Orthodontic Practice US May/June 2018 Vol 9 No 3 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews May/June 2018 – Vol 9 No 3 • orthopracticeus.com

Practice profile Dr. Colin Webb

Cone beam computed tomography guides orthodontists to detect condylar position through precise diagnosis and treatment options Dr. Robert Kaspers

Controlling the vertical dimension Dr. Larry White

An interview with Dr. Larry White Dr. Rohit C. L. Sachdeva

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EDITORIAL ADVISORS Lisa Alvetro, DDS, MSD Daniel Bills, DMD, MS Robert E. Binder, DMD S. Jay Bowman, DMD, MSD Stanley Braun, DDS, MME, FACD Gary P. Brigham, DDS, MSD George J. Cisneros, DMD, MMSc Jason B. Cope, DDS, PhD Neil Counihan, BDS, CERT Orth Bradford N. Edgren, DDS, MS, FACD Eric R. Gheewalla, DMD, BS Dan Grauer, DDS, Morth, MS Mark G. Hans, DDS, MSD William (Bill) Harrell, Jr, DMD John L. Hayes, DMD, MBA Paul Humber, BDS, LDS RCS, DipMCS Laurence Jerrold, DDS, JD, ABO Chung H. Kau, BDS, MScD, MBA, PhD, MOrth, FDS, FFD, FAMS Marc S. Lemchen, DDS Edward Y. Lin, DDS, MS Thomas J. Marcel, DDS Andrew McCance, BDS, PhD, MSc, FDSRCPS, MOrth RCS, DOrth RCS Mark W. McDonough, DMD Randall C. Moles, DDS, MS Elliott M. Moskowitz, DDS, MSd, CDE Atif Qureshi, BDS Rohit C.L. Sachdeva, BDS, M.dentSc Gerald S. Samson, DDS Margherita Santoro, DDS Shalin R. Shah, DMD (Abstract Editor) Lou Shuman, DMD, CAGS Scott A. Soderquist, DDS, MS 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 2018. 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.

Staying airway-aware

wo years ago in July, I was sitting in the sand with my family in Newport Beach, California. I was enjoying the sun when my nephew, Jesse, approached my twin brother, Steve, and I with a very concerned look on his face. He told us both that he just spoken to a lady who was frantically searching for her 2-year-old son. We got up to help her since the lifeguard wasn’t proving to be helpful. We rushed over to where her family was and asked her where she saw him last. “He was digging in the sand just a few feet away a few minutes ago,” she cried. As I surveyed the scene, I noticed a patch of sand that had been recently filled in. My mind Dr. Stuart Frost was immediately flooded with the memory of a conversation I had with a lifeguard a few years earlier. He told me that a child had died digging in a large hole after it collapsed on top of him. I immediately told Jesse to start digging where the sand had been recently disturbed, and Steve and I started digging next to him. The image of Jesse pulling the 2-year-old boy’s lifeless body out of that hole is burned into my memory. My twin brother, Steve, immediately started performing CPR as I held the boy’s head and cleared his throat that was filled with sand. After what seemed like an eternity, his lower lip quivered. I yelled, “Steve, his lower lip moved! Keep going!” Moments later, the boy gasped for air. Color rushed back into the boy’s gray face as he screamed for his father. By the grace of God, this little boy made a full recovery from what could have been a fatal accident. (Editor’s note: To read the full story of the rescue, check out the article titled “Brooks’ Heroes,” Orthodontic Practice US, September/October 2016;7(5):62.) Many who have heard this story call the three of us heroes, but I’ve never considered myself to be a hero. All I did was act in the moment to help someone in need. Reflecting back on that day, I’ve come to realize that as orthodontists, we don’t have to give someone CPR to be a hero. We can literally save lives every day by practicing Airway Aware Orthodontics. Thousands of children suffer from airway issues and go untreated in our communities. Many of them display symptoms of ADHD due to the lack of oxygen getting to the brain, and many pediatricians don’t know what they don’t know and just prescribe medications. One such patient came to my office last year. I sat with a mother in my office who brought her daughter in for orthodontic treatment. This poor girl had a decreased airway and was experiencing weight gain, lack of energy and sleep, bed-wetting, and poor school performance. I decided to rescue this girl by initiating my Airway Protocol, which includes an assessment of the tonsils and adenoids, a minimal constricted airway point measurement using our i-CAT™ FLX, and a Rapid Palatal Expander with braces. After 12 months of treatment, we doubled her airway volume and transformed this girl’s life. The mother cried as she explained the changes that occurred in her daughter’s life over that year of treatment. Her sleep quality and school performance improved; she stopped wetting the bed, and she started playing sports and exercising. At a time in orthodontics when there is a lot of uncertainty and uneasy feelings about the future of our profession, we can rest assured that we will never be replaced if we seek to help “the one.” We can be heroes every day in our practices by saving children’s lives through practicing Airway Aware Orthodontics. I have seen it time and time again in my practice and want to share this protocol with the rest of the world. If you would like to transform your practice in to an Airway Aware practice, I would love to help you. Please text “Airway” to +1-480-630-5180. Dr. Stuart Frost

Stuart Frost, DDS, graduated with honors from the University of the Pacific School of Dentistry (UPSD). He completed a fellowship for Temporomandibular Joint Dysfunctions and a residency in Orthodontics and Dentofacial Orthopedics at the University of Rochester in New York. He is a Damon™ System Mentor and an associate professor at UPSC. Dr. Frost has spoken at the Ormco™ Damon System Forum, the American Association of Orthodontics Annual Session, and the IDAP in Puerto Vallerta, Mexico. He hosts continuing education courses and has repeatedly been named one of the Top Orthodontists in Phoenix Magazine.

ISSN number 2372-8396

Volume 9 Number 3

Orthodontic practice 1

INTRODUCTION

May/June 2018 - Volume 9 Number 3

TABLE OF CONTENTS

Practice profile Colin Webb, DDS, MS, MBA

Expertise, effectiveness, and efficiency

Case studies Nonsurgical treatment of a Class III malocclusion with missing lateral incisors Dr. Ana Maria Cantor discusses treatment for a patient’s esthetic challenge......................................... 14

Clinical A new type of fixed retainer Dr. Patrik Zachrisson describes a tooth-colored milled bonded retainer in PEEK........................................... 38

Small talk A critical distinction: problem solver versus people developer

Corporate profile

Dr. Joel C. Small offers a technique for creative problem solving.................. 44

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TABLE OF CONTENTS

Continuing education Controlling the vertical dimension Dr. Larry White discusses principles gained from current knowledge regarding the vertical dimension of the maxilla and mandible.......................52

Continuing education

Cone beam computed tomography guides orthodontists to detect condylar position through precise diagnosis and treatment options Dr. Robert Kaspers explores how CBCT scans help diagnose and treatment plan orthodontic cases

Product focus Carestream Dental and the Orthodontic Solution .......................................................56

Practice management Communicating change in the dental practice Catherine Cheshire, SPHR, discusses the importance of keeping employees informed..........................................72

Five strategies for building a cohesive team Ali Oromchian, JD, LLM, discusses facilitating optimum performance and accentuating the positive.................76

Orthodontic perspective Industry news...............82 Sharing a fika Dr. Rohit C. L. Sachdeva discusses a 50-year orthodontic career with Dr. Larry White ................................60

Materials & equipment.........................86

PUBLISHER | Lisa Moler Email: lmoler@medmarkmedia.com EDITOR IN CHIEF | Mali Schantz-Feld, MA Email: mali@medmarkmedia.com | Tel: (727) 515-5118 ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkmedia.com VP, SALES & BUSINESS DEVEL. | Mark Finkelstein Email: mark@medmarkmedia.com 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 OFFICE ASSISTANT | Lauren Drake Email: lauren@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)

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Volume 9 Number 3

PRACTICE PROFILE

Colin Webb, DDS, MS, MBA

Expertise, effectiveness, and efficiency Dr. Colin Webb at his Invisalign®-only practice, Clearsmile

What is unique about your practice? Launched in January 2017, Clearsmile is the first and only Invisalign®-only practice in the Charlotte area and one of very few across the country. I developed the idea for this practice while treating patients at my traditional orthodontic office. I was interested in doing something different that would expand our presence while creating an innovative orthodontic experience for patients that reflects where I believe the industry is heading. 6 Orthodontic practice

From equipment to layout and especially inventory and staff, every aspect of this practice is designed to treat aligner cases in the most effective and efficient way. Compared to a traditional orthodontic office that employs around 8-15 employees in a 4,000- to 6,000-square-foot space with an open bay concept designed for teens, Clearsmile’s staff is efficiently lean, and the office is only 1,200 square feet. We’re doing around 10-12 consultations per day and seeing 40-50 patients per day with only two assistants.

How does your practice embody patient-centered care? Patient-centered care is evolving in orthodontics, and it’s at the very heart of my treatment approach. My job as an orthodontist is to facilitate the treatment that the patient wants, not what I want. If a patient wants treatment to correct crowding, rotate a tooth, or eliminate plaque traps but doesn’t have the luxury of time, money, or tolerance to see it through to a 100% textbook finish, I’m willing to focus on his/her top concern. Volume 9 Number 3

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PRACTICE PROFILE We provide a product and a service as orthodontists, so that means we have to focus equally on results and patient desires. As long as a patient is informed of potential consequences of an end-on molar relationship and chooses to forgo that perfection so that she can end treatment in time for her wedding day for instance, then I’m here to improve her smile and give her the confidence she desires as she walks down the aisle. I hope I would not be so arrogant to believe that, as an all-knowing orthodontist, those are my decisions to make. Patientcentered care, not doctor-centered care.

How has clear aligner therapy evolved? As a Diamond Plus provider, I’ve seen how aligner technology has improved over the years — enabling us to treat cases that we would have never tried only a few years ago. We’re treating orthognathic surgery cases, deep bites, cross bites, open bites, underbites, impacted canines, and extraction cases with aligners now. What would you have thought 5 years ago if someone told you that? Regardless of the case presentation, the key to achieving a quality clinical result with aligners is precise treatment planning — so with Invisalign, all of the power is in the ClinCheck®. It’s not as

simple as scanning the patient and accepting the programmed movements that the Invisalign software or technicians suggest. The standard ClinCheck algorithm will not produce anywhere close to the results that I want. You, the doctor, must use your clinical training and use the CIinCheck software to provide a prescription for Invisalign to manufacture aligners to achieve your goals; treat them like a lab not a treatment planner. There are many initial ClinChecks where I’ll have to strip all of the suggested attachments, then resize, reshape, and reposition them on the teeth within the software. I also significantly modify the way that the aligners will move teeth. When working with aligners, it’s good to remember that if your virtual ClinCheck setup looks like a perfect smile, then your actual clinical results probably won’t. Overcorrection is your friend. Managing patient expectations from the initial consultation is also important. If you never have to reposition brackets in your braces cases, then you may not relate to this, but 90% of my aligner cases will have refinements just as 90% of my

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braces cases will need repositions (probably 100%). I inform my aligner patients that the aligner numbers are just to ensure they’re wearing them in the correct order and do not correspond to treatment time.

What accelerated treatment options do you offer? Many of our patients ask for AcceleDent® by name during the initial consult and prefer this noninvasive, accelerated option as opposed to micro-osteoperforations. AcceleDent is an FDA-cleared vibratory orthodontic device that employs SoftPulse Technology™ that has been shown through clinical trials to speed up tooth movement and reduce discomfort during treatment. These are significant benefits to patients who don’t want orthodontic treatment to interfere with their lifestyle, as well as patients who want to complete treatment prior to an important event, such as a wedding or graduation. I have yet to have a patient ask me if I could make his/her treatment longer. Patients will no longer accept 24 months of orthodontic treatment, and that’s why it’s no longer the standard. We’re doing 5-day aligner changes in conjunction with AcceleDent and completing most simple relapse cases in 3 months, open bite/ deep bite cases in 8-10 months, and surgical cases in 12-16 months.

The iTero Scanner adds to the efficiency of Clearsmile’s digital workflow 8 Orthodontic practice

Volume 9 Number 3

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PRACTICE PROFILE

Patient-centered care is evolving in orthodontics, and it’s at the very heart of my treatment approach.

practice and still practices with me full time! My wife, Kelly, is a general dentist and practices 1 day a week at Clearsmile while I’m at Webb Ortho. While I treatment plan every case and program the ClinChecks, she is a lifesaver when it comes to other appointments. She sees monitoring appointments, bonds attachments for initial aligner and additional aligner deliveries, performs IPR, and really lightens my load for the days that I’m at Clearsmile. While we’re not physically in the office together, my wife and I enjoy the process of working on the same cases and discussing the amazing results we’re able to achieve together.

Who has inspired you?

Patient using AcceleDent

We have a very high demand in our practice for AcceleDent because patients view it as a worthwhile investment. Since we don’t mark up the AcceleDent price, the price of accelerated treatment is only costing patients an additional $50 per month on average. We don’t view AcceleDent as a moneymaker, but more as a time/cost saver and a tool to increase patient satisfaction. With AcceleDent, we’re reducing visits and reducing chair time, which allows us to increase our case starts and bottom line. I have also yet to have any patients ask if they could come into the office more frequently and have more chair time. During your next few aligner consults, ask patients if they would rather complete treatment in 8 months or 12 months. During aligner monitoring visits, ask if they want 8 or 16 aligners this time.

How has technology created efficiencies in your office? Holding effectiveness constant, which means I’m doing everything I can to consistently produce quality clinical results, the big variable I have control over is efficiency. Efficiency is producing quality clinical results leaner and faster. This depends on office systems and workflow, and the beauty of the Clearsmile model is that everything fits into a digital workflow because Invisalign is a digital process. Everything from the iTero® scanner to the ClinCheck software and AcceleDent App, it all helps us become more efficient.

How do you approach marketing? Our patients are smart and motivated. The majority are educated young professionals, and they do so much research that 10 Orthodontic practice

they practically know everything about me, Invisalign, and AcceleDent before stepping foot in our office. Our marketing strategies reflect that. We frequently ask patients to submit Google reviews. We partner with local influencers, such as radio personalities and bloggers. We also do a lot of direct-to-patient marketing. Referrals are great, but we can’t expect many referrals because we’re offering a competing service. The strongest aspect of our marketing is our superior track record. Many of the patients I see for consultations have been told by other doctors that their cases do not qualify for clear aligner therapy and are surprised to hear that I’m confident I can get them the results they’re looking for because I’ve treated a similar case. After showing a few before/after photos, they’re assured. My fees are also highly competitive because of our volume and the efficiencies we’ve achieved with this unique practice concept. Patients are getting a Diamond Plus Invisalign orthodontic specialist with tons of aligner experience at the price of a general dentist.

How are you able to maintain a good work/life balance? Maintaining a good balance between work and family has always been important to me. We just had our first child, so it is more important now than ever. I believe you have to work hard and play hard, and that’s why I like to start early with my first patient at 7 a.m. and end early. Another component of my balance is that I work with my family. Two days a week I’m at Clearsmile, and the other three days I’m at Webb Ortho with my dad who started the

I’m inspired by many people, but I’m really inspired by entrepreneurs and disruptors — Uber, Amazon, Tesla, and the like. These companies went against the norms and status quo. They found a way to be more efficient and do something better than how it was previously done. Innovation and an original thought inspire me.

What advice would you give to orthodontists? My advice to orthodontists and especially to recent graduates is to practice forward thinking. In medicine we are treating diseases differently than we were just 5-10 years ago. Similarly, our responsibility is to learn, innovate, and adapt to the changing paradigms in orthodontics. There are a lot of concerns about new treatment options that pose a threat to the traditional orthodontic business model such as direct-to-consumer, at-home aligner treatment. While I acknowledge the concerns of quality control, I also acknowledge that it is out of my control and believe that whatever is truly in the best interest of the patient will eventually prevail. I see this as an opportunity for orthodontists to focus on educating patients about the value of being treatment planned and frequently monitored by a hands-on orthodontist, in person. I explain to patients that I will see them throughout treatment not only to ensure that teeth are tracking according to the programmed movements, but also to monitor gingival and periodontal health. Several patients have asked me about the direct-to-consumer aligner option during consults. After explaining the difference on the most basic level, they immediately recognize the value and are ready to commence treatment at my practice. This is why I think we need to focus our energy on patient education and patient-centered care. OP Volume 9 Number 3

CORPORATE PROFILE

DentalEZ® Integrated Solutions

entalEZ® Integrated Solutions is the power of many working together. For more than 100 years, dental professionals have trusted DentalEZ products to improve their working efficiency and enhance their practices, and the company has continued to evolve over recent years, forming partnerships and introducing innovative products from our five brands. Most recently, as part of its strategic plan and ongoing evolution, DentalEZ partnered with Professional Sales Associates, Inc. (PSA) on sales of its StarDental®, RAMVAC®, and DentalEZ Equipment brands to dental distributors in the United States, Puerto Rico, Canada, and with Dental Hygienics and Decontamination (DHD), on sales of its StarDental, RAMVAC and DentalEZ Equipment brands to all current dental distributors in the United Kingdom. Regarding the PSA partnership, Heather Trombley, President and COO of DentalEZ, noted, “We are changing the status quo. We have a real opportunity to fulfill the company’s vision — becoming a vibrant, integral, and trusted partner in oral and overall health — and we could not have asked for a better partner than PSA.” Trombley continued, “We believe that in partnership with PSA, our company will be better positioned to provide real solutions to the everyday challenges in the delivery of oral healthcare by uniquely combining product innovation focused on simplification, efficiency, and value, coupled with outstanding customer service and support.“ Ms. Trombley added for both the PSA partnership and DHD partnership that “The evolution of DentalEZ continues. Like any good company, we evaluate our business

and market opportunities with an eye on growth. We are committed to our customers and work hard every day to create a more customer-focused company, a company that customers seek out and trust. We are focused on our vision, and these announcements bring us another step closer to realizing it.” DentalEZ Integrated Solutions is committed to the following Core Values, Mission, and Vision: Core Values: We will achieve our goals by being resourceful and creative; working collaboratively; fostering an environment of care, trust, and respect for one another; performing with high standards; and acting with integrity, including saying what we do and doing what we say.

Heather Trombley, President and COO of DentalEZ

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Mission: To provide real solutions to the everyday challenges in the delivery of oral healthcare by uniquely combining innovation focused on simplification and efficiency in value-based products, and outstanding customer service and support Vision: To be a vibrant, trusted, and integral partner in support of oral health and overall health. DentalEZ Integrated Solutions manufactures a full line of product brands, including StarDental, DentalEZ Equipment, RAMVAC, NevinLabs™, and Columbia Dentoform®.

DentalEZ Equipment: The Power of Simplicity Since 1958, DentalEZ Equipment has been at the forefront of developing simple,

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Orthodontic practice 13

CORPORATE PROFILE

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CASE STUDY

Nonsurgical treatment of a Class III malocclusion with missing lateral incisors Dr. Ana Maria Cantor discusses treatment for a patient’s esthetic challenge

lass III malocclusions are classified into four types of skeletal and dental relationships with either 1) mandibular protrusion, 2) maxillary retrusion, 3) a combination of the two, or 4) a normal relationship of the jaws.1–3 The prevalence of Class III malocclusions is estimated to be 1% to 10%, depending on ethnicity, sex and age. The etiology may be skeletal or dentoalveolar.4 The incidence of lateral incisor agenesis in the permanent dentition is estimated to be between 1.6% and 9.6%,5,6 and there is a correlation between the size of the maxilla and agenesis of maxillary teeth.6 The two possible therapeutic options for adult patients with Class III malocclusions are orthognathic surgery or camouflage orthodontics.7 Regardless of the option chosen, it is important to take into consideration increasing the angle of convexity (ANB) to improve the profile of the face with a greater increase in the length of the upper lip.8 It is, however, often difficult to predict the result that can be offset by labial inclination of the maxillary incisors and the subsequent negative effect on the patient’s smile,9 as well as retro-inclination of the mandibular incisors, with deleterious effects on the periodontium. The combination of Class III malocclusion with missing maxillary lateral incisors can be challenging to resolve satisfactorily while enhancing the facial profile of the patient given the constriction of the maxilla. In patients with these characteristics, a combination of orthognathic surgery and orthodontics with a bridge or implants is often recommended.10 Given that the patient in the following case report would not consider orthognathic surgery or opening space orthodontically for the placement of implants, the alternative recommended was camouflage orthodontic treatment. The case

report is intended to illustrate treatment of a Class III malocclusion exhibiting maxillary lateral incisor agenesis with the use a simple Class III functional appliance for anteriorposterior correction, followed by fixed selfligating appliance therapy.

Diagnosis and treatment plan A 30-year-old female patient presented with a concave profile and maxillary hypoplasia with a short upper lip and lower retracted labial protrusion, an obtuse

nasolabial angle, and skeletal Class III maxillary retrusion and mandibular protrusion. Dentally, the patient exhibited a Class III malocclusion with marked crowding, an anterior crossbite, a 1 mm midline deviation, a moderate curve of Spee, and agenesis of the maxillary lateral incisors that the panoramic radiograph confirmed (Figures 1A–1J; Table 1). The treatment goals were to improve the patient’s facial esthetics, correct the Class III malocclusion exclusively with orthodontics,

Dr. Ana Maria Cantor practices orthodontics at the private OdontoKids clinic in Malaga, Spain. She can be contacted at anamacantor@yahoo.es. Disclosure: Dr. Cantor is a key opinion leader and paid speaker for Henry Schein Orthodontics.

Figures 1A-1J: Patient with a Class III malocclusion and agenesis of the maxillary lateral incisors before treatment 14 Orthodontic practice

Volume 9 Number 3

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CASE STUDY reduce the concavity of her profile, and create greater fullness of the upper lip, correct the anterior crossbite, distalize the mandibular posterior segment, protract the maxilla, and close the spaces from the congenitally missing lateral incisors, reconstructing the canines as lateral incisors and the first premolars as canines. Since the patient rejected the more invasive options recommended and opted for camouflage orthodontics, she was cautioned that a satisfactory result depended on her strict compliance with the treatment protocols, specifically the use of elastics.

Wire sequence

Treatment progress

Treatment followed the Carriere® System (Henry Schein® Orthodontics) archwire sequence; except in this case the first wire was a 0.016 in. dimension wire rather than a 0.014 in. wire. The archwires were all thermally activated wires, with lower transformation temperatures chosen as archwire sizes increased to limit force on the periodontium: • 0.016 in. Cu Nitanium (27°C) • 0.014 × 0.025 in. Cu Nitanium (27°C) • 0.017 × 0.025 in. Cu Nitanium (35°C) • 0.019 × 0.025 in. Cu Nitanium (35°C).

Treatment commenced with the simultaneous use of a Carriere® Motion 3D™ Class III Appliance (Henry Schein Orthodontics) for sagittal correction and Carriere® SLX™ (Henry Schein Orthodontics) 0.022 in. MBT prescription pre-adjusted, passive self-ligating brackets bonded with 0.016 in. Cu™ Nitanium® archwires (Henry Schein Orthodontics) engaged in the upper arch for anchorage. The Motion 3D Class III appliance was bonded directly to the mandibular canines and first molars with 6 oz, 0.25 in. intraoral elastics engaged for Class III traction to maxillary second molar tubes. Upper arch levelling and alignment was performed with 0.016 in. Cu Nitanium archwire, and bilateral stops placed mesially to the bonded first molar buccal tubes to assist with protraction of the upper arch. Proper patient compliance achieved correct intercuspation in 4 months; the negative overjet had corrected to an end-on position in 5 months (Figures 2A–2C). At that point, the Motion appliance was debonded, and Carriere SLX 0.022 in. MBT prescription pre-adjusted, passive self-ligating brackets were bonded in the lower arch (Figures 3A–3C).

Treatment results Table 1: Pretreatment cephalometric data

Figures 2A-2C: After 5 months of sagittal treatment, the negative overjet had corrected to an end-on position. Mild extrusion of the mandibular canine can be observed, which was expected and a positive sign of the effects of the sagittal correction. The result was an anticlockwise rotation of the posterior occlusal plane, producing significant improvement in the prognathic profile

After 16 months, treatment concluded with the patient showing a significant profile improvement, a correction of the maxillary hypoplasia, anterior crossbite, and Class III malocclusion with greater upper lip fullness, a balanced smile line, adequate gingival margins, levelling, and suitable overjet and overbite. By replacing the congenitally missing lateral incisors with reconstructed canines and positioning reconstructed first premolars as canines, good occlusion was achieved (Figures 4A-4C). For the re-anatomization of the canines and first pre-molars, we performed a laser diode gingivoplasty, then shaved the cusp tips of the canines and sculptured their distal and mesial borders with composite resin. Finally, we shaved and recontoured the

Figures 3A-3C: After bonding the mandibular brackets

Figures 4A-4C: After 14 months of treatment, the case demonstrated a corrected overjet, overbite, and intercuspation. The canines occupied the positions of the congenitally missing lateral incisors 16 Orthodontic practice

Volume 9 Number 3

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CASE STUDY palatal cusps of the first premolars to avoid premature contact at functional occlusion (Figures 5Aâ&#x20AC;&#x201C;5J; Table 2).

Discussion Many Class III patients elect not to undergo invasive treatment that involves surgery, extractions, and/or implants, especially if treatment affects maxillary anterior teeth considered critical to overall smile esthetics. When such esthetic problems are presented, it is important that orthodontists have adequate training in and experience and awareness of facial esthetics to be able to offer more conservative solutions because such issues, if unresolved satisfactorily, can detrimentally affect the patientsâ&#x20AC;&#x2122; emotional state and self-esteem. The position of the maxillary and mandibular incisors determines facial harmony and a pleasing smile. Maxillary lateral incisor agenesis makes obtaining good treatment results a challenge, especially with reduced maxillary arch length, owing to the lack of these important teeth. Treatment plans for cases of maxillary hypoplasia with agenesis of the lateral incisors often call for opening space for implants. The greatest problem with such plans is that it is impossible to predict when, to what degree, or in which patients unattractive soft- and/or hard-tissue changes around implant-supported porcelain crowns, especially noticeable in the maxillary anterior teeth, will occur. Biological and technical complications are frequent and can appear even after only a few years.12 Space closure with protraction of the maxilla and later re-anatomization of the canines to replace the congenitally missing lateral incisors can be a good alternative. Handled carefully, this option avoids gingival retraction that can accompany implant placement or metal show-through on crowns, bridges, and implants that can occur in some restorations after a period. Clinicians treating Class III patients with maxillary hypoplasia have traditionally avoided space closure because of the potentially adverse effects on the profile. The combined use of the Carriere Motion 3D Class III Appliance and SLX Brackets for applicable cases biomechanically eliminates these side effects by optimizing the relationship between the maxilla and the mandible, both occlusally and esthetically,11 for better results than simply neutralizing the potentially adverse effects of opening space for implants. Camouflage orthodontic treatment can result in protrusion8 of the maxillary 18 Orthodontic practice

Treatment with the Carriere Motion 3D Class III Appliance is efficient for the correction of adult Class III malocclusions, producing satisfactory results both esthetically and functionally.

Figures 5A-5J: Final photographs and radiographs of the patient after 16 months of treatment

Table 2: Posttreatment cephalometric data Volume 9 Number 3

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CASE STUDY incisors (giving an appearance of a short upper lip), as well as retro-inclination of the mandibular incisors, with deleterious effects on the periodontium. The actions of the Carriere Motion 3D Class III Appliance is distalization of the mandibular segments from molar to canine as a unit, with intrusion of the mandibular molars, extrusion of the mandibular canines, and retraction of the mandibular incisors — the result of which

is an anticlockwise rotation of the posterior occlusal plane, producing a significant improvement in the prognathic profile.11 In Class III cases, choosing brackets rather than an aligner for anchorage and bonding them simultaneously with the functional appliance produces distalization of the mandibular posterior segment while achieving torque control of the maxillary incisors11 and space closure, yet with

a protractor effect on the maxilla that develops upper lip fullness.

Conclusion Treatment with the Carriere Motion 3D Class III Appliance is efficient for the correction of adult Class III malocclusions, producing satisfactory results both esthetically and functionally. The Carriere Motion 3D Class III Appliance used in combination with Carriere SLX Self-ligating Brackets is a biomechanically efficient means of addressing cases with maxillary hypoplasia. Compared with alternatives, such as a combination of surgery and conventional orthodontics for opening space for implants or bridges, these appliances can significantly reduce treatment time for treatment of Class III patients. In cases of agenesis of the maxillary lateral incisors, the approach represented by this case is an efficient alternative for closing spaces while balancing the patent’s profile and correcting the Class III malocclusion. OP

REFERENCES 1. Sanborn, RT. Differences between the facial skeletal patterns of Class III malocclusion and normal occlusion. Angle Orthod. 1955;25(4):208-222. 2. Jacobson A, Evans WG, Preston CB, Sadowsky PL. Mandibular prognathism. Am J Orthod. 1974;66(2):140-171. 3. Ellise E 3rd, McNamara JA Jr. Components of adult Class III malocclusion. J Oral Maxillofac Surg. 1984;42(5):295-305.

Figure 6: Superimposition of cephalometric tracings pre- and posttreatment

4. Staudt C, Kiliaridis S. Different skeletal types underlying Class III malocclusion in a random population. Am J Orthod. 1984;136(5):715-721. 5. Boj JR, Catala M, Garcia-Ballesta C., Mendoza A. Abnormalities of dentition in pediatric dentistry: The evolvement of the boy to a young adult. 1st ed. Madrid: Ripano Ed.; 2011. 6

Tavajohi-Kermani H, Kapur R, Sciote J. Tooth agenesis and craniofacial morphology in an orthodontic population. Am J Orthod Dentofacial Orthop. 2002;122(1):39-47.

7. Proffit WR, Sarver D. Combined surgical and orthodontic treatment, in Contemporary Orthodontics. 4th ed. W.R. Proffit, H.W. Fields, Jr., D.A. Sarver, St. Louis, MO: Mosby; 2007. 8. Burns NR, Musich DR, Martin C, Razmus T, Gunel E, Ngan P. Class III camouflage treatment: what are the limits? Am J Orthod Dentofacial Orthop. 2010;137:(1)9-11. 9. Troy BA, Shanker S, Fields HW, Vig K, Johnston W. Comparison of incisor inclination in patients with Class III malocclusion treated with orthodontic surgery or camouflage. Am J Orthod Dentofacial Orthop. 2009;135:(2)146-147. 10. Cozzani M, Lombardo L, Gracco A. Class III malocclusion with missing maxillary lateral incisors. Am J Orthod Dentofacial Orthop. 2011;139(3):388-396. 11. Carriére L. Nonsurgical correction of severe skeletal Class III malocclusion. J Clin Orthod. 2016;50(4):216-23. 12. Zachrisson BU, Rosa M, Toreskog S. Congenitally missing maxillary lateral incisors: canine substitution. Am J Orthod Dentofacial Orthop. 2011;139(4):434, 436, 438.

This article was previously published in Dental Tribune UK Ortho International. 2018;3(1):14-19.

Figures 7A-7H: Photographs of the patient 3 years posttreatment 20 Orthodontic practice

Volume 9 Number 3

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CASE STUDY

Insignia™ System and IZC bone screws for asymmetric Class II malocclusion with root transposition of maxillary canine and premolar Dr. Chris Chang discusses treatment for a patient with root transposition Abstract An 18-year-old female sought consultation with a chief complaint of poor maxillary anterior esthetics. Diagnosis and etiology Clinical examination revealed facial asymmetry: 1. Nasal deviation to the right 2. Occlusal plane canted up on the left side 3. Maxillary midline 1 mm left 4. Mandibular midline 3 mm left Complex malocclusion had the following: 1. Unilateral Class II malocclusion (subdivision left) 2. Severe upper arch crowding 3. Blocked-out upper right canine (UR3) 4. Mesial root transposition of the upper right first premolar (UR4) 5. Lingual crossbite of the upper left lateral incisor (UL2) 6. Buccal crossbite of the upper right second molar (UR7) 7. Retained upper right deciduous canine and second molar 8. An impacted second bicuspid (UR5) The etiology was deemed deviated path(s) of eruption, and habitual sleep posture on the right side of the face. The Discrepancy Index (DI) was 25.

2. Use the Insignia™ system to produce a digital set-up of the final occlusion and to reverse-engineer a full-fixed passive self-ligating (PSL) appliance to conform to the finishing archwires. 3. Place posterior bite turbos on L6s to open the occlusion for correction of the UL2 and UL7 crossbites. 4. Use bilateral infrazygomatic crest (IZC) bone screws to differentially retract both arches to correct the unilateral Class II malocclusion with midline deviations. 5. Move the UR3 mesially with a coil spring. 6. Retract the UR4 with an elastomeric chain. 7. Finish with intermaxillary elastics.

Outcomes This challenging malocclusion (DI 25) was treated in 20 months to a board-quality result, as documented with a Cast-Radiograph Evaluation (CRE) of 24 and a Pink and White Esthetic Score of 2. The only significant deficiency was Class II buccal interdigitation on the right side. The patient was very satisfied with the outcome and was pleased with her “charming smile.” Conclusion The Insignia™ system is very precise and eliminates bracket positioning errors, so few detailing adjustments are required for alignment and finishing. This approach minimizes the repetitive PDL necrosis due to large number of active archwire segments,

Treatment plan 1. Extract the retained deciduous teeth, and instruct the patient to vary nocturnal sleep positions. Chris Chang, DDS, PhD, received his PhD in bone physiology and Certification in Orthodontics from Indiana University in 1996 and is a Diplomate of the American Board of Orthodontics (ABO). Dr. Chang lectures frequently worldwide on a wide range of topics, including impaction treatment, gummy smile, mini-screw and implantorthodontic combined treatment. As a private instructor since 2006, he has taught over 2,000 doctors from more than 21 countries. In addition to teaching and publishing, Dr. Chang also founded Beethoven Orthodontic and Implant Group. Disclosure: Dr. Chang did not receive any financial compensation for this article.

Figure 1: Pretreatment facial and intraoral photographs 22 Orthodontic practice

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CASE STUDY

Figure 2: Pretreatment dental models (casts)

Figure 3: Pretreatment panoramic radiograph. R and L condyles (red outline) are symmetrical. The upper right second premolar (UR5) is impacted (yellow arrow). The upper right canine (UR3) and the first premolar (UR4) had transposed roots (blue arrow)

thereby resulting in a shorter treatment time. However, enamel stripping of the lower incisors and/or increased torque on the maxillary incisors was needed to completely correct the Class II buccal segment on the right side.1

Table 1: Cephalometric summary

24 Orthodontic practice

Post-TX

Diff.

SNA° (82°)

87.5˚

0˚

SNB° (80°)

83.5˚

83˚

0.5˚

ANB° (2°)

4˚

4.5˚

0.5˚

SN-MP° (32°)

26.5˚

27˚

0.5˚

FMA° (25°)

19.5˚

20˚

0.5˚

U1 TO NA mm (4 mm)

2 mm

0 mm

2 mm

U1 TO SN° (104°)

107.5˚

104.5˚

3˚

L1 TO NB mm (4 mm)

5.5 mm

4 mm

1.5 mm

L1 TO MP° (90°)

103.5˚

99˚

4.5˚

E-LINE UL (-1 mm)

-3 mm

0 mm

E-LINE LL (0 mm)

0 mm

%FH: Na-ANS-Gn (53%)

53.7%

53%

0.7%

Convexity: G-Sn-Pg’ (13˚)

16˚

16.5˚

0.5˚

Skeletal Analysis

Introduction Insignia™ (Ormco, Glendora, California) was introduced by Dr. Craig Andreiko in 1987. It is a three-dimensional (3D) reverseengineered fixed appliance for the comprehensive treatment of all malocclusions.2 Bracket placement is extremely accurate, so the initial digital set-up requires very careful attention; problems in the set-up are reflected in the finish. A precision fixed appliance produces a highly efficient, more continuous tooth movement process. Few, if any, detailing adjustments are required for aligning and finishing the final occlusion. Less repetitive periodontal ligament (PDL) necrosis occurs because fewer active archwires are engaged.2,3 The Insignia™ system offers the potential for enhancing the rate of tooth movement and decreasing the incidence of root resorption. Transposition of teeth is a challenging problem for orthodontists. There can be a complete interchange or tipping of two adjacent teeth so that their crowns and/ or roots are transposed. For the present patient (Figures 1-2), the crown of an UR3 is immediately labial to the UR4, but the roots of the adjacent teeth are transposed (Figure 3). Transposition is defined as a positional interchange of two teeth in the dental arch, and its prevalence is relatively rare (0.38%).3 The maxillary canine is the most prevalent transposed tooth. The problem is more commonly associated with the lateral incisor (1.64/1000) compared to the first premolar (0.91/1000).4 Dental transposition is primarily a genetic problem because it is more common in inbred groups.5 The

Pre-Tx

Dental Analysis

Figure 4: Pretreatment lateral cephalometric radiograph

treatment of dental transposition is controversial. Factors such as gingival esthetics, canine eruption, caries risk, and duration of treatment are important considerations.6 The current case report presents the successful non-extraction treatment of dental root transposition, complicated by posterior buccal cross bite.7 Self-ligating brackets positioned with the Insignia™ system2,3 are a good option for enhancing the efficiency of the mechanics.

Diagnosis and etiology An 18-year-old female sought consultation for an unattractive smile. There was no contributing medical history. Facial evaluation showed nasal deviation to the right, an occlusal plane that was canted superiorly on the left side, a convex profile (16˚), and relatively retrusive upper lip (-3 mm to the E-Line). The intraoral examination revealed a Class I molar relationship on the right and Class II on the left side. Overbite was 4 mm, and overjet was 3 mm. The left lateral

Facial Analysis

incisor (UL2) was in lingual crossbite, and the UR7 was in buccal crossbite. Two retained deciduous teeth were noted in the upper left quadrant: canine and second molar. There was a root transposition of the UR 3 and 4 (Figures 1-3). The panoramic radiograph also revealed an impacted UR5. The etiology was probably a deviated path(s) of eruption. Mandibular condyles were relatively symmetric (Figure 3). There were no signs or symptoms of temporomandibular joint dysfunction (TMD). Pretreatment cephalometrics revealed bimaxillary protrusion (SNA 87.5˚, SNB 83.5˚, ANB 4˚) with flared mandibular incisors (LI-MP 103.5˚), while other values were within the normal limits (Figure 4 and Table 1). The discrepancy index (DI) was 25 as shown in the subsequent worksheet.8 Volume 9 Number 3

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CASE STUDY

Figure 5: Occlusal views of the digital set-up show the posttreatment dentition (white) relative to the pretreatment morphology (green) Left: Orange line marks the mesial surfaces of the UL6 pretreatment, and the red line is the mesial of the UL6 after 3 mm of retraction. The purple tooth is the impacted UR5 moved into the arch. Yellow arrows show the directions of upper arch expansion. Right: The lower arch was expanded and roared clockwise to coordinate with upper arch

Treatment objectives 1. C orrect the transposition and relieve crowding 2. Correct the anterior and posterior crossbites 3. Correct Class I canine and molar occlusion with coincident midlines 4. Correct occlusal cant, but maintain facial profile and lip position.

Digital set-up The occlusal views of the digital set-up are shown in Figure 5, and the anterior perspective is documented in Figure 6. Note that the maxillary midline is corrected 1 mm to the right, and the lower arch articulates with the upper arch in a Class I relationship with coincident midlines. Details of the set-up are: • Vertical movement: ºº Upper: Maintain upper incisors, extrude left buccal segment ºº Lower: Intrude incisors 2 mm • Anterior overbite: 1.5 mm • Incisor axial inclinations: ºº Upper: Decrease torque 5 degrees ºº Lower: Decrease torque 5 degrees • Extraction of only the two retained deciduous teeth • A/P movement (Figure 5): Move UL6 distally 4 mm • Midline correction (Figure 6): Upper midline 1 mm right, lower midline 3 mm right • Archwire plane: Center of upper and lower crowns of the central incisors • Supplemental anchorage: Bilateral IZC miniscrews

Treatment progress Before bonding the brackets, both retained upper right deciduous teeth were extracted. An Insignia™ 0.022-in slot fixed 26 Orthodontic practice

Figure 6: Frontal view of the digital set-up for the posttreatment dental alignment (white) is shown relative to the original occlusion (green). Upper: Orange line marks pretreatment midline, and the red line shows its posttreatment position 1 mm to patient’s right. Lower: Orange line marks pretreatment incisal edges, and the red line marks the 2 mm of planned intrusion for the incisors. The yellow arrow points to intrusion of the LL molars to flatten the Curve of Spee

Table 2: Treatment sequence Appointment

Archwire

Notes

1 (0 months)

U/L: 0.014-in Damon CuNiTi

An open coil spring between UR3 to UR6. No brackets were bonded on UR4 to allow it the freedom to move out of the path of tooth movement (Figure 7). Bite turbos were constructed with Fuji II type II glass ionomer cement (GC America, Alsip IL) on the occlusal surfaces of the mandibular first molars in order to facilitate correction of UL2 and LL7 crossbites in addition to LR7 uprighting.

2 (1 month)

L: 0.014x0.025-in Insignia CuNiTi

3 (2 months)

U: 0.018-in Damon CuNiTi

The UR5 had adequate crown exposure to bond the bracket. A button was bonded on the mesio-labial surface of the UR4 to receive an elastomeric chain with elastomeric ligature from UR4-UR5 to rotate the UR4 mesial out. The bite turbos were removed after the UL2 crossbite was corrected. Bite turbos were replaced on the L6s to open the occlusion so that cross elastics (Chipmunk 1/8-in, 3.5-oz), from the buccal hooks on the U7s to the lingual buttons of the lower 7s to upright the L7s.

4 (4 months)

5 (6 months)

U: 0.014x0.025-in Insignia CuNiTi

After preliminary alignment was achieved, torque control began with the rectangular archwire, and a torquing spring to move the root lingually was applied on the UR3 (Figure 8).

6 (8 months)

L: 0.018x0.025-in Insignia CuNiTi

With torque control established in the lower arch, bilateral Class II elastics (Parrot 5/16-in, 2-oz) were worn from the upper canines to the lower first molars to reduce overjet.

7 (12 months)

U: 0.018x0.025-in Insignia CuNiTi

Two OrthoBoneScrews® (Newton’s A Ltd, Hsinchu, Taiwan) were inserted bilaterally into the IZC area as anchorage to correct the maxillary dentition. The torquing spring on UR3 was removed

8 (13 months)

U/L: 0.019x0.025-in Insignia TMA

Upper archwire expansion.

9 (14 months)

UR3 bracket was repositioned. IPR was performed on the upper dental incisors to reduce the mesial incisal embrasures (Figure 9). The upper archwire was expanded to correct posterior overjet. A unilateral L-type Class II elastic (Fox 1/4-in, 3.5-oz) was utilized from UL3 via LL6 to LL7 for midline correction (Figure 10). A cross-elastic (Kangaroo 3/16-in, 4.5-oz) from the UR bone screw to the LR7 lingual button uprighted the LR7.

appliance with passive self-ligating (PSL) brackets was bonded on all teeth in both arches except for the UR4 and UR5. The mechanics and wire sequence are documented in Table 2. Before the appliances were removed at the end of active treatment, fixed lingual retainers were bonded on upper 2-2 and lower 3-3. Upper and lower clear overlays were fabricated. The patient was instructed to wear the overlays full time for

the first 6 months, and nights only thereafter. Home care and retainer maintenance instructions were provided. After the orthodontic treatment was completed, a gingivectomy was performed with a diode laser to establish proper crown height and proportions. The total active treatment time was 20 months. Figures 7-13 document the treatment progress as defined by the mechanics sequence outlined in Table 2. Volume 9 Number 3

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CASE STUDY

Figure 7: Left: At the start of treatment (0M), an open coil spring between the UR3 and UR6 was used to move the UR3 mesially (blue arrow). There is no bracket on the UR4, so it can move out of the way if contacted by the UR3 root (yellow circle with an arrow). Right: Two months into treatment (2M), the UR5 was bonded with a bracket, and a button was bonded on the labial surface of the UR4. A coil spring was activated to increase the space between the UR3 and UR5. An elastomeric ligature from the UR4 to the UR5 was used to rotate the UR4 mesial out (green curved arrow)

Figure 8: A series of right buccal photographs show the progressive progress from the start of treatment (0M), during correction of the transposition at 2 months (2M), lingual root torquing spring (yellow arrow) on the UR3 at 6 months (6M), alignment prior to space closure at 10 months (10M), upper arch space closure at 12 months (12M), and settling of the posterior occlusion with triangular elastics (blue). See text for details

Figure 9: Enamel interproximal reduction (IPR) was performed on the mesial surfaces of the maxillary central incisors to reduce the occlusal embrasure (yellow inverted V). Note that this procedure contributed to failure to correct the Class II buccal segment on the left side. See text for details. Left: Pretreatment Right: Posttreatment

Figure 10: A unilateral left L-type Class II elastic (Fox 1/4-in, 3.5-oz) (blue lines) was utilized from UL3 via the LL6 to the LL7 to achieve midline correction by asymmetrically advancing the LL buccal segment. Elastomeric chains anchored by the IZC bone screws were attached to the U3s to retract the entire upper arch. See text for details

Figure 12: A progressive series of upper occlusal photographs shows the archwire inserted at given intervals in months as shown in the posterior palate. Eight treatment intervals are illustrated: 0, 2, 4, 6, 10, 12, 14, and 18 months

Figure 11: Prior to debonding, a 0.018-in stainless steel wire was adjusted to rotate the upper lateral incisors mesial out (upper image). The maxillary incisors were ideally positioned prior to bonding a fixed lingual retainer (center image). Because of occlusal interference on closing, the fixed retainer was repositioned more gingivally prior to removing the brackets (lower image). See text for details 28 Orthodontic practice

Figure 13: A corresponding series of lower occlusal views shows the same treatment progression as Figure 12 Volume 9 Number 3

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CASE STUDY Treatment results Facial esthetics were maintained. Good dental alignment and intermaxillary occlusion was achieved (Figures 14 and 15). No periodontal problems were noted. The posttreatment panoramic radiograph documented acceptable root parallelism, except for the UL4 and LR7 (Figure 16). The facial profile and vertical dimension of occlusion were maintained (Figures 17 and 18). Superimposed

cephalometric tracings showed the maxillary arch was retracted about 2 mm with IZC bone screw anchorage, and torque control of the upper incisor was moderately decreased 3˚ (U1-SN 104.5˚). The increased axial inclination of the lower incisors was improved 4.5˚ (L1-MP 99˚). Correction of the posterior crossbite increased the mandibular plane angle 0.5˚ (SN-MP 27˚). The patient was well satisfied with the result. Intraoral photos at 1- and 4-month follow-ups demonstrate a stable occlusion and healthy periodontium (Figures 19 and 20). The ABO CRE score was 24 points, as shown in the supplementary CRE chart.9 The principal deficit in the final alignment was a Class II left buccal interdigitation. The pink and white dental esthetic score was 2 points.10

Discussion

Figure 14: Posttreatment facial and intraoral photographs

Figure 15: Posttreatment dental models (casts)

Figure 17: Posttreatment lateral cephalometric radiograph 30 Orthodontic practice

Insignia™: a custom bracket system Insignia™ is a 3D reverse-engineered fixed appliance for the comprehensive treatment of all malocclusions. It is extremely accurate and efficient, but requires very careful detail to the digital set-up from

which the appliance is constructed.2,3 For the present patient, crowding and transposition correction was accomplished in only 6 months (Figure 12) with no detailing bends or bracket repositioning. These mechanics control PDL stress to enhance the rate of tooth movement and minimize the risk of root resorption.2.3 The recommended archwire sequence is summarized in Table 3. Phase I: Stock light round wires As detailed in Table 3, the initial treatment objectives were: 1. Place bilateral bite turbos on the occlusal surfaces of the lower first molars to open the articulation for crossbite correction. 2. Level and align. 3. Initiate arch development as needed. 4. Resolve 90% of the rotations. The management of the root transposition of the UR4 began with space opening, bonding a bracket on the erupting UR5, and continuing space opening between the UR5 and UR3 (Figure 7) while the UR4 was rotated distal in. The flexibility of the initial

Figure 16: Posttreatment panoramic radiograph

Figure 18: Tracings of the pretreatment (black) and posttreatment (red) cephalometric radiographs are superimposed on the anterior cranial base (left), maxilla (upper right) and mandible (lower right). See text for interpretation Volume 9 Number 3

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CASE STUDY Table 3: The recommended archwire sequence is summarized for progressive archwire therapy utilizing the Insignia bracket system I

Stock light round wires

0.014 0.016 / 0.018 (alternative)

Stock Damon CuNiTi

Insignia edgewise CuNiTi wires

0.014 x 0.025 0.018 x 0.025 0.021 x 0.025

Insignia CuNiTi

III

Major mechanics

0.019 x 0.025

Stock SS

Finishing

0.021 x 0.025 0.021 x 0.025 0.019 x 0.025 (backup)

Insignia CuNiTi Insignia TMA Insignia TMA

Figure 19: The upper three images show the treatment outcome at 20 months (20M). The corresponding lower three views document the stable and healthy result at 1-month follow-up (1m-F/u).

round archwire (0.014-in CuNiTi) minimized friction and binding, so the initial alignment of the UR buccal segment was accomplished in <6 months (Figure 8). Phase II: Insigniaâ&#x201E;˘ rectangular CuNiTi wires The objectives of the second phase were to: 1. Begin resolving torque and root angulation problems 2. Complete leveling and alignment 3. Finish rotation corrections 4. Continue arch form development, as needed. In this stage, the UR3 received a torque spring to increase its axial inclination. Early control of the axial inclination of the UR3 contributed to good torque expression in the middle of treatment (Figure 8).11 Phase III: major mechanics The objectives of the third phase (12-18 months) were to close spaces and correct intermaxillary relationships. IZC bone screws were inserted bilaterally to retract the entire maxillary dentition for Class II correction.12 Interdental spaces were closed with elastomeric chains (Figure 8). At 14 months, interproximal enamel reduction (IPR) was performed to correct the wide embrasure between the maxillary central incisors (Figure 9). At the same appointment, a L-type Class II elastic was applied on the left side to align the mandibular midline (Figure 10). Phase IV: finishing The objectives for the final phase of treatment were to complete torque expression and arch coordination to achieve ideal intraarch and intermaxillary alignment. Midline elastics were applied, and maxillary arch expansion was completed. The lingually inclined LR7 was uprighted by engaging full-sized wires and applying cross elastics anchored by the UR IZC bone screw. The posterior occlusion was settled with two 32 Orthodontic practice

Figure 20: Right buccal views compare the immediate posttreatment result at 20 months (20M) (left) to 1-month follow-up (1m-F/u) (center), and 5-month follow-up (5m-F/u). See text for details

triangle elastics bilaterally (Figure 8). At the conclusion of active treatment, first order (in-and-out) bends were applied for final detailing and finishing at the same debonding visit (Figure 11). Occlusal views of progress related to the archwire sequence are shown for the maxillary (Figure 12) and mandibular (Figure 13) arches. The finished occlusion is documented at 20 months, after the brackets were removed and fixed retainers were placed (Figures 14-18), and after 1-5 months of follow-up (Figures 19 and 20) when restorative care was completed.

Extra-alveolar bone screw anchorage Extra-alveolar (E-A) skeletal anchorage is well suited for asymmetric sagittal discrepancies because the bone screws are buccal to the molars rather than between the roots. For the present patient, the Class II malocclusion on the left side was partially corrected by retracting the buccal segment with an elastic chain anchored by an IZC bone screw. The Class II relationship on the left side was not completely corrected because of inadequate overjet to retract the left maxillary quadrant to Class I. The lack of overjet was due to: 1) lingually tipped upper incisors, 2) labially tipped lower incisors, 3) tooth size discrepancy between the upper and lower incisors, and 4) the enamel stripping performed on the medial surface of the maxillary central incisors to correct the embrasure (Figure 9). Near the end of treatment, this problem was still correctable by adjusting incisor torque or IPR and retraction of the lower incisors. However, maintaining the midline correction

Figure 21: Left: Compared to the facial midline (black line), the pretreatment maxillary midline is deviated to the patientâ&#x20AC;&#x2122;s left 1 mm, and the lower midline is 3 mm to the left. Right: Posttreatment, the upper and lower midlines are coincident with the facial midline (black line). See text for details

(Figure 21) required limiting the enamel stripping to the LL quadrant (teeth Nos. LL1-4). Class II malocclusions with moderate crowding treated non-extraction with passive self-ligating brackets can be well aligned, but the outcome is often accompanied with incisal flaring and lip protrusion.12 E-A IZC miniscrews provide osseous anchorage to easily prevent those problems. Furthermore, the right IZC bone screws are effective anchorage for uprighting lingually-tilted lower second molars with cross-elastics (Figure 22). Low profile tubes are particularly effective for buccal crossbite correction because they are less likely to interfere occlusion, which often results in bond failures (Figure 23). CBCT images reveal that the IZC bone screw on the left side penetrated the maxillary sinus (Figure 24), but there were no negative Volume 9 Number 3

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CASE STUDY

Figure 22: The LR7 is tipped lingually prior to treatment (0M). Twelve months (12M) into treatment, the LR7 has failed to upright with a rectangular archwire and bite turbo on the LR6. At 14 months (14M), a cross elastic was applied from a lingual button on the LR7 to the IZC bone screw. The LR7 was well corrected by the end of treatment at 20 months (20M). See text for details

Figure 24: A strip of CBCT coronal views shows the left bone screw was within bone (upper). However, the bone screw installed on the right side penetrated the maxillary sinus, but there were no adverse signs or symptoms. See text for details

consequences for the patient.13 Both IZC bone screws were stable throughout the treatment, and there were no problems with soft tissue irritation.

Transposition As previously introduced, transposition is a rare anomaly defined as two teeth exchanging positions.14,15 Etiology is predominately genetic,16-18 and the problem may occur bilaterally. Maxillary canines (U3s) are the common transposed teeth, probably because they are the last succedaneous teeth to emerge in the mouth. The most common transposition locations are distal to the U4 and mesial to the U2. Both variations may be affected by crowding, crossbite, or a deviated path of eruption. If transposed with the adjacent U4, the canine is usually rotated mesial out, while the first premolar is tipped distally, and rotated mesial in. The maxillary deciduous canine may be retained creating a transient arch space deficiency.19 Transposition may be complete or incomplete. In a complete transposition, both the crown and the entire root are in their transposed position. In an incomplete transposition, the crowns may be transposed, but the root apices still remain in their normal positions.20 Alternately, the roots but not the crowns of the teeth may be transposed (Figures 2 and 3). The treatment of dental transposition is controversial and depends on the severity of 34 Orthodontic practice

the problem. Treatment alternatives include alignment in the normal or transposed position or extraction of one of the transposed teeth, followed by space closure.21 Common treatment options are: 1. Non-extraction treatment: Maintaining the transposed tooth order. When transposed teeth are fully erupted and well aligned in the transposed position, maintaining the transposition order is a viable option.22-23 However, esthetic and functional problems are common, such as atypical root prominence, and gingival margin contours can be expected. If the palatal cusp of a transposed premolar produces occlusal problems, such as a balancing interference, occlusal adjustment is indicated to control the risk of pulpitis or TMD. Furthermore, the buccal cusp of the first premolar is smaller than the canine, and the gingival margin is more occlusal, so a restorative buildup procedure may be needed. For more ideal esthetics, a transposed upper premolar can be intruded to simulate the gingival contour a canine and then restored with a full coverage restoration. 2. Non-extraction treatment: Correcting the transposed tooth order. The drawbacks for orthodontic correction

Figure 23: Left: Original version of the TIB tube has a prominent buccal profile that is susceptible to occlusal interference and debonding. Right: New low profile TIB tube has an improved design to resist debonding due to occlusal interference

are complex mechanics, long treatment time, root resorption, and periodontal clefting or dehiscence.19 3. Extraction of the transposed first premolar: This is usually the best option for crowded cases that require extraction,20 but it may still be the treatment of choice if the buccal segment(s) can be moved mesially to close the space. Mesial space closure in the upper arch is readily accomplished if there is a relatively deep overbite.24 Otherwise, E-A bone screws may be needed for osseous anchorage. For the present patient, the second treatment option was deemed appropriate because the UR3 and UR4 transposition was incomplete; she was young (18 years old), and the facial profile was acceptable. The risk of root damage as the transposed roots are moved past each other is minimized by only bonding a bracket on the tooth that is directly exposed to mechanics (UR3). For instance, no bracket was attached to the adjacent UR4, so the latter could act as a free body and physiologically move out of the path of tooth movement if its root is engaged by the root of the UR3. With the aid of the Insigniaâ&#x201E;˘ system, the transposed teeth were corrected in only 4 months, and the entire comprehensive treatment only required 20 months.

Conclusions 1. Dental transposition is a complex functional and esthetic problem that is a treatment challenge because correcting the natural tooth order is time-consuming and risks both hard and soft tissue damage. 2. Maintaining the transposed tooth order and restoring esthetics and function may be a viable option. Preprosthetic orthodontics to align gingival margins can greatly enhance the final result. Volume 9 Number 3

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CASE STUDY

3. I nsignia™ is a powerful weapon for managing complex orthodontic problems. Optimal bracket positions that require few, if any, detailing adjustments are particularly important for complex, time-consuming treatment plans. 4. IZC bone screws are E-A osseous anchorage that are particularly effective for non-extraction treatment of asymmetric malocclusions, such as unilateral transpositions.

A precision fixed appliance produces a highly efficient, more continuous tooth movement process. from the Santa Barbara Channel Islands of California. Am J Phys Anthropol. 2010;143(1):155-160.

15. Rakosi T, Jonas I, Graber TM. Orthodontic diagnosis. New York: Thieme Medical Publishers; 1993.

6. Hsu YL, Chang CH, Roberts WE. Canine-lateral incisor transposition: controlling root resorption with a boneanchored T-loop retraction. Am J Orthod Dentofacial Orthop.2016;150(6):1039-1050.

16. Peck L, Peck S, Attia Y. Maxillary canine-first premolar transposition, associated dental anomalies and genetic basis. Angle Orthod.1993;63(2):99-109.

Acknowledgment

7. Huang YH, Chang CH, Roberts WE. Treatment of bimaxillary protrusion, blocked-out canine and buccal crossbite. Int J Orthod Implantol. 2014;33:66-87.

Thanks to Mr. Paul Head for proofreading this article. OP

8. Cangialosi TJ, Riolo ML, Owens SE Jr, et al. The ABO discrepancy index: a measure of case complexity. Am J Orthod Dentofacial Orthop. 2004;125(3):270-278.

REFERENCES 1. Huang YH, Lin JJ, Roberts WE. Non-extraction treatment of facial asymmetry, midline deviation, missing UR4, and TMD. J Digital Orthod. 2018;49:76-95. 2. Lee A, Chang CH, Roberts WE. Archwire sequence for Insignia®: a custom bracket system with a bright future. Int J Orthod Implantol. 2017;46:60-69. 3. Lee A, Chang CH, Roberts WE. Skeletal class III crowded malocclusion treated with the Insignia® custom bracket system. Int J Orthod Implantol.2017;47:52-69. 4. Yilmaz HH, Türkkahraman H, Sayin MO. Prevalence of tooth transpositions and associated dental anomalies in a Turkish population. Dentomaxillofac Radiol. 2005;34(1):32-35. 5. Sholts SB, Clement AF, Wärmländer SK. Brief communication: additional cases of maxillary canine-first premolar transposition in several prehistoric skeletal assemblages

36 Orthodontic practice

9. Casko JS, Vaden JL, Kokich VG, et al. Objecting grading system for dental casts and panoramic radiographs. American Board of Orthodontics. Am J Orthod Dentofacial Orthop.1998;114(5):589-599.

17. Peck S, Peck L. Classification of maxillary tooth transpositions. Am J Orthod Dentofacial Orthop.1995;107(5):505-517. 18. Chattopadhyay A, Srinivas K. Transposition of teeth and genetic etiology. Angle Orthod.1996;66(2):147-152. 19. Nishimura K, Nakao K. Orthodontic correction of a transposed maxillary canine and first premolar in the permanent dentition. Am J Orthod Dentofacial Orthop. 2012;142(4):524-533.

10. Su B. IBOI Pink and White Esthetic Score. Int J Orthod Implantol. 2012;28:81-85.

20. Alessandri Bonetti G, Zanarini M, Incerti Parenti S, Marini I, Gatto MR. Preventive treatment of ectopically erupting maxillary permanent canines by extraction of deciduous canines and first molars: A randomized clinical trial. Am J Orthod Dentofacial Orthop.2011;139(3):316-323.

11. Wei MW, Chang CH, Roberts WE. Skeletal Class III malocclusion with canine transposition and facial asymmetry. Int J Orthod Implantol. 2015;40:66-80.

21. Wei MW, Chang CH, Roberts WE. Class I crowding with canine transposition and midline deviation. Int J Orthod Implantol. 2013;32:48-61.

12. Shih YH, Chang CH, Roberts WE. Class II division 1 malocclusion with 5mm of crowding treated nonextraction with IZC miniscrews anchorage. Int J Orthod Implantol.2016;41:4-17.

22. Ciarlantini R, Melsen B. Maxillary tooth transposition: correct or accept? Am J Orthod Dentofacial Orthop. 2007;132(3):385-394.

13. Lee AS, Chang CH, Roberts WE. Failure rate of IZC screws with sinus perforation. Int J Orthod Implantol. 2017. In press. 14. Graber TM. Orthodontics, principles and practice. 2nd ed. Philadelphia: W. B. Saunders; 1976.

23. Giacomet F, Araújo MT. Orthodontic correction of a maxillary canine-first premolar transposition. Am J Orthod Dentofacial Orthop.2009;136(1)115-123. 24. Roberts WE, Nelson CL, Goodacre CJ. Rigid implant anchorage to close a mandibular first molar extraction site. J Clin Orthod.1994;28(12):693-704.

Volume 9 Number 3

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CLINICAL

A new type of fixed retainer Dr. Patrik Zachrisson describes a tooth-colored milled bonded retainer in PEEK Abstract Following all types of active orthodontic treatment, a period of retention is advised in order to prevent relapse and the natural movement of teeth as they wear and shift as we get older. As there are many types of retainers, the one recommended by the orthodontist will be chosen to fit a specific treatment situation. The period of retention varies from usually 12 months to life retention. Retainers are usually removable Essix- or Hawley-type retainers or fixed-wire retention. A new type of retainer, digitally manufactured in PEEK material, can now be bonded onto teeth using conventional composite resin cement techniques to create a strong, durable, tooth-colored flexible, biocompatible, and more anatomically adapted retainer.

Introduction The use of clear retainers or wire retainers following orthodontic treatment is widely accepted. A change in the alignment of lower incisors during the second, third, and fourth decades of life has been widely reported in studies of both who have undergone previous orthodontic treatment followed by retention as well as in untreated patients (Little, et al., 1988, Little 1990). A number of choices are now available to the orthodontist following a course of active treatment. On the National Health Service (NHS in England), the orthodontist is responsible for the retention for 12 months, but in many cases, longer retention is needed, and in some cases, patients continue with retainers for life (Clark, et al., 1997).

Patrik Zachrisson, CertDentImp, FICOI, is a dental surgeon and partner of The Wensleydale Dental Practice (Huntingdon, Cambridgeshire) and the Wensleydale Dental laboratory. He qualified at the Karolinska Institute Sweden in 1996. He provides general dental care for a broad patient base, focusing mainly on digital dentistry, InvisalignÂŽ since 2008, implantology, restorative, and preventive dentistry. He is a keen CEREC user and is a Member of the British Dental Association, Member of the International Team of Implantology, Member of the British Academy of Cosmetic Dentistry, and Fellowship status in the International Congress of Oral Implantologists (FICOI).

38 Orthodontic practice

A new type of retainer, digitally manufactured in PEEK material, can now be bonded onto teeth using conventional composite resin cement techniques to create a strong, durable, tooth-colored flexible, biocompatible, and more anatomically adapted retainer.

The removable retainers are usually used at nighttime. A common type of retainer is the clear thermoformed Essix retainer, which is made to fit on a plaster cast of the teeth. The Essix is a polpropylene or polyvinylchloride (PVC) plastic material, usually in .20 or .30 thickness. It will cover the whole arch and normally extend onto the gum line. There is some evidence that the use of a clear retainer is preferred by patients (Hichens, et al., 2007). We can also make Vivera-type retainers from InvisalignÂŽ, based on the position of a specific aligner or from a new impression or digital scan. They also provide full-arch coverage but are trimmed like the active aligners so are comfortable to wear. A durable alternative is the NimrodRetainer milled from a flexible but hardwearing material, which is thinner than a typical vacuum-formed retainer. Sometimes a Hawley- or Begg-type retainer is prescribed, using a clear or metal wire on the anterior surface of the teeth. The advantage with this type is that it allows a degree of adjustments and occlusal contact between the upper and lower teeth (Sauget, et al., 1997). A fixed retainer is bonded onto the lingual or palatal surface of the teeth and provides around-the-clock support for the teeth. The retainers may consist of a single or multistranded wire, usually a 0.0215 inch multistranded wire or 0.030-0.032-inch sandblasted round stainless steel wire or a reinforced fiber. Most wire retainers are of the multistranded type and bonded to every tooth using acid-etch composite bonding techniques. Occasionally, a wire-bonded

canine-to-canine may be used. The fiber retainer has a following but is considered more prone to fracturing (Heier 1997, Zachrisson 1995). It is essential that fixed wire retainers are fitted completely passively, or else orthodontic movement is likely to occur. The fixed wires cannot be removed by the patient so compliance in good oral hygiene is essential to prevent buildup of scale on the lingual or palatal areas where the wire is fitted. When fitting an upper bonded retainer, special care should be taken to make sure that the lower teeth do not bite on the retainer as it can cause it to debond. There are risks of wire debonding, especially in the upper anterior area due to the bite (Lumsden, et al., 1999; Artun and Urbye 1988).

Reasons for orthodontic relapse A multitude of factors may affect the longterm stability of the completed orthodontic treatment. As the structures supporting the teeth stabilize, the risk of relapse reduces but will remain to a degree and will always be present. Teeth tend to want to relapse into the original passive position, but other factors may play a role. Delayed growth, known as latent jaw growth, may occur in the lower jaw up to the age of 21 in women and up to age of 25 in men. Temporomandibular dysfunction, grinding, and clenching may affect the strain on the teeth, contacts in occlusion, and the repeated tension in the arches may cause misalignment. The ADA estimates up to 95% of Americans have a grinding or clenching habit. It is widely accepted that aging affects Volume 9 Number 3

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CLINICAL

Figure 1: Design of a PEEK wire retainer on a digital model at lab

Figure 2: PEEK wire on a lab model

the dentition as enamel wears, teeth weaken, and we may get further restorations. This can lead to a change in the occlusion and the balance between teeth. It is not unusual to see lower anterior overcrowding as we age. If a tooth is lost, and the space is not restored, mesial drift may cause teeth to migrate anteriorly or tip into a gap. There are also genetic factors to account for (Johnston and Littlewood 2015; Hegde, et al., 2011).

PEEK material and physical properties The organic thermopressed polymer known as PEEK, polyetheretherketone, is a colorless material now widely used in engineering and technology. PEEK has excellent chemical and mechanical resistance properties, even at higher temperature. It has a melting point around 340 degrees centigrade, so can safely be sterilized using autoclaves. It shows a high resistance to biodegradation and damage in organic and aqueous environments. It has a high tensile strength at 90 to 100 MPa with an elastic modulus of 3.6 MPa (Parker, et al., 2012). PEEK is now commonly used in a number of medical applications such as in medical implants, MRI imaging and neurosurgery, and many more, and in industrial applications like pumps, piston parts, and valves. It is now used in aerospace technology and chemical industries where, because of its unique properties, it can work well under load and high temperatures. In 2016, a PEEK filament was made available for the production of 3D-printed parts, using fused deposition modeling (FDM) technology (Surgical Technologies 2016, Design News 2016). Three-dimensional printing has opened up an entire new field of applications for PEEK including orthodontic appliances, partial denture frameworks, clasps, and many more. To make it even more exciting, it is possible to mill PEEK using precision milling in a five-axis CNC machine. PEEK is not seen as a shape-memory polymer, but recent 40 Orthodontic practice

Figure 3: A 3D-printed model is made showing the fit of the wire and planned alignment using the integrated PEEK spurs that rest on the anterior aspect of the canines

Figure 4: Occlusal aspect of wire showing extension of supports labially with wire seated on 3D-printed model

Figure 5: The passive position of the PEEK wire retainer is verified in the mouth using the milled supports

developments mean this can be achieved, which has opened up even further medical applications (Surgical Technologies 2009).

material is giving us a high-strength appliance in white shades to allow passive retention of anterior teeth. The thickness of the wire can be set depending on the situation, but a thickness of 0.8 mm seems to be adequate, allowing us to have a thin and comfortable appliance and still have some physiological movement of the teeth. The PEEK retainer wire can be cemented using conventional acid-etch techniques, allowing us to use a familiar method.

Results and discussion The recent developments in PEEK have allowed us to develop a new type of retainer using digital scanning of the dentition and then CAD design of the appliance. We are able to produce a milled PEEK retainer wire from NimroDental in London. This exciting

Volume 9 Number 3

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CLINICAL Case presentation introduction and presenting situation A woman, age 45, presented with a completed Invisalign treatment. She was currently using a Vivera-type clear retainer; however, she found it bulky and requested a permanent retainer wire to prevent relapse in the lower anterior segment. Her treatment options were discussed, including a new Vivera, Essix retainer, NimrodRetainer, conventional bonded lingual wire, or the PEEK fixed retainer. She chose the PEEK wire.

Treatment carried out The patient was assessed and found to be suitable for the PEEK wire. A digital intraoral scan was carried out using Sirona Cerec Omnicam CEREC Ortho software. The file was uploaded to NimroDental London Dental laboratory where the plan was applied to a digital model. A 3D-printed model was manufactured, and a PEEK wire was milled. The wire was made with supports on the labial surfaces of LR3 and LL3 in order to allow an easier seating of the wire. It is essential that the wire is fitted passively. The teeth were isolated, etched with 37% phosphoric acid etch gel, and rinsed and bonded using Adhese® Universal VivaPen® from Ivoclar Vivadent® using standard protocol as recommended by the manufacturer. Adhese Universal VivaPen contains a single-component, light-cured universal adhesive for direct and indirect bonding procedures and is compatible with all etching techniques: self-etch, selective enamel-etch, and total-etch. A total-etch technique rather than self-etch was preferred. Flowable composite resin Venus® Flow from Kulzer was applied to the labial surfaces of the teeth, and the wire was seated. The resin was light cured from all sides. The lingual supports were removed, and any excess was polished. Articulation was checked for any interferences, and good oral hygiene routines were demonstrated. Materials used: • PEEK wire from NimroDental • Cerec Ortho software was used on a Cerec a/c Omnicam • Venus Flow from Kulzer • Adhese Universal VivaPen from Ivoclar Vivadent

Conclusion NimroDental’s expertise and high-tech machinery make it possible to provide patients with a cost-effective, high-strength, 42 Orthodontic practice

Figure 6: Cementation using conventional acid-etch techniques and flowable resin or warm composite

Figure 7: Removal of the PEEK supports after cementation

Figure 8: The appearance after cementation and removal of supports is very discreet in the anterior view

tooth-colored retainer made in biocompatible PEEK that can easily be cemented using standard techniques. It can be produced from an impression or even better completely digitally using intraoral scan techniques. It allows a limited amount of flexibility to maintain normal tooth function. OP

7. Johnston CD, Littlewood SJ. Retention in orthodontics. Br Dent J. 2015;16;218(3):119-212. 8. Kurtza SM, Devine JN. Peek biomaterials in trauma, orthopedic, and spinal implants. Biomaterials. 2007; 28(3): 4845-4869. 9. Little RM, Riedel RA, Artun J. An evaluation of changes in mandibular anterior alignment from 10 to 20 years postretention. Am J Orthod Dentofacial Orthop. 1988; 93(5):423- 428. 10. Little RM. Stability and relapse of dental arch alignment. Br J Orthod. 1990;17(3):235-241. 11. Lumsden KW, Saidler G, McColl JH. Breakage incidence with direct-bonded lingual retainers. Br J Orthod. 1999; 26(3):191-194.

REFERENCES 1. Arevo Labs announces carbon fiber- and nanotube-reinforced high-performance materials for 3D printing process [news release]. Solvay; March 24, 2014. https://www. solvay.com/en/media/press_releases/20140324-Arevo. html. Accessed February 28, 2018. 2. Artun J, Urbye KS. The effect of orthodontic treatment on periodontal bone support in patients with advanced loss of marginal periodontium. Am J Orthod Dentofacial Orthop. 1988; 93(2):143-148. 3. Clark JD, Kerr WJ, Davis MH. CASES — clinical audit; scenarios for evaluation and study. Br Dent J. 1997;183(3):108-111. 4. Hegde N, Reddy G, Reddy VP, Handa A. Bonded retainers in orthodontics: a review. Int J Dental Clin. 2011:3(3):53-54 5. Heier EE, De Smit AA, Wijgaerts IA, Adriaens PA. Periodontal implications of bonded versus removable retainers. Am J Orthod Dentofacial Orthop. 1997; 112(6):607- 616. 6. Hichens L, Rowland H, Williams A, et al. Cost-effectiveness and patient satisfaction: Hawley and vacuum-formed retainers. Eur J Orthod. 2007:29(4):372-378.

12. Parker D, Bussink J, Hendrik T, et al. Polymers, HighTemperature Ullmann’s Encyclopedia of Industrial Chemistry. Weinheim, Germany: Wiley-VCH; April 15, 2012. https://docslide.us/documents/ullmanns-encyclopediaof-industrial-chemistry-polymers-high-temperature.html. Accessed February 28, 2018 13. Sauget E, Covell DA Jr, Boero RP, Lieber WS. Comparison of occlusal contacts with use of Hawley and clear overlay retainers. Angle Orthod. 1997; 67(3):223-230. Surgical Technologies; MedShape Solutions, Inc. 14. announces first FDA-cleared shape memory PEEK device [news release]. Medshape; September 23, 2009. https://www.medshape.com/news-events/40-medshapesolutions,-inc-announces-first-fda-cleared-shapememory-peek-device-closing-of-$10m-equity-offering. html. Accessed February 28, 2018. 15. 3D printing high-strength carbon composites using PEEK, PAEK [news release]. Design News; April 14, 2014. https:// www.designnews.com/design-hardware-software/3dprinting-high-strength-carbon-composites-using-peekpaek/143795958032579. Accessed February 28, 2018. 16. Zachrisson BJ. Third-generation mandibular bonded lingual 3-3 retainer. J Clin Orthod. 1995;29(1):39-48

Volume 9 Number 3

Fol low

us!

SMALL TALK

A critical distinction: problem solver versus people developer Dr. Joel C. Small offers a technique for creative problem solving

often encounter doctor clients who are frustrated by their team’s lack of ability to achieve a pre-defined, desired result. The scenario goes something like this: Coach: I hear that you are frustrated. Give me more detail. Doctor: Okay. Well, no matter how many times I tell my staff what I want them to do, they are unable to consistently get it right. Even worse, they are constantly coming to me with problems that they should be able to manage. It seems as if they can’t make decisions on their own. I’m too busy to keep repeating myself, and I get frustrated when they come to me needlessly to solve every simple problem. I’ve tried everything I know to change this situation, but to no avail. Coach: Everything? Have you tried becoming a “people developer”? Doctor: I don’t know what that means. Tell me more please. Any coach, in any industry, will recognize this scenario because the premise knows no boundaries. The good news is that even though the problem is universal, so is the solution. The answer lies in understanding the distinction between a “problem solver” and a “people developer.” The doctor in the above scenario is a problem solver. By this I mean that he/ she issues directives without tying them to the foundational principles of the practice. Secondly, he/she has failed to create a practice environment that is conducive to ongoing personal development. How do I know this to be true? Simple. If the doctor had been a “people developer,” he/she would not be plagued with these problems. As we shall see, it is the doctor, not the staff, who has created the problem.

Almost invariably, problem solvers fail to define the purpose of their directives and how the specific purpose correlates with the fundamental practice purpose and values. This is assuming that the doctor has even defined and shared these ideals with the staff. This lack of communication leaves a void that is filled by each team member’s own interpretation of purpose. Purpose is a strong determinant of action, so we can only imagine the confusion and frustration when a team with varying interpretations of purpose tries to achieve a common goal. Furthermore, problem solvers will always be plagued with never-ending questions from their team. Frankly, the problem and solution revolve around our expectations of our staff. Do we expect them to be helpless? Are we okay with their unwillingness and apparent inability to answer even the simplest of questions? I would expect that even the most devout problem solvers would say “No!” and yet they fail to see that they impose the very environment that promotes these forms of learned helplessness. The more we continue to answer questions, the more we become entrenched in the problem solvers’ mentality, and the more our staff is willing to abrogate their creative ability to solve problems on their own. The answer is for us to commit to developing these God-given skills in those who serve our cause. We do this by seeking their input to creative problem solving. We do this by becoming people developers. I am reminded of the old Chinese proverb, “Give a man a fish, and you feed him for a day. Teach a man to fish, and you feed him for a lifetime.” And so it is with people developers. We must first believe that someone is able to fish, or

Joel C. Small, DDS, MBA, FICD, is a practicing endodontist and the author of Face to Face: A Leadership Guide for Healthcare Professionals and Entrepreneurs. He received his MBA, with an emphasis in healthcare management, from Texas Tech University. He is a graduate of the University of Texas at Dallas postgraduate program in executive coaching and limits his coaching practice to motivated healthcare professionals. He is a nationally recognized speaker on the subjects of leadership and professional development. Dr. Small is available for speaking engagements and for coaching healthcare professionals who wish to experience personal and professional growth while taking their practices to a higher level of productivity. **To receive a free copy of Dr. Small’s “Core Values Exercise,” please contact the author at joel@joelsmall.com. He is also available for a complimentary coaching session to discuss your practice-related issues.

44 Orthodontic practice

in this case, solve problems on his/her own. Believing that something can be done will eventually become an expectation that it will be done, and expectations have been shown to be powerful self-fulfilling prophesies. Our team looks to us for answers when we fail to develop their problem-solving skills. If we find ourselves in this situation, here’s a simple solution. First, let the team know that you will be seeking their input to problem solving; then immediately quit answering questions. When someone comes to you seeking a solution to a problem, tell him/her that you have a solution, but you would like to hear his/her solution first. In many cases, that staff member’s solution will work quite well or will require minimal adjustments. Always make a clear correlation between the solution and the guiding practice values and purpose. Over time, staff members will realize that you will not be answering questions without their input. More importantly, they will realize that their solutions are good solutions, and with your support and encouragement, they will begin to solve problems independently within the confines of the practice’s purpose and values. It is important at this juncture to be clear regarding decisions that you feel require your input. Surprisingly, as the people development process progresses, you will find that your input is required less and less. Fundamental to the people development process is a willingness by the leader to encourage input, acknowledge it when received, and affirm its value. People developers will tell you that they have grown to rely on their staff’s problemsolving capabilities. I can tell you that I have personally observed very positive changes in practices that have adopted a peopledevelopment mentality. OP Volume 9 Number 3

CONTINUING EDUCATION

or years I have heard dentists complain that their young patients receive orthodontics in their teens, grind their teeth in their twenties, and experience TMD symptoms in their thirties. Dentists are not happy with the orthodontic treatment their young patients are receiving because dentists feel orthodontists are seeking an esthetic result instead of a functionally balanced occlusion. As an orthodontist who also possesses a TMD practice, I will have to admit that many referring dentists have sent TMD cases to me that have undergone orthodontic treatment previously. Whether TMD patients have had orthodontic treatment in their past or not, the common denominator for most TMD patients is that they possess a “dual bite.” With the aid of cone beam computed tomography (CBCT), I have been able to properly construct a superior repositioning splint to achieve a seated condylar position and muscle relaxation. Many of my colleagues before me have achieved this muscle relaxation phenomenon.1-8 Condylar position has been evaluated over the years based on the position of the meniscus. Sicher, et al.9 felt that if the close relationship between the eminence and the condyle were lost due to disc displacement, there should be changes in the joint space. Christiansen, et al.10,11 analyzed computed tomograms of temporomandibular joints to study changes in the joint space associated with disc displacement. Ikeda and

Dr. Robert Kaspers received his DDS with honors from the University of Michigan. He then completed specialty training in orthodontics at the Northwestern University Dental School and earned a Master of Science degree in Radiology. While in Ann Arbor, Dr. Kaspers worked with Dr. Major Ash on research projects pertaining to temporomandibular dysfunction. Dr. Kaspers has lectured to hundreds of dentists and orthodontists on diagnosis and treatment for both orthodontic and TMD cases. Dr. Kaspers is the founder of the Five Condylar Positions©, which has helped make diagnosing and treatment planning easier for the practitioner. Dr. Kaspers is the founder of ProActive Orthodontics, and it is his desire to help the profession understand the advantages of the CBCT scan machine so that diagnosis of orthodontic cases can be made more easily and more accurately. Currently, Dr. Kaspers maintains a private orthodontic and TMD practice in Northbrook, Illinois.

46 Orthodontic practice

Educational aims and objectives

This article aims to demonstrate how orthodontists can detect condylar positions with 3D imaging.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 51 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Realize how condylar position has been evaluated over the years. •

Identify the five condylar positions.

•

Realize the similarities and differences in condylar positions Nos. 4 and 5 in relation to the others.

•

Recognize the definite advantage of utilizing a CBCT scan to help accurately diagnose condylar positions.

Figure 1

Figure 2

Kawamura12 have shown that the optimal condylar position in the glenoid fossa can be calculated using a CBCT scan. Their studies concluded that in healthy joints, the joint spaces (anterior space, superior space, and posterior space) showed consistent mean values of 1.3 mm (AS), 2.5 mm (SS), and 2.1 mm (PS), thereby verifying a concentric position of the condyle (Figure 1). In clinical practice, orthodontic patients who are asymptomatic will not spend the money to try to establish a seated condylar position by utilizing a superior repositioning splint or other appliances. A cone beam CT scan would give the clinician the ability to make a proper diagnosis and treatment plan at the beginning of a patient’s treatment. The research performed at the University of Detroit-Mercy’s orthodontic program disclosed two new condylar positions.

Figure 3

The current literature discusses only three condylar positions: seated, protruded, and retruded.13 By taking a limited cone beam CT scan in maximum intercuspation (MI), I can determine the effect of the dentition on the condylar position. My findings concluded that the occlusion has a major effect on the condylar position. My Five Condylar Positions© are as follows: 1. Seated condylar position presents the appearance of a condyle being concentric in the glenoid fossa. The condylar position is usually referred to as “centric relation” ( Figure 2). 2. Protruded position of the condyle is where the condyle appears forward on the eminence. The anterior joint space (AS) is similar to the seated condylar position; however, the superior joint space and the posterior joint Volume 9 Number 3

Volume 9 Number 3

Figure 4

Figure 5

Figure 6

Figure 7: The “retruded and down condylar position” is created when the patient pivots around a posterior premature contact (usually a molar) to achieve maximum intercuspation (MIP). The patients activate their lateral pterygoid muscles to move the mandible forward and then activate their masseter and medial pterygoid muscles to close down into MIP

A cone beam CT scan would give the clinician the ability to make a proper diagnosis and treatment plan at the beginning of a patient’s treatment. interference. The clinician will realize that the correct way to treat this patient is to intrude the maxillary molars to help auto-rotate the mandible closed. Many clinicians have stated that a patient cannot physically pivot around a 12-year molar because the pivot point is in front of the masseter and medial pterygoid muscles. If the patient only used his/her masseter and medial pterygoid muscles, those clinicians would be correct. However, the retrudedand-down condylar position is created because the patient must first activate his/ her lateral pterygoid muscles and then activate the masseter and medial pterygoid muscles to close down into MI.

Case 1 The following case is an example of a patient, Samantha, with the “retruded-anddown” condylar position. Samantha was treated by an orthodontist who diagnosed

her with 2D radiographs. After seeing several other clinicians, she had a CBCT scan in my office because she was clicking with both of her jaw joints and had pain with her masseter muscles. In the initial CBCT scan of Samantha (Figure 8), both condyles showed a retrudedand-down condylar position, while the lateral cephalogram looks balanced. I explained to Samantha and her parents that she was pivoting around her 12-year molars to acquire bite. However, Samantha had seen five to six doctors prior to coming to my office, and all of them had a similar diagnosis — that Samantha had arthritic changes in her right temporomandibular (TM) joint — but they could not guarantee any change in her current condition. I decided to place Samantha in a bite plate that she would wear full time except when she ate or brushed her teeth. I informed Samantha and her parents that Orthodontic practice 47

CONTINUING EDUCATION

space are considerably larger. The patient possesses a skeletal Class II discrepancy with the maxilla forward of the mandible, and the patient has to position the lower jaw forward to achieve maximum intercuspation (Figure 3). The patient’s airway is more constricted when the condyle is seated. 3. Retruded position of the condyle is where the patient’s maximum intercuspation forces the mandible distally. The anterior joint space (AS) increases in size while the superior joint space (SS) increases slightly, and the posterior joint space (PS) decreases in size (Figure 4). 4. Retruded condyle which is down in the fossa is a condylar position created when the patient fulcrums around a posterior contact (usually a molar) to achieve maximum intercuspation. Both the anterior joint space (AS) and the superior joint space (SS) have increased in size, while the posterior joint space (PS) has decreased in size. This condylar position is achieved when the patient activates the lateral pterygoid muscles (thereby moving the mandible forward) and then activates the masseter and medial pterygoid muscle to close down into MI (Figure 5). 5. Centered condyle which is down in the fossa is a condylar position created when the patient fulcrums around a first premature contact and holds the mandible considerably forward to achieve MI. The difference between this position and the retruded-and-down condylar position is that this position possesses a significantly larger skeletal Class II component and a larger vertical component (a larger anterior open bite) (Figure 6). Condylar positions Nos. 4 and 5 are similar in design but quite different in the degree of the anterior-posterior and vertical discrepancy. Both condylar positions are developed by having the mandible fulcrum around a posterior interference. Roth defined the fulcrum as a condition in which the condyle distracts away from the eminence when the mandible closes into maximum intercuspation.14 Note in Figure 7 that the clinician has a definite advantage utilizing a CBCT scan to help accurately diagnose when a patient has fulcrumed around a posterior

CONTINUING EDUCATION

Figures 8A-8D

Figure 9A

when Samantha removed her bite plate in the morning to have breakfast, she would bite first on her 12-year molars. After only a few weeks, Samantha had no more pain with her masseter muscles. The clicking of her TM joints had reduced considerably, but as I predicted, she would click more when she ate. Samantha’s condyles would distract away from the eminence when she chewed food, and consequently, the meniscus would become anteriorly displaced. Ironically, at the time, I was still influenced by my prior teaching, believing since Samantha was no longer symptomatic, and her bite had changed so dramatically, that I had achieved a seated condylar position. However, to my surprise, when I took a CBCT scan 3 weeks after delivering the bite plate, I observed very little change in the condylar position (Figure 9). I did not realize until much later that it might take time for the morphology of the joint to change and acquire a seated condylar position. The fifth condylar position — the centered-and-down condylar position — continues to amaze me at just how 48 Orthodontic practice

Figures 9B-9D Volume 9 Number 3

far these patients fulcrum around a posterior interference to acquire maximum intercuspation. A clinician would be wise to find out how much of an anterior-posterior and vertical discrepancy actually exists when the CBCT scan shows this condylar position. For that reason, I would have the patient wear a superior repositioning splint to find out the severity of the case. In Figure 10, on the left side, the patient is biting into MI, but the condyle is in a “centered-and-down” position. However, if the same patient’s condyle was allowed to fully seat into the glenoid fossa, the patient’s occlusion would be considerable more Class II and considerably more open.

Case 2

Figure 11: August 2011

The next case is an example of a patient, Maddie, with a “centered-and-down” condylar position. In Figure 11, Maddie has pivoted around her molars to acquire maximum intercuspation. You can see in the CBCT scan in Figure 12 how the right condyle possesses a “centered-and-down” position. In Figures 13 and 14, Maddie’s condyles are seated, and she is significantly more open and more Class II. CBCT scans give you information ahead of time so the clinician can adjust his/her treatment plan. Maddie clearly needed orthognathic surgery to help advance her lower jaw and close her open bite. However, it be imperative for Maddie to wear a splint prior to having surgery to make sure the morphology of the right TM joint has changed to a seated condylar position, or the surgery may not be successful.

Discussion Figures 12A-12B Volume 9 Number 3

At this point in this article, you may be asking yourself how often you will encounter Orthodontic practice 49

CONTINUING EDUCATION

Figures 10A-10B: The “centered and down condylar position” is created when the patients pivot around a first premature contact and hold their mandible forward to achieve MIP. The difference between this position and the “retruded and down condylar position” is that this position possesses a significantly greater anterior-posterior and vertical discrepancy. When the patient’s condyle assumes a seated condylar position, the occlusion is significantly more Class II and more open

CONTINUING EDUCATION an asymmetrical condylar position. When writing a research paper at the University of Detroit-Mercy Orthodontic program, I examined 220 consecutive patients, and the results were eye-opening: Only 3.2% of the patients studied had both condyles in a seated position. The results of the research showed the following:

• Seated condylar position º 7/220 had “both” condyles fully seated (only 3.2%) º 62/220 had at least one fully seated condyle (28.2%) • Protruded condylar position º 78/220 had “both” condyles protruded in the fossa (35.4%)

º 148/220 had at least one protruded condyle (67.3%) • Retruded condylar position º 6/220 had “both” condyles retruded in the fossa (2.7%) º 21/220 had at least one retruded condyle (9.5%) • Retruded-and-down condylar position º 25/220 had “both” condyles “retruded-and-down” (11.4%) º 65/220 had at least one “retruded-and-down” condyle (29.5) • Centered-and-down condylar position º 6/220 had “both” condyles “centered-and-down” (2.7%) º 34/220 had at least one “centered-and-down” condyle (15.4%)

Conclusion

Figure 13

Upon reviewing the data, the protruded condylar position is the most common. However, it is important to note that approximately 40% of patients will be pivoting around a posterior interference to achieve maximum intercuspation. Hopefully, orthodontists everywhere will soon realize the advantages of 3D technology. OP

REFERENCES 1. Shore NA. Temporomandibular Joint Dysfunction and Occlusal Equilibration. 2nd ed. Philadelphia, PA: JB Lippincott; 1976. 2. Williamson EH. A technique for construction of superior repositioning splints. Facial Orthop Temporomandibular Arthrol. 1986:27. 3. Humsi ANK, Naeije M, Hippe H, Hansson TL. The immediate effects of a stabilization splint on the muscular symmetry in the masseter and anterior temporal muscles of patients with a cranio-mandibular disorder. J Prosth Dent. 1989;62(3):339-343. 4. Naeije M. Muscle physiology relevant in craniomandibular disorders. J Craniomandib Disord; Facial & Oral Pain. 1988;2(3):153-157. 5. Gilboe DB. Centric relation as the treatment position. J Prosth Dent. 1983;50(5):685-689. 6. Dyer EH. Importance of a stable maxilla-mandibular relation. J Prosth Dent. 1973;30(3):241-251. 7. Dawson PE. Temporomandibular joint pain-dysfunction problems can be solved. J Prosth Dent. 1973;29(1):100-112. 8. Roth RH. Temporomandibular pain-dysfunction and occlusal relationships. Angle Orthod. 1973;43(2):136-153. 9. Sicher H, DuBrul EL. Sicher’s Oral Anatomy. 5th ed. St. Louis, MO: C.V. Mosby; 1980. 10. Christiansen EL, Chan TT, Thompson JR, et al. Computed tomography of the normal temporomandibular joint. Scand J Dent Res. 1987;95(6):499-509 11. Christiansen EL, Thompson JR, Zimmerman G, et al. Computed tomography of condylar and articular disk positions within the temporomandibular joint. Oral Surg Oral Med Oral Pathol. 1987;64(6):757-767. 12. Ikeda K, Kawamura A. Assessment of optimal condylar position with limited cone-beam computed tomography. Am J Orthod Dentofacial Orthop. 2009;135(4):495-501.

Figure 14: February 2012 50 Orthodontic practice

13. Pullinger A. The significance of condyle position in normal and abnormal temporomandibular joint function. In: Clark GT, Solberg W, eds. Perspectives in temporomandibular disorders. Chicago, IL: Quintessence; 1987.

Volume 9 Number 3

REF: OP V9.3 KASPERS

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Cone beam computed tomography guides orthodontists to detect condylar position through precise diagnosis and treatment options KASPERS 1. Whether TMD patients have had orthodontic treatment in their past or not, the common denominator for most TMD patients is that they possess ________. a. a â&#x20AC;&#x153;dual biteâ&#x20AC;? b. a supernumerary tooth c. a tendency toward bruxism d. a history of multiple extractions 2. With the aid of _______, I (Dr. Kaspers) have been able to properly construct a superior repositioning splint to achieve a seated condylar position and muscle relaxation. a. panoramic imaging b. cone beam computed tomography (CBCT) c. multiple specialists d. 2D imaging 3. Condylar position has been evaluated over the years based on the position of the _______. a. tubercle b. hypoglossal canal c. meniscus d. glenoid fossa 4. Their studies (Ikeda and Kawamura) concluded that in healthy joints, the joint spaces (anterior space, superior space, and posterior space) showed consistent mean values of _______, thereby verifying a concentric position of

Volume 9 Number 3

the condyle. a. 1.3 mm (AS), 2.5mm (SS), and 2.1 mm (PS) b. 2.5 mm (AS), 1.3 mm (SS), and 2.1 mm (PS) c. 2.1 mm (AS), 1.3 mm (SS), and 2.5. mm (PS) d. 1.3 mm (AS), 2.1 mm (SS), and 2.5 mm (PS) 5. (In the retruded position of the condyle) The anterior joint space (AS) ________ in size while the superior joint space (SS) increases slightly, and the posterior joint space (PS) decreases in size. a. decreases b. decreases slightly c. increases d. remains stable 6. This condylar position (Retruded condyle which is down in the fossa) is achieved when the patient activates the lateral pterygoid muscles (thereby moving the mandible forward) and then activates the _______ to close down into MI. a. masseter muscle b. medial pterygoid muscle c. externus muscle d. both a and b 7. The difference between this position (Centered condyle which is down in the fossa) and the retruded-and-down condylar position is that this position possesses a significantly larger

skeletal _________ component and a larger vertical component (a larger anterior open bite). a. Class I b. Class II c. Class III d. Class IV 8. In the initial CBCT scan of Case 1, Samantha (Figure 8), both condyles showed a retrudedand-down condylar position, while the lateral cephalogram _______. a. showed the same position b. showed arthritis c. looks balanced d. none of the above 9. In Case 2, Maddie clearly needed _____ to help advance her lower jaw and close her open bite. a. aligner therapy first b. several extractions c. orthognathic surgery d. nighttime headgear 10. It is important to note that approximately ______ of patients will be pivoting around a posterior interference to achieve maximum intercuspation. a. 10% b. 20% c. 30% d. 40%

Orthodontic practice 51

CE CREDITS

ORTHODONTIC PRACTICE CE

CONTINUING EDUCATION

Controlling the vertical dimension Dr. Larry White discusses principles gained from current knowledge regarding the vertical dimension of the maxilla and mandible Abstract The vertical dimension in orthodontics remained unimportant and unexplored until Fred Schudy began his epochal studies and publications in the 1960s. Until then, orthodontists presumed that most maxillarymandibular sagittal discrepancies were due to horizontal growth deviations, and subsequently, practically all orthodontic therapies were designed with horizontal interventions. Class II malocclusions in particular were typically treated with horizontal mechanics without regard to vertical growth and/or biomechanical features that might influence the vertical position of the mandible. Subsequently, orthodontists slowly began to seek remedies that addressed the vertical component of malocclusions with directional-pull headgears, limitation of classical Class II elastics, molar holding arches, repelling springs and magnets, jaw surgery, and more recently, the intrusion of molars with temporary anchorage devices (TADs). This article will illustrate some of the principles gained from current knowledge regarding the vertical dimension of the maxilla and mandible and a possible easily applied remedy for controlling the deleterious effects of too much vertical dimension.

Introduction In 1963, Fred Schudy1-5 began publishing articles regarding the influence that the vertical dimension has on occlusion, facial development, and appearance. Until that time, orthodontists were firmly convinced that the vertical position of teeth had little or no influence on the correction of malocclusions, and that conviction stayed entrenched for several more years. Convinced that controlling the vertical eruption of maxillary and mandibular molars was critical in the treatment of Class II malocclusions, Schudy and Creekmore developed a directional-pull headgear that sought to limit the eruption of the maxillary molars and possibly to intrude them.

Educational aims and objectives

This article aims to discuss some of the principles gained from current knowledge regarding the vertical dimension of the maxilla and mandible and a possible easily applied remedy for controlling the deleterious effects of too much vertical dimension.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 55 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify some history regarding the vertical dimension in orthodontics. •

Identify some possible treatments for correction of facial vertical excesses.

•

Realize some inadequacies of previous attempts to control the vertical dimension.

•

See a mechanism for applying intrusive forces to maxillary and mandibular molars simultaneously.

For a time, surgical interventions via the Le Fort 1 procedure6-9, which impacted the maxillary arch, were the gold standard for certainty and stability in the corrections of facial vertical excesses. As the truth of Schudy’s discoveries began to take hold, others attempted to control the vertical development of the posterior occlusion with various appliances. Dellinger11,12, Barbre12, Darandellier13, Joho14, Killaridis15, and Woods16 among others had some success controlling molar eruption with magnetic appliances, while others recorded some success with bite blocks17-19. Some tried spring-loaded appliances20-21, while others22 reported some success with removable apparatuses. Unfortunately, most of the previously mentioned techniques proved too unwieldy and never gained more than minimal professional endorsement and use. In 1983, Creekmore23 excited orthodontics with his use of a surgical screw to intrude maxillary incisors and reveal the possibility of skeletal anchorage heretofore untried in orthodontics to control the vertical dimension. Within 15 years, others, notably in Japan24 and South Korea25-29, developed

Figure 1: Rapid Molar Intrusion appliance of Carano; used with permission from the Angle Orthodontist, 2005:5(5):736-746

techniques for intruding teeth with screwsecured bone plates or mini-screws. Carano30,31 developed an interesting concept for intruding maxillary and mandibular molars simultaneously by using a modified Jasper Jumper (Figure 1) that he called the Rapid Molar Intrusion Appliance (RMI). Although capable of closing anterior bites, the appliance has not proven popular for a couple of reasons: It required headgear tubes on both molars bands, maxillary and mandibular lingual arches, and the jumper material quickly fatigued and needed frequent, difficult, and expensive changes.

Larry White, DDS, MSD, FACD, is in Private Practice of Orthodontics in Dallas, Texas.

Figure 2: 35 mm NiTi (Soft Spring) closed coil spring with eyelets (JES Orthodontics, Fort Lauderdale, Florida) 52 Orthodontic practice

Volume 9 Number 3

Figure 4: 35 mm NiTi molar intrusion spring installed fully extended

More recent studies by Buschang,32,33 et al., have illuminated some of the inadequacies of previous attempts to control the vertical dimension with the previously mentioned techniques. In their study, where only the maxillary molars intruded with TADs, the mandibular molars erupted and negated much of the gains from the maxillary molar intrusion. When they subsequently intruded both maxillary and mandibular molars, the anterior open bite closed, the mandible rotated forward, and the chin projected forward. Obviously, when only one arch receives treatment, whether it is with headgears, mini-screws, bone plates, or removable appliances, it only achieves an ineffective, compromised result.

New instrumentation Carano's idea takes on a new and needed cogency, and the strategy needs only improved materials and a simpler attachment method, which the illustrated therapy provides. A 35 mm NiTi closed coil spring shown in Figure 2 (Soft Spring) with eyelets provides an ideal mechanism for applying intrusive forces to maxillary and mandibular molars simultaneously. Figures 3 and 4 illustrate this new NiTi molar intrusion spring with a typodont. As the mouth closes, the spring assumes a U-shape that places equally light intrusive pressures on the maxillary and mandibular molars. But those pressures work constantly and do not require large forces to effect their result. Weinstein34 showed in 1967 how constant forces as low as 1.68 gm could produce measurable effects, and clearly the forces produced by the Soft Springs (50 gm to 75 gm) have that clinical capability.

Figure 5: Patient with an anterior open bite

Patient therapy The photos in Figures 5-8 illustrate the potential this new molar intrusion spring has. Volume 9 Number 3

Figure 6: The malocclusion after 1 month of therapy with intruding springs Orthodontic practice 53

CONTINUING EDUCATION

Figure 3: Activated 35 mm NiTi closed coil spring with eyelets

CONTINUING EDUCATION Note the maxillary and mandibular lingual arches that negate the facial moments the intrusion springs create on the molars.

Summary After 3 months with molar intrusion springs, the patient is ready to complete the bonding of posterior brackets and fulfillment of treatment. Obviously, one successful anterior bite closure patient cannot offer unequivocal endorsement for universal employment. Nevertheless, this technique presents an instrument that satisfies the most current research that encourages clinicians to simultaneously intrude maxillary and mandibular molars rather than concentrating intrusion therapy in only one arch. Also, clinicians need to realize that when the banded and bonded appliance includes incisors, those teeth will receive an eruptive force even as the molars receive intrusive forces. Regardless of the

primary corrective feature, the technique shows promise in correcting open bites. Additionally, these NiTi springs provide a comparatively inexpensive, noninvasive, and simply implemented method of intruding molars in both arches while concurrently aiding in the extrusion of the anterior teeth. Greater use of the NiTi intrusion springs in anterior open bite patients will reveal any deficiencies inherent in the technique, but the limited experience thus far has shown good acceptance by patients, little interference with occlusal functions and minimum breakage. OP

4. Schudy FF. The cant of the occlusal plane and axial inclinations of the teeth. Angle Orthod. 1963;33(2):69-82. 5. Schudy FF. The association of anatomical entities as applied to clinical orthodontics. Angle Orthod. 1966;36:190-203. 6. Schendel SA, Eisenfeld J, Bell WH, Epker BN, Mishelevich DJ. The long face syndrome: vertical maxillary excess. Am J Orthod. 1977;70(40):398-408. 7. Bell WH, Proffit WR, White R. Surgical correction of dentofacial deformities. Philadephia, PA: B. Saunders Company; 1980. 8. Schendel SA, Eisenfeld J, Bell WH, Epker BN, Mishelevich DJ Superior repositioning of the maxilla: stability and softtissue relations. Am J Orthod. 1976;70:633-674. 9. Bell WH, Creekmore TD, Alexander RG. Surgical correction of the long face syndrome. Am J Orthod. 1977;71(1):40-67. 10. Dellinger, E., Active vertical corrector treatment--longterm follow-up of anterior open bite treated by the intrusion of posterior teeth. Am J Orthod Dentofacial Orthop. 1996;110(2):145-154.

REFERENCES

11. Dellinger, EL. A clinical assessment of the Active Vertical Corrector--a nonsurgical alternative for skeletal for skeletal open bite treatment. Am J Orthod Dentofacial Orthop. 1986;89(5):428-436.

1. Schudy FF. Vertical growth versus anteroposterior growth as related to function and treatment. Angle Orthod. 1964; 34(2):75-93.

12. Barbre R, Sinclair PM., A cephalometric evaluation of anterior openbite correction with the magnetic Active Vertical Corrector. Angle Orthod. 1991;61:93-102.

2. Schudy FF. The rotation of the mandible resulting from growth: Its implications in orthodontic treatment. Angle Orthod. 1965;35:36-50.

13. Darendeliler MA, Yüksel S, Meral O. Open-bite correction with the magnetic activator device IV. J Clin Orthod. 1995;29(9):569-576.

3. Schudy FF. The control of vertical overbite in clinical orthodontics. Angle Orthod. 1968;38:19-39.

14. Joho JPD. Correction of Class II/1 malocclusions with the help of a magnetic field. In: Mechanical and Biological Basics in Orthodontic Therapy. Hoesl E, Baldauf A, eds. Heidelberg, Germany: Hütig; 1997. 15. Kiliaridis S, Egermark I, Thilander B.Anterior open bite treatment with magnets. Eur J Orthod. 1990;12(4):447-457. 16. Woods MG, Nanda RS. Intrusion of posterior teeth with magnets: An experiment in growing baboons. Angle Orthod. 1988;58(2):136-150. 17. Kuster R, Ingervall B. The effect of treatment of skeletal open bite with two types of bite-blocks. Eur J Orthod. 1992;14:(6)489-499. 18. Melsen BF, Giorgio F. Upper Molar Intrusion. J Clin Orthod. 1996;30:(2):91-96. 19. Melsen B, McNamara J, Hoenie D. The effect of bite-blocks with and without repelling magnets studied histomorphometrically in the rhesus monkey (Macaca mulatta). Am J Orthod. 1995;108(5):500-509. 20. Işcan H, Akkaya S, Koralp E. Effects of spring-loaded posterior bite-bloc appliance on masticatory muscles. Eur J Orthod. 1992;14:54-60. 21. Akkaya SS, Haydar S, Bilir E. Effects of spring-loaded posterior bite-block appliance on masticatory muscles. Am J Orthod Dentofacial Orthop. 2000; 118:179-193. 22. Alessandri Bonetti G, G.D. Molar Intrusion with a Removable Appliance. J Clin Orthod. 1996;30(8):434-437.

Figure 7: The malocclusion after 2 months of therapy with intruding springs

23. Creekmore TD, Eklund MK. The possibility of skeletal anchorage. J Clin Orthod. 1983;17(4):166-169. 24. Umemori M, Sugawara J, Mitani H, Nagasaka H, Kawamura H. Skeletal anchorage system for open bite correction. Am J Orthod Dentofacial Orthop. 1999;115:166-174. 25. Park, HS The use of micro-implant orthodontic anchorage. 2001, Seoul: Nare Publishing Co. 26. Park HS, The skeletal cortical anchorage using titanium microscrew implants. Kor. J. Orthod., 1999;29:699-706. 27. Park HS, Jang SL, Kyung HM. Micro-implant anchorage for lingual treatment of a skeletal Class II malocclusion. J Clin Orthod. 2001;35(11):643-647. 28. Park HS, Bae SM, Kyung HM, Sung JH. Micro-implant anchorage (MIA) for treating skeletal Class I bialveolar protrusion. J. Clin. Orthod. 2001; 35(7):417-422. 29. Bae SM, Park HS, Kyung HM, Kwon OW, Sung JH., Clinical application of micro-implant anchorage. J Clin Orthod. 2002;36(5):298-302. 30. Carano A, Siciliani G, Bowman SJ. Treatment of Skeletal Open Bite with a Device for Rapid Molar Intrusion: A Preliminary Report. Angle Orthod. 2005;75(5):736-746. 31. Carano, A.a.M., W.C.. A rapid molar intruder for “noncompliance” treatment. J Clin Orthod. 2002;36(3):137-142. 32. Buschang P, Jacob H, Chaffee M. Vertical control in Class II hyperdivergent growing patients using miniscrewimplants: a pilot study. Journal of the World Federation of Orthodontists, 2012;1: e13 - e18. 33. Buschang P, Carrillo P, Rossouw Orthopedic Correction of Growing Hyperdivergent, Retrognathic Patients With Miniscrew Implants. J Oral Maxillofac Surg. 2011;69:754-762.

Figure 8: The malocclusion after 3 months of therapy with intruding springs 54 Orthodontic practice

34. Weinstein S. Minimal forces in tooth movement. International Journal of Orthodontia and Dentistry for Children. 1967;53(12)881-903.

Volume 9 Number 3

REF: OP V9.3 WHITE

FULL NAME

AGD REGISTRATION NUMBER

LICENSE NUMBER

ADDRESS

CITY, STATE, AND ZIP CODE

TELEPHONE/FAX

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

Controlling the vertical dimension WHITE

1. In 1963, Fred Schudy began publishing articles regarding the influence that the vertical dimension has on _______. a. occlusion b. facial development c. appearance d. all of the above 2. Convinced that controlling the vertical eruption of maxillary and mandibular molars was critical in the treatment of _______ malocclusions, Schudy and Creekmore developed a directional-pull headgear that sought to limit the eruption of the maxillary molars and possibly to intrude them. a. Class I b. Class II c. Class III d. Class IV 3. For a time, surgical interventions via the ______ procedure, which impacted the maxillary arch, were the gold standard for certainty and stability in the corrections of facial vertical excesses. a. Le Fort I b. LeFort II c. maxillary segmental osteotomy d. vertical ramal osteotomy 4. (Regarding Caranoâ&#x20AC;&#x2122;s Rapid Molar Intrusion Appliance) Although capable of closing anterior

Volume 9 Number 3

bites, the appliance has not proven popular for a couple of reasons: It required headgear tubes on both molars bands, maxillary and mandibular lingual arches, and the jumper material quickly fatigued and needed _______ changes. a. frequent b. difficult c. expensive d. all of the above 5. In their (Buschang, et al.) study, where only the maxillary molars intruded with ______, the mandibular molars erupted and negated much of the gains from the maxillary molar intrusion. a. TADs b. RMIs c. headgear d. removable appliances 6. A _______ shown in Figure 2 (Soft Spring) with eyelets provides an ideal mechanism for applying intrusive forces to maxillary and mandibular molars simultaneously. a. 35 mm open coil spring b. 35 mm stainless steel open coil spring c. 35 mm NiTi closed coil spring d. 28 mm stainless steel closed spring 7. As the mouth closes, the spring (new NiTi molar intrusion spring with a typodont) assumes a ____ that places equally light intrusive pressures

on the maxillary and mandibular molars. a. U-shape b. V-shape c. S-shape d. straight-shape 8. After ______ with molar intrusion springs, the patient is ready to complete the bonding of posterior brackets and fulfillment of treatment. a. 3 weeks b. 6 weeks c. 2 months d. 3 months 9. Also, clinicians need to realize that when the _________ includes incisors, those teeth will receive an eruptive force even as the molars receive intrusive forces. a. banded appliance b. bonded appliance c. removable appliance d. both a and b 10. Additionally, these NiTi springs provide a ______ method of intruding molars in both arches while concurrently aiding in the extrusion of the anterior teeth. a. comparatively inexpensive b. noninvasive c. simply implemented d. all of the above

Orthodontic practice 55

CE CREDITS

ORTHODONTIC PRACTICE CE

PRODUCT FOCUS

Carestream Dental and the Orthodontic Solution

t automatically traces cephalometric images! It tracks clear aligner therapy! It juliennes fries! Well, not exactly, but wouldn’t it be nice if there were one piece of equipment that met all of an orthodontist’s needs? To never have to purchase another gadget that may or may not get used? We may still be a few years away from such an all-in-one device, but in the meantime, we have the next best thing: Integrated systems. Integration is more than a buzzword; it’s a concept that redefines the workflow of a practice to make everyday tasks more efficient and streamlined. A neatly organized bulleted list that walks you through what an integrated workflow should look like is deceiving. True integration isn’t linear; it’s cyclical — overlapping, backtracking, and weaving through every aspect of the office. However, one thing is certain: Systems that integrate easily combine to create one powerful orthodontic solution.

Practice management software It all starts with software. From the time patients check in for their first appointment to when they finish treatment, their entire journey is documented in that all-important

CS OrthoTrac v14’s treatment card

practice management system. However, whenever a user has to navigate away from the software — to import a digital impression into the patient record, make note of clear aligner therapy, etc.— it wastes time, reduces efficiency, and may even lead to errors. Instead, using a practice management system that can integrate with imaging equipment makes it easier for the practice to maintain a single digital record for all patients, cutting back on clicks, navigation, and searching for patient records or images across multiple systems. For example, CS OrthoTrac v14’s redesigned treatment card consolidates previews of clinical images all in one place. Additionally, add-on modules enhance the software’s capabilities and reduce clicks

CS 8100SC 3D CS 9300C 56 Orthodontic practice

even further. eConnections, for example, can integrate directly within CS OrthoTrac to help practices manage, market, and grow their practice, without having to navigate to a system outside of their software.

Imaging Cone beam computed tomography (CBCT) is a growing trend in orthodontics that has many doctors wondering if it’s worth the investment. Going back to our kitchen gadget analogy, keeping a blender, food processor, and stand mixer on the counter looks cluttered and encroaches on workspace. Similarly, few offices have the space for the all-important panoramic/cephalometric imaging system, room to accommodate CBCT upgrades, and a separate desktop laser scanner (to scan impression or models). However, when it comes to imaging, there actually are a few all-in-one solutions. The CS 8100SC 3D and CS 9300C combine panoramic and cephalometric imaging, cone beam computed tomography, and 3D object scanning to meet the growing demands of busy orthodontic practices. Each practice can choose what best fits its needs — the small footprint of the CS 8100SC 3D with selectable fields of view, or the power of a single 3D scan from the CS 9300C to create any orthodontic view desired. The systems’ CS Orthodontic Imaging software even offers automatic landmark detection that can trace a ceph in as little as 90 seconds, which can increase case acceptance. A traced ceph shows patients and their parents that their doctor went the extra mile in evaluating their case. CS Imaging Software also consolidates Volume 9 Number 3

SOME PURSUE WORKFLOW EXCELLENCE CS ORTHOTRAC HELPED CREATE IT

2018: CS OrthoTrac Carestream Dental

1992: ORTHOTRAC OMSystems, Inc.

WORKFLOW INTEGRATION I HUMANIZED TECHNOLOGY I DIAGNOSTIC EXCELLENCE

Carestream Dental. Now 100% Digital. Carestream Dental may be a new dental digital company, but we have a long history of defining practice management and imaging technology. Our strong legacy brands—which include Eastman Kodak and OrthoTrac—have paved the way to bring practice management into the new realm of digitalization. And, as an independent company solely focused on the oral healthcare market, we will continue to drive innovation and deliver new solutions for practices. From consultation to final treatment, we have the solution that’s right for you.

For more information, call 800.944.6365 or visit carestreamdental.com

PRODUCT FOCUS panoramic images, CBCT scans, cephalometric images, and digital 3D models in one central location that can be accessed from the patient’s chart in CS OrthoTrac for that key integration aspect.

Intraoral scanning For orthodontists who are ready to leave traditional impressions in the past, an intraoral scanner can give them the benefits of 3D digital models, in addition to the numerous benefits it brings to patients (no impression material, no gagging, etc.). The beauty of an intraoral scanner, like the CS 3600, is that its small size makes it easy to move from chair to chair; the scanner isn’t tethered to a proprietary computer or trolley and can plug into any PC — talk about integration. Most significant is the fact that the CS 3600 is part of an open system. Not only does the scanner integrate easily with Carestream Dental imaging and practice management software, it also integrates with many other practice management software applications. CS 3600 images are saved using universal and open file formats to make them compatible for use with any digital lab and numerous clear aligner systems. Looping back to practice management software, clear aligner therapy can be easily managed in CS OrthoTrac v14 with Universal Aligner Tracking, regardless of manufacturer, brand, or if made in-house.

Visualization aids and modules What really takes integration to the next level in an orthodontic office are modules that allow doctors to piece together the workflow that suites their practice and patients’ needs

CS 3600 intraoral scanner

best. The industry is changing rapidly, and it may seem difficult to keep a competitive edge with the latest technology if the “latest technology” is out-of-date as soon as the “next big thing” comes along. However, dynamic add-on modules that complement equipment can make doctors’ investments go further. For example, once an impression or stone model has been digitized, CS Model creates and mounts the model on a virtual base for analysis. Doctors can use the software to take measurements or display the pressure map to visualize the occlusion. CS Model+ takes the model analysis even further by automatically segmenting, setting up, analyzing, and presenting digital models representing projected treatment outcomes within minutes. These valuable — yet timeconsuming — steps were once reserved for only the most complicated cases. CS Model+

CS Model+ automatically segments sets up, analyzes, and presents models CS Airway module 58 Orthodontic practice

automatically analyzes each case and generates detailed orthodontic reports, ranging from Bolton Analysis to ABO Discrepancy Index. It can also create visual simulations of orthodontic treatment options to aid in case acceptance. Digital models created using either CS Model or CS Model+ can be easily accessed within the patient’s imaging chart for seamless integration that keeps all records centrally located, ideal for managing storage and staying compliant with states’ record-keeping regulations. Similarly, the CS Airway module can be used in conjunction with CBCT images to quickly segment the airway in 3D for clearer visualization, faster analysis, and enhanced communication with patients. A color-coded 3D view of the pharyngeal region helps doctors visualize constrictions in airway passages, and the software can provide segmentation in as few as two clicks. Results from the CS Airway module are seamlessly integrated with CS 3D Imaging software. We may be some way off from a Veg-OMatic-like device that can be all things to all orthodontists, but Carestream Dental can be an orthodontist’s all-in-one partner. It’s one of the few companies that designs, manufactures, and supports every piece of an orthodontist’s digital workflow. Doctors can pick and choose the systems and software that work best for them for simplified workflow, streamlined integration, and consolidated training, leading to the ultimate integrated solution. To learn more about Carestream Dental’s portfolio of imaging products and software for orthodontic practices, please call 800-944-6365 or visit carestream dental.com today. OP This information was provided by Carestream Dental.

Volume 9 Number 3

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REFERRALS

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ORTHODONTIC PERSPECTIVE

Sharing a fika* Dr. Rohit C. L. Sachdeva discusses a 50-year orthodontic career with Dr. Larry White

little flavor on the Swedish word/ritual fika. (Definition by John Duxbury) Often translated as “a coffee-and-cake break,” in reality, a fika is a concept, a state of mind, an attitude, and an important part of Swedish culture. It means making time for friends and colleagues to share a beverage and snack. But even more important than the food, it’s all about companionship, socializing and catching up to share some time with the people we live and work with every day.

Kindly share with us your journey to becoming an orthodontist. When I was 10 years old, I had a primary molar removed sans anesthesia. It hurt so much, I vowed I would never again visit a dentist, but of course, my mother had other ideas about that, and she heard about a new, young dentist in Lubbock, Texas, who had quickly developed a good reputation. That appointment with Dr. Jim Reynolds was so pleasant that on our way home to Hobbs, New Mexico, I told my mother that I thought I might enjoy being a dentist someday. That was the beginning of a lifelong friendship with Jim Reynolds that has benefited my life beyond measure.

Among the many individuals who you give credit for being influencers in your life, two names seem to stand out. Can you elaborate on those people? And what are the characteristics of a good mentor? My mentors were certainly influential in special ways, but great parents who helped shape my behavior and gave me solid values

and the necessary discipline prepared me to respond favorably to good mentors. But good mentors need to have authenticity and obviously good character, plus the willingness to share the whys that are behind the concepts they are trying to share with you. My high school coach, Duane Fisher, knew his craft quite well, and he always wanted players to understand why he trained them to perform a certain task. He strongly believed if people understood why they did something, they would more readily endorse it. I find that applicable in training dental assistants as well. He also wanted his players to have the courage to do their best. Now, it is one thing to have the physical courage to stand In front of a large charging running back, but it also takes emotional courage to stay past 5:00 p.m. and replace some broken brackets and wires when the whole staff had rather be on their way home. Jim Reynolds, on the other hand, shared with me the value of professional camaraderie. Because there will always be someone who knows something that you don’t, you need to cultivate friendships that allow you to access the special knowledge you need to grow professionally. Professional hubris prevents a lot of promising orthodontists from developing as fully as they could.

Throughout your career and currently, you are a mentor to many fortunate individuals. Can you tell me whether the mentee seeks the mentor, or is it the other way around? In my professional life, it was the mentee that sought the mentor. For me, it began in

Rohit C.L. Sachdeva, BDS, M Dent Sc, is a consultant/coach with Rohit Sachdeva Orthodontic Coaching and Consulting, which helps doctors increase their clinical performance and assess technology for clinical use. He also works with the dental industry in product design and development. He is the co-founder of the Institute of Orthodontic Care Improvement. Dr. Sachdeva is the co-founder and former Chief Clinical Officer at OraMetrix, Inc. He received his dental degree from the University of Nairobi, Kenya, in 1978. He earned his Certificate in Orthodontics and Masters in Dental Science at the University of Connecticut in 1983. Dr. Sachdeva is a Diplomate of the American Board of Orthodontics and is an active member of the American Association of Orthodontics. In the past, he has held faculty positions at the University of Connecticut, Manitoba, and the Baylor College of Dentistry, Texas A&M. Dr. Sachdeva has over 90 patents, is the recipient of the Japanese Society for Promotion of Science Award, and has over 160 papers and abstracts to his credit. Visit Dr. Sachdeva’s blog on http://drsachdeva-conference.blogspot.com. Please contact rcsorthocoach@gmail.com to access information.

60 Orthodontic practice

Dr. Larry White

Dr. Larry White as consultant to an ortho company

the spring of 1968, when Dr. Tom Mulligan presented a paper for membership in the Angle Orthodontic Society. That meeting was in Dallas, and the residents at the Baylor Orthodontic Department were guests. I was just about to graduate, and Tom talked about moment-to-force ratios, lingual-arch activations, cantilever concepts, moments produced by forces, and static equilibrium. I didn’t understand a word he said, and neither did any of our faculty. I approached Tom and asked if he would consider mentoring me regarding Burstone Biomechanics, and he graciously agreed. I know I must have perplexed him on many occasions, but he stuck with me for 50 years, and he taught me biomechanical concepts that transcend bracket designs, philosophies of treatment, and therapeutic systems, etc., and I will forever be in his debt. I suppose in other cases, it might be a mentor who discovers a student or player who displays unusual interest or talent and would motivate the mentor to seek the Volume 9 Number 3

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ORTHODONTIC PERSPECTIVE

College days

Dr. White dressed for the concert

mentee, but professionally, people need to seek those who have information and skills they lack.

how has playing the oboe enriched your life?

You were the first All-American footballer at the University of New Mexico and were inducted into the New Mexico Hall of Honor. Also, you were named by Sports Illustrated as one of the “50 Greatest Athletes of the Past Century” in New Mexico. By any measurable standards, these are noteworthy accomplishments. As a linebacker whose play was designed around a defensive strategy, are there any parallels that you can draw that have influenced your approach to orthodontic care? The willingness to have the courage to do your best under trying circumstances and even play through injuries offer worthy lessons for any profession. Life offers a lot of worthy goals one might seek. But one needs to understand unmistakably that a certain amount of sacrifice is the price you need to pay to achieve those goals.

You play the oboe, and as you jokingly say, “People on the football team remember me as a great oboist, and people in the orchestra remember me as a great football player.” It is also said that “the oboe picks the student rather than the student picking the oboe.” So what made the oboe pick you, and 62 Orthodontic practice

I began playing the clarinet in grade school, and by the time I entered junior high school, the band didn’t have an oboe player, and the director encouraged me to switch to the oboe. I never regretted it. Musical training helped me develop an appreciation of music and have enormous respect for musicians who study and train so hard to perfect their crafts. I continued to play during my college days, and for 2 years played in the Albuquerque Symphony (which at the time was a amateur organization, and I still have the distinction of being the absolute worst oboist that symphony has ever had). I also played in the University of New Mexico (UNM) symphonic band.

You speak Spanish fluently, and I know you dedicated yourself to learning this second language much later in life. Why did you pursue this? Most of my life was spent in New Mexico, which had and still has a rich Hispanic influence and culture. Our particular city had very few Mexican people in the 1940s and 1950s, but by the 1970s and 1980s, I could see how the demographics were changing and felt I needed to have the ability to communicate with patients and families that might not be comfortable speaking English. The Mexican population of that small town in New Mexico is now 60%. So I think I forecast that correctly. Currently in Dallas, Mexicans comprise 85% of my practice, so speaking

to them in their native language seems to put some parents and patients at ease.

I understand John Rassias at Dartmouth College was your Spanish instructor. Can you share with us his unique teaching methods and your personal learning habits that helped you gain fluency in Spanish so rapidly? Among other efforts to learn Spanish, I did spend part of a summer at Dartmouth under the teaching of John Rassias. He used a version of the Socratic Method sharing a sentence and suddenly pointing to a particular person to supply the correct verb. You couldn’t let your mind wander. Unfortunately, they taught a Castilian form of Spanish, which differs from the Mexican version, which I really wanted to learn.

As a bibliophile, with a voracious appetite for both fiction and nonfiction, can you recommend “must reads” for the orthodontist? Professionally, of course, my go-to book is Dr. Tom Mulligan’s Common Sense Mechanics, which unfortunately is no longer available. Tom doesn’t plan to republish this and intends to donate it to some school that agrees to put it online for free distribution. Drs. Melsen and Fiorelli have an online publication on Biomechanics that offers sound fundamentals, and I also often consult Dr. Proffit’s book on orthodontics. The book by Graber, et al., offers readers a cornucopia of techniques. Volume 9 Number 3

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ORTHODONTIC PERSPECTIVE Personally, several books have influenced me and continue to do so: • Gift from the Sea Anne Morrow Lindbergh • In the Shadow of Man Jane Goodall • The True Believer, The Ordeal of Change, and others Eric Hoffer • Games People Play Eric Berne • Adventures of a Bystander Peter Drucker • Know Your Child Stella Chess and Alexander Thomas • The Social Contract Robert Ardrey • The Cost of Discipleship Dietrich Bonhoeffer • 12 Rules for Life Jordan Peterson

What is the takeaway message from the books you have recommended? Life offers so much complexity; people need all the information and advice they can gather from those whose experiences differ from our own narrow interests, and I find that an eclectic selection makes life more interesting and offers me some of those aha moments of clarity.

You have run many parallel lives in professional orthodontics — a clinician, an editor of a widely read clinical journal, and an academic. What do you believe is the role of an editor? Editors need to have less provinciality in their selection of articles and need to be open to the ideas of others. I particularly dislike the tendency of many editors to reject good clinical advice from clinicians with no affiliation to universities. In the current climate,

Books authored by Dr. Larry White

I seriously doubt people like Drs. Schudy, Tweed, Steiner, Holdaway, etc., could find many outlets for their ideas. Also, I would like to see editors pay more attention to proper grammar. For example, we “retract” molars not “distalize” them. We don’t “mesialize” teeth, “lingualize” teeth or “buccalize” teeth. Editors should insist on professional language in articles such as “maxillary” and “mandibular” not “upper” and “lower.” Nor should they use “decimate” for “destroy.” Decimate refers to a tenth not a total. One final caveat — editors should stop allowing six authors to publish a 2-page article. I believe that is nonsense and simply padding the authorship.

I would like to probe your thoughts on the current state of professional publications. What appears to me is that hacking occurs on both sides of the aisle. There are clinicians whose clinical interpretations of their findings are commonly subject to misattribution, and the professional researcher/ academician commonly hides his/ her work under the veil of statistical

significance (p- hacking) which has little or no clinical relevance. What do you think about this theory? Yes, and may I also add that an overlooked peril of statistics in an article is that for every formula in an article, you lose one-half of the readers. It only requires about three formulas, and a writer has almost no audience. Clearly, researchers need some statistics to justify conclusions, and I understand that. That said, researchers need to make certain with their statistics that they are not simply suffering from physics envy. Also, we forget to our peril that wherever statisticians thrive, freedom and individuality diminish.

Do you believe that if our professional culture were more accepting of failure, we would be more transparent, and as a result, cultivate a generative rather than pathological environment of learning? That is absolutely true. The airline industry offers the example par excellence because the features of every flying accident are re-created in flight simulators where pilots rehearse the accident and learn to prevent a

Dr. Larry White with Drs. Nikhil and Bhuma Vashi from Bombay, India 64 Orthodontic practice

Volume 9 Number 3

ORTHODONTIC PERSPECTIVE dangerous outcome. We have no big data collection of failures in orthodontics, resulting in generation after generation continuing to make the same mistakes. I would suggest that our institutions of learning worldwide pool data on clinical failures along with the written narratives and see if they can reach some helpful conclusions. That could be a highly useful NIH grant that could provide needed and interesting information to improve orthodontic processes.

In the “real world,” how constrained is an editor in fulfilling this role? I feel editors probably have more constraints by publishers and committees than we imagine.

As a seasoned clinician who decided to join the “academic ivory tower,” what were you unprepared for? I was unprepared for all of the political correctness that permeates academia and for the entitlements students seem to expect. In my view, administrators have lost the courage to confront nonsense, and this of course, goes to the very top of our

institutions. Our faulty jurisprudence system encourages this to our detriment.

And what advice can you share with those who are contemplating switching gears from a private practice to that of a full-time faculty member? Make sure you have the temperament to deal with the features I have mentioned and many more that I haven’t but which you will confront. You will no longer call the shots as in your private practice, and be prepared to accept unfulfilled promises. I finally realized that though I enjoy sharing ideas and experiences with others that is only a small part of an academic life. Thus, I remain a clinician, not an academician. I salute those who have the personality to do this full time, but I realize I am not among them.

You are constantly refreshing your personal skills to better care for patients. How have you managed to create a care team that is resilient to change? You must have your staff buy into any vision you have for your practice. Without

that, you will experience frustration, so explain why you want to improve a technique, and help them know they will experience a learning curve as they try to implement the necessary changes.

In the practice of clinical orthodontics, we continually strive to revise our mental models. Having practiced orthodontics for well over 50 years, can you share with us specific examples of “mind shifts” that you have personally encountered in the way you provide patient care? I was trained to diagnose and treatment plan with the Tweed Triangle and Steiner Technique. These were based on using the mandibular incisor as the key to diagnosis. Dr. Reed Holdaway was the first to make me realize the maxillary incisors, and not the mandibular, were the key, and he taught me how to perform and implement the Visual Treatment Objective, whereas Burstone and Marcotte taught me to use occlusograms. These remain fundamental in my diagnosis and treatment-planning regimen.

The term illusionary truth refers to the tendency to believe information to be correct (even if not) after repeated exposure. Have you personally been subject to this effect, and if so, can you share some examples? I think that just about every dentist at one time or another experiences this. We are pretty much blank slates when we enter our professional training and accept completely what we are told. It takes years of experience to understand that much of what passes as “dental gospel” is simply wrong or at best incomplete. If something is done wrong often enough, it becomes right; that is, volume is a defense against error.

And how do clinicians guard themselves and, more importantly, their patients in a world that abounds with misinformation?

Family celebration of his wife, Lue’s 80th birthday

Bertrand Russell once said that there is an unbridgeable gap between knowledge by description and knowledge by acquaintance and no way of going from one to the other. That is, there is no substitute for experience. Professionals need to have the willingness to change when their experience indicates improvements are available.

Larry and Lue in New Zealand 66 Orthodontic practice

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ORTHODONTIC PERSPECTIVE as occlusograms or the Virtual Treatment Objective (VTO) because they believe they add to their tasks and provide little value in patient care. How do these decision aids help you, and how have you incorporated these into your clinical work processes? In my previous New Mexico practice, I had a rather large staff, and we took records of new patients on a half-day or sometimes a full day. So I had trained people to do the occlusograms, and after making a few important points on a cephalometric film, another would do the tracing with the lines I used. Now, I have a much smaller practice and staff, so I now do all of the tracings and occlusograms myself, and it takes almost 1 hour to complete a diagnosis and treatment plan. I don’t mind doing them because they give me reasonable expectations and a final destination to aim for. I would hate to start any treatment without knowing where I am going, and how I will arrive. I personally believe that initiating orthodontic therapy without closely considering the records is like playing poker without ever looking at your cards.

You are proponent of simplicity in managing patient care. Obviously, the road to simplicity is a long and arduous one. Can you guide us through the journey map of any particular facet in the clinical management of your patients that you have simplified substantially over the years? Rather than use a computer to record treatment notes, I still prefer to use a paper chart with the photos, panograph, and scanned mouth records inside. On the front side of the chart is a miniaturized diagnosis and treatment plan along with space to record procedures that are done. On this chart, I can record any interproximal enamel reduction with a line between ideograms of the teeth, and I can immediately see the VTO and refer to the occlusograms for remembering if there is a tooth size discrepancy. I cannot get this information immediately from any computer program that I am currently aware of. So I strongly believe a picture is worth a thousand words. In my experience, for some things analog is better than digital.

We are both considered “agers” in orthodontics since we have crossed the age of 60. What is the greatest gift bestowed to one who 68 Orthodontic practice

Website for Dr. White’s new practice

is fortunate enough to cross this chronological threshold? I crossed that line almost 25 years ago, and the greatest gift I have received is the friendship and camaraderie that I continue to build in this profession even at this late date.

You recently opened up a solo practice in Dallas at age 85. This would be considered unthinkable and untenable for one to do at this stage in life. And yet, you have accomplished the impossible and are running a successful practice. So what provoked you to do so? I was replaced by a younger person in my nonprofit dental clinic and at the school where I served one-half day a week. I didn’t think I was finished professionally and felt I still had some good years left, and there remained so many things I still didn’t understand about orthodontics. I wanted to continue pursuing the knowledge I didn’t yet have.

What were the mental boundaries that you had to overcome to achieve this goal? I didn’t have any doubts that patients would eventually respond to my practice’s appeal because I intended to use a strategy I had successfully used in New Mexico. I would require a rather small monthly payment

with nothing down. I just didn’t know how quickly they would respond. Fortunately, they responded a little quicker than I expected.

What is different about this practice than the first one you started? This one has started faster because I knew exactly the audience I intended to appeal to and how they might respond. My 59 years of experience does confer some advantages.

You have been the witness of many “eras in orthodontics.” Each era is associated with the belief system and cultural values of a particular generation. Could you elaborate on the changes you have observed? Unfortunately, I find people less likely to spend time diagnosing and treatment planning now than before, and I feel that causes patients to stay in treatment longer and probably receive less definitive care.

You have been keen student of the late Peter Drucker. What is the most important management lesson you learned from his writings? Drucker was an amazing writer with a vast historical knowledge along with unparalleled management expertise. To choose just one invaluable lesson I would offer his Volume 9 Number 3

ORTHODONTIC PERSPECTIVE remark, “Efficiency is doing things right; effectiveness is doing the right things.”

enriched you professionally. Are there any such “aha” moments that you can share with us?

price, and I think that clinicians will eventually understand that a fundamental understanding of diagnosis, treatment planning, and a thorough knowledge of biomechanics can obviate many of the digital solutions now available and also in the future.

The music industry was among the first to adopt digital technologies, and as we all recognize, it was disruptive, painful, and transformational. And today, “vinyl is back.” Deloitte Global forecast the sales of physical records in 2017 and has witnessed vinyl’s 7th straight year of double-digit growth with sales of over 40 million new records with a revenue of over $900 million. Do you believe a reversal in tide may occur in orthodontics that is from digital to analog, and if so, in what particular aspects of the care ecosystem, and why?

The biggest “aha” moment I ever received was from Dr. Clarence Bryk, who taught me about the usual futility of removing mandibular premolars in Class II malocclusions. That came after 30 years of struggling with those decisions. Dr. Janson from Brazil further corroborated Dr. Bryk’s experience in several studies. Another aha moment came from Dr. Carlos Coelho in Brazil when he showed me his Mandibular Protraction Appliance (MPA) that could be fitted chairside with a minimum of investment and time.

I am not going to ask you to predict the future of our profession; however, if you did have a magic wand, how might you reframe it? Not just for dentistry but for society, I would like to see a return to common sense and commonly held values that have enriched mankind for centuries. Holy Writ admonishes us to “forget not the ancient landmarks.” Those landmarks of behavior developed over centuries, and it disturbs me to see people cavalierly set them aside as though they have no value in the “modern world.”

There are many things that cannot be done effectively by digital means such as effective and sincere patient relations or even professional relations. Regarding analog music now being revived – digital never gave the quality of analog, but it did give mobility that analog cannot. So much of the digital solutions now offered in dentistry improve our quality of care but at a much greater

You are an “unsung hero” of our profession. My thanks and eternal gratitude to you for being my mentor, my guardian angel, colleague, and friend. In parting, what would be the first lines of the lyrics you would compose for a song to be sung by the next generation of budding orthodontists?

I know that you have lectured worldwide and still continue to do so very actively. In your interaction with our international colleagues, I am sure there have been instances of “moments of learning” that have

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PRACTICE MANAGEMENT

Communicating change in the dental practice Catherine Cheshire, SPHR, discusses the importance of keeping employees informed

ost of us go to great lengths to manage communications with patients and referring dentists. Nurturing your internal messaging for your practice team is mission-critical too, especially during times of growth and change. Regular, transparent, and considerate messaging keeps your team engaged and keeps your practice’s culture thriving. Especially if your crew is growing, or some kind of organizational change is afoot (such as adding a satellite office or new employees), it’s time to get strategic about internal communication. In our technology-filled lives, every day, we live and breathe the power of messaging. So we take note of the immediate impact and the on-going ripple effect communications have within our own workspace. If any lesson rings the truest during times of growth and transition as well as in an everyday well-run practice, it’s that communicating any kind of change, and keeping communication constructive when you grow, requires a good and proper plan. Three company culture steps are needed to be sure that your team is ready to receive your messaging.

1. Align your leadership ... and gather intel You need buy-in from your practice team, both the office and the clinical associates. Make sure you have a connected team that gets the “why” behind the changes. Support your leaders, and show them their place in the practice’s future. Your team is critical to the success of your communication strategy. You need them to be ready to reinforce the practice’s internal messaging and to embody

Catherine Cheshire, SPHR, is a people operations and communications consultant, specializing in executive and employee coaching, culture development and employer branding. As a certified practitioner in the Coaching Mindset Index, she helps managers develop self-awareness and enhance their effectiveness as coaches. She has over 10 years of experience as an HR and communications executive, and has a degree in Psychology. You can reach Catherine Cheshire through LinkedIn or via email: catcheham@gmail.com

72 Orthodontic practice

Regular, transparent, and considerate messaging keeps your team engaged and keeps your practice’s culture thriving. the company culture. Integrate their experience and opinions about your operation and communications — they will be critical in helping you with the next step.

2. Create a culture of communication You already have a communication culture in your company. But is it a good one? When you bring a message of change to your team, is your message going to be received from a place of established respect and openness? It’s time to assess where your communications stand. Take a look at how communication flows through your practice. Break down your info-share into “bottom-up” and “top-down” methods. Bottom up: Is there a stronger tendency for your team to communicate upward the owner/clinician or the office manager, rather than the other way round? For example, do you have feedback programs or open-door managers always ready for questions and employee feedback?

Top down: Does most information filter down from the top to the team? For example, internal emails from management and clinician/office manager intranet updates? Ask your team what communication channels are working, which aren’t, and which are missing. Will your current methods continue to work in your new world order? This includes, a move, addition of a satellite office, or expansion of a current practice? And are those pathways and communication styles constructive? A practice with an organic and non-formalized communication style might find itself stuck when a new hierarchy is introduced or new folks are added to the mix. You might be consumed with new patients and new hires, with a mess of crossed messages, yet-to-be-written processes, and good intentions. You need to identify how your messages will be best communicated to your team, and create a proactive schedule that preemptively Volume 9 Number 3

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PRACTICE MANAGEMENT answers questions you know are coming. And then you need to be ready for the questions you didn’t foresee.

3. Give your team a voice Sounds elementary? Most of us who are into employee engagement in the modern era assume that our team is heard. The truth is that is not always the case. Consider those personalities who don’t speak up — ever. Consider the workplace whirlwind. As you grow, or there is a period of uncertainty, make sure you are ready to hear your team. Set the importance of team input and feedback as a culture priority. And remember to prep your leaders to foster an atmosphere of openness and real communication (you might need to source some coaching!) You want to make sure that information is being shared from the top effectively, and that your team’s valuable inputs are heard and acted on. There’s a recent trend for companies to turn top-down communication on its head. Many company-wide meetings are taking on the traditional townhall approach — a short leader-led presentation followed by ample time for questions and comments from the team. The result? Cohesive, high-morale, highfunctioning companies where ground-level business intelligence is making its way to the top, and making them better.

Be patient while everyone adapts Establishing new behaviors takes time. It can take months for your team to get the hang of asking questions, especially if they are not used to doing so. If it feels like a slow start, stay the course! Be consistent. Encourage feedback — and provide different communication pathways for different personalities. Follow up on that feedback. Act on it, fast, and always reply — as you would for a patient. OP Originally published on Bigsea.co.

74 Orthodontic practice

Key traits to develop your communications Know yourself and your goals. What are your practice’s core values? What are its goals? Integrate what will remain the same, or how the changes reinforce and support the company mission. If there is a culture change afoot, explain how things will be different and why. Be considerate, meaningful, and genuine. Ask yourself and your leaders what impact your team members experience as a result of the changes — operationally, financially, personally, and interpersonally. How will teams and individuals fit into the changes? Note those impacts, and address them in your communications. Deliver clarity and transparency. People are more likely to get onboard if they are treated with respect, and they see the reasoning behind the decisions. Share your business intelligence and clarify how that information links to your mission. What are your expectations of the team? Provide (and communicate) structure and support your people for success. Make updates regular and timely. Foster the expectation that you will be forthcoming with updates and feedback. Surprises are for birthdays, not for major life changes. Put your team communications on a schedule, and hold yourself or your office manager to it. Your people will come to know they can expect an on-going stream and trust you all the more for it. Think about the timing of the information you are sharing. Are you prepared to follow up with updates or lack of updates, and to handle the questions that follow? Are you being transparent while at the same time taking care not to overburden your team with too much information? Say thank you. Recognize the challenges, the sacrifices (family impacts, disruption, comfort zone bursting). Share the tangible results and accomplishments that result from the team’s rally. Who has been instrumental in your recent positive change, or who has helped you go through the challenges — whether it’s teams or individuals, take time to recognize those contributions in a way that is beneficial and meaningful to them. Loop it back! Feedback is your friend. (Constructive) feedback/rich environments are where truly cohesive teams emerge. Establish a means for the team to ask questions, share information to you from the ground. You’ll gain critical insight, and your team will be heard — it’s a base requirement that is directly related to performance and positive associations. Communicating uncomfortable change can be hard. Positive change can come with challenges too, especially if there is confusion from half-baked communication, or parts of your team are going to meet new challenges without the support or resources they need. The good news is that a people-first communication strategy primes you for better understanding between you and your team, and the opportunity to course-correct as you receive feedback. And the ultimate result of people-first communications? A practice team that understands and buys into your mission, stronger engagement, and a vibrant, intact corporate culture. Here’s to your growth!

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PRACTICE MANAGEMENT

Five strategies for building a cohesive team Ali Oromchian, JD, LLM, discusses facilitating optimum performance and accentuating the positive

hen evaluating your orthodontic practice, you might consider your assets to be your property, your building, your supplies, and your finances. However, your most important asset is your team! Your staff is the glue that holds your practice together. They run your operations, manage your patients, and assist you in being the most efficient orthodontic practice possible. What would you do without them? Stop and read that sentence again, slowly. What would you do without them? It would be an understatement to say that your life would be a lot more complicated without your employees. Similarly, having inefficient and ineffective employees can be just as bad as not having any employees at all. To be sure that you have and retain the best employees possible, there are several strategies to facilitate optimum performance while simultaneously building a cohesive team.

1. Understanding job importance First and foremost, it is important to examine the ways in which your employees perceive their roles in the workplace. This should include an understanding of how your employees view their contributions to the practice. The more integral employees feel, the more likely they are to take their roles more seriously and strive to excel in performance. Conversely, if your employees feel underappreciated or irrelevant in their contributions, you may see patterns of poor performance and insubordination. Once you have had the opportunity to gauge how Ali Oromchian, JD, LLM, received his BA from the University of California at Davis, LLM in taxation from George Washington University Law School, and JD law degree from the University of California, Davis School of Law. He is the founding attorney of the Dental & Medical Counsel, PC law firm and is renowned for his expertise in legal matters pertaining to dentists. Mr. Oromchian has served as a key opinion leader and legal authority in the dental industry with dental CPAs, consultants, banks, insurance brokers, and dental supplies and equipment companies. He serves as a legal consultant for numerous dental practice management firms that rely on his expertise for their clientsâ&#x20AC;&#x2122; businesses. He is also recognized as an exceptional speaker and educator who simplifies complex legal topics and has lectured extensively throughout the United States. Disclosure: Mr. Oromchian is co-founder and Chief Executive Officer of HR for Health in the San Francisco Bay area.

76 Orthodontic practice

your employees perceive the importance of their jobs, you can move on to affirming that importance. Positive reinforcement is a great way to consistently build confidence relating to your staffâ&#x20AC;&#x2122;s duties in your orthodontic practice. This means acknowledging their worth, value, and contributions either verbally or in writing. These types of supportive affirmations lead to an increase in employeesâ&#x20AC;&#x2122; understanding of their value and promote a sense of pride within the workplace. Pride leads to action that, when executed efficiently, can lead to success. When each member of your practice feels as though he/she has a hand in its success, that success begins to become a reality.

2. Laying out job expectations and opportunities Another way you can facilitate employee performance is by setting detailed expectations. One crucial part of a successful orthodontic practice is the development of a thorough employee manual, which outlines specific job expectations and opportunities. Providing your employees with detailed

expectations of tasks and duties related to their job will leave little room for miscommunications or misunderstandings regarding job performance. Clarity and precision are keys to ensure that the guidelines in your employee manual are consistently applied. In addition to job expectations, your manual should also include consequences for when employees do not comply with their responsibilities. Specific clauses relating to consequences can help protect your practice from liability issues. When employees have a tangible means of understanding and attaining great achievements through their work, they have a clear pathway that can lead them there.

3. Committing to regular feedback and open dialogue In addition to outlining job expectations in your employee manual, you should also provide regular feedback to your employees and opportunities to maintain an open dialogue with management. Your employee manual can only say so much, so it is up to you to fill in any gaps with supplemental conversations and meetings. An easy way Volume 9 Number 3

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PRACTICE MANAGEMENT to promote these kinds of interactions is by scheduling regular check-ins and opportunities for open discussion and evaluations. It is important to note that different employees might be more receptive to differing styles of discussions, suggestions, and criticism. For instance, some may feel discomfort when discussing constructive criticisms in front of their peers. Others may have no issues with large group discussions. By developing opportunities for various levels of dialogue, you can be sure that you are obtaining a variety of responses from a broader group of employees. While you should certainly offer regular feedback for all employees, the employees in management roles should have an even more extensive level of communication with you as the employer. As you seek to guide your employees in professional development, it is imperative you consistently promote and facilitate leadership, accountability, and communication. Scheduling frequent meetings and check-ins allows you to build a rapport with your team, resolve issues, and facilitate leadership growth.

4. Developing healthy professional relationships with peers, superiors, and subordinates In a similar fashion, building healthy relationships between and among peers, superiors, and subordinates can be essential to your orthodontic practice’s success. If your practice’s workplace relationships are on the down-slope, you will need to make certain that your entire practice is not heading in that direction as well. However, if you help to forge relationships that are too tight-knit, you could be placing yourself at risk in other ways. For instance, when relationships in a workplace are overdeveloped, newcomers can find the workplace environment as either unwelcoming or even sometimes hostile. In addition, those kinds of tight-knit relationships could also lead to risky legal implications if they get out of control. You will need to maintain a balance between the above extremes. How can you maintain a healthy balance? You can include time for positive teambuilding exercises and extracurricular events. They tend to work out best if you are the one who schedules both. While some practices may send their employees on retreats to develop team-building skills, you can do similar activities in your own space. Examples can easily be found on the Internet. In addition to structured team-building events, it is also a good idea to schedule less-structured 78 Orthodontic practice

The more integral employees feel, the more likely they are to take their roles more seriously and strive to excel in performance. “hangout time” for your employees, should they wish to participate. This could be a monthly dinner outing to a place near the office. Having the opportunity to socialize over a meal can help employees decompress together. Regularly having these types of events (i.e., once a quarter) will promote healthy professional relationships not only between you and your employees, but also among all your employees. These activities are also an excellent way to develop leadership skills in your workplace.

5. Inspiring employees through practice values Lastly, you should evaluate whether you make a positive personal impact on your employees. What are your goals and inspirations related to your orthodontic practice? Do you put your patients first over everything else? Do you seek excellence through providing high-quality services? How do you treat your employees? All too often, a workplace environment suffers from a trickledown effect. This means that your practice style and behaviors may trickle down to your

subordinates. Make sure what trickles down is positive. Attitude is everything. If you show fear, it can spread like a wildfire. Conversely, if you exhibit confidence, you can build confidence in others just as quickly. You are the one who has complete control over whether you want to show compassion, dedication, and drive in your work ethic and values. When you choose to lead by example and exude these qualities, you might be surprised at the positive results that trickle-down. Building and maintaining a successful orthodontic practice may seem like a daunting task. If you think about it that way, it is easy to let negativity seep in. The previously mentioned five strategies can assist you in avoiding burnout and facilitate employee performance while building a cohesive team. When you think of the ways in which you can create success in your work, the bottom line always comes back to your employees. By promoting the ideal workplace environment and interactions, your employees’ successes can be successes for you and your practice as well. OP Volume 9 Number 3

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PRODUCT PROFILE

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

Submitting articles Orthodontic Practice US requires original, unpublished article submissions on orthodontic topics, multidisciplinary dentistry, clinical cases, practice management, technology, clinical updates, literature reviews, and continuing education. Typically, clinical articles and case studies range between 1,500 and 3,000 words. Authors can include up to 15 illustrations. Manuscripts should be double-spaced, and all pages should be numbered. Orthodontic Practice US reserves the right to edit articles for clarity and style as well as for the limitations of space available. Articles are classified as either clinical, continuing education, technology, or research reports. Clinical articles and continuing education articles typically include case presentations, technique reports, or literature reviews on a clinical topic. Research reports state the problem and the objective, describe the materials and methods (so they can be duplicated and their validity judged), report the results accurately and concisely, provide discussion of the findings, and offer conclusions that can be drawn from the research. Under a separate heading, research reports provide a statement of the research’s clinical implications and relevance to implant dentistry. Clinical and continuing education articles include an abstract of up to 250 words. Continuing education articles also include three to four educational aims and objectives, a short “expected outcomes” paragraph, and a 10-question, multiple-choice quiz with the correct answers indicated. Questions and answers should be in the order of appearance in the text, and verbatim. Product trade names cited in the text must be accompanied by a generic term and include the manufacturer, city, and country in parentheses. Additional items to include: • Include full name, academic degrees, and institutional affiliations and locations • If presented as part of a meeting, please state the name, date, and location of the meeting • Sources of support in the form of grants, equipment, products, or drugs must be disclosed • Full contact details for the corresponding author must be included • Short author bio • Author headshot 80 Orthodontic practice

Pictures/images

Disclosure of financial interest

Illustrations should be clearly identified, numbered in sequential order, and accompanied by a caption. Digital images must be high resolution, 300 dpi minimum, and at least 90 mm wide. We can accept digital images in all image formats (preferring .tif or jpeg).

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

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

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

Manuscript review All clinical and continuing education manuscripts are peer-reviewed and accepted, accepted with modification, or rejected at the discretion of the editorial review board. Authors are responsible for meeting review board requirements for final approval and publication of manuscripts.

Proofing Page proofs will be supplied to authors for corrections and/or final sign off. Changes should be limited to those that are essential for correctness and clarity. Articles should be submitted to: Mali Schantz-Feld, editor in chief mali@medmarkmedia.com

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

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

(Multiple) Doe JF, Roe JP

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

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

Volume 9 Number 3

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INDUSTRY NEWS Dentsply Sirona annnounces acquisition of technology solutions provider OraMetrix Dentsply Sirona announced the signing of a definitive agreement to acquire OraMetrix, a leading industry provider of innovative 3D technology solutions improving the quality and efficiency of orthodontic care. OraMetrix offers an advanced CAD platform developed for dental professionals to deliver consistently predictable orthodontic outcomes. The acquisition, in combination with GAC’s bracket expertise and Dentsply Sirona’s digital technologies, will enable Dentsply Sirona to provide a comprehensive orthodontic offering that will include a full arch clear aligner solution. Among its innovative products and services, OraMetrix offers a powerful, software platform that integrates multiple diagnostic media, including CBCT, cephalometric, panoramic, optical, and facial data. Following the acquisition, Dentsply Sirona will be able to provide an end-to-end digital workflow with a comprehensive range of devices to enable dental professionals to match their patients’ growing demands for esthetics and speed of treatment. OraMetrix will be a complementary part of Dentsply Sirona’s orthodontics business unit and strengthens Dentsply Sirona’s overall portfolio offering as The Dental Solutions Company™. For more information, visit www.dentsplysirona.com.

3M Oral Care introduces new leadership 3M announced the appointment of Sebastian Arana as its new President and General Manager of its Oral Care Solutions Division. Arana’s extensive experience spans several geographies and includes the oral care product porfolio. Arana is a proven leader with over 19 years of experience in marketing, sales, business development and strategy as well as key leadership roles in Poland, Chile, and the United States. He holds a BA in Economics and Finance and an MBA. Arana replaces James Ingebrand, who retired April 1. For more information, visit 3M.com/oralcare.

OrthoAccel Technologies, Inc., expands market reach through distribution agreement with Henry Schein® Orthodontics for AcceleDent® Optima™ OrthoAccel® Technologies, Inc., announced that it has entered into an exclusive U.S. distribution agreement with Henry Schein® Orthodontics to distribute AcceleDent® Optima™, an FDA-cleared, Class II medical device employing patented SoftPulse Technology® that produces gentle pulsating forces clinically shown to speed up bone remodeling. The agreement states that Henry Schein Orthodontics, one of the industry’s most trusted providers of innovative clinical solutions, will be the exclusive U.S. distributor of AcceleDent Optima. OrthoAccel is retaining its direct sales force, and the hybrid distribution model is expected to expand the company’s market leadership. A small, lightweight, waterproof device, Optima is the first and only orthodontic device that connects patients and practices through usage monitoring, direct messaging, and virtual awards via an app or web portal. Patients use the handheld, prescription-only device for 20 minutes daily, and the gentle vibrations from the device mouthpiece are clinically shown to speed up tooth movement by as much as 50% while reducing discomfort by up to 71% during orthodontic treatment with clear aligners or braces. For more information about AcceleDent, visit AcceleDent.com.

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CS 8100SC 3D wins 2018 Edison Award™ for its innovative design The CS 8100SC 3D extraoral imaging system by Carestream Dental has been awarded a Bronze 2018 Edison™ Award in the category of Dental/Medical Digital Imaging by the internationally renowned Edison Awards™. The distinguished award, inspired by Thomas Edison’s persistence and inventiveness, recognizes innovation, creativity, and ingenuity in the global economy. To earn a Bronze 2018 Edison Award, the CS 8100SC 3D was judged on its concept and development, value, and impact on the industry. The CS 8100SC 3D offers two-dimensional panoramic imaging, cephalometric imaging, cone beam computed tomography (CBCT) imaging, and model/impression scanning all in one compact system. That means doctors can go from diagnosis to treatment faster, without having to send patients to an imaging center. Not only is the system more convenient, but it’s also faster — featuring the fastest scanning cephalometric module on the market — and safer. The CS 8100SC 3D’s low dose program can deliver 3D imaging at a dose equal to or lower than panoramic imaging. For more information, visit carestreamdental.com, or call 800-944-6365.

Volume 9 Number 3

INDUSTRY NEWS Darby Dental Supply continues West Coast expansion with acquisition of SmartPractice® Dental Supply Division Dental distributor Darby Dental Supply announced its planned acquisition of the dental supply division of Phoenix-based SmartPractice®, which will capitalize on each company’s core competencies with Darby leveraging SmartPractice’s acclaimed glove expertise and manufacturing capabilities. SmartPractice’s supply and glove customer base will benefit from Darby’s expansive stateof-the-art distribution network, extended product lines, capital equipment, technology services, and equipment service. With this acquisition, Darby will be expanding its Chandler, Arizona, facility to provide customers with additional services while extending its hours of operation. Additional sales, customer care, and support services will join the Arizona team to provide convenient access for customers across the country. The transaction fuels Darby’s growth strategy to extend its ecosystem of full-service solutions, while supporting its ongoing West Coast expansion. For more information, visit www.darby.com.

ASI unveils White Silk tubing New for 2018, ASI’s “White Silk” handpiece tubing is now the standard instrument tubing on its dental systems. Because this new tubing is lighter, softer, and smoother, it provides clingfree use. When a handpiece is removed from the holder, it glides smoothly across neighboring tubing. The silky smooth texture reduces the risk of tangling or accidentally dislodging other handpieces. All new ASI dental systems in 2018 will be equipped with White Silk handpiece tubing. Visit ASI’s new website at www.asidental.com.

New software for orthodontists streamlines workflow, increases practice efficiency Carestream Dental has introduced CS OrthoTrac v14 practice management software and CS Model+ software to minimize clicks, automate processes, and simplify everyday tasks. CS OrthoTrac v14 is the latest update to the industry’s longest-standing orthodontic practice management software. The new treatment card improves practice efficiency with features such as patient compliance monitoring. Users are given an overview of broken or rescheduled appointments, damaged wires, broken brackets, etc. The treatment card also includes the first-of-its-kind universal aligner tracking. Universal aligner tracking is a designated place within the treatment card to track how many aligners are given to a patient and document the prescription instructions and duration — regardless of manufacturer, brand, or if made in-house. CS OrthoTrac v14 is available as either an on-premise or cloud option. For the back office, Carestream Dental has also launched CS Model+. Rather than just digitizing a manual process, CS Model+ actually instantly sets up, segments, analyzes, and presents digital models. That means clinicians regain what was once a timeconsuming — yet valuable — step of treatment planning. Once a model is setup, the software automatically analyzes the level of difficulty of the case and generates robust orthodontic reports, ranging from Bolton Analysis to ABO Discrepancy Index. For more information, call 800-944-6365, or visit carestream dental.com.

Ultradent Products, Inc., celebrates 40th anniversary This year, Ultradent Products, Inc., a family-owned, international dental supply and manufacturing company, is celebrating 40 years in the dental industry. Ultradent has become a worldwide leader in its field — known for its innovative dental products, rock-solid core values, and family-friendly, peoplecentered business culture. Ultradent is also a proud USA manufacturer. The company researches, designs, manufactures, packages, and ships 95% of what it sells in its South Jordan facility. It also exports 70% of its products beyond U.S. borders to over 100 countries throughout the world. Ultradent’s hallmark products include its expanded line of tissue management products, which still includes Astringedent® hemostatic, and its world-renowned, industry-leading line of tooth-whitening products, Opalescence® Whitening Systems. Ultradent’s product family also includes the multiple-award winning VALO® and VALO® Grand curing lights, Ultra-Etch® etchant, and its recently introduced dualwave soft tissue diode Gemini® laser. For more information, visit ultradent.com, or call 800-552-5512.

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Volume 9 Number 3

Shine a light on your orthodontic practice health Evaluate potential trends and see how your business compares in critical areas including patient acquisition, production, collections averages and more. Our report is packed full of easy-to-process data, derived from our annual, nationwide client survey. Discover key insights to help you measure the financial health of your practice and plan for the future.

Average Production by Provider:

% Production to Collections:

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Average Net Income as % of Production:

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Cain Watters and Associates LLC is an Investment Advisor registered with the Securities and Exchange Commission. Information provided does not take into account individual financial circumstances and should not be considered investment advice. Request Form ADV Part 2A for a complete description of Cain Watters financial planning and investment advisory services.

M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT G&H Orthodontics® adds to the orthodontists’ artistic palette with new miniPrevail™ family G&H® has introduced its new miniPrevail™ family of products. The new, low profile buccal tube, the miniPrevail™ LP Tube, is an example of taking feedback from clinicians and experts in the field and then focusing on innovation. While developing this new tube, the company’s designers took ease of placement for the orthodontist, as well as patient comfort as its primary goals. As a result, the tube takes the guesswork out of placement with a distinct “crosshair” sight lines positioning feature as well as a funneled entrance for easy wire insertion. The sleek hook design allows for simplified bonding and ultimate patient comfort. The miniPrevail™ SL is the company’s newest interactive, self-ligating bracket. Using a NITI spring clip, the new bracket allows for passive engagement during initial leveling and alignment while using round wires. When the treatment plans call for rectangular wires, the miniPrevail™ SL becomes active to provide effective torque and rotational control to finish a successful treatment plan. This means shorter treatment times for patient cases and more efficiency for orthodontists. The cornerstone of this portfolio is being renamed to miniPrevail™ LP Twin to capture the customer-driven enhancements that have been made over the past couple of years and its important role in the miniPrevail™ family. For more information, visit GHOrthodontics.com.

Dolphin Imaging and Management Solutions announces Blue Dolphin Imaging and Management Solutions announced Blue, a brand-new, browser-based web application of all core Dolphin functions. The application is designed for the orthodontic practice, with features for pediatric dental and oral maxillofacial practices to be added in the imminent future. Blue is enterprise-ready, meaning it can accommodate an extremely large number of patients with no performance degradations, while supporting multiple clinicians and office locations. All data privacy compliance measures have been addressed in Blue, enabling practices to easily keep their PHI (Protected Health Information) and PII (Personally Identifiable Information) secure, and stay compliant with HIPAA (Health Insurance Portability and Accountability Act of 1996). Further, strict privacy compliance and data security are designed and implemented based on Dolphin’s parent organization, Patterson Companies. Blue is available in two tiers: Blue Imaging includes all imaging and patient communications, such as 2D photos and radiograph capture and archiving, image annotations, cephalometric tracings and measurements, Aquarium® patient education movies, and patient letters with images. Blue Enterprise includes the entire feature set of Blue Imaging plus a customizable practice Dashboard with programmable widgets, and the following practice management features: scheduling, financials, treatment card/charting, patient questionnaire, SMS (short message service feature), electronic claims, Appointment Reminders (via SMS or Email), Care Calls, electronic signature, and practice reporting. Visit www.dolphinimaging.com, or call 818-435-1368.

Planmeca Emerald™ intraoral scanner can be used to produce Panthera Sleep Mandibular Advancement Devices Planmeca has announced that it is now possible to use the new Planmeca Emerald™ intraoral scanner to produce Panthera Sleep Mandibular Advancement Devices (MAD). Panthera Sleep designs, develops, manufactures, and markets high-end Mandibular Advancement Devices (MAD) for the treatment of snoring and/or obstructive sleep apnea. The Planmeca Emerald™ intraoral scanner can now be smoothly integrated into sleep practices’ workflows. After scanning the upper and lower arches, first alone and then in occlusion, dentists can instantly export the scans to Panthera Sleep. Visit www.planmeca.com or www.pantherasleep.com.

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Ormco™ unveils Symetri™ Clear bracket system Ormco™ Corporation announced the next generation of esthetically pleasing ceramic twin brackets: Symetri™ Clear. Adding to Ormco’s expansive product portfolio of both lingual and self-ligating bracket systems, Symetri Clear is a refined, esthetic bracket system incorporating design features that apply expert clinical advice and analysis, end-user feedback, and technological advancements and achievements of the company. Boasting a low profile and ample torque and tie-wing strength, Symetri Clear addresses and minimizes the challenges that may come with leveraging a ceramic system — bracket breakage, wire notching, and difficulties while debonding. Serving the needs of doctors and patients, the twin bracket is designed with round surfaces and edges, creating enhanced patient comfort and greater radii on sliding surfaces. To learn more, visit www.ormco.com/products/symetri/.

Volume 9 Number 3

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M AT E R I A L S lllllllllllll & lllllllllllll EQUIPMENT New Ovation® S polysapphire clear brackets by GAC set a new standard for esthetics and durability Dentsply Sirona Orthodontics, a division of Dentsply Sirona, announced the introduction of Ovation S clear brackets. Second in hardness only to diamond, the specially formulated ceramic material of Ovation S offers a combination of clarity and strength that traditional ceramics cannot match. The esthetics of Ovation S braces are unique in how the material lets the natural color of the teeth shine through making the brackets all but invisible. Plus, the high-tech finish minimizes the reflection issue that traditional ceramic brackets suffer from while providing a powerful barrier against stains. Manufactured using the latest in ceramic injection molding technology, the unique molecular structure, state-of-the-art finish, and triple-chamfered slot of Ovation S brackets reduce friction by 41% compared to traditional ceramics. This allows for the smooth, steady movement of archwires without binding or crimping to maximize patient comfort. Because the material that Ovation S brackets are made from is so strong, the brackets can be made smaller and with a lower profile for a more comfortable patient experience. For more information, call 800-645-5530.

MOVE Your Patients with multi-award-winning 3Shape TRIOS® 3 wireless intraoral scanner The 3Shape TRIOS® MOVE is a brand-new hardware setup for the multi-award-winning 3Shape TRIOS 3 Wireless intraoral scanner. The new 3Shape TRIOS MOVE now places the 3Shape TRIOS intraoral scanner, monitor, and PC on the lightweight, fully-adjustable, ergonomic 3Shape TRIOS MOVE. The mobility of the 3Shape TRIOS MOVE enables doctors to always position the screen in the right place. This provides a superior experience for both the orthodontist and patient and makes it easy to share dynamic treatment information close-up with patients to advance treatment dialogue and acceptance. 3Shape TRIOS MOVE is perfectly-balanced and can be rolled effortlessly. Professionals using the 3Shape TRIOS MOVE with TRIOS 3 Wireless additionally benefit from complete freedom of movement because there are no connecting cables between the wand and hardware. For more information, visit www.3shape.com.

Henry Schein® introduces proprietary SLX™ Clear Aligner System

Hu-Friedy launches AdvantaClear™ surface disinfectant product line Hu-Friedy announced the latest offering in its line of infection control products — AdvantaClear surface disinfectant. Available as wipes, liquid, or spray, AdvantaClear features a 1-minute kill time for 30 of the most common pathogens, including HIV-1, HBV, HCV, MRSA, Influenza A Virus (H1N1), Salmonella enterica, ESBL E. coli, and other pathogens with a 2-minute kill time for tuberculosis (TB). AdvantaClear expands Hu-Friedy’s reach as a primary source of infection control products, which now covers instrument processing, cleaning and sterilization monitoring, waterline cleaning, and hand care, as well as this new entry into surface disinfection. For more information, visit http://www.hu-friedy.com.

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Henry Schein®, Inc., has entered the rapidly growing market for orthodontic aligners with its proprietary SLX™ Clear Aligner System. The SLX™ Clear Aligner System is a complete solution that incorporates the popular Sagittal First/Motion 3D technology, a proprietary offering of the company’s Henry Schein Orthodontics (HSO) business. According to HSO’s lead clinical advisor, Dr. Dave Paquette, Sagittal First/Motion 3D can significantly reduce the number of aligners needed for use in a typical case, providing meaningful time savings and clinical benefits to doctors and patients alike. The SLX™ Clear Aligner System, which has been cleared by the U.S. Food and Drug Administration, uses patented manufacturing processes to achieve aligner clarity and a precise fit for greater comfort and improved tooth control. The SLX™ Clear Aligner web portal will accept STL digital impressions from all leading intraoral scanners and, combined with an open-source platform, is easy to use. For more information, call 800-547-2000 or 760-448-8600, email usasales@henryscheinortho.com, or visit www.Henry ScheinOrtho.com.

Volume 9 Number 3

Dental Sleep Practice is honored... to have been chosen to sponsor the Dental Sleep Education Track for the Greater New York Dental Meeting, Nov. 25-28, 2018

Dental Sleep Practice will sponsor two lectures each day from Sunday, November 25 through Wednesday, November 28. These eight seminars, taught by industry leaders who represent the top educators in sleep dentistry, will support dentists through practical sleep apnea education. The program will be led by DSPâ&#x20AC;&#x2122;s Editor in Chief Dr. Steve Carstensen. DSP in partnership with the GNYDM will give you the facts and information you need to expand your practice in this growing and important field of dentistry. Watch for more details this Summer: Connect. Be Seen. Grow. Succeed.

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