexity of dental sleep medicine, SleepArchiTx™, a company that launched nationwide on September 1, is taking a very different approach. SleepArchiTx recognizes that treating sleep patients requires experience from many fields, so SleepArchiTx was founded by bringing together the most experienced leaders from all the relevant disciplines. Members of this Sleep Leadership Advisory Board include: • Orthodontics — Marco Navarro, DDS, MS, a practicing orthodontist, renowned for sleep appliance and TMJ therapy and early development intervention • Sleep Medicine — Jerald Simmons, MD, D.ABPN, D.ABSM, D.ABCN, a triple board-certified neurologist specializing in sleep disorders • Dental Sleep/Practice Growth — Lou Shuman, DMD, CAGS, as 16 Orthodontic practice

Managing Editor of Orthodontic Practice US and Dental Sleep Practice, has a personal passion for orthodontists to engage in sleep dentistry. Board Director of Foundation for Airway Health • General Dentistry — Payam Ataii, DMD, a practicing general dentist who has been treating sleep patients for over 10 years and serves as an Invisalign® Expert on the Faculty of Align Technology. Co-inventor of Aligner Sleep Appliance® (ASA) • Dental Sleep Appliances — Rob Veis, DDS, CEO of Space Maintainers Lab and the co-author of Principles of Appliance Therapy for Adults and Children, considered one of the definitive texts on the subject. Co-inventor of Aligner Sleep Appliance (ASA)

• Education — Max Schulze, MDT, CDT, an internationally prominent technical clinician who runs Straumann’s educational training for key opinion leaders nationwide

Harvard Business School comes to dentistry Alice Limkakeng, CEO of SleepArchiTx, comes from the healthcare executive and venture-investing world for over 20 years. Most recently, she was Chief Business Officer of Boston Heart Diagnostics and helped lead the cardiovascular services company from early stage to over $100 million of profitable revenue through organic growth and innovation. She attained her undergraduate degree at the Wharton School of Business and her masters at Harvard Business School (HBS) where she graduated with High Distinction as a Baker Scholar, a designation given only to Volume 8 Number 6

BUILDING YOUR SLEEP PRACTICE WITH A UNIQUE 360° TURNKEY SOLUTION.

Introducing the first FDA-cleared aligner sleep appliance — available exclusively through SleepArchiTx

• Comfortably fits over clear aligner at any stage of treatment.

• Easy adjustable screws for bilateral retrofitting.

• SleepArchiTx offers much more than just dental sleep appliances — learn about our 360° dental sleep service.

• Up to 8 mm of mandibular advancement.

Contact us to learn more about purchasing the ASA. Mention this ad (code FREEASA) to receive a free ASA with enrollment in SleepArchiTx full dental sleep program. Special offer expires December 31.

PHONE: 888.777.3198 EMAIL: reachus@sleeparchitx.com WEBSITE: www.sleeparchitx.com

Support

Expertise

Technology

Practice Growth

COMPANY SPOTLIGHT

The ASA is projected to be a game-changer for clinicians who are increasingly seeing patients who suffer from malocclusion and sleep disorders concurrently.

the top 5% of each graduating class. Limkakeng believes dental sleep medicine is a perfect opportunity to leverage her medical healthcare experience to address a very needy patient population. As Executive Director of the Foundation for Airway Health, Sal Rodas, Chief Product Officer of SleepArchiTx is committed to airway health as a life mission. Most recently, he led a sleep diagnostics company as Chief Operations Officer.

Exclusive Aligner Sleep Appliance® (ASA) Within its broad selection of dental sleep appliances, SleepArchiTx is proud to be the exclusive provider of the only appliance in the market that can be used in conjunction with clear aligners, the Aligner Sleep Appliance® (ASA). The ASA, an FDA-cleared, patented appliance, enables practitioners to treat patients who are diagnosed with sleep disorders with appliance therapy in combination with aligner therapy. The ASA is projected to be a game-changer for clinicians who are increasingly seeing patients who suffer from malocclusion and sleep disorders concurrently.

Turnkey 360° Solution

Exclusive Aligner Sleep Appliance®

Building your sleep practice with a unique 360° turnkey solution. Support

Expertise

• Dedicated Support Team • Communication with Patient’s Physicians

• Comprehensive Education • Sleep Physician Expertise • Diagnostics and Treatment Planning

Growth

Technology

• Turnkey Billing Service • Marketing Support

• Workflow Guiding Web Portal • Portfolio of Innovative Appliances

SleepArchiTx has crafted a comprehensive offering that enables practitioners to initiate or build their sleep practice. Instead of point solutions that require the dental office to coordinate with different service providers, SleepArchiTx has created an all-in-one solution, including: • Education — for both doctor and staff • Home Sleep Testing — full coordination with the patient. No investment in equipment • Turnkey Medical Billing — experts working full time to get practitioners paid for their services • Portfolio of FDA-cleared Sleep Appliances — because one appliance does not fit all patients • Treatment Planning — multidisciplinary expertise to help practitioners with each case • Ongoing Support — critical focus of the company. Dedicated representatives providing ongoing support, even chairside with the patient. For more information, call 888-7773198, email reachus@sleeparchitx.com, or visit www.sleeparchitx.com. OP This information was provided by SleepArchiTx™.

18 Orthodontic practice

Volume 8 Number 6

BEST CLEAR ALIGNER TRAY CLEANER IN THE WORLD! WHY PRODENTCLEAN? Dr. Todd Morgan, DMD invented Prodentclean when he became concerned watching his staff use gloves and masks to handle the cleaning of patient's dental appliances.   _  _ 

Prodentclean is laboratory tested and FDA Compliant Uses breakthrough cleaning technology; safe, non-toxic, alcohol-free Cleans all dental and orthodontic materials with no staining in minutes Concentrated formula lasts twice as long, a great value

"I have been a dental assistant for 44 years. In that time I have used numerous products. I was amazed how clean it got my retainers. They looked like new! I was so excited I gave some to my daughter to try for her invisalign retainer. She loves it too. We also use it in the office to clean patient's removable appliances while they are getting their teeth cleaned. Just wanted to let you know how pleased I am with Prodentclean. In the 44 years of my career I have never written a letter to a manufacturer of a product." SINCERELY, SHARON VANLUCHENE, R.D.A.

Dr. Todd Morgan invites you to try a 1 Gallon bottle for your office for only $25 + shipping. (30% savings off MSRP). Take Advantage of this special offer by calling us at 760-473-8628 and mention this AD or Go to www.prodentclean.com and use code AAD20l7 at checkout.

W W W.PRODENTCLEAN.COM

CLINICAL INSIGHT

In my practice: aligner therapy with added high-frequency vibration Dr. David R. Boschken discusses a combination of therapies that can lead to more efficient orthodontic treatment

uring my 20-year orthodontic career, it has been my experience that tooth movement can lead to discomfort and pain. It has been reported that orthodontic pain has a prevalence of 72%–100%, perceived as feelings of soreness, pressure, or tension in the affected teeth.1 Even though our mechanics over the past decade have evolved to using more light wires and slow continuous movements, as opposed to steel wires and punctuated movements, patients still complain of discomfort caused by the inflammatory response created when teeth move within bone. In recent years, a majority of my patients have been treated with clear aligner therapy with Invisalign®. Seventy-five percent of my patients, ages 7 years old to 70 years old, are involved in aligner therapy, and within the next 12 to 18 months, that number should rise to 90 percent of patients. With the opportunity to treat these patients more quickly, I felt the necessity to implement a way to make tooth movement less painful as well.

About 6 years ago, I began using the manual osteoperforations (MOPs) technique (Propel), a procedure I use to allow a more targeted planning of tooth movements, as well as speed treatment. MOPs is a process of creating small holes in the bone around the teeth to accelerate tooth movement. I found that this treatment translated to greater efficiency in moving teeth in less time. A few years later, Propel developed an option for orthodontists that patients could use at home — VPro5™, a high-frequency vibration (HFV) aligner seater. In my practice, this device was offered to patients either as an alternative or in addition to MOPs. The device, which was used for 5 minutes each night as per instructions for use was designed to facilitate better aligner seating. When the aligners fit more snugly to the teeth, the result was more efficient tooth movement. Over time, Invisalign developed a new material — SmartTrack — that improved

the process of tooth movement and represented a massive advancement in the technology of plastic and aligner therapy. According to Align Technology, SmartTrack material is a “highly elastic material that delivers gentle, more constant force to improve control of tooth movements.”2,3 The material “conforms more precisely to tooth morphology, attachments, and interproximal spaces, which delivers improved control.”3 VPro5 allowed those aligners to fit even better. Over time, my patients began giving me feedback about a reduction in discomfort and pain in conjunction with VPro5 use. Anecdotally speaking, hundreds of my patients who have used the VPro5 comment that they either feel less discomfort or don’t feel pain when switching aligners every 5 to 7 days.4 I believe that HFV with VPro5 helped us offer that protocol to a greater range of patients with a wide range of clinical issues and compliance levels.

Figures 1 and 2: Patient 1 — Peter. Diagnosis: Class I crowding. Treatment plan: 32 upper and lower aligners, 5-day exchange with HFV each day. Expected treatment time: 12-14 months. Actual treatment time: 5 months Dr. David R. Boschken, DMD, graduated from the University of California, Berkeley, with a double major in Biology and Anthropology. He received his DMD from the University of Pennsylvania Dental School. He completed a Guy’s and St. Thomas Hospital Residency in London, England, and an Orthodontic certification from the University of Pennsylvania Dental School. Dr. Boschken is recognized as an Elite Invisalign® Top 1% provider and has been on Align Technology Speaker’s Bureau for 17 years training Primary Care Dentists (PCD) and Orthodontists throughout North and South America, Europe, and Asia. He owns two orthodontic offices, Los Altos and San Jose, California, offering comprehensive orthodontic treatment to children and adults. Disclosure: Dr. Boschken has served on the Clinical Advisory Board (CAB) and has been a KOL member for Propel Orthodontics since the company’s inception.

20 Orthodontic practice

Volume 8 Number 6

One of my patients, Peter, is an example of how Invisalign and VPro5 can work together. At 26 years and 10 months old, Peter had Class I crowding (Figure 1) that we decided to treat with aligners and HFV. Treatment was expected to take 12-14 months. The treatment entailed 32 upper and lower aligners and HFV each day. Aligners were to be changed every 5 days. At the end of 5 months (Figure 2), no further refinements were needed, and treatment was completed 7 months ahead of schedule.

Patient 2 Another patient, illustrated here, is Ryan. This 36 years and 9 months old patient had Class I crowding and a crossbite (Figure 3), which we had decided to treat with 33 upper and lower aligners to be changed every 5 days and HFV each day. Our expected treatment time was 14.5 months. This compliant patient actually completed treatment in four appointments over the course of 6.5 months (Figure 4). This patient saved approximately four appointment visits and 8 months of treatment time, and needed no refinements.

CLINICAL INSIGHT

Patient 1

J U S T W H AT T H E D O C TO R O R D ER E D

FLEX

UNLIMITED TM

W O R RY- F R E E F O R 5 FULL YEARS 2 2 2 02 2020 22 200 20 0 0 20

Figures 3 and 4: Patient 2 â&#x20AC;&#x201D; Ryan. Diagnosis: Class I crowding and a crossbite. Treatment plan: 33 upper and lower aligners, 5-day exchange with HFV for each day. Expected treatment time: 14.5 months. Actual treatment time: 6.5 months Volume 8 Number 6

C L E A RCO R R E C T.CO M /FL E X

Orthodontic practice 21

CLINICAL INSIGHT

Figures 5 and 6: Patient 3 — Hugh. Diagnosis: Class I, spacing issues, and edge-to-edge occlusion. Treatment plan: 17 upper and lower aligners, 5-day exchange with HFV each day. Expected treatment time: 8.5 months. Actual treatment time: 3.5 months

Patient 3 The combination aligner therapy and HFV have continued to provide my patients consistently positive results, even with a range of orthodontic issues. The images speak for themselves. Hugh, 30 years and 10 months old was diagnosed with Class I, spacing issues, and edge-to-edge occlusion (Figure 5). We had expected treatment duration to last 8.5 months, to finish the course of 17 upper and lower aligners and VPro5 each day. After using the aligners and HFV as directed, Hugh actually only needed three appointments and completed treatment in 3.5 months (Figure 6). The patient finished treatment approximately 5 months ahead of schedule with no refinements necessary. HFV along with MOPs or by itself, in my opinion, helps patients to tolerate the discomfort that goes along with tooth movement. I have treated patients who receive MOPs, switch aligners every 3 days along with the use of VPro5, with high levels of predictability. These patients can complete the course of 24 aligners and be ready for refinements, if needed, in 3-4 months. We always try our best to ensure that the patients understand HFV technology and how we prescribe it within their orthodontic treatment plan. My Director of Operations, Nicole Pruitt, and I each present accelerated orthodontics at the initial exam. We describe our opinion of the potential clinical benefits of VPro5 as an aligner seater to better capture the clinical movements dialed into each aligner. While time is often shaved off with 5-day aligner changes, we do not emphasize

the speed aspect. We want all patients to understand our belief that the VPro5 adds value with a reduction in tracking issues, pain reduction (in our opinion), and better expression of tooth movement. Pruitt adds, “We tell patients that we offer accelerated orthodontics to complement their Invisalign experience. We tell them that the aligner seater (VPro5) will help seat the aligners to give them a better fit, which can give the doctor more predictability in his treatment. The upside is that, if all goes well, it shortens the patient’s treatment time, and we find that it also may help reduce pain in some cases. We find that most of our patients want to be efficient with their treatment, and this gives us another tool to try to make it happen. Happier patients that finish treatment quickly and efficiently create more referrals in our practice.” After we speak with the patients, about 50% of them accept accelerated orthodontics. Non-accepting patients still track through aligners every 7-10 days for most complicated cases. Accepting patients typically track through aligners at 5 day intervals. Our patients are very compliant, since we see them every 12-14 weeks. Often 25 aligner cases are ready for the refinement stage in less than 5 months with only two appointments. Health insurer Humana® noted that more than 4 million Americans already wear braces.4 Millions more are looking for an orthodontist to suit their needs. In my practice, in the epicenter of Silicon Valley, new patients not only want a beautiful smile, but also want it “yesterday,” and, of course, they

Figure 7: VPro5™, a high-frequency vibration aligner seater

would be even happier if they didn’t experience pain in the process. In 1999, when I started using Invisalign, I could not have attempted to ask patients to switch aligners every 7 days, let alone 5 days. At that time, I was recommending 17 to 18 days. Besides helping patients to achieve beautiful smiles, I also want them to have a positive experience in my office, and offering them an opportunity to move their teeth without discomfort is a major advantage. OP REFERENCES 1. Long H, Wang Y, Jian F, Liao L-N, Yang X, Lai W-L. Current advances in orthodontic pain. Int J Oral Sci. 2016;8(2):67-75. 2. invisalign® Science in Every Smile [doctor brochure]. INVISALIGN® INTRODUCES SMARTTRACK. © 2013 Align Technology, Inc. All rights reserved. https://www.invisalign. com.au/doctor/doc/brochures/SmartTrack_brochure.pdf. Accessed August 6, 2017. 3. Align Technology Introduces One-Week Aligner Wear for Invisalign® Teen and Full Products [press release]. San Jose, California: Align Technology; October 11, 2016. http://investor.aligntech.com/releasedetail.cfm?ReleaseID =992964. Accessed August 13, 2017. 4. Shipley T, Brigham G, Sparaga J. Pain Reduction Observed with Orthodontic Forces and Vibration. [Data on file with manufacturer, Propel Orthodontics, Ossining, New York] 2017. 5. Humana. Dental braces: facts and benefits [patient brochure]. https://www.humana.com/learning-center/ health-and-wellbeing/healthy-living/dental-braces. Accessed August 13, 2017.

The Excellerator™ series driver has been cleared by the U.S. Food and Drug Administration (FDA) with an indication for manually drilling holes in tissue and bone for orthodontic and dental operative procedures. Propel Orthodontics markets the VPro5™ as a high-frequency vibration aligner seater. This article may describe additional uses of the Excellerator™ series driver or the VPro5™ that have not been evaluated by FDA. Propel Orthodontics provided financial support to the author.

22 Orthodontic practice

Volume 8 Number 6

The Most Advanced Progression In Passive Self-Ligation Efficiency Design elements that benefit today’s practicing Orthodontist most:

CONVENIENCE THROUGH

M I DAT L A N T I C O R T H O.C O M 800-255-3525

Reduced Slot Dimension (.020X.026) for increased control over torques and rotations through all working and finishing phases of treatment

No Drop Pins Needed

as FiT.20 Hooks are integral to the bracket structure itself

FiT.20 Has A ‘Reciprocal’ Clip Mechanism reducing the amount of force and stress upon the tooth itself when opening

FiT.20 Clip Opens Occlussally

reducing premature clip opening due to directional chewing forces

True Twin Tie Wing Undercuts

easily accommodates Ties and Chain

Compatible With A Broader Array Of Wires

from square sizes to FiT.20 extra broad archforms for full treatment expression

Mechanical Locking Base for consistently reliable bonds

The FiT.20 System is a solution long overdue for both .018 and .022 users alike as it compensates for variable programming and tolerances so you don’t have to. It is the biggest leap forward in 3D Control and Full Expression to date.

Dr. Robert “Tito” Norris BOARD CERTIFIED ORTHODONTIST AND FIT.20 DESIGNER

ORTHODONTIC TIPS

Low-cost assessment of UV sensitive adhesive Drs. Roberto Soares da Silva Júnior, Lídia Parsekian Martins, Larry W. White, and Renato Parsekian Martins offer advice for removing residual adhesives on debonding day

ailure to completely remove adhesive remnants after bracket debonding can lead to pigmentation due to aging1,2 and produce retentive areas that can favor the accumulation of dental plaque and caries.2 This procedure is one of the hardest jobs in orthodontics because commonly used orthodontic adhesives mimic sound enamel pretty well, making it difficult to clearly tell them apart. The inability of clearly seeing the adhesive can prevent the orthodontist from completely removing the adhesive without damaging enamel. Methods to see adhesive remnants3-6 could assist the orthodontist in the removal process and diminish the probability of damage to the enamel. The addition of fluorescent chemicals to adhesives, such as done in Opal Bond* and Opal Seal*, is an evincing method that improves residual adhesive removal significantly without causing additional damage to the enamel.6 Fluorescence is the ability to emit light when exposed to ultraviolet (UV) radiation — i.e., the material absorbs the radiation at a shorter wavelength, invisible to the naked eye, and reflects visible light with a longer wavelength. UV fluorescent material can be detected by the naked eye by UV light, through a UV light lantern (Figure 1) or by a special lens that can be attached to the Valo LED**, with the downside that both methods require the purchase of products not normally used by orthodontists. However, the orthodontist can detect these types of adhesives in an easy and quick manner with devices that already exist in the office.

Roberto Soares da Silva Júnior is a graduate student, Program of Orthodontics, Universidade Estadual Paulista, Araraquara, São Paulo, Brazil. Lídia Parsekian Martins is chairman and professor at the Program of Orthodontics, Universidade Estadual Paulista, Araraquara, São Paulo, Brazil. Larry W. White is a professor in the Departament of Orthodontics, Baylor Dental College, Dallas, Texas. Renato Parsekian Martins is in private practice and is an adjunct professor in the Program of Orthodontics, Universidade Estadual Paulista, Araraquara, São Paulo, Brazil.

24 Orthodontic practice

Figure 1: UV fluorescent material can be detected by the naked eye by UV light, through a UV light lantern

Figure 2: When these UV fluorescent adhesives are placed under any blue color curing light, they can be clearly viewed under an orange light shield or with the use of orange curing light protective glasses

When these UV fluorescent adhesives are placed under any blue color curing light, they can be clearly viewed under an orange light shield or with the use of orange curing light protective glasses (Figure 2). This can be very helpful when removing the residual adhesives without adding extra costs to the orthodontic office. OP

REFERENCES 1. Eliades T, Gioka C, Heim M, Eliades G, Makou M. Color Stability of Orthodontic Adhesive Resins. Angle Orthod. 2004;74(3):391-393. 2. Karamouzos A, Athanasiou AE, Papadopoulos MA, Kolokithas G. Tooth-color assessment after orthodontic treatment:

A prospective clinical trial. Am J Orthod Dentofacial Orthop. 2010;138(5):537.e 1-8 discussion 537-539. 3. Pretty IA, Hall AF, Smith PW, Edgar WM, Higham SM. The intra- and inter-examiner reliability of quantitative light-induced fluorescence (QLF) analyses. Br Dent J. 2002;193(2):105-109. 4. Rachala MR, Kishore MS, Vamisilatha K. Staining adhesive remnants for easy removal. J Clin Orthod. 2013;47(11):672. 5. Abdallah MN, Light N, Amin WM, Retrouvey JM, Cerruti M, Tamimi F. Development of a composite resin disclosing agent based on the understanding of tooth staining mechanisms. J Dent. 2014;42(6):697-708. 6. Ribeiro AA, Almeida LF, Martins LP, Martins RP. Assessing adhesive remnant removal and enamel damage with the aid of ultraviolet light: an in vitro study. Am J Orthod Dentofacial Orthop. 2017;151(2):292-296.

*Opal Orthodontics, South Jordan, Utah **Ultradent, South Jordan, Utah

Volume 8 Number 6

20 WATTS SUPER-PULSED

POWER CHARRING

TISSUE TAG

TISSUE PULLING

Traditional Diode Laser

Gemini Diode Laser

1 Watt Average Power, 400 micron fiber, Robotically Controlled Speed

CONTINUING EDUCATION

Combining temporary anchorage devices with accelerated orthodontics to treat transposition Dr. David Alpan discusses alternatives to extractions, implants, and orthognathic surgery Abstract Treating transposed teeth is very similar to impacted teeth or ectopic teeth. A detailed biomechanical plan is required to direct orthodontic forces to create the most ideal outcome, while minimizing unwanted effects. Utilizing temporary skeletal anchorage can allow forces to be unilaterally directed to improve orthodontic efficiency, and eliminating reciprocal forces that create unwanted movements of adjacent teeth. Incorporating accelerated orthodontics with micro-osteoperforations (MOPs) or pulsatile forces can facilitate difficult tooth movements in a reasonable treatment time, while increasing predictability and reducing negative sequela. Combining technologies allows orthodontists choices when offering patients an alternative to extractions, implants, and orthognathic surgery.

Educational aims and objectives

The purpose of this article to discuss how combining technologies allows orthodontists choices when offering patients an alternative to extractions, implants, and orthognathic surgery.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 36 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify the characteristics of transposition. •

Identify some transposed teeth treatment options.

•

Identify some benefits of TADs use.

•

Realize some new technologies to aid in the timely completion of orthodontic treatment.

Introduction Tooth transposition is defined as a reversal of the position with adjacent teeth in the same quadrant, particularly at the roots.4 Transposition may be incomplete when the crowns overlap, but the root apices are in their relative normal position, or complete when both the crowns and roots are parallel in their transposed malposition.1,2 Transposition is a form of ectopic eruption where one permanent tooth has interchanged its location in the dental arch, and it is not gender-specific.3 It is considered a rare dental anomaly, yet transposition has never been reported in both arches simultaneously nor in the deciduous dentition.4 The maxillary cuspid transposition is the most common, but it can happen in the mandibular arch as well.4

Figure 1: AY ceph initial skeletal Class III before treatment

Figure 2: AY ceph after Invisalign® with TADs and AcceleDent® and TADs

Transposed teeth treatment options include alignment in their transposed position, extraction of transposed teeth, extraction and replacement with implant(s), and orthodontic alignment to their normal position in the arch.1 Incorporating accelerated orthodontics (AO) with temporary anchorage devices (TADs) can significantly improve treatment outcomes when treating incomplete or complete transposed teeth into their

normal position. Ideal treatment for transposition would be prevention with early treatment to help guide the erupting teeth into the correct position in the arch. Early adolescent expansion and early extraction of deciduous teeth have shown to prevent transposition of teeth.5 People with transposed teeth do have some common traits such as congenital absence of teeth, peg-shaped lateral incisors, and severe arch-length discrepancies, which is the main etiology.6 Although the principle of orthodontic anchorage has been understood since the 17th century,7 it was not clearly defined until 1923 when Dr. Louis Ottofy8 defined it as “the base against which orthodontic force or reaction of orthodontic force is applied.” Most recently, Dr. John Daskalogiannakis9 defined anchorage as “resistance to unwanted tooth movement.” Fixed anchorage has played a

David Alpan, DDS, received his Doctor of Dental Surgery degree from Arthur Dugoni School of Dentistry (UOP) and was licensed in California and Nevada in 1996. He earned an Orthodontic Specialty Certificate in 1998 and was awarded a Masters in Science in Dentistry (MSD) for his research on a TMJ project. Dr. Alpan founded his private practices, Alpan Orthodontics, in Los Angeles, Beverly Hills, and Las Vegas in 1999. In 2015, Dr. Alpan transitioned out of the Las Vegas practice and, in 2016, added the Century City location, while merging his Beverly Hills office. He played an integral role for Align Technology Clinical Education Department from 2002-2008 and participated as a consultant and a speaker for 6 years. He was a member of the Ormco Insiders group for 10 years. He is one of the founding members of the Incognito Circle of Excellence and a part of 3M Unitek’s research panel. Disclosure: Dr. Alpan is a key opinion leader for Propel and AcceleDent®.

26 Orthodontic practice

Volume 8 Number 6

direction, and the equal and opposite force is transferred to the bone that is fixed and has a large surface area to absorb the reactive force.3 TADs provide excellent anchorage to accomplish treatment goals otherwise needing orthognathic surgery, extractions, or implants. AO provides bone modulation affecting the biology of tooth movement on a cellular level. Incorporating AO with the use of bone modulation technologies, such as vibration or micro-osteoperforation, has shown reduction in treatment time and increased treatment predictability.17,18,23,24,25 AO’s tangible benefits include decreased root resorption, decalcification, white spots, caries, gingivitis,

periodontitis, loss of motivation, occlusal wear, and treatment time. These benefits are desired by the patients and practitioners alike.22 Early completion of treatment reduces chances of unwanted sequela and creates a more pleasant experience for the patient and practitioner.17 AO increases predictability and allows practitioners to treat more severe malocclusions in reasonable treatment times. Incorporating AO into practice requires alternative treatment planning, appointment intervals, and new practice management systems.19,20

Research and clinical outcomes With the demands and expectations of the patients, orthodontists are motivated

Combining PSL, TADs, and AO has allowed for more complicated treatment outcomes that were not even an option in the past.

Figure 3: Initial pano with large edentulous spaces

Figure 4: Final pano posttreatment with extractions PSL, TADs, and MOPs

Figure 5: Before treatment skeletal and dental Class III with crowding and anterior crossbites

Figure 6: After treatment with PSL TADs in buccal shelf with NiTi springs — nonsurgical Class III correction

Volume 8 Number 6

Orthodontic practice 27

CONTINUING EDUCATION

significant role as an adjunct to orthodontic treatment in the last 2 decades. Mini plates and mini screws have been utilized in oral and maxillofacial surgery procedures for short- and long-term stability of bone fractures as well as orthognathic surgery for nearly 4 decades. Incorporating skeletal anchorage utilizing TADs, mini-screws, or mini plates as Drs. Jason B. Cope10 and John W. Graham11 had introduced over a decade ago, has impacted treatment outcomes, reducing the need for orthognathic surgery (Figures 1 and 2). Orthodontic biomechanics is all about juggling Newton’s third law of motion, defined as every action having an equal and opposite reaction. When applying forces to teeth, there is always a consideration that other teeth will move in an unwanted position. The introduction of TADs and mini-plates has given orthodontists the ability to reduce or eliminate the opposite reactive force.3 Utilizing skeletal anchorage allows orthodontists to move teeth in one

CONTINUING EDUCATION

Figure 7: Initial pretreatment complete impaction and transposition of mandibular right cuspid

to reduce treatment time with AO and incorporate TADs to prevent more invasive procedures. Patients present with financial or emotional limitations around surgery and the possibility of, for example, retracting the mandibular arch to correct a skeletal Class III, which without surgery was unimaginable prior to TADs.3 (Figures 5 and 6) Given the recent advances in biology, materials, and clinical treatment, this orthodontic tooth movement is not only a possibility, but also a reality.3 Cliniciansâ&#x20AC;&#x2122; daily dilemmas are a wide variety of malocclusions, ethnicities, sizes of teeth, variable bone biology, and various levels of patient compliance. Research demonstrates that accelerating the biology of tooth movement is a modality to add to our armamentarium.18,29,30,31,32 The practice of clinical orthodontics is managing the science of biomechanics, which inherently is harnessing or manipulating the biology of tooth movement.13,19 Treating transposition of teeth is a challenge diagnostically and therapeutically.12 Severe orthodontic malocclusions, such as complete transposition of teeth, are a difficult case type to demonstrate the utilization of TADs with AO to accomplish a normal tooth position in the arch (Figures 7-22). Case 1 The teenage female age 13 years 8 months (Figures 7-22) presented with a mandibular right cuspid in complete transposition with the mandibular right lateral incisor, which is a rare anomaly and not commonly seen.4 A similar situation presented several years prior, except on the left side, but I did not attempt to correct the transposition, and subsequently, there were heavy functional forces applied to the lateral incisor, which was not adequately structured morphologically to withstand those occlusal forces. 28 Orthodontic practice

Figure 8: Initial pano showing complete transposition of mandibular right cuspid

Figure 9: PA X-ray of impacted transposed cuspid bonded with a gold chain subgingival with primary closure

Figure 10: First TAD for skeletal anchorage; second TAD creating a pulley effect directing the force apical

Figure 11: Pulling the impacted transposed cuspid distal

Figure 13: PA X-ray cuspid crown in place, root apex still transposed

Figure 12: After crown in position removed one TAD

Figure 14: Image of cuspid crown in cuspid position in arch, added a bracket with a power arm to help translate root apex

Figure 15: Progress using TAD with NiTi spring to power arm; started MOPs

Figure 16: Progress bi-dimensional forces; started vertical elastics and MOPs Volume 8 Number 6

spring with a twisted ligature wire slung as a pulley effect around the second TAD to direct the forces apically. Once the crown was intruded and tipped facially, I then distalized the cuspid with the first TAD with a NiTi spring; subsequently, the second TAD was removed as the crown was distalized into the arch. The patient utilized vertical elastics to extrude the mandibular right quadrant, as a remedy for the intrusion effect of all the adjacent teeth due to the extrusion of the mandibular right cuspid post distalization. Vertical, midline, Class II, and Class III elastics were prescribed to counteract all the forces required to achieve this result. The first TAD was used to help

Figure 17: Buccal TAD with NiTi spring for uprighting; lingual power chain keeping crown in lingual position

Figure 18: Crown and root in place 2 mm of attachment loss; removed TADs and springs; continue interarch elastics

Figure 19: Final images post TAD and MOPs procedure

Case 2 The young man (Figures 23-28) started as a Phase I treatment, and by his Phase II, he had developed an incomplete transposition of the maxillary left permanent cuspid in between the maxillary left central and lateral incisors. Phase I treatment consisted of maxillary 2 x 4 and mandibular lingual arch, no expanders. Since I had consolidated maxillary spaces from lateral to lateral in the Phase I, we were hoping the cuspid would follow the path of least resistance, but it did not and became impacted as an incomplete transposition. During his Phase II treatment, we intruded, distalized, and then extruded the maxillary left cuspid into the normal position within the arch.

Figure 20: Initial and final occlusal images]

Figure 21: Final pano with cuspid in normal position; mild root resorption of lateral incisor and cuspid Volume 8 Number 6

distalize the root with a TAD and a NiTi spring attached to a power arm on the bracket. Several bracket repositions were required to complete the uprighting and positioning of the cuspid back into the arch. Unfortunately, the patient did have some minor root resorption and recession requiring connective tissue grafting for the mandibular right cuspid.

Figure 22: Performing MOPs with Propel

Orthodontic practice 29

CONTINUING EDUCATION

Figures 7-22 demonstrate an attempt to complete treatment with an ideal occlusal pattern with a full correction of an impacted transposed canine into its natural position in the arch. This treatment option would not have been possible if the impacted, transposed tooth was fully erupted. The root proximity and thin interdental bone limits this treatment option to only impacted transposed teeth that are not fully developed. The intrusion mechanics were performed subgingival similar to an impacted canine with primary closure post expose and bond. The initial intrusion mechanics presented in Figure 10 are applying one TAD with a NiTi closing

CONTINUING EDUCATION

Figure 23: Initial pano pre-phase I — cuspid position looks normal, but central and lateral incisor positions look abnormal

Figure 24: End of Phase I maxillary left cuspid erupting between the roots of the maxillary left central and lateral incisor. Notice the normal eruption of all the other teeth

MOPs technique is similar to TAD placement In 1988 to 2010, multiple researchers found that the application of NSAIDs decreased the rate of tooth movement significantly, and cytokines played an important role in activating the bone-remodeling machinery.13,19,25 Removing all NSAIDs in combination with accelerating the biology of tooth movement via MOPs or with vibration is paramount. Research shows if inhibiting the expression of certain cytokines decreases the rate of tooth movement,7 then if we perform an iatrogenic trauma to stimulate the expression of inflammatory cytokines through small micro-osteoperforations (MOPs) (Figure 22) of the cortical bone, research shows MOPs increase the rate of bone remodeling and ultimately increase the rate of tooth movement.13 Previous studies have demonstrated that bone injury causes cytokine release and leads to an accelerated bone turnover and a decrease in regional bone density.14,15,16,17,20 The idea of traumatizing the bone is not novel and is now correlated with the increase in the inflammatory cytokines that can increase bone remodeling.18 I routinely perform this procedure as if I was placing a TAD or changing an archwire. The MOPs technique is outlined and explained in the April 2016 article in Orthodontic Practice US.28 Some patients require the use of a local anesthetic via syringe, but in most cases, profound topical is sufficient. Mild discomfort is experienced by the patient postoperatively, usually for 24-48 hours, and is moderated with Tylenol® only, no NSAIDs.18,29,31,32 MOPs can be localized to two teeth whereas pulsatile forces affect all the teeth. When using MOPs, there is no issue of patient compliance as there is with vibration. MOPs are performed every 12-16 weeks depending on the patient’s treatment response. The depth of perforation is usually 3 mm-5 mm. Patients’ soft 30 Orthodontic practice

Figure 25: Start of Phase II maxillary cuspid has erupted into the root of the maxillary left central

Figure 26: Initial Phase II ceph — cuspid is in a labial position in relation to the adjacent roots

Figure 27: Final pano with cuspid in normal position in the arch, with some resorption of the maxillary left central and lateral roots

Figure 28: Post Phase II maxillary left cuspid is no longer in a facial position but in the ideal position in the arch

tissue can vary in thickness from 1 mm-2.5 mm in thickness. So, the tip will go into the cortical plate and microfracture the cortical bone about 1.5 mm-3 mm in depth, also referred to as alveolocentesis. TADs can be located transosteally, subperiosteally, or endosteally; and they can be fixed to bone either mechanically (cortically stabilized) or biochemically (osseointegrated).3 I prefer the Vector TAD system and will use a 6 mm or 8 mm TAD based on the anatomy and position desired. The procedure is very similar to MOPs except the TAD is screwed in once and left in place. There is a huge concern for root proximity, thus PA X-rays are taken prior to placement and after for verification.3

Pulsatile forces or vibration technique Since OrthoAccel® publicly launched AcceleDent® Aura in early 2012 and now

Optima™ in 2017, clinicians and patients are experiencing reduction in treatment time,34,35,36 increased treatment predictability, and a pleasant analgesic effect.37 Micropulse vibration, 20 min/day at a frequency of 30 Hz at a force of 0.25N (25g) in combination with orthodontic treatment is demonstrating reduced treatment time or acceleration of tooth movement. The clinical research states a 50% increase in the rate of tooth movement,18,34,35,36 but I have found this does not correlate to the same reduction in overall treatment time. Acceleration is more efficient during leveling and aligning then sagital corrections.35 With AO, I am observing an average of 35% reduction in overall treatment time dependent on the appliance choice, mechanics utilized, or compliance with acceleration devices. Pulsatile forces offer an analgesic effect,37 which MOPs do not. To be efficient and make Volume 8 Number 6

Practice management considerations Informed consents for treating transposed teeth into their ideal position in the arch are highly recommended. The prognosis can be questionable based on the treatment plan and proximity of teeth to adjacent structures. Use of CBCT 3D digital records is strongly recommended as viewing the path of eruption will help with proper treatment planning with the ideal mechanics needed.12 Since there are risks involved such as root resorption, root damage, mobility, and loss of periodontal support, the patient must be informed in comparison to the benefits. Informed consents are signed by all patients who are undergoing AO, and separate informed consents for all patients being treated with TADs. My initial application of MOPs is for difficult or stubborn teeth — e.g., impacted or transposed teeth, or laterals treated with aligners. Treatment acceptance with MOPs is higher with existing patients who need to get completed just based on their cost. We recommend AO to all extended treatments as we begin to see they will not meet their estimated treatment time. Wanting to finish treatment as soon as possible, patients toward the end of treatment find AcceleDent to be cost-prohibitive and are more receptive to MOPs. Fee considerations play a role in the doctors’ and patients’ decisions. Recently, patients have incorporated the AO into the total treatment fee, and I have found a higher case acceptance. I have also chosen a no-fee MOPs treatment, as there is a benefit to completing treatment early. (Extended treatment costs are greater than the cost of the Propel tip.) Patients are able to reliably accelerate their treatment with a cost-effective, minimally invasive procedure such as MOPs32 or with low-frequency vibration. Some AO alternatives such as Wilckodontics® or Piezosurgery® are not cost-effective and require surgery at a price range of $5,000$10,000.There is a potential for negative sequela and extended recovery time with these surgical procedures. AcceleDent may be more costly, but vibration requires no doctor chair time and is less clinical work. Volume 8 Number 6

If the patient is not compliant, vibration has little to no clinical effect. Orthodontic fee agreements are either paid in full or spread over time. The majority of orthodontists require the full fee due by treatment finish. Patients appreciate the convenience of paying the treatment over time, as it lowers their monthly fee. Since AO has changed the original estimated treatment time, we have had to update existing contracts. This poses a new challenge with our new starts, since we don’t have as much time to amortize their fee. For some patients, we have extended the payment arrangements past the finish date, but most patients are asked to complete payment by the end of their treatment. We have added this language to our contract to assist us with this issue: “If the active phase of treatment is completed before the agreed estimated time, the full fee is due and payable at that time.” The commitment needs to be agreed upon before AO treatment is initiated.

Conclusion TADs with AO can facilitate treatment outcomes only seen with orthognathic surgery or extractions. Preventing transposition of teeth with early detection and early expansion treatment monitored with CBCT scans can help to prevent teeth from becoming transposed.5 Treating transposition of teeth can now be successfully managed with the use of CBCT imaging and progressive biomechanics utilizing TADs and AO. Incorporating AO with TADs can significantly improve treatment outcomes when treating incomplete or complete transposed teeth into their normal position. Orthodontists can now recommend alternative treatment plans that would have never been an option with traditional mechanics. The benefits of decreased treatment time and increased predictability far outweigh any of the costs or additional work required by the patient or the practitioner utilizing AO. TADs have proven to be an effective anchorage device to control or harness anchorage not available with just tooth-borne appliances. Combining PSL, TADs, and AO has allowed for more complicated treatment outcomes that were not even an option in the past. OP REFERENCES 1. Shapira Y, Kuftinec MM, Stom D. Maxillary canine-lateral incisor transposition — orthodontic management. Am J Orthod Dentofacial Orthop. 1989;95(5):439-444. 2. Joshi MR, Bhatt NA. Canine transposition. Oral Surg Oral Med Oral Pathol. 1971;31(1):49-54. 3. Singh K, Kumar D, Jaiswal KR, Bansal A. Temporary anchorage devices — mini implants. Natl J Maxillofac Surg. 2010;1(1):30-34. 4. Shapira Y, Kuftinec MM. Tooth transpositions — a review of the literature and treatment considerations. Angle Orthod. 1989;59(4):271-276.

5. Trivedi BD. Early Diagnosis and prevention of complete transposition of mandibular lateral incisor during mixed dentition. Pediatr Dent Care. 2016;1(1):102 6. Shapira Y, Kuftinec MM. Orthodontic management of mandibular canine-incisor transposition. Am J Orthod. 1983;83:271-276. 7. Creekmore TD, Eklund MK. The possibility of skeletal anchorage. J Clin Orthod. 1983;17(4):266–269. 8. Ottofy, L. Standard dental dictionary. Chicago, IL: Laird & Lee, Inc.; 1923. 9. Daskalogiannakis J. Leipzig: Quintessence Publishing Co; 2000. Glossary of Orthodontic Terms 10. Herman R, Cope J. Temporary anchorage devices in orthodontics: mini implants. Semin Orthod. 2005;11:32-39. 11. Graham JW, Cope JB. Miniscrew Troubleshooting. Orthodontic Products. 2006;13(3):26-32 12. Lee MY, Park JH, Jung JG, Chae JM. Forced eruption of a palatally impacted and transposed canine with a temporary skeletal anchorage device. Am J Orthod Dentofacial Orthop. 2017;151(6):1148-1158. 13. Teixeira CC, Khoo E, Tran J, et al. Cytokine expression and accelerated tooth movement. J Dent Res. 2010; 89(10):1135-1141. 14. Frost HM. The regional acceleratory phenomenon: a review. Henry Ford Hosp Med J. 1983;31(1):3-9. 15. Frost HM. The biology of fracture healing. An overview for clinicians. Part I. Clin Orthop Relat Res. 1989;248:283-293. 16. Frost HM. The biology of fracture healing. An overview for clinicians. Part II. Clin Orthop Relat Res. 1989;248:294-309. 17. Shih MS, Norrdin RW. Regional acceleration of remodeling during healing of bone defects in beagles of various ages. Bone. 1985;6:3(5)377-379. 18. Alikhani , Raptis M, Zoldan, et al. Effect of the micro-osteoperforations on the rate of tooth movement. Am J Orthod Dentofacial Orthop. 2013;144(5):639-648. 19. Arias OR, Marquez-Orozco MC. Aspirin, acetaminophen, and ibuprofen: their effects on orthodontic tooth movement. Am J Orthod Dentofacial Orthop. 2006;130(3):364-370. 20. Yaffe A, Fine N, Binderman I. Regional accelerated phenomenon in the mandible following mucoperiosteal flap surgery. J Periodontol. 1994;65(1):79-83. 21. Adachi Y, Okazaki M, Ohno N, Yadomae T. Enhancement of cytokine production by macrophages stimulated with (1-->3)-beta-D-glucan, grifolan (GRN), isolated from Grifola frondosa. Biol Pharm Bull. 1994;17(12):1554-1560. 22. Alhashimi N, Frithiof L, Brudvik P, Bakhiet M. Orthodontic movement Arend WP, Palmer G, Gabay C (2008). IL-1, IL-18, and IL-33 families of cytokines. Immunol Rev. 2000;223:20-38. 23. Başaran G, Ozer T, Kaya FA, Hamamci O. Interleukins 2, 6, and 8 levels in human gingival sulcus during orthodontic treatment. Am J Orthod Dentofacial Orthop. 2000;130(1):e1-6. 24. Dale DC, Boxer L, Liles WC. The phagocytes: neutrophils and monocytes. Blood. 2008;112(4):935-945. 25. Alhashimi N, Frithiof L, Brudvik P, Bakhiet M. Orthodontic movement induces high numbers of cells expressing IFNgamma at mRNA and protein levels. J Interferon Cytokine Res. 2000;20:7–12. 26. Dienz O, Rincon M. The effects of IL-6 on CD4 T cell responses. Clin Immunol. 2009;130(1):27-33. 27. Krishnan V, Davidovitch Z. On a path to unfolding the biological mechanisms of orthodontic tooth movement. J Dent Res. 2009;88(7):597-608. 28. Nicozisis J. Accelerated orthodontics through micro-osteoperforation. Orthodontic Practice US. 2013;4(3):56-57. 29. Guinn K. Propel orthodontics enabling faster and more predictable results. Orthotown magazine. December 2013;38-41. 30. Pobanz J, Storino S, Nicozisis J. Orthodontic acceleration: Propel alveolar micro-osteoperforation. Orthotown magazine. May 2013;1-4. 31. Nicozisis J. Accelerated tooth movement technology. Orthotown magazine. July/Aug 2013;1-4. 32. Garlet TP, Coelho U, Silva JS, Garlet GP. Cytokine expression pattern in compression and tension sides of the periodontal ligament during orthodontic tooth movement in humans. Eur J Oral Sci. 2007;115(5):355-362. 33. Uribe F, Padala S, Allaredidy V, Nanda R. Patients’, parents’, and orthodontists’ perceptions of the need for and costs of additional procedures to reduce treatment time. Am J Orthod Dentofacial Orthop. 2014;145(suppl 4)65-73. 34. Pavlin D, Anthony R, Raj V, Gakunga PT. Cyclic loading (vibration) accelerates tooth movement in orthodontic patients: A double-blind, randomized controlled trial. Seminars in Orthodontics. 2015; 21(3): 187-194. 35. Bowman SJ. The effect of vibration on the rate of leveling and alignment. J Clin Orthod. 2014; 48(11):678-688. 36. Ortan-Gibbs S, Kim NY. Clinical experience with the use of pulsatile forces to accelerate treatment. J Clin Orthod. 2015;49(9):557-573. 37. Lobre WD, Callegari BJ, Gardner G, Marsh CM, Bush AC, Dunn WJ. Pain control in orthodontics using a micropulse vibration device: A randomized clinical trial. Angle Orthod. 2016; 86(4):625-630.

Orthodontic practice 31

CONTINUING EDUCATION

AO work, treating orthodontists would have to change patients’ appointment intervals. Patients who choose vibration need to be compliant daily: I check the compliance interface at each visit, which gives a chronologic history by day, month, time, and length of use. For fixed braces, we are activating treatment every 3 weeks.

CONTINUING EDUCATION

Tooth substitutions in orthodontic treatment Dr. Ricky E. Harrell discusses how to manage space for teeth that are either congenitally missing or lost due to disease or trauma

ne of the significant decisions facing an orthodontic practitioner is the management of missing teeth in orthodontic therapy. For the purpose of this article, the discussion of those missing teeth will exclude third molars as they are the most commonly missing teeth (9%-50% of patients)1,2 and rather examine substitution patterns for missing maxillary lateral incisors, mandibular second premolars, mandibular molars, and mandibular incisors. Teeth may be congenitally missing, with 3%-8% of the population missing one or more teeth exclusive of third molars,3 or teeth may be lost for any number of reasons, including dental disease and trauma.

Educational aims and objectives

The purpose of this article is to explore the thoughtful substitution of teeth with the elimination for prosthetic restoration that requires maintenance for the remainder of the patient’s life.

Expected outcomes

Realize some treatment options for substitution of a mandibular first permanent molar for a congenitally missing mandibular second premolar.

•

Realize some treatment options for substitution of second and third molars for first and second molars.

•

Realize some treatment options for substitution of mandibular canine for mandibular lateral incisor.

Substitution of maxillary canine for maxillary lateral incisor The maxillary canine for a congenitally missing maxillary lateral incisor is a substitution frequently encountered in orthodontic practice. The incidence of congenitally missing maxillary lateral incisors varies between different racial groups and genders, with an incidence reported to be 1%-3% of females demonstrating a greater incidence than males.4 The decision to open space or to close space for a missing maxillary permanent lateral incisor is predicted on a number of issues: • posterior occlusal pattern • shape and color of the maxillary permanent canine • residual bone in the lateral space • tooth display at rest and smiling • patients’ needs Figures 1-3 show the dentition of an adolescent female who is congenitally missing tooth No. 10 and has a malformed tooth No. 7. The patient also demonstrated absence of teeth Nos. 1, 17, 18, 31, and 32,

Figure 1: Frontal occlusal

which influenced the decision on whether to open space for the maxillary lateral incisors or to close space as it affects the final occlusion of the maxillary and mandibular molars. The occlusion presents with normal overbite and overjet with the buccal occlusion presenting as a half-step Class II relationship. The profile is slightly full with normal vertical facial thirds. After consultation with parents and the patient, the decision was reached to extract tooth No. 7, to close the spaces while centering the maxillary midline onto the lower midline and mid-sagittal plane of the patient, and to reshape the canines to look more like lateral incisors with the possible long-term solution being either

Ricky E. Harrell, DMD, MA, is a Diplomate of the American Board of Orthodontics and Program Director at the Georgia School of Orthodontics. Disclosure: This material was not presented at any meeting. There was no support in the form of grants, equipment, products, or drugs. There is no conflict of interest present in any material presented.

32 Orthodontic practice

Figure 2: Right buccal

Figure 3: Left buccal

porcelain veneers or full coverage porcelain restorations. The 24-month treatment regimen consisted of fixed orthodontic appliances with Class III elastic support. The extraction space for tooth No. 7 and space in the area of tooth No. 10 were closed with posterior protraction (Figures 4 and 5), and an acceptable functional and esthetic result was achieved. Molar relationship at the completion of treatment was Class II, and the maxillary canines were substituted for the lateral incisors and the maxillary first bicuspids substituted for the maxillary canines (Figures 6 and 7). Volume 8 Number 6

A first permanent molar for a congenitally missing second premolar is the second most commonly encountered tooth substitution in orthodontics, although the incidence of missing mandibular second premolars is higher than that of maxillary lateral incisors (1.6%-9.0% according to the population and study).5 Dental disease, ankylosis, and idiopathic root resorption — all are reasons that non-replaced second deciduous molars are removed, often at a young age. The orthodontic practitioner and restorative dentist face the dilemma of a long-term restoration or tooth substitution by closing the space via resolution of dental crowding or protraction of the mandibular first and second permanent molars. Before the advent of TADs (temporary anchorage devices or miniscrews), two problems were frequently encountered: 1. Closing this 9 mm-10 mm of space remaining in the arch after loss of the second deciduous molar was deviation of the mandibular midline toward the side of the lost second premolar as a result of the space closure, especially in a unilateral loss situation. 2. Over-retraction of the mandibular incisors and canines resulted in an adverse outcome on the occlusion and, in certain situations, the facial profile. Figure 8 shows the right buccal occlusion of an adolescent patient who had lost the contralateral non-replaced second deciduous molars. #A was ankylosed and had allowed mesial tipping of tooth No. 3. Because two of the three non-replaced second deciduous molars were either missing or scheduled for extraction, it was decided to extract both #A and #T and close the residual spaces. A TAD (Ormco™ VectorTAS™ 6 mm TAD 1.4 mm diameter) was utilized for direct anchorage to protract tooth No. 30 into the space left from the extraction of tooth No. 7. An Ormco power arm was utilized for attachment of the coil spring to place the point of force application close to the center of resistance of tooth No. 30 (Figure 9). A lingual attachment was placed for elastic traction to counteract the tendency of the molar to rotate mesiolingually as the protraction occurred (Figure 10). Tooth No. 31 was allowed to passively follow tooth No. 30 as the first molar translated mesially and bonded toward the later stage of treatment to close residual space. The resulting occlusion exhibited a Class I molar relationship with good control of molar Volume 8 Number 6

Figure 4: Right buccal progress

Figure 5: Left buccal progress

Figure 6: Right buccal final

Figure 7: Left buccal final

Figure 8: Right buccal

Figure 9: Right buccal TAD

Figure 11: Right buccal final Figure 10: Occlusal

Orthodontists can attain satisfactory results by thoughtful substitution of teeth with the elimination of prosthetic restoration that requires maintenance for the remainder of the patient’s life. tip (Figures 11 and 12). Tooth No. 3 was also moved into the space of ankylosed A during the treatment. One could argue that #T should have been left in place and a Class II molar relationship accepted as the final result for the right side occlusion. However, should #T exhibit later resorption and eventual loss,

Figure 12: Radiograph

either an implant-supported restoration or a fixed prosthesis would be necessary, or a second orthodontic treatment regimen could resolve the lost primary first molar. Here are two options: 1. An implant-supported restoration or fixed prosthesis would be necessary. 2. A second orthodontic treatment regimen would need to be initiated to resolve the issue of the lost primary first molar. Orthodontic practice 33

CONTINUING EDUCATION

Substitution of a mandibular first permanent molar for a congenitally missing mandibular second premolar

CONTINUING EDUCATION Substitution of second and third molars for first and second molars Figures 13-16 show an adult female patient who presented with non-restorable teeth Nos. 19 and 30. She also exhibited an impacted malformed maxillary left second bicuspid with an over-retained #J, and an endodontically treated tooth No. 4 with a full coverage restoration. The chosen plan of treatment included these steps: • Remove tooth No. 4, J, and impacted tooth No. 13, root tips No. 19, and the failing tooth No. 30. • Protract and substitute the mandibular second molars for the first molars, and the third molars for the second molars. Use TADs to assist in the protraction of the mandibular molars (Figure 17). As a result of the treatment, a Class I canine relationship and Class II molar relationship (with mandibular second molars substituted for first molars and third molars substituted for second molars) were to be established. After 36 months of fixed appliance wear, the spaces left by the extraction of the mandibular first molars were closed with second molar protraction and substitution, and the mandibular third molars were substituted for mandibular second molars (Figures 18, 19, and 20). Treatment time was within the normal range in adults, i.e., 2 to 4 years, according to bone density, bone availability, turnover rate, and hyalinization of the periodontal ligament. The treatment established the Class I canine and Class II molar relationships, and the patient does not have to seek any prosthetic replacements for the missing mandibular first molars.

Substitution of mandibular canine for mandibular lateral incisor One or more mandibular incisors are congenitally missing in approximately 0.5%3.4% according to the population studied, with Asian populations demonstrating the higher range of incidence. Due to their early emergence in the eruption scheme of the permanent dentition, the space is often diminished by drifting of the adjacent teeth. This poses a problem for both the orthodontist and restorative dentist with the decision to reopen space and to place a restoration or to close the space and either accept a compromise in overbite/overjet and midline coincidence. One solution in this arena is substitution of a mandibular canine for a lateral incisor, provided certain parameters 34 Orthodontic practice

Figure 13: Right buccal

Figure 15: Left buccal

Figure 17: Radiograph TAD

Figure 14: Radiograph right buccal

Figure 16: Radiograph left buccal

Figure 18: Right buccal

Figure 19: Left buccal

are met. There is a significant size discrepancy between the canines and the lateral incisors with the mandibular canines averaging 6.7 mm in width with the mandibular lateral incisors averaging 5.9 mm in width. Root anatomy and size are also different, and the task of moving a large canine root into the portion of the alveolus normally occupied by the lateral incisor can pose problems as well. In this final patient, a late adolescent female, the clinical presentation was that of a full-step Class II molar relationship on the left side, end-to-end Class II relationship on the right side, small maxillary lateral incisors, and a missing mandibular right lateral incisor with generalized spacing in the mandibular arch. The mandibular right buccal dentition had drifted significantly in a mesial direction, diminishing the severity of the Class II

Figure 20: Mandibular occlusal

molar relationship. The mandibular canines were not particularly large, which aided in the treatment decision. Neither overbite nor overjet were excessive (Figures 21, 22, 23). The decision was made to take the following steps: • Extract maxillary first bicuspids. • Restore teeth Nos. 7 and 10 to a normal size and shape. • Finish the left side with a Class II molar relationship. • Substitute tooth No. 27 for teeth Nos. 26, 28, and 27. • Establish a Class I molar relationship on the right side as a part of the treatment objectives. Volume 8 Number 6

Figure 22: Left buccal initial Figure 23: Lower occlusal initial REFERENCES 1. Nanda RS. Agenesis of the third molar in man. Am J Orthod. 1954;40(9): 698-706. 2. Garn SM, Lewis AB. The relationship between third molar agenesis and reduction in tooth number. Angle Orthod. 1962; 32(1):14-18. 3. Polder BJ, Van’t Hof MA, Van der Linden FP, KuijpersJagtman AM. A meta-analysis of the prevalence of dental agenesis of permanent teeth. Community Dent Oral Epidemiol. 2004;32(3): 217-226.

Figure 24: Right buccal final

Tooth No. 27 was slenderized to make the fit more compatible with that of a mandibular lateral incisor. The final results are shown in Figures 24 and 25.

Summary For a significant number of patients, orthodontists must decide how to manage space for teeth that are either congenitally missing or lost due to disease or trauma. Often patients are young at the time of presentation so that placement of a

Volume 8 Number 6

Figure 25: Lower occlusal final

restoration or prosthesis is a lifelong maintenance issue and should be considered carefully before embarking upon orthodontic treatment. With thoughtful treatment planning, patient cooperation, and excellent biomechanical control of the teeth during treatment, orthodontists can attain satisfactory results by thoughtful substitution of teeth with the elimination of prosthetic restoration that requires maintenance for the remainder of the patient’s life. OP

4. Joshi H, Goje SK, Parmar V, Vaghani B. Management of congenital missing maxillary lateral incisor by orthodontic treatment followed by prosthetic implant. Indo-European Journal of Dental Therapy and Research. 2016; 5(2):346-49. 5. Polder BJ, Van't Hof MA, Van der Linden FP, KuijpersJagtman AM. A meta-analysis of the prevalence of dental agenesis of permanent teeth. Community Dent Oral Epidemiol. 2004;32(3):217-226. 6. Jorgenson RJ. Clinician’s view of hypodontia. J Am Dent Assoc. 1980; 101(2):283-286. 7. Hom BM, Turley PK. The effects of space closure of the mandibular first molar area in adults. Am J Orthod. 1984;85(6): 457-69. 8. Iino S, Sakoda S, Ito G, Nishimori T, Ikeda T, Miyawaki S. Acceleration of orthodontic tooth movement by alveolar corticotomy in the dog. Am J Orthod Dentofacial Orthop. 2007; 131(4):448. e1-8. 9. Baik UB, Chun YS, Jung MH, Sugawara J. Protraction of mandibular second and third molars into missing first molar spaces for a patient with anterior open bite and anterior spacing. Am J Orthod Dentofacial Orthop. 2012;141(6):783-795.

Orthodontic practice 35

CONTINUING EDUCATION

Figure 21: Right buccal initial

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

REF: OP V8.6 ALPAN REF: OP V8.6 HARRELL

CONTINUING EDUCATION BROUGHT TO YOU BY

FULL NAME

Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 24 CE credits for only $149; call 866-579-9496 to subscribe today. To receive credit, complete the 10-question test by circling the correct answer, then either: n Post the completed questionnaire to: Orthodontic Practice US CE 15720 N. Greenway-Hayden Loop. #9 Scottsdale, AZ 85260 n Fax to (480) 629-4002.

AGD REGISTRATION NUMBER

LICENSE NUMBER

ADDRESS

CITY, STATE, AND ZIP CODE

To provide feedback on this article and CE, please email us at education@medmarkaz.com Legal disclaimer: The CE provider uses reasonable care in selecting and providing accurate content. The CE provider, however, does not independently verify the content or materials. Any opinions expressed in the materials are those of the author and not the CE provider. The instructional materials are intended to supplement, but are not a substitute for, the knowledge, skills, expertise and judgement of a trained healthcare professional.

TELEPHONE/FAX

Please allow 28 days for the issue of the certificates to be posted.

Your CE certificate(s) will be emailed to the address you provided above. Please add medmarkaz.com to your Approved Senders List in your email account. You may need to check your junk/spam folder for your certificate email.

Combining temporary anchorage devices with accelerated orthodontics to treat transposition

Tooth substitutions in orthodontic treatment HARRELL

ALPAN 1.

Treating transposed teeth is very similar to _____. a. missing teeth b. impacted teeth c. ectopic teeth d. both b and c

Ideal treatment for transposition would be ____ to help guide the erupting teeth into the correct position in the arch. a. prevention with early treatment b. waiting until the permanent teeth have erupted c. avoiding expansion until late in treatment d. maintaining the deciduous teeth

Although the principle of orthodontic anchorage has been understood since the 17th century, it was not clearly defined until 1923 when ____ defined it as “the base against which orthodontic force or reaction of orthodontic force is applied.” a. Dr. John Daskalogiannakis b. Dr. Edward Angle c. Dr. Louis Ottofy d. Dr. Pierre Fauchard Incorporating skeletal anchorage, utilizing ____ as Drs. Jason B. Cope and John W. Graham had introduced over a decade ago, has impacted treatment outcomes, reducing the need for orthognathic surgery. a. TADs b. mini-screws c. mini-plates d. all of the above When applying forces to teeth, there is always a consideration that other teeth will move in an unwanted position. The introduction of ____ has given orthodontists the ability to reduce or eliminate the opposite reactive force. a. mini-brackets b. TADs c. mini-plates d. both b and c

36 Orthodontic practice

In 1988 to 2010, multiple researchers found that the application of NSAIDs _____, and cytokines played an important role in activating the boneremodeling machinery. a. decreased the rate of tooth movement significantly b. increased the rate of tooth movement significantly c. increased the rate of tooth movement only slightly d. had no effect on the rate of tooth movement

(After the MOPs technique) Mild discomfort is experienced by the patient postoperatively, usually for 24-48hours, and is moderated ____. a. with NSAIDS only, no Tylenol® b. with Tylenol® only, no NSAIDs c. alternating with both Tylenol® and NSAIDs d. by cold compresses on the site

TADs can be located ____ ; and they can be fixed to bone either mechanically (cortically stabilized) or biochemically (osseointegrated). a. transosteally b. subperiosteally c. endosteally d. all of the above

10.

Use of ____ digital records is strongly recommended as viewing the path of eruption will help with proper treatment planning with the ideal mechanics needed. a. 2D b. intraoral photographic c. panoramic d. CBCT 3D Informed consents are signed by all patients who are undergoing AO, and ____ for all patients being treated with TADs. a. no informed consent is necessary b. separate informed consents c. instead of a consent, a complete list of risks involved included d. a signed list of other available options

Teeth may be congenitally missing, with ____ of the population missing one or more teeth exclusive of third molars, or teeth may be lost for any number of reasons, including dental disease and trauma. a. 3%-8% b. 10%-20% c. 25%-30% d. 42% The incidence of congenitally missing maxillary lateral incisors varies between different racial or ethnic groups and genders, with an incidence reported to be 1%-3% of ____. a. males demonstrating a greater incidence than females b. females demonstrating a greater incidence than males c. Asians demonstrating a greater incidence than Caucasians d. African Americans demonstrating a greater incidence than Hispanics A first permanent molar for a congenitally missing second premolar is the second most commonly encountered tooth substitution in orthodontics, although the incidence of missing mandibular second premolars is higher than that of maxillary lateral incisors (____ according to the population and study). a. 1.6%-9.0% b. 11%-15.2% c. 17%-20% d. 21%-25.6%

_____ — all are reasons/is a reason that non-replaced second deciduous molars are removed, often at a young age. a. Dental disease b. Ankylosis c. Idiopathic root resorption d. all of the above

Before the advent of TADs (temporary anchorage devices or mini-screws), two problems were frequently encountered: 1. Closing this ____ of space remaining in the arch after loss of the second deciduous molar was deviation of the mandibular midline toward the side of the lost second premolar as a result of the space closure, especially in a unilateral loss situation.

a. b. c. d.

2 mm-4 mm 5 mm-6 mm 7 mm-8 mm 9 mm-10 mm

(Relating to the patient in Figure 8) However, should #T exhibit later resorption and eventual loss, ___. a. an implant-supported restoration would be necessary b. a fixed prosthesis would be necessary c. a second orthodontic treatment regimen could resolve the lost primary first molar d. all of the above

One or more mandibular incisors are congenitally missing in approximately 0.5%-3.4% according to the population studied, with ___ populations demonstrating the higher range of incidence. a. Hispanic b. Asian c. African American d. Caucasian

Due to their (mandibular molars) ___ emergence in the eruption scheme of the permanent dentition, the space is often diminished by drifting of the adjacent teeth. a. late b. early c. unusual d. problematic

There is a significant size discrepancy between the canines and the lateral incisors with the mandibular canines averaging ___ in width with the mandibular lateral incisors averaging 5.9 mm in width. a. 2.3 mm b. 4.5 mm c. 5.6 mm d. 6.7 mm

10.

____ is/are also different, and the task of moving a large canine root into the portion of the alveolus normally occupied by the lateral incisor can pose problems as well. a. Root anatomy b. Size c. Relation to the sinus d. both a and b

Volume 8 Number 6

CE CREDITS

ORTHODONTIC PRACTICE CE

First in Class

An investment in knowledge pays the best interest. Benjamin Franklin

The name Forestadent stands for quality and excellence. Our educational programs are no different. They are the best in the industry…

The McLaughlin 2 Year Program with Dr. Richard McLaughlin “During my 42 years in practice, the McLaughlin Program was the single most important educational experience after completion of my residency….it provided the foundation to systematically change my approach to diagnosis, treatment mechanics, case finishing and office efficiency.” Dr. Ron Heiber Fairfield County, Idaho 2018-2019 COURSE DATES March June October February June December

02-06 23-25 05-07 09-11 08-10 07-09

2018 2018 2018 2019 2019 2019

COURSE 1 COURSE 2 COURSE 3 COURSE 4 COURSE 5 COURSE 6

– – – – – –

Ortho Treatment Mechanics and the Pre-adjusted Appliance Inter-Arch Treatment Mechanics, Part I IDB Inter-Arch Treatment Mechanics, Part II Management of the Dentition The Occlusion, the TMJ, and Orthodontic Treatment Surgical Treatment

TO REGISTER FOR THE McLAUGHLIN PROGRAM, Call: 619-225-1611 or Visit: www.McLaughlinCE.com

Just Short of Perfect – JSOP With Dr. Ron Roncone “In my 35 years in practice and taking numerous CE Courses, JSOP and the implementation of the PDS System have been a “Game Changer!” During the last three years I have reduced my overhead to 40%. This has happened by streamlining my systems, reducing my treatment times and cutting down rework.” Dr. Kim Littlefield ~ Swansea, IL JSOP XXI GRAD JSOP 33 January 25-28 2018 April 19-22 2018 July 12-14 2018

Session 1 : The Business of Orthodontics Session 2 : Clinical Systems - Featuring PDS Session 3 : Practice Marketing

TO REGISTER FOR THE JSOP, Call: 800.758.5836 or Visit: www.ronconeroi.com

www.forestadentusa.com

TECHNOLOGY

Artificial Intelligence (AI) and orthodontics — can you imagine where we will be in the very near future?

Dr. C. William Dabney discusses computer systems’ ability to perform tasks normally requiring human intelligence

Experience I want to start with what I think is the most appropriate definition of experience, from Dr. Randy Pausch’s book, The Last Lecture: “Experience is what you get when you didn’t get what you wanted.” All orthodontists have experiences, whether it is the experience of a few months, a few years, or a few decades. We build on that experience as a learning system/module. We take it step by step. History does repeat itself. We need to study the past to improve our future. Now, consider a few orthodontists I followed through my 30-year orthodontic career — Drs. Ronald M. Roncone, Anthony Gianelly, Rohit C.L. Sachdeva, and David Sarver, among many other great teachers and clinicians. If only we could tap into one or more of these fine doctors’ orthodontic knowledge and “experience.” Can you imagine that? That was a past we can appreciate, respect, and build upon — a past that C. William Dabney, DDS, is a skilled specialist in Midlothian, Virginia, who offers orthodontic treatment and lectures in the U.S. and abroad on the importance of utilizing the most innovative techniques, including Dental Monitoring™ and suresmile® technology. Dr. Dabney is graduate of the Medical College of Virginia Dental School and was a resident at Fairleigh Dickinson University. Dr. Dabney began his private practice in 1984 and is passionate about sharing his knowledge of lingual and digital orthodontics with other doctors around the globe.

38 Orthodontic practice

would know another definition of experience and one that would be amazed by today’s Machine Knowledge through Artificial Intelligence (AI).

Artificial Intelligence (AI) AI is the theory and development of computer systems able to perform tasks normally requiring human intelligence such as visual perception, speech recognition, decision making, and translation between languages. AI is the broader concept of machines that can carry out certain tasks very quickly and reliably. The problem with our initial foray was decisions made were directly related to the data integrity. The computer programs worked as an assembly line. Programmers “taught” the machine to perform a series of actions, and the machine performed them one after another. Every action had to be programmed in advance, which contains no room for any variations and is forever only as good as it was when first programmed. Examples of this style of AI are seen in GPS directions and stock market predictions, among others. Dental Monitoring™ (DM), a Paris-based corporation distributed in the United States by Rocky Mountain Orthodontics® (RMO), took AI to a higher level. DM made the early choice to use the most advanced technology,

Deep Learning, when creating the most advanced treatment management system in orthodontics. Deep Learning, a new branch of Machine Learning, aims to skip the teaching (programming) step. Inspired by the architecture of the human brain’s visual cortex, Deep Learning produces artificial neural networks that can learn by themselves. These networks can deal with the smallest nuances and become faster and more precise, the more data they analyze.

Applications of Deep Learning Neural networks can teach themselves to detect patterns without being taught what to look for. This ability has found applications in virtual industry. The Internet giant Google uses these algorithms to detect everything from cats to cars in pictures in order to make their images. Apple uses Deep Learning to make its artificial assistant, Siri®, better able to recognize human voices (although Siri is not so accurate in translating my southern accent into real words). Deep Learning is already better than doctors in skin cancer and heart attack detection, among other medical applications.

How is Deep Learning used in DM? DM’s neural networks were trained on one of the world’s largest collections of dental pictures depicting more than 170 different Volume 8 Number 6

DM and AI in your world Can you imagine the possibilities? DM offers several choices for monitoring. The photo-only mode allows for you to follow your patients’ progress from pretreatment through posttreatment. Imagine the ability to tell your patients and their families that if they take photos/videos every few months, you can follow their growth and development remotely. Then when you see that patients have lost the deciduous teeth needed, or teeth are finally starting to erupt, you can request they come in for a “live” visit. Parents will greatly appreciate time saved

TECHNOLOGY

clinical situations, from hygiene insufficiency to debonded brackets, unseated aligners, tooth movement, or tooth wear. Every clinical situation-depicted database was qualified by an orthodontist making sure that the neural networks would “learn” from the best. As DM continues to add more data into its system, the more data the algorithms can work with it to better detect every type of clinical system. One monitoring system that DM offers is called GoLive™, which is used to rapidly and accurately detect unseated aligners and then compute a message to send the patient according to the protocols established by the treating doctor and the severity of the unseat. “Every detection made by the DM algorithms is, and always will be, validated by a certified dental practitioner,” says DM founder and CEO, Philippe Salah. This allows DM to guarantee the quality of the system and ensures that this quality will always grow as more and more patients and doctors use DM to manage treatments more efficiently and conveniently.

Inspired by the architecture of the human brain’s visual cortex, Deep Learning produces artificial neural networks that can learn by themselves.

from unnecessary appointments caused by delayed eruption patterns. The opposite is also true in patients showing accelerated eruption patterns. Timing in orthodontics is what we all believe in, and now you will know when and what to schedule in advance instead of having to make decisions when the patients show up in your busy office in the middle of a hectic afternoon. One of my favorite uses of photo monitoring is with aligner patients. DM’s GoLive lets you and DM remotely follow all aligner patients. With this innovative product, the DM algorithms can detect aligner seating problems and then alert your office for potential problems. Depending on protocols established by your office, the patient will be alerted to continue wearing the same

aligner or OK the patient to advance to the next aligner. Imagine how that would help your office schedule and productivity. DM’s 3D monitoring is a quantitative analysis that maps out tooth movement in each arch in addition to individual tooth movement. This can help you decide if an archwire is still active or has become passive and, thus, alert you it is time to go to your next wire in your specific sequence. It can also be used to “check” RPE progress without bringing the patient into your office. This saves appointment times and shows your families that you value their time. This is a good practice differentiator in your community, and all data is HIPPA encrypted. Within the DM platform is a communication system that lets you email/text patients words of encouragement about their treatment or alert them if they need to improve their oral hygiene or increase elastic wear. This information is sent to the patients, and a copy goes to their parents. Imagine how this would increase your personal relationship with your patients and create a true “WOW” factor. Rocky Mountain Orthodontics® (RMO) is the exclusive distributor of Dental Monitoring™ (DM) technology in the U.S. For more information or to purchase a DM starter kit, email sales@rmortho.com, or call 800-525-6375. OP This information was provided by Rocky Mountain Orthodontics® (RMO).

Dental Monitoring allows you to view the position and alignment of your patients’ teeth remotely and continuously Volume 8 Number 6

Orthodontic practice 39

PRACTICE DEVELOPMENT

SEO: Scam or critical marketing service? part 2 Ian McNickle, MBA, discusses strategies to rank highly on Google and other search engines

n part 1 of our series, we defined SEO, and how it works at a high level. The primary takeaway from part 1 was that search engines evaluate your website and online presence on a monthly basis, so it is important to have an ongoing and robust online marketing program in order to be rewarded by Google. As a reminder, Google has over 200 variables it evaluates when assigning search rankings to websites. I normally group the most important variables into five major categories: 1) website code, 2) website content, 3) incoming links to the website, 4) online reviews, and 5) social media. In part 2 of our SEO series, we will explore these five major categories, so each practice will be able to understand what they need to do (or what their SEO company should be doing) in order to rank highly on Google and other search engines.

Category No. 1 — website code There are literally dozens of things Google (and other search engines) look for in your website code, but we will focus on our discussion on the primary items: title tag, description tag, image tags, and keyword tags. Each of these items should be properly implemented on your website in order to tell Google what it wants to know about your business. Remember Google reads your code; so if you don’t put the right information in your website code, Google likely will not rank your site well in search results. Ask your website or SEO company to install these elements in your website code and to contain the primary keywords you want to rank for (type of practice, primary services, etc.). If you are paying for SEO and these basic items are not done, then you are certainly not getting real SEO. Ian McNickle, MBA, is a national speaker, writer, and marketer. He is a Co-Founder and Partner at WEO Media, winner of the 2016 and 2017 Cellerant Best of Class Award for Online Marketing and Websites. If you have questions about any marketing-related topic, please contact Ian McNickle directly at ian@ weomedia.com, or by calling 888-246-6906. For more information, you can visit online at www.weomedia.com.

40 Orthodontic practice

Category No. 2 — website content The main factor you’ll want to make sure is that your website has unique content. Search engines give very little credit to websites with duplicate content (i.e., content that also resides on other websites in addition to your website). Your SEO company should write entirely unique content for all pages on your website in order to get the best search results. Most companies say they’re doing SEO, but don’t even do this fundamental step, so make sure your SEO company is doing this critical item in the SEO process.

Category No. 3 — incoming links to your website When another website has a link on it that links back to your website that is considered an incoming link (or backlink) to your website. Search engines reward websites with lots of incoming links. Think of it like a popularity contest online; the more links pointing to your website, the better because Google will consider websites with numerous incoming links to have more valuable information and will rank them higher in search results. In general, more links are good, and links from websites with lots of traffic are even better.

Category No. 4 — online reviews In the dental industry, the four most important online review sites are Google, Yelp, Healthgrades, and Facebook. Google is always the most important, but they are all very important. Search engines place a high level of importance on the number of reviews, and how recently the reviews are posted. It is wise to implement some sort of program to generate online reviews. Our company offers a service called WEO Reviews, but other services exist. The main point is to have a strategy to generate new patient reviews on these four major review sites on an ongoing basis. In addition to helping your SEO performance, the other major benefit is improved online reputation.

Category No. 5 — social media Obviously, social media is a huge topic, but for the purposes of SEO, we’ll just focus on a couple of items. In general, it is helpful to have ongoing posts on your social media pages, but what really helps SEO performance is when people actually engage with your posts by commenting, sharing, retweeting, reposting, etc. Social media engagement can be a strong SEO factor. Facebook is the most important social media site in the dental industry, so focus most of your efforts there, although other sites can have significant importance as well.

Is your SEO working? If you are working with an SEO company with the goal of driving new patients, then their recommended program should have all five of these categories covered as part of their strategy. In my experience, the majority of SEO companies do not properly implement a comprehensive SEO program covering these five categories and often don’t do nearly as much as they should be doing. In part 3 of our series, we will discuss questions to ask when interviewing SEO companies, and how to spot scams (and low-end SEO services).

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

Receive your free marketing consultation today: 888-246-6906 or info@weomedia.com Volume 8 Number 6

MKS M I N D S E T

K N O W L E D G E

S K I L L

Hilton Anatole Dallas | October 26-27, 2018 | www.TheMKSForum.com

Donâ&#x20AC;&#x2122;t Miss the BIGGEST Orthodontics Show in Town

IMPACTFUL DAYS

CE CREDIT HOURS

INDUSTRY LEADING SPEAKERS

700

FELLOW ORTHODONTISTS

2018

PRODUCT PROFILE

For new updates to CS OrthoTrac, it all starts with the users Kris Kinlen, Uriyah Robinson, Rick Alfieri, and Jerry Dickens discuss achieving absolute comfort with this practice management software

oday, we carry our whole lives around on our smartphones; we grow so accustomed to our phones that we can almost use them in our sleep. This means that when a software update is released, it can cause confusion and frustration; after all, maybe you were perfectly happy with the feature that Apple or Google decided needed “improving.” It’s no different with the practice management software that powers orthodontic practices. Users work within the software for 8 or more hours a day, and their lives and livelihoods are intimately tied to its functionality. While new updates can help, they can also be a hindrance, as users have to relearn the software they have grown used to.

Finding comfort in software updates This was something that a dedicated team of designers, developers, and market Kris Kinlen is a user experience designer and leader with over 17 years of experience in the interactive industry. He helps to craft bespoke, engaging, line-of-business solutions for the oral health industry. As product line manager for CS OrthoTrac, Uriyah Robinson is dedicated to working with orthodontic practices to ensure that Carestream Dental’s practice management software meets their unique needs. Uriyah has more than 10 years of experience in product management and strategy, and his most previous role was as strategic marketing manager at Bard Medical. Rick Alfieri has been serving customers since 2001 when he first joined the CS OrthoTrac support team. Now, as a product owner, his main focus is delivering better user experiences that align with industry workflows. Rick’s previous work experience in a dental office helps him empathize with customers’ unique challenges and anticipate their needs. Jerry Dickens has 15 years of experience as a user experience (UX) designer and is the lead designer on the CS OrthoTrac Treatment Card redesign project. Part of his role includes building empathy with customers through site visits, interviews, surveys, and data gathering in order to best understand their workflows. Through this research, he’s able to hone in on opportunities for solving problems orthodontic practices deal with daily. As part of his job, Jerry welcomes feedback from users in order to create a better software product.

42 Orthodontic practice

managers recognized when it came time to update Carestream Dental’s CS OrthoTrac practice management software. Fully aware of practices’ dependence on the software, while acknowledging the potential disruption any new updates could cause, the team had a special term for what they wanted to accomplish: hygge (pronounced hue-gah). There’s no direct English translation for the Danish word; it can be best described as the feeling one has when he/she finds absolute comfort in his/her surroundings. CS OrthoTrac users spend hours in the software, but are they comfortable in it? Are they relaxed and confident moving from screen to screen? That was the ultimate goal for the development team — for CS OrthoTrac users to find a feeling of absolute comfort in the software. If hygge answered the “what” of the new update, then investment was the “why.” In 2017, Carestream Dental refocused on its software offerings, making significant investments to deliver meaningful updates to users with a shorter turnaround time. Users would gain new value from their software or rediscover existing value that they may not have been taking advantage of. In addition to targeted redesigns, the investment brought new talent; the CS OrthoTrac team grew significantly, each new member bringing fresh perspective not only on how to handle this important update, but future ones as well.

Customer-centered research and development From the very beginning, customer engagement was paramount to whatever the CS OrthoTrac update would include. First, the team analyzed common complaints from users in order to have a starting point. Rather than letting their own observations from the first round of analysis determine the direction of the update, the team then went to The Exchange, Carestream Dental’s free online software user community, where they asked dedicated users exactly what they would like to see changed. Using The Exchange also lent

Treatment card before 2017 update

transparency to the development process — users and designers had a direct line to each other. The team solicited feedback through polls; and when the time came, an interactive prototype was released, as well as several videos that demonstrated the new workflow. With the blessing of CS OrthoTrac users, the team focused on updating the treatment card. Rather than retreating behind closed doors, the team threw themselves into the field. Collaborating closely with an advisory group of 12 practices, they made frequent site visits to see the burgeoning treatment card in use in a real practice environment. Once in an office, contextual inquiry and observation brought the customer deeply into the decision-making process. Rapid iterative design allowed the team to be nimble and incorporate user feedback quickly. While visiting a practice, the designers could make an immediate update to the prototype based on user feedback. Back at headquarters, the development team would then re-create the update in the real product. The real test of the new update came at the AAO’s 2017 Annual Meeting; it was time to put the treatment card through its paces. Dressed in coveralls and calling themselves the “CS OrthoTrac Pit Crew,” the team invited every attendee to take a “test-drive on the OrthoTrac.” The crew solicited feedback from more than 400 attendees. Much of what Volume 8 Number 6

The CS OrthoTrac Pit Crew in action at AAO 2017

Treatment card prototype before AAO

Treatment card prototype after AAO, based on attendee feedback Volume 8 Number 6

was showed at AAO was experimental — to give the team an idea of what to work on next. A new banner design definitely resonated with orthodontic professionals, and the ability to track clear aligners was highly valued by users. The team returned from the show feeling validated, but also knew there was more work ahead of them, such as implementing changes to the treatment card history. In fact, the treatment card that was eventually released looks very different from what was shown at AAO. Today, the redesigned treatment card focuses on one of the most used parts of the software: the clinical space. Care was taken to preserve current functionality while adding a premium viewing experience and improving workflows. We’ve added new features such as a compliance tracker called the Patient Insight Panel (PIP) where clinicians can respond to conditions that may contribute to longer than expected treatment durations. The new version also enables the user to launch (and layer) family members’ treatment cards — a long-awaited feature that elegantly helps handle family appointments. The “combo-box” section is now more robust and keeps track of “duration in the mouth” archwires, elastics, and appliances. Controls have also been upgraded, so it is now possible to add and track more than one element of the combo-boxes at a time. Lastly, the redesigned clinical space makes it possible for doctors to track details for aligner patients. Development of the new Treatment Card was a true team effort among developers, designers, and hundreds of CS OrthoTrac users. Constant feedback and complete transparency ensured that the latest update is something that orthodontic practices not only need, but also want and are excited to start using. Ultimately, practice management software is more than just 1s and 0s; it’s about users achieving absolute comfort, so they can perform their jobs with confidence. OP Please Note: All patient data shown is fictitious and for illustrative purposes only. This information is provided by Carestream Dental.

Orthodontic practice 43

PRODUCT PROFILE

Taking the software for a test-drive

PRODUCT PROFILE

Great Lakes offers a complete 3D digital orthodontic solution The ultra-fast 3Shape TRIOS® Ortho System™ streamlines impression taking, improves practice workflow, and increases patient satisfaction

ore orthodontists are investing in intraoral scanners to create a more efficient workflow and to eliminate the hassle, patient discomfort, and inaccuracies of traditional impressions. There are a lot of options to choose from, and not all digital solutions are equal. Choosing the right system and buying from the right distributor are critical.

Impress your patients with digital impressions A better patient experience starts with the scan. A small, lightweight, fast, and accurate intraoral scanner means that your patients will be more comfortable. The TRIOS®3 with pen or handle-grip design instantly provides on-screen, realistic-color intraoral scans that clearly distinguish between teeth, gingiva, and materials. You can let your patients watch as their scan appears on-screen in real time, and case acceptance improves when patients can see their clinical situation on-screen. Scanning is easy, accurate, and powder-free.

Digital workflows improve treatment planning through visualization and modeling tools The scan instantly loads into the Ortho System Software so you can complete a full case analysis: • Combine digital impressions with CBCT, patient photographs, X-ray panoramics, and ceph tracing • Visualize arc shapes, overjet/overbite, Bolton ratios, occlusion, and spaces • Simulate orthodontic treatments, including extractions, interproximal reductions, constraints, and full details of tooth movements

• Optimize occlusion in real time with virtual articulators • Customize treatment by exporting planned stages for appliance manufacturing and bracket positioning • Monitor treatment by scanning throughout the treatment course to compare the current situation with your treatment plan Case analyses can be customized according to your own methods, needs, and workflows. Software also includes customizable analysis wizards to guide users stepby-step through the process and allows for easy comparison of before and after treatment situations. Complete case histories are accessible from anywhere, and with 3Shape Communicate™, orthodontists can share and discuss cases online with colleagues and their labs or present treatment plans to patients. Data also integrates with thirdparty practice management systems such as Dolphin and topsOrtho™.

Seamless lab integration Scans can be sent seamlessly to virtually any lab via 3Shape Communicate™. TRIOS® is approved for Invisalign™ case submission. This makes workflow easier and eliminates the costs and time associated with mailing models and impressions.

Exceptional service and support When it comes down to selecting a scanner, much of the challenge is making sure your distributor will be there for you as you integrate the new technology into your practice. Great Lakes is dedicated to making the transition for you seamless. We provide 2-day setup and training in your office, as well as access to training information and videos, and ongoing software support from experienced technicians. Great Lakes doesn’t just sell digital scanners and software. We use them in our own lab, so we understand them inside and out. Orthodontists have trusted us for over 50 years to help them build practices, and we’re here to help you as you take your practice digital. For information, please call 800-8287626, or visit Digital-Ortho.com. OP This information was provided by Great Lakes Orthodontics, Ltd.

TRIOS®3 Color Pod 44 Orthodontic practice

Ortho System Software — advanced tools for treatment planning and case analysis

Disclaimer: Dolphin is owned by Patterson Dental; topsOrtho™ and Invisalign™ are trademarks of their respective companies.

Volume 8 Number 6

A complimentary copy of Tony Robbins best selling new book,

UNSHAKEABLE & a free review of your 401(k) plan

#1 Best Seller

HOW IT WORKS 1. Visit FreeCopyPlease.com and give us the details of your 401(k) plan. We will uncover all layers of hidden and unnecessary fees. 855.905.4015

2. After a brief call to review the results, we will send you a complimentary copy of UNSHAKEABLE.

INDUSTRY NEWS

ClearCorrect™ acquired by Straumann Group ClearCorrect, LLC, manufacturer of clear aligners, announced its acquisition by the Straumann Group, a global leader in tooth replacement solutions, for a total consideration of approximately $150 million. For over 10 years, ClearCorrect (a privately held company) has established itself as a leader in clear aligner manufacturing, servicing doctors in North America, Europe, Israel, Australia, and New Zealand. This investment will help ClearCorrect to improve its products and expand to offer its popular Flex and Unlimited treatment options to more providers around the world. Straumann’s acquisition is a vote of confidence in ClearCorrect’s role in driving the rapidly growing clear aligner market. It comes as part of a new initiative by Straumann to enter the orthodontic market and leverage the power of digital technology to deliver total orthodontic solutions. Visit clearcorrect.com, or call 888-331-3323 for information.

Ultradent has multiple products honored with 2017 Cellerant “Best of Class” Technology Award Ultradent Products, Inc., announced that the Gemini® 810 + 980 diode laser and the VALO® curing light family — which includes VALO Corded, VALO Cordless, and the largest LED curing light available on the market, VALO® Grand — have been selected as 2017 recipients of the Cellerant “Best of Class” Technology Award. Now in its 9th year, the Cellerant “Best of Class” Technology Award recognizes manufacturers and service providers for their innovations and is one of the most prestigious dental industry honors. For more information, visit www.ultradent.com.

Carestream Dental becomes independent global company following acquisition by Clayton, Dubilier & Rice and Hillhouse/CareCapital Clayton, Dubilier & Rice (CD&R) and CareCapital Advisors Limited (part of Hillhouse Capital Management) completed the previously announced acquisition of Carestream Dental, the dental digital business of Carestream Health. The carve-out transaction establishes Carestream Dental as an independent global company, wholly owned by CD&R and Hillhouse/CareCapital funds. Carestream Dental is a leading provider of dental digital product lines and services, including imaging equipment, CAD/ CAM systems, and practice management software that enables oral healthcare providers around the world to advance their standards of care and improve clinical efficiency. For information, visit carestreamdental.com, or call 800-944-6365.

Henry Schein® Orthodontics™ announces new general manager Henry Schein® has announced that Ted Dreifuss has been promoted to the position of General Manager, Henry Schein® Orthodontics™ (HSO). Dreifuss has over 30 years of sales, marketing, and general management experience in the medical and dental device sectors, including the orthodontic industry. He joined Henry Schein 5 years ago as Vice President of Marketing for the Global Dental Specialties Group and later assumed responsibility for the commercial activities — where he was instrumental in transforming HSO into one of the industry’s top orthodontic companies. For more information, visit henryscheinortho.com.

46 Orthodontic practice

MMG Fusion honored again in 2017 with the Cellerant “Best of Class” Technology Award MMG Fusion — the provider of the only all-in-one market software solution for the dental industry — has been selected as a 2017 recipient of the Cellerant “Best of Class” Technology Award. This is the second consecutive year that MMG Fusion has been selected as “Best of Class.” Now in its 9th year, the Cellerant “Best of Class” Technology Award is one of the most prestigious dental industry honors recognizing innovation from manufacturers and service providers. Founded in 2015, MMG Fusion is dedicated to creating innovative technology solutions that help dentists build thriving practices by making front office management and practice marketing simple and intuitive. The MMG Fusion suite of tools — available as allin-one integrated systems or as separate modules — provides management of online marketing, search optimization, social media marketing, online reputation management, patient communications and engagement, call recording and tracking, schedule optimization, and ROI assessment. MMG Fusion is a cloud-based software as a service offering that integrates seamlessly with practice management software presenting information via a single streamlined dashboard interface. For more information, visit mmgfusion.com.

Volume 8 Number 6

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

Faster Formlabs announces biocompatible materials for long-term use Formlabs, the designer and manufacturer of powerful and accessible 3D printing systems, announced the release of Dental LT Clear, the first long-term biocompatible resin in desktop 3D printing for orthodontic applications for orthodontic devices. Formlabs also released improvements to its Dental SG Resin, reducing print speeds for surgical guides by up to 50%. The fastest Formlabs material to-date, Dental LT Clear can be used to print splints and retainers in less than 50 minutes for a single unit. Full build platforms, with up to seven splints, can be completed in under 2 hours. With the latest PreForm software update, Form 2 3D printer users can also benefit from speed improvements in Formlabs’ Dental SG Resin. Single surgical guide prints will now be 50% faster, while full builds benefit from a 20% speed boost. Interested customers can request a free sample of Formlabs’ Dental LT Clear or Dental SG material at https://formlabs.com/ request-sample-part/.

Reliance introduces GoTo™ premium light-cured bracket paste Reliance has gone back to the drawing board to perfect the everyday “go to” bonding adhesive by introducing the GoTo™ premium light-cured bracket paste. With GoTo™, handling, bracketloading and flash cleanup are the differences between an everyday paste and one you will be excited to use. GoTo™ does not allow bracket flotation once placed on the tooth or as flash is being removed. This filler construction makes for single-piece flash removal — “roping” off the tooth without breaking. GoTo™ is priced far less than any other popular light cure pastes used today. For information, go to www. RelianceOrthodontics.com.

48 Orthodontic practice

Ormco™ announces “Schedule-an-Appointment” patient feature for its award-winning Damon™ Braces Doctor Locator Ormco™ Corporation, a leading manufacturer and provider of advanced orthodontic technology and services, announced the availability of a “Schedule-an-Appointment” feature for its awardwinning Damon™ Braces Doctor Locator — an informative website and mobile app that enables prospective patients to quickly and easily find the nearest orthodontist offering Damon System braces. The new feature allows consumers to schedule an initial consultation with their selected orthodontist directly through the streamlined, user-friendly orthodontist search portal. To access the Schedule-anAppointment feature within the Damon Doctor Locator, consumers simply need to click the “Schedule Appointment” button beneath the name of a provider and submit their name, email address, phone number, and preferred appointment time. Respective providers are electronically notified of the appointment request so they may follow up and schedule the appointment directly with the consumer. For more information, visit www.ormco.com or call 800-854-1741.

Panoramic Corporation launches a new digital panoramic and cephalometric imaging system Panoramic Corporation has launched a new digital panoramic and cephalometric imaging system, adding to its legacy of high-quality products offered through Panoramic’s exclusive direct-selling model. Envision, available in panoramic and panoramic/cephalometric configurations, is an advanced imaging system with a premium Cadmium Telluride (CdTe-CMOS) sensor technology that produces over 3,000 layers of diagnostic information, a characteristic unique for 2D extraoral machines. It also combines exceptional image quality, enhanced sharpness and contrast on a user platform that is easy for the dental team to position patients for high-quality and consistent X-rays. Due to this special sensor technology and continuous autofocus function, Envision by Panoramic always delivers the optimal image, greatly minimizing positioning errors in both panoramic and cephalometric versions. To learn more, call Panoramic Corporation at 800-654-2027, or visit www.pancorp.com.

Volume 8 Number 6

Lifetime retention from a single impression Same day retainer delivery with digital bracket removal Prevent relapse with backup retainers and durable 3D printed models

GUARDIAN® Enhancement Options

Embedded Pontics

Fixed Lingual Retainers

NEW Protect the smiles of your athlete patients by adding a custom sports mouthguard to any GUARDIAN® Retainer. GUARDIAN® Mouthguard

800.522.4636 specialtyappliances.com

COMING

SOON

YOU HAVE TO KNOW THE PAST TO UNDERSTAND THE PRESENT — Carl Sagan

From the introduction of the original Straight-Wire™ launched in 1970 by A-Company, Ormco is uniquely positioned to marry the wisdom of legacy with the latest in ceramic materials and our advanced manufacturing technology. To learn about the Symetri design and the future of ceramic appliances, contact your Ormco representative, 800.854.1741 or visit ormco.com Not yet available for commercial sale. Pending FDA Clearance. © 2017 Ormco Corporation