Orthodontic Practice US - May/June 2014 - Vol5.3 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews

PROMOTING EXCELLENCE IN ORTHODONTICS BioDigital Orthodontics: Management of patients with Class 2 malocclusion — nonextraction (II): part 9 Drs. Rohit C.L. Sachdeva, Takao Kubota, and John Lohse

PROPEL: the fourth order of orthodontics

Are you getting the most out of your bracket Rx?

Orthodontic Practice US

May/June 2014 – Vol 5 No 3

Dr. Jonathan L. Nicozisis

Shifting compliance to create choices Dr. Ron Maddox

The effects of enlarged adenoids on a developing malocclusion Dr. Derek Mahony

Practice profile Dr. Sarah C. Shoaf

Corporate profile Ormco™ Corporation

May/June 2014 – Vol 5 No 3

Go to page XXX 33 to learn more. PAYING SUBSCRIBERS EARN 24 CONTINUING EDUCATION CREDITS PER YEAR!

to be sure.

SEVEN FEWER

OFFICE VISITS

PER CASE YOU KNOW WHAT THAT MEANS

The personalization offered by Ormco Custom is proven to reduce treatment time on average by 37% with 7 fewer office visits per case.* With the unrivaled efficiency that Ormco Custom provides, you’ll have a little more of that priceless “you time” to hit the back nine. It’s your world – Ormco Custom is just here to help you maximize it. To learn more about how our portfolio of products can improve your practice visit: OrmcoCustom.com © Copyright 2014 Ormco Corporation. All rights reserved.

*Weber DJ 2nd, Koroluk LD, Phillips C, et al. Clinical effectiveness and efficiency of customized vs. conventional preadjusted bracket systems. J Clin Orthod. 2013

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 Eric R. Gheewalla, DMD, BS Dan Grauer, DDS, Morth, MS Mark G. Hans, DDS, MSD William (Bill) Harrell, Jr, DMD John L. Hayes, DMD, MBA Paul Humber, BDS, LDS RCS, DipMCS Laurence Jerrold, DDS, JD, ABO Chung H. Kau, BDS, MScD, MBA, PhD, MOrth, FDS, FFD, FAMS Marc S. Lemchen, DDS Edward Y. Lin, DDS, MS Thomas J. Marcel, DDS Andrew McCance, BDS, PhD, MSc, FDSRCPS, MOrth RCS, DOrth RCS Mark W. McDonough, DMD Randall C. Moles, DDS, MS Elliott M. Moskowitz, DDS, MSd, CDE Atif Qureshi, BDS Rohit C.L. Sachdeva, BDS, M.dentSc Gerald S. Samson, DDS Margherita Santoro, DDS Shalin R. Shah, DMD (Abstract Editor) Lou Shuman, DMD, CAGS Scott A. Soderquist, DDS, MS Robert L. Vanarsdall, Jr, DDS John Voudouris (Hon) DDS, DOrth, MScD Neil M. Warshawsky, DDS, MS, PC John White, DDS, MSD Larry W. White, DDS, MSD, FACD CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day BDS, VT Julian English BA (Hons), editorial director FMC Dr. Paul Langmaid CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-in-chief 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

PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com MANAGING EDITOR | Mali Schantz-Feld Email: mali@medmarkaz.com Tel: (727) 515-5118 ASSISTANT EDITOR | Elizabeth Romanek Email: betty@medmarkaz.com EDITORIAL ASSISTANT | Mandi Gross Email: mandi@medmarkaz.com NATIONAL ACCOUNT MANAGER | Michelle Manning Email: michelle@medmarkaz.com NATIONAL ACCOUNT MANAGER | Adrienne Good Email: agood@medmarkaz.com CREATIVE DIRECTOR/PRODUCTION MANAGER | Amanda Culver Email: amanda@medmarkaz.com PRODUCTION ASST./SUBSCRIPTION COORD. | Jacqueline Baker Email: jbaker@medmarkaz.com

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© FMC 2014. All rights reserved. FMC is part of the specialist publishing group Springer Science+Business Media. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Orthodontic Practice US or the publisher.

1 Orthodontic practice

A customized approach I

f you’re a patient walking into my office, here’s what you can expect: You’ll be greeted by a friendly smile, educated on the latest practice techniques, and introduced to advanced treatment technologies. My practice goal is to customize each patient experience. To help achieve this goal, we’ve incorporated leading digital technologies that enhance patient education and further increase practice profitability. Digital orthodontic technology is no longer just cool and exclusively for the early adaptors. Today’s digital treatment tools are user-friendly, with a minimal learning curve, and translate into a more personalized and profitable practice. The mantra that continues to ring true each day I step foot into my office is, “Treat the why before the how.” I’ve found that upon evaluating a new patient, it’s essential to first educate them on why they should invest in treatment. It’s important to first explain the reasons for treatment, whether it’s a health benefit or cosmetic benefit. From there, I delve into the “how,” highlighting the high-tech tools and techniques used to achieve a beautiful finished result. The truth of the matter is showing how I’ll improve their smile helps the patient fully understand the treatment process. I’ve discovered that the best way to encourage patient participation is through an animated video. Projecting animated videos onto a monitor in a comfortable, living room-like setting provides patients with an individualized look into their smile journey and shows how I’ll help them achieve their treatment goal — whether it’s a wider smile or more aligned bite. By taking the time to sit down with a patient and provide treatment education, you’ll find they’re exponentially more engaged in the process. I run a very technologically progressive practice and use tools such as Ormco’s Insignia™ Advanced Smile Design™ to help patients visualize the before, during, and anticipated final smile result. You’ll be amazed at how connected and invested patients suddenly become when they can actually see the transformation of their smile! In addition to giving them an “inside look” at the development of their smile, Insignia provides a level of patient customization that can’t be beat. It includes customized brackets, wires, and precision placement guides made for each patient’s unique occlusal anatomy. Every single case is different and should be treated as such. Some clinicians are skeptical of adopting a digital practice, and I understand that. However, I’m an advocate for the digital orthodontic practice. As I mentioned above, technology is no longer just cool … it’s practical. Today’s high-tech tools and appliances are the epitome of user-friendly. My practice was one of the first to integrate Ormco’s Lythos™ Digital Impression System into our daily practice. Yes, it’s very cool, but more than that, it’s incredibly easy to use, has eliminated the need for traditional polyvinyl siloxane (PVS) impressions, and offers my patients improved comfort. Seamless integration with AOA laboratory has increased our profitability by significantly reducing the number and length of many appointments. The Lythos/ AOA solution has virtually eliminated the need for our in-office laboratory. Rather than the traditional point-and-click technology that is limited to single image capture, Lythos’ technology captures up to 2.5 million 3D data points per second. This creates an entire high-resolution, dual-arch scan that provides an all-encompassing view of a patient’s tooth surface. My advice: Don’t be afraid to get your feet wet with digital technology. It is through these tools that you’ll be able to customize your practice, cut costs, decrease the number of office visits for patients and foster a thriving, progressive practice. Combine this with a variety of educational tools, including animated videos, and you’ve got a recipe for success — not to mention happy customers who are invested in their smile journey. It doesn’t get much better than that! Dr. Mark Coreil Mark Coreil, DDS is a board-certified orthodontist and currently treats patients at Le Centre Orthodontic Arts in Houma, Louisiana. Dr. Coreil is Associate Professor of Clinical Orthodontics at the Louisiana State University School of Dentistry and is actively involved as an orthodontist on the Children’s Hospital Cleft and Craniofacial Team in New Orleans, Louisiana. Dr. Coreil graduated from Louisiana State University School of Dentistry in 1986 and completed his orthodontic specialty training at the university in 1988. To further his education, he completed the Roth/Williams Advanced Clinical Program in 1993. Dr. Coreil is an active speaker on both a national and international level, lecturing on a number of topics pertaining to orthodontics. You can visit Dr. Coreil’s practice website at www.lecentreortho.com

Volume 5 Number 3

INTRODUCTION

May/June 2014 - Volume 5 Number 3

TABLE OF CONTENTS Case report A case report using Esprit™ Dr. Robert Miller discusses a new Class II corrector......................... 14

Technology Shifting compliance to create choices Dr. Ron Maddox discusses using the Carriere® Motion™ Appliance to create the perfect patient experience ................................................... 18 PROPEL: the fourth order of

Practice profile

Sarah C. Shoaf, DDS, MEd, MS

orthodontics Dr. Jonathan L. Nicozisis discusses a product that facilitates true tissue remodeling preceding force application .................................. 24

Recipe for great smiles

Corporate profile

Ormco Corporation ™

With a distinguished 50-plus year history, Ormco™ Corporation has long been providing the orthodontic profession with high-quality products backed by the company ethos — Your Practice. Our Priority.

ON THE COVER Cover photo courtesy of Dr. Ron Maddox. Article begins on page 18.

2 Orthodontic practice

Volume 5 Number 3

uct d o r P ted Trus

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FINI O T ---

If We Toss Innovation Around Like We Own It…It’s Because We Do When you think GAC and innovation, you probably think of our In-Ovation brackets. But at GAC, innovation is so much more. • Innovation is GCARE reshaping the educational landscape. • Innovation is GACPowered.com giving you the ability to grow your practice. • Innovation is the UOBG harnessing the power of group buying. So the next time you think of innovation in orthodontics, think beyond the bracket. Think GAC.

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TABLE OF CONTENTS

50 Periodontal rationale for transverse skeletal normalization

Orthodontic concepts BioDigital Orthodontics: Management of patients with Class 2 malocclusion â&#x20AC;&#x201D; nonextraction (II): part 9 Drs. Rohit C.L. Sachdeva, Takao Kubota, and John Lohse discuss additional care management strategies to treat Class 2 patients .....................................................29

Industry news ...........42 4 Orthodontic practice

Continuing education The effects of enlarged adenoids on a developing malocclusion Dr. Derek Mahony discusses early diagnosis and treatment of pathological conditions that can lead to the obstruction of the upper airways..........................................43

Product profile GALILEOSÂŽ Comfort Plus .........54

AAO encore .................55 Product profile 3M Unitek ...................................56

Periodontal rationale for transverse skeletal normalization Drs. Ryan K. Tamburrino, Shalin R. Shah, and Daniel L.W. Fishel strive to objectively measure and optimize the skeletal transverse dimension........50 Volume 5 Number 3

“Propel increased the rate of clear aligner progression by increasing the rate of bone remodeling. Treatment time was reduced over 70% and the overall amount of appointments were reduced from 20+ to 8.”

Thomas Shipley, DMD, MS

A better way to deliver orthodontic success As a practitioner, the most important thing is achieving the best clinical outcome. Propel’s chairside technique can be performed in minutes in conjunction with any orthodontic modality. Our patented, disposable device is redefining treatment protocol without sacrificing patient comfort or the desired finish.

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PRACTICE PROFILE

Sarah C. Shoaf, DDS, MEd, MS, DABO Recipe for great smiles

What can you tell us about your background? I grew up in Winston-Salem, North Carolina, but my parents moved to Durham, North Carolina before I started high school. After high school in Durham, I went to Wake Forest University in a 3-2 program with the Bowman Gray Physician Assistant program, so my undergraduate degree was a BS in Allied Medical Health Professions with a Physician Assistant major. I worked as a PA for 3 years in Philadelphia at a small regional hospital, then 3 years in New Orleans at their VA Medical Center. While in New Orleans, I got a Masters of Education degree, intending to find a faculty position in a PA program. But that was the time that President Ronald Reagan was pulling all the funding from the PA programs, and many were folding, so none could offer me a long-term position. I took this as a bad omen for the PA profession (which has since been disproven), and went to dental school at UNC. I did well in dental school, attaining Omicron Kappa Upsilon (OKU) dental honor society status and winning a Dentist-Scientist government grant for 5 years of study. I chose Eastman Dental Center in Rochester, New York for my Orthodontic specialty training, and also obtained a Masters degree in Biochemistry/ Genetics. My intent was to select a position in a dental school or medical school faculty to do both clinical orthodontics and work with craniofacial anomaly patients. My dream job opened up at Wake Forest University Medical Center, and I was on faculty as their orthodontist from 1992 to 2009, teaching dental residents as well as medical and PA students. While there, I also developed expertise in sleep apnea appliances, Invisalign treatment, and forensic odontology. But private practice called out to me, and I went to work in Mount Airy, a small town north of WinstonSalem, where I worked for a friend for 2 years before deciding to go out on my own. My present practice, Salem Smiles Orthodontics, opened January 2012, and we now have almost 900 active patients. 6 Orthodontic practice

Why did you decide to focus on orthodontics? I selected dental school as a way to get into orthodontics to be able to work with craniofacial anomaly patients. So, I had pre-selected orthodontics prior to getting into dental school, and focused on that goal from the start.

How long have you been practicing, and what systems do you use? I graduated from Eastman Dental Center in 1992, and have practiced continuously since that time. I am a simple practitioner, using non-self-ligating appliances for most treatment, but really like the Invisalign速 (Align Technology, Inc.) system. I was part of the first Invisalign training session on the East Coast in 1999, and stayed with them through their formative growing pains to their present excellent product. In fact,

if I could have an entire practice of only Invisalign patients, I would be most happy!

What training undertaken?

have

you

I outlined my BS, PA certificate, MEd, DDS, and MS above, but also attained Diplomate Status in the American Board of Orthodontics in 2003, which less than 25% of practicing orthodontists can claim. In addition, I worked with the NC Center for Cleft and Craniofacial Deformities from 1992 to 2009, and am an active member of the American Cleft Palate-Craniofacial Association. I took the Forensic Odontology course from the Armed Forces Institute of Pathology in 1996 and am called upon by NC State and regional law enforcement for dental identifications and bite mark identifications. My sleep expertise is selftaught, beginning while as a graduate student in Rochester, and I am continuing Volume 5 Number 3

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PRACTICE PROFILE

the fabrication of oral sleep appliances with the Wake Forest Medical Center sleep center and local referrals.

Who has inspired you? Dr. Bill Proffit of UNC was very inspirational during my dental school days, urging me to use my talent for teaching. Also, my father has been inspiring while I opened my business, as he never thought I’d be out on my own working in my own practice.

What is the most satisfying aspect of your practice? I like seeing the look on the patients’ faces when they see their “before” and “after” pictures at their retainer placement. They get so proud of the changes! I am also very proud of my craniofacial patients who obtain a solid functional occlusion when nature did not give them one.

Professionally, what are you most proud of? I am proudest of starting my own practice at age 56. After a long run in academia, I had to learn a lot of business and find a way to surround myself with good people who could do the things I’m weakest in. I am also proud of all the teaching I’ve done to dental, medical school, and PA school residents over the years. I hope I’ve made a difference to some of them.

What do you think is unique about your practice? It is a “new” practice, but I am an experienced clinician, so very different from others in the area. We also do a lot of Invisalign treatment, which I am very 8 Orthodontic practice

excited about and try to steer patients to that modality whenever I can, as I believe it is a superior product. And there is no one doing forensic dentistry in the northwest section of NC beside myself. My staff members laugh because I know American Sign Language from my tenure in Rochester and in craniofacial patient circles, and also know Spanish, so I can get along with a wide variety of patients.

a number of culinary courses at Guilford Tech Community College. With only one or two more courses, I would have had my Associates Degree with a Baking Certificate. Even now, I do wedding cakes for friends and family and aspire to bake wonderful desserts for high-end restaurants.

What has been your biggest challenge?

I firmly believe that we will all be doing just Invisalign-type treatment in the future, and that wires and bonded brackets will go the way of the hand-welded bands on every tooth. It is just so much easier for the patients and much easier to clean.

Starting a practice from scratch at a late age. I had the experience and the money saved but had to learn a lot about business practices along the way. But I found excellent attorneys, accountants, design, construction, and equipment people to help me, so that made it a lot easier!

What would you have become if you had not become a dentist? I’m awfully good with my hands, and took

What is the future of orthodontics and dentistry?

What are your top tips for maintaining a successful practice? Surround yourself with good people to do the things you do not have expertise in or to counsel you objectively in the areas Volume 5 Number 3

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PRACTICE PROFILE

Under the sea with Dr. Shoaf

Dr. Shoaf with husband, Alan Miller

I like seeing the look on the patients’ faces when they see their “before” and “after” pictures at their retainer placement. They get so proud of the changes! I am also very proud of my craniofacial patients who obtain a solid functional occlusion when nature did not give them one.

where you do have skills. Paying for good lawyers, accountants, lab work, equipment service, IT, and supplies are worth it in the long run. I would especially tell people to get a professionally-designed logo to base all your marketing and learn to “brand” your office in all types of media, particularly the Internet.

is so worth using that first 3-month trial employment to be sure you have the right people in the right position. Be patient when hiring — don’t take the first ones who show up for interviews! But know what you are looking for.

What advice would you give to budding orthodontists?

My husband, Alan Miller, is an underwater photographer, so we have been around the world to go scuba diving in all sorts of exotic locations (Hawaii, Cabo San Lucas, Australia (5 times), Raja Ampat in Indonesia, the Cayman Islands, British and American Virgin Islands, Bahamas, Panama, etc.). When we are not diving, I make jewelry with lots of fun and colorful semi-precious stones, some of which I find on our travels. Also, I am a big Wake Forest Demon Deacon supporter — we try to go to all the men’s basketball and football games, and support all the teams,

Take more senior orthodontists out for lunch, and pick their brains. Who knows — one of them may be impressed and offer you a job or a practice! And don’t be afraid to spend a lot of money to get “the good stuff” when opening your practice. It takes a lot more time and money to throw out the old stuff and buy new equipment. The last advice I’d give is to not “settle” for hiring mediocre staff. Good staff members are worth their weight in gold and will constantly make your life much easier. It 10 Orthodontic practice

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

especially women’s golf. I also play golf with the Executive Women’s Golf Association Piedmont Triad Chapter, and have gone to regional and national competitions within that group on several occasions. I keep a sourdough starter and make artisan bread weekly, which goes to a local restaurant and wine store. My husband and I own part of the wine store, and do weekly tastings to add to our 2,000+ bottle wine cellar in our 122-year-old home. OP

Top ten favorites 1. My husband, who takes as much delight in everything as I do, and knows how to share the fun! 2. Doing orthodontics – this is the BEST profession!! 3. My parents, who have always been my most ardent supporters 4. Eating well-prepared meals accompanied by excellent wine 5. Scuba diving 6. Traveling 7. The changes in adolescents as they grow and become more confident in their new smiles 8. Dear friends I’ve known since high school and college days 9. Baking, especially wedding cakes, artisan sourdough bread, and desserts 10. Invisalign cases

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CORPORATE PROFILE

Ormco™ Corporation

ith a distinguished 50-plus year history, Ormco™ Corporation has long been providing the orthodontic profession with high-quality products backed by the company ethos — Your Practice. Our Priority. With a breadth of innovative products and solutions, the company is fully committed to helping orthodontists achieve their clinical and practice management objectives. From its recent Damon™ Clear2 launch to unveiling Ormco™ Custom, an end-to-end digital platform, Ormco has a reputable track record for product innovations and continues to lead the way, helping doctors provide remarkable results with a variety of treatment options.

A History of Innovation Frank Miller founded Ormco in 1960, and proceeded to shake up the industry with the introduction of preformed bands and preassembled brackets. Today, Ormco continues to impact the industry with unwavering dedication to innovation and a focus on driving the field of digital orthodontics. In the rich 50-plus years that followed Miller’s inception of Ormco, the company introduced a number of notable “firsts,” including direct bonding, rhomboid, and computer-aided design (CAD) brackets, Copper Ni-Ti® wires, TMA™ beta titanium wires, Titanium Orthos™, and Damon™ Clear. The company also is a pioneer in 3D digital orthodontics with Insignia™ Advanced Smile Design™, an integrated system of customized appliances, bracket placement, and software. One of Ormco’s flagship products — the Damon™ System — was initially introduced by Dr. Dwight Damon and Ormco as Damon™ SL. Created by and for orthodontists, the Damon System is a unique passive self-ligating bracket system comprised of passive SL brackets, hightech archwires, and minimally invasive treatment protocols that work together to provide exceptional benefits for the doctor and patient. The progressive system, designed with periodontal health in mind, has undergone ongoing design enhancements with eight bracket evolutions leading up to the new Damon™ Custom and Damon Clear2 this year. With clinically-proven metal brackets and 12 Orthodontic practice

clear brackets, the Damon System has continued to evolve with patient and doctor demands. More than 4.5 million patients have been treated with the Damon System, and thousands of orthodontists around the world continue to rely on the solution to deliver remarkable results. Ormco’s innovations don’t stop at self-ligation. Since 2010, the company has invested more than $50 million in digital orthodontics research and development, and in 2014, it announced plans to ramp up investment further. The added funding will accelerate the development of Ormco Custom — the first comprehensive package for 3D digital imaging records, 3D digital treatment planning, photo realistic outcome visualization, and fabrication of customized aligners and fixed and lab appliances. This solution will assist clinicians in driving treatment directly to their desired finish, with unparalleled efficiency, profitability, and personalization.

Ormco™ Custom In the past, manufacturing limitations have prevented brackets and wires from being truly customized for individual patients. Now with state-of-the-art digital technologies and personalization techniques, Ormco has made unprecedented levels of customization possible, resulting in better smiles and more efficient practices. The Ormco Custom suite of products and services includes Insignia™ Advanced Smile Design™, the Lythos™ Digital Impression System, and AOA lab. The Insignia platform, which is proven to reduce treatment time by 37% with 7% fewer patient visits*, now has an enhanced Insignia Advanced Smile Design Approver Interface that features an updated sleek design, creating a more intuitive experience. The new interface, called Insignia™ Ai, includes a Wizard that navigates users through the suggested approval process step-by-step to provide an added level of case support and customization. With advanced technology, a video can be created and shown within Insignia’s

software that will superimpose the tooth movement from initial malocclusion to the final design of the patient’s smile. This visual is a great tool to help patients better understand the treatment process and build excitement for the final results. Yet another advancement available with Insignia is the ability to interact with the patient’s occlusion from multiple angles. Now orthodontists have access to an unprecedented level of interactive visualization to achieve both the esthetics and occlusion preferred. Designed to integrate easily into any practice, Lythos allows users to own, store, and send treatment scans to anyone that accepts .stl files — at no cost. Ormco’s Lythos Digital Impression System uses AFI technology to capture and stitch together data in real-time, acquiring high-definition surface detail at all angulations of the tooth surface. Unique to orthodontic impression systems, Lythos can provide up to 2.5 million 3D data points per second which results in a rapid single high-resolution scan option for added simplicity. Lythos is easily integrated into any practice workflow, allowing professional teams to transition quickly to digital impressions while keeping chair time to a minimum. Likewise, with a unique open platform format and rebate program, the Lythos scanner is a sound financial investment. Lythos’ open system allows data to be easily integrated with orthodontic labs and manufacturers to Volume 5 Number 3

The Damon Difference As a category innovator, Ormco believes whole-heartedly in the benefits of selfligating brackets. To continue leading the self-ligating industry and exceed customer expectations, Ormco has dedicated significant resources to ongoing Damon System bracket advancements. Ormco’s move toward customization is also benefiting the Damon System line. Doctors said they wanted the Damon System available in more prescriptions. The Ormco team heard the message. Now, the Damon System is available in an all new prescription — yours! With the introduction of Damon Custom this summer, orders can be made for the exact prescription values** needed to best treat each individual patient. An industry first, Damon Custom allows orthodontists to order their own prescription value for every upper and lower 5-5 Damon Custom bracket. Harnessing the power of Ormco’s patented technology, Damon Custom is conveniently packaged in completely individualized prescription single patient kits. Additionally, enhancements have been made to the popular Damon Clear bracket with the introduction of Damon Clear2. Featuring a new ultra-precision slot, Damon Clear2 — the only 100% clear self-ligating bracket on the market — offers 2 times the rotational control*** for meticulous finishing and efficient treatment. Completely esthetic with an unparalleled clear design, Damon Clear2 is an ideal solution for today’s image-conscious adults and teens — providing the performance and control needed to treat a wide range of cases, including crowding, flat profiles, open bites, cross bites, and patients in need of space closure and arch development. The brackets are now shipping to doctors in North America and can be ordered through Ormco sales representatives or by Volume 5 Number 3

completing the Damon Clear2 interest form at www.ormco.com. With constant R&D, the Damon System pairs its sophisticated MIM process with educational support, practice marketing tools, and an award-winning online Damon Doctor Locator. It’s estimated that the Damon Doctor Locator, accessible by consumers at www.damonbraces.com, drives one to two starts each month to participating clinicians. Furthermore, over a 4-year period, there has been a 283% increase in Damon Doctor Locator searches — which currently translates to $82 million in potential practice revenue each month for Damon doctors in North America.

Supporting Your Growth To support local practice marketing and patient education campaigns, Ormco provides an online resource center with a complete range of marketing assets and staff training tools. The robust online platform, www.marketing.ormco. com, hosts a library of patient imagery, consultation tools, practice videos, press release templates, webpage assets, and more for doctors offering the Damon System, Insignia, Lythos, and Inspire ICE™. And don’t forget about Damon System endorser and past patient Soul Surfer Bethany Hamilton! Bethany joined the Ormco family in late-2011 and has been promoting the Damon System to her active teen fan base. With a thriving social media presence, Bethany Hamilton has helped dramatically boost traffic to the Damon Smile consumer website, and she continues to draw attention to the importance of a healthy smile and investing in orthodontic treatment. Be sure to visit www.marketing.ormco.com for available assets to leverage Bethany in your office. Many are aware of the annual Damon™ Forum event, held in January or February each year, which brings together thousands of orthodontists and staff members to learn new treatment modalities, progressive technologies, and practice differentiation strategies. The annual Damon Forum is just one of many educational events offered by Ormco. There are also comprehensive CE programs throughout the year that range from regional events, in-office courses, webinars, roadshows, and more. Visit www.ormco.com/education to learn more

about all Ormco educational programs. Following Ormco’s mission — Your Practice. Our Priority. — it transitioned Ormco Loyalty Rewards to Ormco Lifetime Rewards more than a year ago to allow members to earn points that never expire. The concept is simple: Earn points on every dollar you spend on Ormco’s selection of orthodontic appliances, and redeem them whenever you’d like for a number of orthodontic products and services. Research indicates that, through the rewards program, the average doctor earns up to 30% back in lifetime rewards points.

Looking to the Future A recent digital orthodontic survey distributed to orthodontists reported that 98% of respondents believe the future of the orthodontics industry will increasingly rely on a digital workflow. These numbers don’t lie — and Ormco will be there every step of the way. With 110 globally filed patents in digital orthodontics, Ormco has plans to scale its digital business aggressively in 2014 and beyond. Ormco will continue building upon its current digital suite, which in 2013 grew in revenue by 121% in North America alone. The coming years will bring big innovations for the orthodontic industry. Future technology with increased customization will offer unprecedented convenience, control over cases, and office efficiency. While making your practice our priority, Ormco is eager to give doctors more time than ever to focus on delivering great smiles. And the innovation won’t stop there; that’s a promise! For more information, visit Ormco online at www.ormco.com. OP *Weber II DJ, Koroluk LD, Phillips C, Nguyen T, Proffit WR. Clinical Effectiveness and Efficiency of Customized vs. Conventional Preadjusted Bracket Systems, J Clin Orthod. 2013;47(4): 261-266. ** Within manufacturing limitations. *** As compared to Damon Clear, data on file. Standard torque, upper 3-3 brackets.

This information was provided by Ormco Corporation.

Orthodontic practice 13

CORPORATE PROFILE

produce a variety of custom appliances and/or study models. The last, but certainly not least, component of Ormco Custom is AOA Lab. Ormco’s laboratory arm fabricates customized appliances, including Class II correctors, aligners, splints, retainers, and more. To help streamline the dental practice workflow, AOA Lab accepts .stl files from a number of scanners but has a unique integration with Lythos to allow for an even easier submission process.

CASE REPORT

A case report using Esprit™ Dr. Robert Miller discusses a new Class II corrector

ver the past 4 years, Opal® Orthodontics has been developing a new universal Class II spring that has several unique properties that make it more durable and tolerable for the patient. Although many orthodontists use MARA and Herbst appliances, a majority use a Class II corrector that can be added to fixed edgewise appliances at any time. Class II elastics are the most widely used because they are easiest on the patient, but elastics have limitations — mainly compliance. Over the past 10 years, the Forsus™ device has gained in popularity because it is compliance-free and works quickly. Recently, an article was published studying the patient experience of the Forsus device.1 Although most patients tolerate the appliance (82%), 16% had a negative experience (bad to really bad). Roughly half of the patients had negative issues initially, but they overcame problems associated with cheek irritation after the first 4 weeks. These issues were also observed at about the same rate in our practice with Forsus appliances. In this case report, we used a new Class II corrector on a patient who had a moderate Class II malocclusion characterized by a slight right/moderate left Class II dental discrepancy. Her condition was compounded by a left posterior crossbite (Figure 1). One of the advantages of using the Xbow™ device, developed by Dr. Duncan Higgins, is it allows for simultaneous compensatory crossbite correction while one corrects the

Figure 1: Initial photographs

Figure 2: Esprit Class II corrector

Dr. Robert Miller received his DMD degree in 1983 from The Medical University of South Carolina, and then completed an orthodontic residency at the Medical College of Virginia in 1985. After completing his orthodontic residency, Dr. Miller served proudly in the USAF where he was Chief of Orthodontics at Clark Air Base in the Philippines for 3 years. Dr. Miller began practicing in Culpeper, Virginia, in 1988 and became a Diplomate of the American Board of Orthodontics in 1992. Dr. Miller is a past president of the Virginia Association of Orthodontics. He is a pioneer in the area of orthopedic correctors, having developed the Flip Lock™ Herbst device in the early 1990s. More recently, Dr. Miller assisted in the development of the Esprit spring. Dr. Miller is the author of numerous professional publications in orthodontics. He holds membership in the American Association of Orthodontists, the World Orthodontic Federation, the Southern Association of Orthodontics, Virginia Association of Orthodontists, American Dental Association, Virginia Dental Association, and the Northern Virginia Dental Society, and is the Leader of the Spear Study Club of Northern Virginia. He is also a member of the Northern Virginia Orthodontic Study Club. More recently, Dr. Miller joined the Edward H. Angle Society of Orthodontists (EHASO), North Atlantic Component after presenting original research to fellow members in Barcelona, Spain, in March 2012. To learn more, visit EHASO’s website at http://anglenorthatlantic.org. His research was later published in The Angle Orthodontist, May 2013.

14 Orthodontic practice

antero-postero discrepancy.2 By using this approach instead of adding the springs to the arch wire, we reduce overall treatment time by 6 months with 10 months less time in fixed, edgewise appliances.3 Also, no significant incisor proclination changes were found when comparing the 2 methods (Xbow versus springs connected to the arch wire). Therefore, using negative torque (-6 degrees) does not prevent final proclination of lower incisors as many believe, so one must properly select cases with minimal incisor crowding. Volume 5 Number 3

Innovative clip design allows easy placement

Now Aligned Smooth CNC-machined body for patient comfort and durability

Enclosed spring prevents painful pinching

Comfortable mesial hook is easy to install and remove

Laser-welded components hold up to the toughest conditions

NOW avaILabLE Visit our website or call to learn more about Esprit! opalorthodontics.com/esprit

888.863.5883 Innovative machined clip design allows easy placement with predictable locking

Photos courtesy of Dr. Robert Miller Class II to Class I in 4.5 months

Comfortable machined mesial hook enables smooth gliding, prevents rolling, and reduces the need for push-rod bends

When we asked doctors what they wanted in a Class II corrector, the response was clear: More comfort. More durability. Easier placement. So we developed Esprit. The breakthrough appliance that offers everything your Class II corrector is missing.

CASE REPORT

Figure 3: Planned overcorrection 4.5 months (Esprit)

Figure 4: Final photographs

Figure 5: One-year posttreatment

The Esprit spring has better patient acceptance and tolerance because the spring is nested or internal (Figure 2). Upon insertion, patients respond more favorably to Esprit than to springs used in the past, such as Forsus, because they cannot feel the spring. This patient, Savanah S., used the Xbow with the Esprit spring for 4.5 months (Figure 2), and we see typical overcorrection for planned rebound (Figure 3). In Figure 4, we see her final records after 4.5 months of Esprit springs and 16 months of fixed edgewise appliances. (She had a 2-month break between the Xbow and the fixed edgewise appliances.) Figure 6 shows the cephalometric tracings, which demonstrate little if any change from growth as expected due to her age at treatment onset (age 13.5), but favorable dentoalveolar changes. At her 1-year posttreatment visit, photos show additional settling and improvement in her occlusion (Figure 5). The most notable part of her treatment was less cheek irritation from the Esprit spring. Most patients experience little, if any, cheek irritation because they cannot feel the spring. The push rod and clip connector are easier on both the patient and the clinician. In summary, the Xbow device provides a great alternative to Herbst and MARA devices in moderate Class II discrepancies because it is more tolerable for patients and requires no stainless steel crowns. The Esprit spring is a better alternative to Forsus as the engine that powers either Xbow or connection to the arch wire because it is more durable and comfortable for the patient. OP

References 1. Bowman AC, Saltaji H, Flores-Mir C, Preston B, Tabbaa S. Patient experiences with the Forsus Fatigue Resistant Device. Angle Orthod. 2013;83(3):437-446. 2. Xbow. Homepage. www. crossboworthodontic.com. Accessed April 28, 2014.

Figure 6: Superimpositions showing dentoalveolar changes

16 Orthodontic practice

3. Miller RA, Tieu L, Flores-Mir C. Incisor inclination changes produced by two compliance-free Class II correction protocols for the treatment of mild to moderate Class II malocclusions. Angle Orthod. 2013;83(3):431436.

Volume 5 Number 3

TECHNOLOGY

Shifting compliance to create choices Dr. Ron Maddox discusses using the Carriere® Motion™ Appliance to create the perfect patient experience Introduction From the first day that we enter in our respective graduate orthodontic programs, we possess a burning desire to learn everything we can about creating beautiful smiles. We study, research, and listen as our professors share their wealth of knowledge. When we begin to apply these techniques clinically, we quickly realize that there is a major factor necessary to achieve the desired outcome: patient compliance. Without patient compliance, we learn that the best diagnosis and treatment planning will fall short of our desired outcome, especially when it involves bite correction. The most prevalent obstacle we will face is the correction of the Class II malocclusion. We learn many different techniques during our clinical training: headgear, elastics, intraoral springs, and a variety of functional appliances. We rarely have enough time during our residencies to fully understand the efficacy of each of these techniques. As we transition into private practice, we then must apply our knowledge and clinical experience to help our patients achieve the beautiful smiles that they desire.

Figure 1: Carriere Motion with Carriere Oral Elastic attached to hook on the cuspid pad. Class I platform is present when a cuspid occlusion, in which centric relation coincides with centric occlusion, and the molar occlusal relationships are a perfect Class I

Discussion One of the key lessons I’ve learned in private practice is keeping myself and my team focused on creating an exceptional patient experience. The way I stay focused is adhering to what I call the “3 C’s” — connection, commitment, and choices. We have all heard the famous quote from our professors and consultants, “Patients don’t care how much you know until they know how much you care.” We must focus on connecting with our patients and

Ron Maddox, DDS, received his dental degree from Baylor University College of Dentistry in Dallas, Texas. He also holds a Certificate in Orthodontics from the University of Southern California (USC). He maintains a private practice at Maddox Orthodontics in San Dimas, California, and Crossroads Orthodontics in Upland, California. He is a member of the National Orthodontic Advisory Board for Pacific Dental Services, Member and Past President of the USC Orthodontic Alumni Association and Treasurer of the Dougherty and Tanaka Orthodontic Foundation.

18 Orthodontic practice

letting them know how deeply we care about them as individuals and how much we care about helping them achieve their oral health goals. “Commitment” is building the bridge of trust that gives our patients confidence that we will provide the best care for them. “Choices” is striving to give patients the best alternatives to reach their desired outcome. Quite frankly, over the years I have fallen short on providing choices. One becomes entrenched in the day-to-day operations of the practice and tends to streamline the choices in order to maintain efficiency. Fortunately, a fellow colleague invited me to a study club meeting to listen to an orthodontist discuss the benefits of using the Carriere® Motion™ Appliance to correct Class II malocclusions. I tend to be skeptical about new techniques until I have seen the data and analyzed the clinical results. After listening to the first half-hour of the presentation, I realized that

this would be an excellent way to provide new choices for my patients and greatly reduce my reliance on patient compliance at the end of treatment. One of the most important features about utilizing the Carriere Motion Appliance is that it shifted patient compliance to the beginning of treatment instead of the end when many patients are suffering from “burnout,” poor oral hygiene, or both. From the outset I knew this would be a monumental change for my patients and my practice. I could enhance the ability to provide an exceptional patient experience by providing my patients with more choices for tooth alignment.

Carriere Motion Appliance Utilization of the Carriere Motion Appliance in my practice was a very simple transition. Making treatment less complex for my patients has always been a key goal, and I strive to reduce the number of Volume 5 Number 3

G A ME C HANGE R TURN CLASS IIs INTO SIMPLE CLASS I PATIENTS* Molar Ball & Socket

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Simplicity, ease of use and patient compliance add up to fast, more predictable results. With its sleek, aesthetic and non-invasive design, the Carriere Motion Appliance shortens treatment time by up to four months*. Easier than Herbst ®, simpler than Forsus ®, and faster than elastics alone*, the Carriere Motion Appliance can be a real game changer for your practice. To learn more about the Carriere Motion Appliance and our other game changing products and services, please contact your local Henry Schein ® Orthodontics ™ (HSO) representative, or HSO directly at 888.851.0533 or HenryScheinOrtho.com.

TECHNOLOGY

Figure 2: Independently moves each posterior segment, from canine or premolar to molar, as a unit

appointments for my patients while remaining laser-focused on achieving the optimal outcome. At the first appointment, I scan the lower arch, place separators for the molars, and measure the canineto-molar distance to make sure that I have the perfect fit for the appliance. The patient is dismissed within 15 minutes and appointed for the cementation of the lingual arch and bonding of the appliance. By scanning the patient and uploading the file to our digital laboratory for fabrication of the lingual arch, we have omitted the extra appointment that is normally needed for fitting the bands, taking the impression, replacing the separators, and doing the lab work to send the model to the laboratory for fabrication. Eliminating these steps saves chair time, assistant time, and results in fewer appointments and discomfort for the patient. When the patient returns, the lingual arch is cemented, and the pre-measured Carrier Motion Appliance is then bonded into place. Instructions for the elastic wear are reviewed with the patient and parent, and they are usually dismissed within 30 to 45 minutes. The following appointments are brief and require very little doctor time to assure that the patient is cooperating with the elastic wear and that the Class II correction is on track. Typically, I see the patient monthly to monitor his/her cooperation and progress. The normal treatment time is 3 to 5 months. Once 20 Orthodontic practice

the Class II correction is complete, I remove the appliance and the lingual arch, polish the teeth, and either bond the fixed appliances or scan for clear aligner fabrication. The transition into the tooth alignment stage is usually seamless based on the choices that were offered prior to the bite correction. The level of cooperation observed while correcting the bite is also a strong indicator of patient cooperation during treatment, which allows greater accuracy in predicting their estimated treatment time. Shifting compliance to the beginning of treatment when the patient is excited to start orthodontic treatment has drastically reduced issues with patient cooperation, reduced overall treatment time, and provided greater choices for the patients and parents on the method they may use to help achieve a beautiful smile.

Carriere Motion Appliance key advantages: • Efficient — Improves compliance and reduces overall treatment time • Effective — Corrects Class II malocclusion bilaterally or unilaterally • Discrete — Esthetically pleasing with a low profile design and is easy to clean • Fewer emergencies — No broken wires or springs • Enhanced choices — After bite correction, teeth may be aligned with clear aligners or braces

Conclusion We all strive to be caring and committed orthodontists in our quest to create beautiful smiles, but providing alternative choices for our patients and their families greatly enhances our opportunity to provide an exceptional patient experience. Shifting to the Carriere Motion Appliance has been one of the most significant treatment advances I have implemented over the past 5 years in my practice. Patients always desire to complete their treatment as quickly as possible, and with the Carriere Motion Appliance, I have been able to reduce the overall treatment time and significantly reduce the time that my patients are in clear aligners or braces. Most patients and parents comment on how little discomfort they experience and how surprised they are that it does not affect their speech while wearing the elastics. I have also seen much better oral hygiene than in patients with full fixed appliances. By shifting the time for the correction of the Class II malocclusion to the beginning of treatment, I have much happier patients that spend less time in treatment and that are much more willing to share their positive experience with their friends and co-workers. OP

Volume 5 Number 3

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“As an orthodontist in a PDS®-supported practice, I am able to work directly with Dr. Deepika Dhama, the owner dentist at Hamner Dental Group and Orthodontics. Together, we focus on providing comprehensive dental care and Clinical Excellence for our patients. Dr. Dhama prepares them by discussing any orthodontic concerns prior to their consult, which helps me convert these consults into actual starts. I also get to enjoy a healthy work/life balance outside of the office, so that at the end of the day I can go home and spend time with my family.”

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With accurate, CNC-machined slots, Avex brackets help you achieve beautiful, board-standard finishes with less wire bending. Photo Credit: Dr. Richard P. McLaughlin

After

Before

Research has shown that most brackets have oversized slots.1 Avex brackets are made using a proprietary CNC process that provides more accuracy than any other bracket.

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1. Cash AC, Good SA, Curtis RV, McDonald F. An evaluation of slot size in orthodontic brackets—are standards as expected? Angle Orthod. 2004;74(4):450–453.

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The new textbook from Dr. McLaughlin and Dr. Bennett, Fundamentals of Orthodontic Treatment Mechanics, fully explains this all-new prescription through practical instructions, a series of stage-by-stage treated cases, and in-depth discussions on topics such as case settling and posttreatment management.

Call 888.863.5883 to order your copy today.

*Not yet verified by peer-reviewed research. Faster and easier refers to fewer wire bends and improved in/out.

TECHNOLOGY

PROPEL: the fourth order of orthodontics Dr. Jonathan L. Nicozisis discusses a product that facilitates true tissue remodeling preceding force application ‘The future ain’t what it used to be.’ -Yogi Berra

he history chapters of orthodontic textbooks have taught us much on the evolution of our industry. Debates and understanding of growth and development, extraction versus non-extraction, expansion at all costs versus expansion at your own peril, etc., have run their course. Some decide to continue in such debate for the mental exercise or personal benefit as new tools for measurement and imaging continue the ability to kick the can of promising and definitive answers down the proverbial road. Likewise the merits and advantages of appliance systems over others have provided much pulp for collegiate discourse. Often when talking about tip, torque, and rotational control, we forget the simplicity of the dichotomy of tooth movement; we focus in on bracket design, slot size, slot width, twin wing, single wing, active clip, passive clip, torque in the base, torque in the face, etc., to best control the first, second, and third orders of movements. The future of orthodontics used to be about these arguments. When one zooms the focus out of these debates, attention is brought back to the biologic system involved with the physiology of tooth movement. We then realize the wide open territory of creating the ability to proactively augment a patient’s biology to facilitate and stabilize tooth movement. This might be considered the

Case 1: 4-mm anterior open bite closed down using Invisalign® (Align Technology) and Class 3 elastics. Tooth movement on the ClinCheck® mimics the MEAW Appliance (Multi-Loop Edgewise Arch Wire) to intrude posterior teeth and extrude anterior teeth. PROPEL was used 2 times at stage 9 and 18 to help get through 27 stages to refinement scan in 11 months. Refinement and detailing finished the case in a total of 16 months. No TADs were used. It took under 20 minutes for PROPEL to be performed from the mesial of second molars to the mesial of the laterals in all four quadrants

“fourth order” of orthodontics: harnessing and augmenting the biology of tooth movement to our advantage. Currently, we talk to teeth and host tissues by applying forces and the periodontium, and teeth react after the fact. When one thinks about it, this is truly an unsophisticated way to talk to teeth. It would be to our advantage and a true paradigm shift in orthodontics to have the host tissues react prior to force application. Linge (1976) concluded that mechanical properties of the host

Jonathan Nicozisis, DMD, MS, has been in the specialty practice of orthodontics since 1999. He completed his dental education at the University of Pennsylvania before attending Temple University for his orthodontic residency. While at Temple University, Dr. Nicozisis received his specialty certificate in orthodontics and a master’s degree in oral biology. During his training, he also completed an externship at the Lancaster Cleft Palate Clinic in Lancaster, Pennsylvania, where he was involved with the care of patients with craniofacial syndromes. Dr. Nicozisis is a member of Invisalign® National Speaker’s Bureau and Clinical Research Network where he helps conduct research and development of new technologies and improvements to the Invisalign technique. Dr. Nicozisis is also the founding orthodontist and a scientific advisory board member of BAS Medical (now Corthera), a development stage company founded in 2003 with a mission to develop and market a novel technology to accelerate and improve the stability of orthodontic treatments. Dr. Nicozisis’ master’s research is the basis for BAS Medical innovative research. In February 2010, Corthera was acquired by Novartis. Dr. Nicozisis has been awarded membership to the Edward H. Angle Society of Orthodontists. He is a member of the American Association of Orthodontists, Middle Atlantic Society of Orthodontists, New Jersey Dental Association, Mercer County Dental Society, and the Greater Philadelphia Society of Orthodontists. Dr. Nicozisis is a paid lecturer, but not a consultant, for PROPEL Orthodontics.

24 Orthodontic practice

tissue determine the characteristics and distribution of mechanical forces at the site of tissue reactions. It is the alteration of these tissue mechanical properties with treatment adjuncts that is attractive to the clinician. Having this ability enables the clinician to directly affect tissue response rather than doing it indirectly through secondary forces from the tissue resistance. To that end, tissue response could therefore be changed from a pattern of tissue damage repair following force application to that of true tissue remodeling preceding force application. What used to be considered science fiction is now a reality. Previous attempts to this end have been tried and documented. “Electric braces” proved to be ineffective, and after a completed human clinical trial, the naturally occurring protein relaxin as a therapeutic adjunct to facilitate and stabilize tooth movement succumbed to the FDA’s stifling wave of resistance. Surgical techniques involving full thickness flaps and corticotomies or piezoelectric corticotomies are well-known Volume 5 Number 3

CS 3500

TECHNOLOGY

NO impression material

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ALL YOU NEED FOR THE PERFECT RESTORATION, AND NOTHING YOU DON’T WELCOME TO THE NEW REALITY In the new reality, the CS 3500 intraoral scanner creates highly accurate, true color 2D images and 3D models of teeth without conventional impressions. Case 2: Narrow maxillary arch and rotated and distal tipped centrals. 22 stages of Invisalign in 22 weeks and three PROPEL treatments for total of 5.5 months of treatment. Detail and settling the posterior occlusion took another 6 weeks for a total treatment time of 7 months. Perforations done from the mesial of the first molar to the distal of the centrals in all four quadrants in under 15 minutes

• Truly handheld, portable with no trolley and plug and play • Powder-free with slim scanner head for comfortable, custom-fit restorations • Unique light guidance system for more patient-focused scanning • Part of a flexible and open system, allowing you to choose between in-house or lab milling

and effective but carry their own negatives. Patients’ acceptance can be limited due to expense, the invasive nature of the procedure, and length of recovery time and discomfort following the procedure. Vibration devices delivering pulsatile forces have also been investigated and are now commercially available. The original research behind this technology investigated the application of pulsatile Volume 5 Number 3

SCAN

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MILL

Enter the new reality at carestreamdental. com/cs3500 or call 800.944.6365 © Carestream Health, Inc. 2014. 10651 OR DI AD 0514

Orthodontic practice 25

TECHNOLOGY

Case 3: Class 2 subdivision right with a reverse smile line and uneven gingival display. Invisalign and Class 2 elastic used on the right only without distalization of the upper as the lower arch is asymmetric to the right. PROPEL performed 2 times to get through 22 stages in 5 months before the refinement scan. Perforations done in upper and lower anterior and upper and lower right quadrant only to better affect host tissues in a targeted approach to facilitate more challenging movements. The procedure took under 15 minutes to perform.

forces’ effects on the sagittal growth of the premaxillae and premaxillary sutures in rabbits. These suture responses, results, and conclusions from this research were then applied to the response of the periodontal ligament involved in tooth movement. While having some similarities in tissue composition, suture growth, and suture response to orthopedic forces (with or without vibration) is very different than that of the periodontal ligament in homeostasis or in response to the influence of orthodontic forces. Nevertheless, the marketplace has a product with an FDA Class 2 medical device designation that is approved to be used with fixed braces. Fast forward to 2011 when technology developed at NYU’s Department of Orthodontics and licensed by PROPEL Orthodontics allows us to cross the threshold into the fourth order of orthodontics; host tissue remodeling prior to force application to facilitate tooth movement. Without a surgical flap, PROPEL Orthodontics’ proprietary technology, the Excellerator, creates micro-osteoperforations through both fixed and movable mucosa, into the bone between the roots of the teeth. These micro-osteoperforations go through the cortical bone and into the medullary bone. In doing so, the Excellerator stimulates the local inflammatory response and increases expression of cytokines and other secondary messengers at the cellular level. This increase in cytokine expression causes an increase in recruitment and differentiation of osteoclasts which in turn causes an expedited rate of bone 26 Orthodontic practice

remodeling to occur. The end result is faster tooth movement. Truly, now tissue response can be changed from a pattern of tissue-damagerepair following force application to that of true tissue remodeling preceding force application. This is the new fourth order of orthodontics and PROPEL’s technology delivers it in an effective, efficient, and safe manner. PROPEL has been widely accepted by both clinicians and patients. Clinicians have accepted the treatment for its characteristics, which include ease of use, the ability to be in full control without relying on patient compliance, and the capability of applying it in a targeted area of the mouth rather than vibrating the whole dentition when that might cause

anchorage concerns or excessive mobility. Patients have accepted PROPEL for its reasonable cost, lack of recovery from a surgical procedure, and ability to go about their day’s activities immediately following the office visit. Research shows that Excelleration should be repeated until the desired tooth movement is accomplished, the frequency of which is about once every 8 to 12 weeks. This translates to using one to three devices for an average case. That means an extra $100-$300 to save half the number of office visits for the case. The Excellerator is the only patented device specifically designed to perform transmucosal osteoperforations. All other protocols would be using that instrumentation in an off-label manner, thus exposing oneself to Volume 5 Number 3

Volume 5 Number 3

TECHNOLOGY

liability issues. The November 2013 issue of the American Journal of Orthodontics and Dentofacial Orthopedics (AJODO) has the first published clinical trial study for PROPEL and the impact micro-osteoperforations (MOPs) have on tooth movement. The conclusions from the study show that micro-osteoperforations significantly increased the expression of cytokines and chemokines known to recruit osteoclast precursors and stimulate osteoclast differentiation. They also increased the rate of canine retraction 2.3-fold compared with the control group. Patients reported only mild discomfort locally at the spot of the MOPs with little to no pain experienced at days 14 and 28. It was concluded that micro-osteoperforations are an effective, comfortable, and safe procedure to accelerate tooth movement during orthodontic treatment and could reduce orthodontic treatment time by 62%. The Excellerator device itself is a Class 1 FDA-registered medical device that is indicated to be used with any orthodontic modality of treatment. Its surgical-grade stainless steel tip will not break during use. Depths of 3 mm, 5 mm, and 7 mm can be selected by the doctor depending on where in the mouth the perforations are to be performed. Once that depth is reached, a red indicator light turns on alerting the clinician that the desired depth has been reached and the device can then be removed by turning it counterclockwise before proceeding to the next perforation site. Finally, the driver tip is encased in a retractable sheath that helps hold the gingival tissue taut preventing excessive tissue stretching and tearing. It is indicated to do two to three perforations per site between each set of roots starting in the fixed tissue and going as apical as reasonably possible. The effect of increased inflammatory response has been measured to radiate 6 mm-10 mm around the perforation site. Protocol for anesthesia and sepsis control is the same for TAD placement. A profound gel anesthesia or local anesthesia is sufficient along with rinsing with Chlorhexidine for a minute before and after. Such sophisticated yet simple technology based on a sound foundation of basic science has allowed us to bridge the gap between our basic science research and clinical application of that research. As such, this paradigm shift once thought of as science fiction, is now a reality as

YOUR PRACTICE. OUR PASSION.

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Orthodontic practice 27

TECHNOLOGY Excelleration allows the host tissues to be proactive rather than reactive to the forces we impart on them. The end result is better outcomes and faster treatment incorporating an adjunct to therapy that has been found to be safe, effective, efficient, and reasonably priced ensuring broad acceptance. Yogi Berra was right in saying that the future ain’t what it used to be. The time for the fourth order of orthodontics has come, and PROPEL is carving this path with more developing technology to follow.

PROPEL product overview Bi-Products of Excelleration: The Excellerator and Excellerator RT The most recent product innovations from PROPEL are the Excellerator and the Excellerator RT. Both offer improvements over the first generation devices that were first launched in the fall of 2012. First, the tip of each is much sharper than the first-generation device, making for not only easier penetration through the soft tissue and periosteum, but also the cortical plate of bone for more successful engagement of the threads into the bone. Second, the pitch angle of the threads is steeper. This improvement allows for fewer turns or revolutions of the device necessary to reach desired depths. This translates to less chairtime necessary to perform the procedure. Clinical experience tells us that four quadrants takes 15 minutes whereas several teeth take but only a few minutes to complete the procedure. This means little disruption to office scheduling. There are several features that are unique to the Excellerator. The clinician need not worry about sterilization as it is disposable to be discarded after the patient’s office visit. Each device can be

28 Orthodontic practice

used for any number of perforations during that one visit. Desired depths can be dialed in at 3 mm, 5 mm, and 7mm by turning the clicking and locking head. Finally, once the desired depth is reached, the red LED light is illuminated, alerting the clinician that the desired depth has been reached. The Excellerator is good for doctors who are beginning their journey into the fourth order of orthodontics and do not want to spend too much in initial armamentarium costs. Also, as mentioned, it is great for doctors who do not want to deal with sterilization procedures or who need the LED depth light as a guidance during the procedure. The Excellerator RT has several hallmarks that make it stand apart. First, it has disposable tips that are inserted into an autoclavable metal driver head. While there may be a slight increase in initial startup costs, the disposable tips will save you money in the long term. Second, the metal driver head has a thicker handle than its sibling device. Due to this larger diameter, some have reported that this feature makes it easier to grip and turn. Combining this with the sharper tip and higher pitch angle of the helixes truly makes the procedure effortless for the clinician. Unlike its sibling, the Excellerator RT does not have a depthindicating light. Instead it has three depthindicating lines on the retractable sheath with which to measure the depth of the micro-osteoperforations. The Excellerator RT has been enjoyed by clinicians of varying experience. When choosing one over the other, it simply comes down to doctors’ preference and comfort for which device will best fit into their office systems. While there are two choices for the same solution, there is only one system that bridges the fourth order

of orthodontics to the private practice in a simple, effective, and efficient manner. Excel at your practice with PROPEL and their Excellerator Series products. OP

References 1. Linge L. Tissue reactions in facial sutures subsequent to external mechanical influences. Monograph #6, Craniofacial growth series. University of Michigan, Center for Human Growth and Development. 1976. 2. Nicozisis JL, Nah-Cederquist HD, Tuncay OC. Relaxin affects the dentofacial sutural tissues. Clin Orthod Res. 2000;3(4):192-201. 3. Davidovitch Z, Nicolay OF, Ngan PW, Shanfeld JL. Neurotransmitters, cytokines, and the control of alveolar bone remodeling in orthodontics. Dent Clin North Am. 1988;32(3):411-435. 4. Davidovitch Z, Finkelson MD, Steigman S, Shanfeld JL, Montgomery PC, Korostoff E. Electric currents, bone remodeling, and orthodontic tooth movement. II. Increase in rate of tooth movement and periodontal cyclic nucleotide levels by combined force and electric current. Am J Orthod. 1980;77(1):33-47. 5. Wilcko WM, Wilcko T, Bouquot JE, Ferguson DJ. Rapid orthodontics with alveolar reshaping: two case reports of decrowding. Int J Periodontics Restorative Dent. 2001;21(1):9-19. 6. Kopher RA, Mao JJ. Suture growth modulated by the oscillatory component of micromechanical strain. J Bone Miner Res. 2003;18(3):521-528. 7. Nishimura M, Chiba M, Ohashi T, Sato M, Shimizu Y, Igarashi K, Mitani H. Periodontal tissue activation by vibration: Intermittent stimulation by resonance vibration accelerates experimental tooth movement in rats. Am J Orthod Dentofacial Orthop. 2008;133(4):572-583. 8. Teixeira CC, Khoo E, Tran J, Chartres I, Liu Y, Thant LM, Khabensky I, Gart LP, Cisneros G, Alikhani M. Cytokine expression and accelerated tooth movement. J Dent Res. 2010;89(10):11351141. 9. Alikhani M, Raptis M, Zoldan B, Sangsuwon C, Lee YB, Alyami B, Corpodian C, Barrera LM, Alansari S, Khoo E, Teixeira C. Effect of micro-osteoperforations on the rate of tooth movement. Am J Orthod Dentofacial Orthop. 2013;144(5):639-648.

Volume 5 Number 3

Drs. Rohit C.L. Sachdeva, Takao Kubota, and John Lohse discuss additional care management strategies to treat Class 2 patients Introduction In a previous article,1 a framework for managing patients presenting with a Class 2 malocclusion enabled by SureSmile® Technology was discussed. The purpose of this paper, with the aid of selected patient histories, is to discuss additional care management strategies to treat Class 2 patients developed by Sachdeva.

Patient KY Patient KY is a 12-year-old female presented with a Class 2 Div. 1 malocclusion (Figure 1). Her Virtual Diagnostic Model (Figure 2A) was used to decide the appropriate treatment plan as well as the nature of “orthopedic” versus “orthodontic” displacements required to correct her presenting problem. Since the patient was circumpubertal, it was anticipated that the patient had the potential of demonstrating about 2 mm of horizontal growth along the occlusal plane (Figure 2C). Additional dentoalveolar movements to correct her malocclusion were also planned, including the residual Class 2 correction, archwidth, and overbite correction. It was also

Rohit C.L. Sachdeva, BDS, M Dent Sc, is the co-founder and 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. He is a Clinical professor at the University of Connecticut and Temple University and the Hokkaido Health Sciences Center Japan. In the past, he held faculty positions at the University of Connecticut, Manitoba and the Baylor College of Dentistry, Texas A&M. Dr. Sachdeva has over 80 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://drsachdevaconference.blogspot.com. All doctors are invited to join the “Improving Orthodontic Care” discussion blog. Please contact improveortho@gmail.com for access information.

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Figure 1A-1B: Patient KY. 1A. Initial intraoral records of patient presenting with a Class 2 malocclusion. 1B. Initial X-rays

anticipated that the lower incisors would advance, and this was planned into the 3-D Virtual Digital Simulation (VDS) (Figure 2D). The final plan is shown in Figure 2E. Relative archwidth correction in the upper arch to adjust for the Class 2 correction was achieved with a Quadhelix (Figure 3). The upper anteriors were intruded and retracted with the aid of an intrusive arch with the line of action through the estimated center of resistance of the upper anterior segment. The lower anteriors were intruded with a utility arch. Light short Class 2 elastics in the buccal segments

were concurrently used (Figures 4 and 5). A therapeutic scan was taken 7 months into active treatment (Figure 6). The Virtual Therapeutic Model (VTM), Virtual Target Setup (VTS), and the SureSmile precision archwire design are shown in Figure 7. Since the Class 2 correction was not entirely resolved, additional dentoalveolar correction was planned with less reliance on the orthopedic correction. This is shown later in Figure 11. The SureSmile precision archwires .017” x .025” CuNiTi were inserted 6 weeks post therapeutic scan. Class 2 elastics were concomitantly used Orthodontic practice 29

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BioDigital Orthodontics: Management of patients with Class 2 malocclusion — non-extraction (II): part 9

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Figures 2A-2F: Patient KY. 2A. Virtual Diagnostic Model (VDM). 2B. Virtual Diagnostic Simulation (VDS) shows the initial simulation with the “orthopedic change” to partially correct the Class 2. 2C. VDM (green) versus VDS (white). Also, in the inset table, one notes the amount of corrective displacement required to achieve the desired orthopedic effect. 2D. The next step in the simulation involves dentoalveolar correction of the Class 2 malocclusion. Also note the slight archwidth changes planned to accommodate for the new mandibular position. VDM (green) and VDS with dentoalveolar and orthopedic changes (white) 2E. Final VDS shows post orthopedic and dentoalveolar correction. 2F. Shows the nature and magnitude of displacements of the dentition to correct the “dental portion” of the malocclusion

Figure 3: Patient KY. Beginning of treatment. Dentoalveolar expansion of both upper and lower arches

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Figure 4: Patient KY. Three months into treatment, intrusion of the upper anteriors and alignment of lower anteriors and leveling being achieved with a utility arch piggy backed on a 0.16” NiTi alignment archwire

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Figure 5: Patient KY. Five months from start of treatment planned expansion, achieved lower alignment, and leveling was almost complete

Figures 6A-6B: Patient KY. 6A. Overbite correction achieved. Mid-Treatment intraoral photos were taken at 7 months into active treatment. Patient remains slightly Class 2 in the buccal segments 6B. Mid-Treatment X-rays

Figures 7A-7C: Patient KY. 7A. Virtual Therapeutic Model (VTM). 7B. Virtual Target Setup (VTS) with SureSmile precision archwire designed. 7C. SureSmile archwire viewed against VTS

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for a period of 3 months. Figure 8 shows the patient 2-months post SureSmile precision archwire insertion. The patient was debonded 4-months post SureSmile precision archwire insertion and 12.5 months from start of treatment. The final intraoral images, X-rays are shown in Figure 9. The virtual final model (VFM) and superimposition of the VDS with the VFM are shown in Figure 10B. Note that the simulation is similar to the final result.

ORTHODONTIC CONCEPTS A closer look at the Virtual Target Setup (Figure 11) demonstrates the treatment strategy designed into the setup to gain correction of the residual Class 2 observed at the time of the Therapeutic Scan (Figure 11B). Note minimal orthopedic changes are planned both at the distal tip of the buccal segment, and the mesial out rotations have been designed into the SureSmile precision archwires that will work in tandem with the Class 2 elastics to provide the desired correction. This is shown in Figure 11G.

Figure 8: Patient KY. Two months post SureSmile precision archwire (.017â&#x20AC;? X .025â&#x20AC;&#x153; CuNiTi) insertion with the use of Class 2 elastics

Figures 9A-9B. Patient KY. 9A. Final intraoral photos taken at debond four months post SureSmile wire insertion and 12.5 months from start of treatment. 9B. Final X-rays

Figures 11A-11J: Patient KY. Right buccal views. 11A. VDM. 11B. VTM. 11C. VDS with orthopedic changes. 11D. Orthopedic displacement. 11E and 11F. VDS with orthopedic and dentoalveolar changes. 11G. Dentoalveolar displacements. Intraoral images of rt buccal segments. 11H. Initial, 11I. Therapeutic, 11J. Final

Figures 10A-10B: 10A. Virtual Final Model 10B. Comparison of the Virtual Diagnostic Simulation (green) with the Virtual Final Model (white) 32 Orthodontic practice

Volume 5 Number 3

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ORTHODONTIC CONCEPTS Patient KU Patient KU is a 14-year-old male presented with a Class 2 division malocclusion with a deep overbite and a crossbite tendency in the left buccal segment (Figure 12). A non-extraction treatment plan was designed (Figure 13). Class 2 correction was planned with distal movement of the upper buccal segments (Figure 14) against temporary anchorage devices placed in the palate (Figure 15C). Overbite correction was achieved by intruding the lower anteriors with the use of a lower utility arch. The Therapeutic Scan was taken 7 months from the start of active treatment (Figure 18). Figure 19 is a superimposition of the VDM versus the VTM and shows that the distal movement of the buccal segments was achieved. Also, see Figure 15C. A Virtual Target Setup was designed with the corresponding upper and lower SureSmile precision archwires (.017â&#x20AC;? x .025â&#x20AC;? CuNiTi) (Figure 19). The archwire was inserted 6-weeks post scanning and complemented with light Class 2 elastic wear. The patient was debonded 4 months post therapeutic scan (Figure 22) and 11 months from start of active treatment. The Virtual Final Model and a superimposition of the Virtual Diagnostic Simulation against the Virtual Final Model are shown in Figure 23. Note the close approximation of the initial plan to the final model.

Figure 12A-12B: Patient KU. 12A. Initial intraoral records of patient presents with a Class 2 Sub Div. 1 left. 12B. Initial X-rays

Figures 13A-13D: Patient KU. 13A. Virtual Diagnostic Model (VDM). 13B. Virtual Diagnostic Simulation (VDS). 13C. VDM (green) vs. VDS (white). 13D. Shows the nature and magnitude of displacements of the dentition to correct the malocclusion

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Figure 14: Patient KU. The planned distal movement of the buccal segment to correct the Class 2

Figure 15: Patient KU. 15A. Initial VDM. 15B. Initial intraoral photos. 15C. Therapeutic intraoral photos. 15D. Therapeutic Model

Figure 16: Patient KU. Beginning of treatment, temporary anchorage devices are being used to distally move the upper molars

Figure 17: Patient KU. Four months into treatment. The utility arch is being used to level the lower arch

Figures 18A-18B: Patient KU. 18A. Mid-Treatment intraoral photos at the time of Therapeutic scan taken 7 months from start of active treatment. 18B. Mid-treatment X-rays

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Figures 19A-19D: Patient KU. 19A. Virtual Therapeutic Model (VTM). 19B. Virtual Therapeutic Simulation (VTS) with prescription archwire designed. 19C. VDM (green) versus VTM (white). Note that the buccal segments have moved distally. 19D. Prescription archwire viewed against VTS

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Figure 21: Patient KU. Six weeks post SureSmile archwire insertion

Figures 22A-22C: Patient KU. 22A. Final intraoral photos were taken at debond 1-month post SureSmile precision archwire insertion and 11 months from start of active treatment. 22B. Virtual Final Model (VFM). C. Final X-rays

Figures 23A-23B: Patient KU. 23A. Virtual Final Model (VFM). 23B. Virtual Final Model (VFM). VFM (white) superimposed on the initial VDS (green)

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Figure 20. Patient KU. SureSmile precision archwire .017â&#x20AC;? x .025â&#x20AC;? CuNiTi inserted 6-weeks post therapeutic scan, and distal movement of upper molars has been discontinued. Light Class 2 elastics are being used

ORTHODONTIC CONCEPTS

Figures 24A-24B: Patient KS. 24A. Initial intraoral records of patient presents with a Class 2 Subdiv. 1 right. 24B. Initial radiograph

Patient KS Patient KS, a 55-year-old female presented with a Class 2 division 2 malocclusion, a deep overbite, and a previous history of orthodontic treatment with four first bicuspid extractions (Figure 24). The Virtual Diagnostic Model (Figure 25A) was used to design the Virtual Diagnostic Simulation (Figure 25B). The treatment objectives consisted of maintaining the buccal segment relationship and correcting the upper anterior root torque, the deep overbite, and the crowding in the lower arch. The planned orthodontic tooth movements are seen in Figures 25C-25E. With 018” brackets bonded, initial alignment was initiated with a .016” x .022” CuNiTi archwire in both the upper and lower arches. Anterior turbos were bonded to disocclude the posterior teeth to encourage lower bicuspid extrusion. The therapeutic scan was taken 2-months post bonding (Figure 26). The virtual target setup with its associated SureSmile precision archwires were also designed (Figure 27). Two pairs of SureSmile .017” x .025” CuNiTi archwires were designed for the upper arch (Figure 28). To the base archwire whose design is driven by the Virtual Target Setup, two types of precision archwires were designed (Figure 28A).The first, Type 1, was a full expression archwire with compensating labial crown torque placed in the archwire to control for bracket slop (Figure 28B). The second wire, Type 2, with the same dimension, had an additional 10 degrees of labial torque built into the anterior segment (Figure 28C). Six weeks post therapeutic scan, the Type 1 archwire was initially installed, and anterior labial root torque was augmented in the upper arch by using an ART® spring (Atlanta Orthodontics, www.theartauxiliary. com). In the lower arch, leveling was performed with the 017” x .025” CuNiTi full 38 Orthodontic practice

Figures 25A-25E: Patient KS. 25A. Virtual Diagnostic Model (VDM). 25B. Virtual Diagnostic Simulation (VDS). 25C. VDM (green) vs. VDS (white). 25D. Shows the nature and magnitude of displacements of the dentition to correct the malocclusion. 25E. Note the planned torque on the upper right central incisors viewed in crosssection using a clipping plane Volume 5 Number 3

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Figures 26A-26B: Patient KS. 26A. Mid-treatment intraoral photos at the time of Therapeutic scan. 26B. Mid-treatment panoramic X-ray

Figures 27A-27C: Patient KS. 27A. Virtual Therapeutic Model (VTM). 27B. Virtual Target Setup with precision archwire designed. 27C. Virtual precision archwire viewed against VTS

Figures 28A-28C: Patient KS. 28A. Base archwire whose design is driven by the Virtual Target Setup, two types of precision archwires were designed. 28B. Type 1, a full-expression archwire with compensating labial crown torque to control bracket slop. 28C. Type 2 same dimension as Type 1, with additional 10 degrees of labial torque built into the anterior segment Volume 5 Number 3

Orthodontic practice 39

ORTHODONTIC CONCEPTS

Figure 29: Patient KS. Six weeks post therapeutic scan, the Type 1 .017” x .025” CuNiTi SureSmile wires archwire were installed, anterior labial root torque augmented with an ART® spring in the upper arch. Lower tip-back spring fabricated from .017” x .025” TMA, being used to intrude the lower incisors, has been inserted

expression archwire and the use of .017” x .025” tip-back springs (Figure 29). Four months later, Type 1 was replaced with Type 2, and the use of the upper torqueing auxiliary was discontinued. The lower archwire remained unchanged, and the use of the lower tip-back spring continued (Figure 30). These mechanics continued for 3 additional months (Figure 31). The patient was debonded a month later (Figure 32), and 11.5 months from start of active treatment. In Figure 33, we can see the virtual final model and the superimposition of the virtual digital simulation (VDS) on the virtual final model (VFM). All the objectives

Figure 30: Patient KS. Four months later, note the improvement in overbite in upper anterior root torque. Type 2 archwire is inserted, posterior turbos on the lower molars have been placed, upper tip-back springs have been added. The lower SureSmile archwire was maintained

Figures 31A-31B. Patient KS. 31A. Three months post insertion of Type 2 archwire. Note substantial improvement in upper anterior root torque and overbite. Also, light Class 2 elastics were used in the intervening period. Therapeutic re-scan with intraoral photos. 31B. Therapeutic re-scan panoramic X-ray

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Figures 33A-33B: Patient KS. 33A. Virtual Final Model (VFM). 33B. Virtual Final Model (VFM). VFM (white) superimposed on the Initial VDS (green)

designed initially were met. Although substantial upper anterior labial crown torque was accomplished, nevertheless, the upper anteriors were not torqued labially to the extent planned. This may have been because of the biological constraints offered by the palatal cortex to root movement (Figure 24B).

Conclusions The aim of this paper was to demonstrate the versatility of SureSmile technology both from a perspective of planning the individual care needs of a patient and personalizing therapeutics to treat patients with Class 2 malocclusions effectively. The technology can be used at any point in the care

process as the doctor sees fit to benefit patient care. It cannot be emphasized enough that adhering to the principles and practice of BioDigital Orthodontics are a prerequisite to enabling a successful outcome in a timely manner. This mandates that a robust treatment plan drives the design of personalized therapeutics i.e. Diagnopeutics (Sachdeva).1-8 In other words, the design selection and management of the therapeutic appliances should be consistent with the treatment plan. Auxiliary appliances such as the Quadhelix, Temporary anchorage devices, and torquing auxiliaries all need to be used in concert with the SureSmile precision archwire to achieve the desired care

goals. Also, it is important for the doctor to adhere to the Clinical Pathway Guidelines as best as he/she can. Such guidelines provide a great resource to the clinician to navigate through the care path for a patient. Protocol A1 is the most common clinical pathway guideline used to manage the non-extraction treatment of patients presenting with a Class 2 malocclusion.

Acknowledgments The authors thank Dr. Sharan Aranha, BDS, MPA, and Maya Sachdeva for their immense support in the preparation of the manuscript. OP

References 1. Sachdeva R, Moravec S, Kubota T. Management of class 2 non–extraction patients: Part 8. Orthodontic Practice US. 2014;5(2):11-16. 2. Sachdeva R. BioDigital orthodontics: Management of Class 1 non–extraction patient with “Fast–Track”©– six month protocol: Part 5. Orthodontic Practice US. 2013;4(5):18-27. 3. Sachdeva R, Kubota T, Hayashi K. BioDigital orthodontics: Management of Class 1 non–extraction patient “Standard–Track”©– nine month protocol: Part 6. Orthodontic Practice US. 2013;4(6):16-26.

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4. Sachdeva R, Kubota T, Hayashi K. BioDigital orthodontics: Management of space closure in Class I extraction patients with SureSmile: Part 7. Orthodontic Practice US. 2014;5(1):14-23. 5. Sachdeva R. BioDigital orthodontics: Designing customized therapeutics and managing patient treatment with SureSmile technology: part 2. Orthodontic Practice US. 2013;4(2):18-26. 6. Sachdeva R. BioDigital orthodontics: Diagnopeutics with SureSmile technology: part 3. Orthodontic Practice US. 2013;4(3). 2013;4(3):22-30.

7. Sachdeva R. BioDigital orthodontics: Outcome evaluation with SureSmile technology: Part 4. Orthodontic Practice US. 2013;4(4):28-33. 8. Sachdeva R. BioDigital orthodontics: Planning care with SureSmile Technology: Part 1. Orthodontic Practice US. 2013;4(1):18-23. 9. Sachdeva RCL, Kubota T, Hayashi K, Uechi J, Hasuda M. BioDigital orthodontics-11: Management of class 2 non– extraction patients: Part 1. Journal of Orthodontic Practice (Japan). 2013:1-17.

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Figures 32A-32C. Patient KS. 32A. Final intraoral photos at debond taken 1 month later and 11.5 months in active treatment since start. 32B. Virtual Final Model (VFM). 32C. Final X-rays

INDUSTRY NEWS

Dr. Laurance Jerrold appointed as Chair and Program Director of Orthodontics at Lutheran Medical Center Department of Dental Medicine Lutheran Medical Center Department of Dental Medicine (LMC Dental) announced the appointment of Dr. Laurance Jerrold as Chair and Program Director of Orthodontics. Dr. Jerrold is a third-generation Diplomate of the American Board of Orthodontics. He received his dental degree from New York University (NYU) in 1975, and completed his orthodontic training there in 1978. He received his JD from Touro Law School in 1988 and his certificate in Bioethics from Columbia University in 1997. Dr. Jerrold served as the Program Director for the orthodontic programs at NYU, St. Barnabas Hospital, and Jacksonville University in Florida before joining LMC Dental; he has also served in leadership positions in all facets of organized dentistry. Dr. Jerrold is a nationally recognized expert in the fields of dental risk management and ethics and has published and presented over 300 papers and presentations. He is also the section Editor for Litigation and Legislation in the American Journal of Orthodontics and Dentofacial Orthopedics. Dr. Jerrold joins a pioneering hospital and community health center (CHC)-based program, which over the last 40 years has trained more than 2,000 dental residents in eight general and specialty areas, served more than 1.5 million dental patients, and provided oral healthcare to underserved populations in 200 owned and partnered CHC’s in 27 U.S. states (including Alaska and Hawaii) as well as the Caribbean. New enrollments grew 31% between 2012 and 2013 to 347 residents supporting LMC Dental’s mission to deliver services to our neediest citizens while instilling confidence and knowledge in dental professionals to meet any future oral healthcare challenge. More than 35% of LMC Dental’s graduates remain in public health dentistry after completing the program while others become highly skilled practitioners or influential policymakers.

OrthoAccel® Technologies, Inc., announces addition of Orthodontic Specialist, Dr. Sonia Palleck, to Key Opinion Leadership Group OrthoAccel® Technologies, Inc., (OrthoAccel) announced that orthodontic specialist, Dr. Sonia Palleck, has been named to its Key Opinion Leadership Group of world-class clinicians who present scientific and clinical evidence supporting OrthoAccel’s groundbreaking medical device, AcceleDent®. Now available in over 1,000 orthodontic locations in North America, AcceleDent is the only FDA-cleared, Class II medical device that speeds up orthodontic treatment by as much as 50 percent. A member of the American Association of Orthodontists and the Canadian Association of Orthodontists, Palleck has been in private practice for over 15 years and is a graduate clinical instructor of orthodontics at the University of Western Ontario. Orthodontists and staff members interested in learning more about AcceleDent, or how to offer the technology at their practice, can locate an OrthoAccel sales representative at AcceleDent.com/orthodontists or call 866-866-4919.

OraMetrix announces certification of TRIOS® 3Shape imaging technology OraMetrix announced that the TRIOS® 3Shape imaging system has been certified by OraMetrix, Inc., for use with suresmile digital orthodontics. Since suresmile is designed to enable orthodontists to visualize and simulate multiple diagnostic setups and design archwires accurate to 0.1mm, the accuracy of the patient scans plays a critical role in maximizing the effectiveness of the system. For more information about the TRIOS, visit www.3shapedental.com/trios. For more information about suresmile, contact OraMetrix at 888-672-6387, or visit suresmile.com.

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Volume 5 Number 3

Dr. Derek Mahony discusses early diagnosis and treatment of pathological conditions that can lead to the obstruction of the upper airways Abstract This article reviews upper airway obstruction caused by hypertrophied adenoids and the possibilities of a subsequent malocclusion. Early diagnosis and treatment of pathological conditions that can lead to the obstruction of the upper airways is essential to anticipate and prevent alterations in dental arches, facial bones, and muscle function. Correct nasal breathing facilitates normal growth and development of the craniofacial complex (Figures 1A and 1B). Important motor functions such as chewing and swallowing depend largely on normal craniofacial development. Any restriction to the upper airway passages can cause nasal obstruction possibly resulting in various dentofacial and skeletal alterations.1 Upper respiratory obstruction often leads to mouth breathing (Figure 2). Habitual mouth breathing may result in muscular and postural anomalies, which may in turn cause dentoskeletal malocclusions2 (Figure 3). Hypertrophy of the adenoids, and palatine tonsils, are one of the most frequent causes of upper respiratory obstruction (Figure 4). Philosophies regarding the treatment of adenoid hypertrophy range from dietary control and environmental modifications to dentofacial orthopaedics,

Educational aims and objectives The aim of this article is to review upper airway obstruction caused by hypertrophied adenoids and the possibilities of a subsequent malocclusion. Expected outcomes Orthodontic Practice US subscribers can answer the CE questions on page 49 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Recognize the skills and tools that assist the clinician in identifying upper airway obstruction. • Identify ways to improve the diagnosis of adenoid hypertrophy. • Realize methods to improve the classification and treatment of associated malocclusions.

Figure 1A: Patient before

Figure 1B: Patient after

change of breathing exercises, and surgical procedures.

The research in this area is expansive, but largely inconsistent. Thus, the cause-andeffect relationship of adenoid hypertrophy and malocclusion must be carefully examined on a case-by-case basis.5 Regardless of the various researchers’ conclusions, one theory remains common — that airway obstruction caused by adenoid hypertrophy and malocclusion are related. The degree of that relationship and what it affects is still under debate. This paper attempts only to highlight the positive existence of this relationship and its possible effects regarding dentofacial growth and development.

Introduction Derek Mahony, BDS(Syd), MScOrth(Lon), DOrthRCS(Edin), MDOrthRCPS(Glas), MOrthRCS(Eng), MOrthRCS(Edin)/CDS(HK), completed his dental degree at the University of Sydney. Dr. Mahony proceeded to the United Kingdom where he completed his Masters Degree in Orthodontics at the Eastman Dental Hospital, Institute of Dental Surgery, London. Further studies led to the successful completion of a Diploma in Orthodontics at the Royal College of Surgeons, Edinburgh. Dr Mahony passed examinations leading to a postgraduate qualification in Dentofacial Orthopaedics from the Royal College of Physicians and Surgeons in Glasgow. He has attained his Membership in Orthodontics qualification from the Royal College of Surgeons, England. He has also completed his Membership in Orthodontics qualification from the Royal College of Surgeons, Edinburgh. He is internationally known as the author of numerous articles in the United States and foreign journals and as a lecturer in Australia, New Zealand, South East Asia, Russia, the United Kingdom, and the United States.

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The methodology used in this literature analysis consists of a thorough review of narrowly tailored research and journal articles. The paradigm explored in each article involves upper airway obstruction, adenoid hypertrophy, and malocclusion. The results and conclusions stemming from these articles generally fall into three categories: 1. That hypertrophied adenoids have a definitive effect resulting in skeletal malocclusion.3 2. That hypertrophied adenoids, coupled with other factors, may aid in the development of skeletal anomalies.4 3. That adenoid hypertrophy has no effect on airway obstruction and malocclusion.

Basic facial growth and development Developments in the understanding of human craniofacial growth have stemmed from histological and embryologic studies, radiographic cephalometry, correlation of Orthodontic practice 43

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The effects of enlarged adenoids on a developing malocclusion

CONTINUING EDUCATION

Figure 2

Figure 3: Mouth breathing

growth and facial anomalies analysis of surgical interventions, animal research, and other science fields.6 Despite these studies, we are still waiting for a definite consensus regarding the controlling mechanism of craniofacial tissue. Postnatal facial growth is influenced by genetic and environmental factors.2 Most facial growth and development occurs during the two childhood growth peaks. The first growth peak occurs during the change from primary to permanent dentition (between 5 and 10 years of age) and the second growth peak occurs between 10 and 15 years of age.2 The study of the early years of life shows that by the age of four, 60% of the craniofacial skeleton has reached its adult size. By the age of 12, 90% of facial growth has already occurred.7 By age seven, the majority of the growth and development of the maxilla is complete and by age nine, the majority of the growth and development of the mandible is complete. Proper facial growth is affected either positively or negatively, early in life, by the sequential occurrences of four major factors: 1. The cranial base must develop properly. 2. The naso-maxillary complex must grow down and forward from the cranial base. 3. The maxilla must develop in a linear and lateral fashion. 4. A patent airway must develop properly. The relationship between the nasomaxillary complex and the cranial base is significant for esthetic reasons and proper facial bone, muscle, and soft tissue support. To allow proper downward and forward rotation of the mandible, the maxilla must be adequately developed, in width, for acceptance of the mandible. Any limitation on mandibular rotation may affect the relationship of the condyle to the glennoid fossae (in the temporal bone) resulting in 44 Orthodontic practice

multiple TMJ problems. An improper airway will affect the global individual growth.8 The simultaneous growth of these factors is not nearly as significant as how these factors interrelate during facial growth and development. For example, the basic design of the face is established by a series of interrelated factorial developments. The naso-maxillary complex is associated with the anterior cranial fossae. The posterior boundary of the maxilla determines the posterior limits of the midface. This structural plane is significant to facial and cranium development. The basic structural format of facial growth and development is dependent on, and governed by, the interrelation of multiple functional matrices. These functional matrices include a phenomenon of bone displacement and growth at the TMJ with the maxillary forward and downward movement equaling mandibular growth upward and downward. The displacement and growth phenomenon is responsible for the spatial relationship necessary for functional joint movement resulting in the final result of facial growth.9 Additionally, muscle adaptions affect dentoskeletal development. The integration of the musculoskeletal system affects respiration, mastication, deglutition, and speech.2 This basic understanding of facial growth and development is relevant as adenoidal tissue enlargement coincides with major facial growth; that is, they occur simultaneously. Facial growth may be restricted by abnormal development of adenoidal tissue resulting in abnormal swallowing and breathing patterns (Figure 5).

Adenoidal growth and development Lymphoid tissue is normally present as part of the Waldeyer’s tonsillar ring in the form of a nasopharyngeal tonsil (Linder-Aronson

Figure 4: Hypertrophy of the adenoids and palliative tonsils

Figure 5: Abnormal breathing patterns

1970). The Waldeyer’s ring is the system of lymphoid tissue that surrounds the pharynx. This system of tissue includes adenoids and pharyngreal tonsils, lateral pharyngeal tonsils, lateral pharyngeal bands, palatine tonsils, and lingual tonsils (Figure 6). Tonsils and adenoids have disparate embryonic origins and cytology even though they are both part of Waldeyer’s ring.10 Bacteria may play a role in adenoid hyperplasia. Specifically, different pathogens, such as Haemophilus influenza and Staphylococcus aureus, have been associated with lymphoid tissue hyperplasia. The adenoid lymphoid structures are lined with ciliated respiratory-type epithelium, which is normally distributed throughout the upper and posterior nasopharynx walls. During the presence of disease, the distribution of the dendritic cells (antigen presenting cells) is altered. The result is that there is an increase in dendritic cells in the crypts, and extrafollicular areas, and a decrease in surface epithelium dendritic cells. Lymphoid tissue is normally not apparent in the early infant stage of life. Marked symptoms of adenoid development are most common in the childhood age range of 2–12. During adolescence, a decrease in adenoid size is noted as current with the growth of the Volume 5 Number 3

Figure 8: Facial structures are modified by structural alterations

Figure 9: Narrow, V-shaped dental arches

nasopharynx. Rarely is adenoid tissue present in adults, and when it is noted, it is usually in an atrophic condition. The cause of the involution of the Waldeyer’s ring is still under investigation.12 The imbalance in the relationship between the enlargement of the nasopharynx/nasopharyngeal airway and the concomitant growth of adenoid tissue can result in reduced patent nasopharyngeal airway and increased nasopharyngeal obstruction.10 The growth of adenoidal tissue as demonstrated by a bell curve, peaks at or near age six and also begins involution at or near this age as well (Figure 7). Facial growth is coupled with adenoidal growth. As the cranial base forms the roof of the nasopharynx, a close examination of the growth and development of the craniofacial complex becomes significant for evaluation of the size and configuration of the nasopharyngeal airway. Any abnormal development regarding this craniofacial complex may affect the nasopharyngeal airway. Abnormal adenoidal growth that occurs during childhood may consume the nasopharnx and extend through the posterior choanae in the nose.13 This excessive adenoidal growth usually interferes with normal facial growth and Volume 5 Number 3

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Figure 6: Main components of Waldeyer’s ring

Figure 7: Growth curves of tonsils and adenoids

Figure 10: Pseudo-skeletal discrepancies

can result in abnormal breathing patterns, congestion, snoring, mouth breathing, sleep apnea,4 eustachian tube dysfunction/ otitis media, rhinosinusitis, facial growth abnormalities, swallowing problems, reduced ability to smell and taste, and speech problems.12 Theoretically, many clinicians believe the blockage should be removed as soon as possible through a surgical procedure called adenoidectomy. However, according to a study conducted by Havas and Lowinger, one-third of child study patients, with traditional adenoidectomies, were ineffective with intranasal extensions of the adenoids obstructing the posterior choanoe. For this segment of the study population the “powdered-shaver adenoidectomy” was effective in the complete removal of the obstructive adenoid tissue ensuring postural patency.13

Upper airway obstruction and mouth breathing During normal nasal respiration, the nose filters, warms, and humidifies the air in preparation for its entry into the body’s lungs and bronchi. This nasal airway also provides a degree of nasal resistance in order to assist the movements of the

diaphragm and intercostals muscles by creating a negative intrathoracic pressure. This intrathoracic pressure promotes airflow into the alveoli.7,15 Correct normal resistance is 2 to 3.5 cm H2O/L/Sec and results in high tracheobronchial airflow which enhances the oxygenation of the most peripheral pulmonary alveoli. In contrast, mouth breathing causes a lower velocity of incoming air and eliminates nasal resistance. Low pulmonary compliance results.7 According to blood gas studies, mouth breathers have 20% higher partial pressure of carbon dioxide and 20% lower partial pressures of oxygen in the blood, linked to their lower pulmonary compliance and reduced velocity.7,16 Contributing factors in the obstruction of upper airways include: anatomical airway constriction, developmental anomalies, macroglossia, enlarged tonsils and adenoids, nasal polyps, and allergic rhinitis.5 However, for purposes of this paper, the focus shall be on enlarged adenoids as the major contributing factor. There are numerous studies that link adenoid hypertrophy with nasopharyngeal airway obstruction to the development of skeletal and dental abnormalities.14 Orthodontic practice 45

CONTINUING EDUCATION

Figure 11: Difficulty breathing possible deviation or turbinates

Figure 12: Flexible optic endoscopes

Airway obstruction, resulting from nasal cavity or pharynx blockage, leads to mouth breathing, which results in postural modifications such as open lips, lowered tongue position, anterior and posteroinferior rotation of the mandible, and a change in head posture. These modifications take place in an effort to stabilize the airway. As previously discussed, facial structures are modified by postural alterations in soft tissue that produce changes in the equilibrium of pressure exerted on teeth and the facial bones (Figure 8). Additionally, during mouth breathing, muscle alterations affect mastication, deglutition, and phonation because other muscles are relied upon.2

Malocclusion â&#x20AC;&#x201D; the issue still in debate Is there a cause-and-effect relationship between adenoids, nasal obstruction, and malocclusion? Dentofacial changes associated with nasal airway blockage have been described by CV Tomes in 1872 as adenoid facies. Tomes coined this term based on his belief that enlarged adenoids were the principle cause of airway obstruction and resulted in noticeable dentofacial changes.7 Tomes reported that children, who were mouth breathers, often exhibited narrow V-shaped dental arches10 (Figure 9). This narrow jaw is a result of mouth breathers keeping their lips apart and their tongue position low. The imbalance between the tongue pressure and the muscles in the cheek, result in cheek muscles compressing the 46 Orthodontic practice

alveolar process in the premolar region. Simultaneously, the lower jaw postures back (Figure 10). These simultaneous actions have been termed the compressor theory.11 Tomesâ&#x20AC;&#x2122; views were supported in the 1930s by numerous leading orthodontists. These supporting clinicians reported airway obstruction as an important etiologic agent in malocclusion. Rubin advocated that in order for these patients to fully be assessed they must be thoroughly evaluated by both a rhinologist and orthodontist.7 Malocclusion is the departure from the normal relation of the teeth in the same dental arch or to teeth in the opposing arch.3 Airway obstruction, coupled with loss of lingual and palatal pressure of the tongue, produces alterations in the maxilla. The positioning of the tongue also plays an important role in mandibular development. The tongue displaced downward can lead to a retrognathic mandible, and an interposed tongue can lead to anterior occlusal anomalies. Additionally, maxillary changes can be viewed in the transverse direction, producing a narrow face and palate often linked with cross bite; in the anteroposterior direction, producing maxillary retrusion; and in the vertical direction, causing an increase in palatal inclination as related to the cranial base and excessive increases of the lower anterior face height. The most commonly found occlusal alterations are cross bite (posterior and/or anterior), open bite, increased overjet, and retroclination of the maxillary and mandibular incisors.2

Figure 13: Lateral cephalometric radiograph with obstructive adenoids

Figure 14: Rapid maxillary expander

Mahony and Linder-Aronsonâ&#x20AC;&#x2122;s findings were in agreement with the significant correlation between changed mode of breathing and diminished mandibular/ palatal plane angle (ML/NL) found in adenodectomized children.22 Several authors have taken the position that alleged faces are not consistently found to be associated with adenoids, mouth breathing, nor a particular type of malocclusion; and that there is no causeand-effect relationship between adenoids, nasal obstruction/mouth breathing, and malocclusion. Proponents of this position believe that the V-shaped palate was inherited and not acquired through mouth breathing (Hartsooh 1946). A review of literature related to mouth breathing concluded that mouth breathing is not a primary etiological factor in malocclusion. Additionally, Whitaker (1911) found that in a study of 800 children, who underwent adenoidectomy or tonsillectomy, only 30% had dental anomalies that needed orthodontic Volume 5 Number 3

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Figure 15B: Frontal after

Figure 15A: Frontal before

Figure 15C: Upper before

Figure 15D: Upper after

Figure 15E: Face before

intervention. There is some suggestion that adenoids and hypertrophic tonsils are a consequence of a thyroid hormone deficiency. This hormone deficiency acts as a catalyst for activating the organism’s defense mechanisms which include hypertrophy of lymphoid tissue.11 Another orthodontic clinician, Vig, took the position that without documented total nasal obstruction, any surgery or other treatment to improve nasal respiration is empirical and difficult to justify from an orthodontic point of view.7,17

in this area, practitioners should observe each patient carefully. Here is the suggested protocol: 1. As the patient enters the room, facial and head posture should be noted to see if the lips are closed during respiration. 2. Signs of allergic rhinitis should be noted, as well as histories of frequent colds or sinusitis. 3. Assessment of family history for allergies is important. 4. Sleep history should be evaluated: sleep apnea, loud snoring, open-mouth posture while asleep. 5. Patient is asked to seal his/her lips — difficulty breathing through nose should be noted. One nostril can be occluded and the response noted — same procedure on the other side (Figure 11). The evaluation of nasal airway patency is complicated, especially when the

Nasal respiratory evaluation The relationship of airway obstruction and dentofacial structures/malocclusion is still the subject of investigation and controversy among orthodontists. The correlation between functional problems and morphologic characteristics is yet to be solidified. Regardless of varied opinion Volume 5 Number 3

Figure 15F: Face after

possibility exists that airways may clinically appear inadequate but be quite functional physiologically. Lip separating or an openmouth habit is not an infallible indicator of mouth breathing. Often complete nasal respiration is coupled with dental conditions that cause open-mouth posture.10

Adenoid evaluation Nasopharyngeal space and the size of adenoids have been evaluated using different methods of assessment: 1. Determination of the roentgenographic Orthodontic practice 47

CONTINUING EDUCATION adenoid/nasopharyngeal ratio (a lateral cephalometric X-ray) 2. Flexible optic endoscopes (Figure 12) 3. Acoustic rhinometry 4. Direct measurements during surgery Direct measurements are considered to be the most accurate because space can be assessed in three directions.12 A lateral cephalometic radiograph is an added valuable diagnostic tool for the orthodontist in the evaluation of children with upper airway obstructions14 (Figure 13).

3. Maxillary expansion (RME or SAME) — an orthodontic procedure that widens the nasal vault7,18 (Figure 14). 4. Cryosurgery or electrosurgery — this is a viable option for patients with vasomotor rhinitis.7 5. Bipolar radiofrequency ablation (allergic rhinitis) — performed under local anesthetic. 6. Inferior turbinectomy — using powered instrumentation. 7. Use of nasal sprays.

Treatment of nasal obstruction Adenoidectomy with or without 1. tonsillectomy is indicated if hypertrophied adenoids (and tonsils) are the cause of upper airway obstruction.7 Powered-shaver adenoidectomy — adenoidectomy coupled with endoscopic visualization will assist in achieving adequate removal of adenoids particularly high in the nasopharnx. Use of the powered-shaver technique allows for better clearance of obstructive adenoids. The end result is more reliable restoration of nasal patency.13 2. Septal surgery (rarely indicated in the child) but may be considered in the presence of a marked nasal septal deflection with impaction. Conservative septal surgery in growing patients will not have an adverse effect in dentofacial growth.7,18,19,20

The effect of adenoids on facial expression, malocclusion, and mode of breathing has been a topic of debate and investigation by practitioners in the field for the last 100 years. A review of the literature exposes several theories. A healthcare provider, with a practice philosophy based on prevention of malocclusion development, cannot ignore the early years of the patient’s growth cycle. By age 12, 90% of facial growth has already occurred. This is the age when many practitioners begin orthodontic treatment.7 This is the age when 80%90% of craniofacial growth is complete, so most formation and/or deformation has occurred.21 To wait until 90% of the abnormality has occurred, before beginning treatment, is not consistent with a preventive philosophy. Interceptive

Conclusion

measures must be initiated sooner. Early intervention requires an acceptance of a multidisciplinary approach to total patient health. An integrated approach to patient evaluation, diagnosis and treatment is most effective. Primary care physicians, dentists, allergists, otorhinolaryngologists, and orthodontists must all work together for early prevention and management of young patients with increased nasal airway resistance. After diagnosis, a comprehensive risk benefit analysis regarding early intervention must be considered. Although hereditary and environmental factors must be considered, the universal goal is the promotion of proper nasal respiration throughout a child’s early years of facial growth. Figures 15A-15F shows the before and after treatment results of a young girl who had her adenoids removed, then underwent maxillary expansion before full-fixed braces. She was treated as a second opinion against the removal of four premolar teeth to relieve dental crowding. OP

References 1. Mattar SE, Anselmo-Lima WT, Valera FC, Matsumoto MA. Skeletal and occlusal characteristics in mouth-breathing pre-school children. J Clin Pediatr Dent. 2004;28(4):315-318. 2. Valera FC, Travitzk LV, Mattar SE, Matsumoto MA, Elias AM, Anselmo-Lima WT. Muscular, functional and orthodontic changes in pre-school children with enlarged adenoids and tonsils. Int J Pediatr Otorhinolaryngol. 2003;67(7):761-770. 3. Khurana AS, Arora MM, Gajinder S. Relationship between adenoids and malocclusion. J Indian Dental Ass. 1986;58:143-145. 4. Pellan P. Naso-respiratory impairment and development of dento-skeletal sequelae: a comprehensive review. Int J Orthod Milwaukee. 2005;16(3):9-12. 5. Soxman JA. Upper airway obstruction in the pediatric dental patient. Gen Dent. 2004;52(4):313-316. 6. Ranly DM. Craniofacial growth. Dent Clin North Am. 2000;44(3):457-470. 7. Rubin RM. Effects of nasal airway obstruction on facial growth. Ear Nose Throat J. 1987;66(5):212-219.

48 Orthodontic practice

8. Pistolas PJ. Growth and development in the pediatric patient. Funct Orthod. 2004-2005;22(1):12-22.

15. Adams GL, Boies CR, Papaiella MM. Boies’ Fundamental Oto. Philadelphia, PA: WB Sanders; 1978.

9. Enlow DH, Hans MG. Essentials of Facial Growth. New York, NY: W.B. Saunders Co.; 1996: 79-98, 206.

16. Ogura JH. Physiologic relationships of the upper and lower airways. Ann Otol Rhinol Laryngol. 1970;79(3):495-498.

10. Diamond O. Tonsils and adenoids: why the dilemma? Am J Orthod. 1980;78(5):495-503. 11. Linder-Aronson S. Adenoids. Their effect on mode of breathing and nasal airflow and their relationship to characteristics of the facial skeleton and the denition. A biometric, rhino-manometric and cephalometroradiographic study on children with and without adenoids. Acta Otolaryngol Suppl. 1970;265:1-132. 12. Casselbrant ML. What is wrong in chronic adenoiditis/tonsillitis anatomical considerations. Int J Pediatr Otorhinolaryngol. 1999;5;49(suppl 1):S133-5.

17. Vig PS, Sarver DM, Hall DJ, Warren DW. Quantitative evaluation of nasal airflow in relation to facial morphology. Am J Orthod. 1981;79(3):263-272. 18. Gary LP, Brogan WF. Septal deformity malocclusions and rapid maxillary expansion. Orthodontist. 1972;4(1):2-14. 19. Cottle MH. Nasal surgery in children. Eyo, Ear, Nose and Throat Monthly. 1951;30:32-38. 20. Jennes JL. Corrective nasal surgery in children. Long term results. Arch Otolaryngol. 1964;79:145-151.

13. Havas T, Lowinger D. Obstructive adenoid tissue an indication for powered-shaver adenoidectomy. Arch Otolaryngol Head Neck Surg. 2002;128(7):789-791.

21. Mahony D, Page D. The airway, breathing and orthodontics. Ortho Tribune. 8-11.

14. Oulis CJ, Vadiakas GP, Ekonomides J, Dratsa J. The effect of hypertrophic adenoids and tonsils on the development of posterior crossbite and oral habits. J Clin Pediatr Dent. 1994;18(3):197-201.

22. Mahony D, Karsten A, Linder-Aronson S. Effects of adenoidectomy and changed mode of breathing on incisor and molar dentoalveolar heights and anterior face heights. Aust Orthod J. 2004;20(2):93-98.

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The effects of enlarged adenoids on a developing malocclusion

Periodontal rationale for transverse skeletal normalization

MAHONY 1. Early diagnosis and treatment of pathological conditions that can lead to the obstruction of the upper airways is essential to anticipate and prevent alterations in _______. a. dental arches b. facial bones c. muscle function d. all of the above 2. Important motor functions such as chewing and swallowing depend largely on _____. a. normal craniofacial development b. deglutition c. alteration of the dendritic cells d. distribution of lymphoid tissue 3. Most facial growth and development occurs during the _____childhood growth peaks. a. two b. three c. four d. six 4. The study of the early years of life shows that by the age of four, ____ of the craniofacial skeleton has reached its adult size. a. 20% b. 30% c. 50% d. 60% 5. The integration of the musculoskeletal system affects______ and speech. a. respiration b. mastication c. deglutition d. all of the above

Volume 5 Number 3

6. The _____ is the system of lymphoid tissue that surrounds the pharynx. a. Curve of Spee b. Waldeyer’s ring c. Retromolar trigone d. Monson’s ring 7. Specifically, different pathogens, such as______, has/have been associated with lymphoid tissue hyperplasia. a. Salmonella b. Haemophilus influenza c. Staphylococcus aureus d. both b and c 8. The growth of adenoidal tissue as demonstrated by a bell curve, peaks at or near age ____ and also begins involution at or near this age as well. a. five b. six c. eight d. ten 9. Tomes reported that children, who were mouth breathers, often exhibited narrow ____dental arches. a. V-shaped b. U-shaped c. ovoid d. round 10. ________ is an added valuable diagnostic tool for the orthodontist in the evaluation of children with upper airway obstructions. a. A 2D radiograph b. A lateral cephalometric radiograph c. A tomogram d. None of the above

TAMBURRINO 1. As there are treatment goals for the final tooth positions based on sagittal and vertical skeletal dimensions, there must be a set of defined goals for the transverse. For the posterior teeth, these would be to have them ______, as shown in Figure 1. a. upright b. centered in the alveolus c. well-intercuspated with proper arch coordination d. all of the above 2. _______, which uprights and centers the teeth in the alveolus, then reveals the underlying “skeletal crossbite” and amount of skeletal correction required, is shown in Figure 2. a. “Decompensation” b. “Intercuspation” c. “Skeletal mismatch” d. “Significant disharmony” 3. When the width of the maxilla and mandible were measured, it was consistently shown that these “normal” patients, which met the stated transverse goals, had a maxilla that was roughly ______ (measured at Mx-Mx) than the mandible (measured at MGJ-MGJ),as shown in Figure 3. a. 2 mm wider b. 3 mm wider c. 5 mm wider d. 7 mm wider 4. Instead, every patient is his/her own “normal” using the baseline dimension of the ______. a. basal bone b. mandibular width c. maxillary width d. soft tissue thickness 5. While it is possible to achieve good uprighting and intercuspation of the posterior teeth in the presence of a skeletal disharmony, a risk of doing so is potential compromise to the ______. a. periodontium b. alveolus c. intercuspation d. dentition inclination

6. However, in severe transverse discrepancies, an attempt to normalize the posterior dentition inclination and intercuspation in light of the uncorrected skeletal disharmony risks _____, as shown in Figure 5. a. parafunctional loading b. root fenestration c. clinically obvious attachment loss d. both b and c 7. However, a practitioner can gain an appreciation for where an underlying skeletal crossbite is present, in the absence of a dental one, by looking at the ____. a. maxillary length b. inclinations of the mandibular teeth c. baseline dimension d. the posterior teeth 8. Therefore, the negative sequelae of loss of attachment and recession may not appear until years or decades later, depending on the patient’s ______. a. adaptability b. periodontal biotype c. genetic makeup d. all of the above 9. Histological arrangement of the PDL fibers show that _____ to the dentition can be well tolerated, but react to lateral or off-axis forces with much less resilience. a. vertical stresses b. horizontal stresses c. occlusal trauma d. off-axis forces 10. The combination of increased force, lateral direction of stress application, and high area of stress concentration seen with a hanging palatal cusp or non-working interference is the ____ combination to have within a parafunctionally susceptible patient who has a reduced resilience of the periodontium to withstand this stress. a. best b. worst c. least damaging d. most neutral

Orthodontic practice 49

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ORTHODONTIC PRACTICE CE

CONTINUING EDUCATION

he goals of orthodontic treatment are well established for the sagittal and vertical dimensions in terms of how the teeth and jaws should relate, fit, and work together. Diagnostic and treatment strategies focusing on these dimensions are the topic of many orthodontic symposiums, conferences, and research papers. However, the transverse dimension is often missing from generally accepted and performed patient analyses and discussions. Additionally, well-defined criteria for determining if there is a need for correction based on objective means, instead of subjective, frequently are not used. As there are treatment goals for the final tooth positions based on sagittal and vertical skeletal dimensions, there must be a set of defined goals for the transverse. For the posterior teeth, these would be to have them upright and centered in the alveolus

Educational aims and objectives The aim of this article is to discuss treatment goals to optimize the skeletal transverse dimension. Expected outcomes Orthodontic Practice US subscribers can answer the CE questions on page 49 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Identify the skeletal transverse discrepancy. • Gain an understanding of the numerical measurement relationships for the width of the maxilla or the mandible. • Realize potential compromise to the periodontium resulting from certain tooth movements in the presence of a skeletal disharmony. • Realize the consequences of attempted tooth position normalization, without skeletal correction, and their effect on long-term periodontal viability. • Realize that over time and in susceptible patients, some negative sequelae may occur depending upon certain factors. • Recognize the importance of objectively measuring and optimizing the skeletal transverse dimension in conjunction with comprehensive orthodontic treatment whenever possible.

Ryan K. Tamburrino, DMD, a native of Pittsburgh and co-founder of the Center for Orthodontic Excellence, graduated from Duke University with a double major in biomedical engineering and mechanical engineering/ materials science. He then attended the University of Pennsylvania for dental school and stayed an additional 2 years for specialty training in orthodontics. During his orthodontic training, Dr. Tamburrino concurrently completed additional training in advanced orthodontic diagnosis, functional occlusion, and TMJ health with the AEO/Roth-Williams Group and the Andrews™ Six Elements courses. Shalin Raj Shah, DMD, MS, received his Certificate of Orthodontics and Masters of Science in Oral Biology from the University of Pennsylvania and is a Diplomate of the American Board of Orthodontics. He is also a graduate of the University of Pennsylvania College of Arts and Sciences and School of Dental Medicine. Currently, Dr. Shah is Clinical Associate of Orthodontics at the University of Pennsylvania and is in private practice (Center for Orthodontic Excellence) in Princeton Junction, New Jersey, and Philadelphia, Pennsylvania. Daniel L.W. Fishel, DMD, is a dual-trained specialist in orthodontics and periodontics. He maintains multiple practices in south central Pennsylvania. His practice philosophy focuses on providing orthodontic results that decrease periodontal susceptibility, primary though skeletal growth modification.

50 Orthodontic practice

Figure 1: Ideal posterior dental treatment goals — teeth upright and centered in the alveolus, and well-intercuspated

in addition to being well-intercuspated with proper arch coordination, as shown in Figure 1. When there is a skeletal transverse discrepancy, oftentimes this is recognized by a posterior dental crossbite. However, many times there is no posterior dental crossbite, but the maxillary posterior teeth are tipped buccally, and mandibular posterior teeth are inclined lingually to compensate for the skeletal disharmony. This compensated dental arrangement opens the patient to a higher likelihood for

non-working interferences from plunging palatal cups, centric prematurities, and functional shifts, in addition to placing off-axis forces on the dentition. “Decompensation,” which uprights and centers the teeth in the alveolus, then reveals the underlying “skeletal crossbite” and amount of skeletal correction required, as shown in Figure 2. Coronal cuts of untreated patients, where the posterior teeth were upright in the alveolus, centered in the alveolus, and well intercuspated were examined for the Volume 5 Number 3

relationship between the jaws.1 When the width of the maxilla and mandible were measured, it was consistently shown that these “normal” patients, which met the stated transverse goals, had a maxilla that was roughly 5 mm wider (measured at MxMx) than the mandible (measured at MGJMGJ), as shown in Figure 3. There is no exact numerical measurement for the ideal width of either the maxilla or the mandible. Instead, every patient is his/her own “normal” using the baseline dimension of the mandibular width. Since the mandibular basal bone is unable to be affected with conventional orthodontic means, it is the orthodontist’s role to then normalize the maxilla to it. Therefore, the difference of width between the two, instead of the baseline jaw dimensions taken individually, is the important concept. While a difference of 5 mm is the ideal goal (meaning maxillary width - mandibular width = 5 mm), the authors feel comfortable with dentally camouflaging a skeletal difference of 2-5 mm. Any differences < 2 mm (meaning the maxilla has smaller width compared to what should be ideal for a that patient’s mandible) may benefit from correction via orthopedic, surgical, or other means, as deemed appropriate on a case-by-case basis. While it is possible to achieve good uprighting and intercuspation of the posterior teeth in the presence of a skeletal disharmony, a risk of doing so is potential compromise to the periodontium. In an attempt to upright and well intercuspate the teeth in the presence of a discrepancy, the amount of soft tissue and bone overlying the roots becomes thinner (Figure 4) because Volume 5 Number 3

Figure 3: Three examples of untreated cases with ideal posterior dental relationships. Note the skeletal difference between the width of the jaws at the level of the first molar is 5 mm

Figure 4: Cartoon of creating upright and well-intercuspated posterior teeth in the presence of a transverse skeletal mismatch. Note the reduced thickness of bone/soft tissue on the buccal portion of the maxillary molar as the discrepancy becomes greater

Figure 5: Example showing posterior teeth uprighting in the presence of a significant transverse skeletal disharmony of 7 mm. Note loss of attachment. There was buccal displacement of the teeth and thinning of the attachment when normalizing the dental archform on an underlying skeletal base disharmony

Orthodontic practice 51

CONTINUING EDUCATION

Figure 2: Comparison of an ideal posterior relationship vs. one where a skeletal transverse discrepancy is present. Decompensation of the teeth reveals the maxillary skeletal deficiency

CONTINUING EDUCATION

Figure 7: Case example of teeth being buccally tipped to camouflage the skeletal discrepancy Figure 6: Examples of cases where no dental crossbite is present, but the clinician can suspect a camouflaged transverse discrepancy due to the excessive lingual inclination of the mandibular molars

the teeth will no longer be centered in the alveolus. In mild discrepancies, the effects of this dental positioning may not pose a concern. However, in severe transverse discrepancies, an attempt to normalize the posterior dentition inclination and intercuspation in light of the uncorrected skeletal disharmony risks root fenestration and clinically obvious attachment loss, as shown in Figure 5. Moderate skeletal discrepancies are the most common missed situation using just clinical observation and not an objective analysis. However, a practitioner can gain an appreciation for where an underlying skeletal crossbite is present, in the absence of a dental one, by looking at the inclinations of the mandibular teeth (Figure 6). In these scenarios the consequences of attempted tooth position normalization, without skeletal correction, and their effect on long-term periodontal viability may not be immediately realized clinically. On debond it may appear that the posterior teeth were corrected with just using brackets, crosselastics, or expanded archwires. However, because no overt attachment loss was seen during treatment, the practitioner may wrongly assume that no harm was done to the patient or the periodontium is viable and resilient for the long term. Over time and in a susceptible patient, as stated above, the gingival attachment may be less resilient to normal stresses placed on it due to the reduced bulk of tissue versus the amount present in a noncompromised patient. There is now a higher risk for mechanically induced periodontal tissue loss, especially for those patients 52 Orthodontic practice

Figure 8: Comparison of functional and parafunctional loads placed on the dentition7

who may have a thinner tissue biotype at baseline. Therefore, the negative sequelae of loss of attachment and recession may not appear until years or decades later, depending on the patient’s adaptability, periodontal biotype, and genetic makeup.2 Anzilotti and Vanarsdall brought this phenomenon to light.3 In their thesis, it was suggested that those people who had skeletal discrepancies more than 5 mm from the ideal relationship were at a higher risk for periodontal disease and gingival recession than those with optimally related skeletal bases. While there are many biologic, intrinsic, and extrinsic factors that lead to periodontal compromise, thinned tissue will have less resistance to sustain forces placed on it by normal mechanical means, such as toothbrushing. Compounding factors (occlusal trauma,4

biological pathogens,5 and so on), in addition to a reduced tissue thickness, may further exacerbate tissue loss. The Anzilotti paper describes what happens with attempted normalization of tooth inclinations on a skeletal base mismatch. In another scenario where teeth are tipped to compensate for a significant skeletal discrepancy, periodontal consequences can also occur. Here, posterior teeth are not uprighted but instead are tipped buccally via crosselastics or archwires in an attempt to “eliminate the crossbite” or “broaden the archform,” as shown in Figure 7. Histological arrangement of the PDL fibers show that vertical stresses to the dentition can be well tolerated, but react to lateral or off-axis forces with much less resilience.6 For normal masticatory function Volume 5 Number 3

with vertical chewing strokes, this dental arrangement may still prove viable as long as the forces placed on the dentition and periodontium are physiologic and there is a normal to thick tissue biotype present. The threshold to the patientâ&#x20AC;&#x2122;s level of periodontal adaptability is reduced when the teeth are not upright in the alveolus. Additionally, the potential for adverse effects to the periodontium is increased when compromised posterior tooth inclinations are combined with parafunctional activity. Okeson describes that the forces generated through nocturnal parafunction can be 3-4 orders of magnitude higher than what is generated through normal physiologic masticatory function (Figure 8).7 In addition to vertical clenching, the often co-present jaw eccentric motion

of bruxism places lateral forces on the dentition. As mentioned previously, the PDL fibers are oriented in such a fashion so they exert tensile forces (osteoblastic for orthodontic movement) upon alveolar bone when a tooth is loaded along its long axis. However, compressive forces (osteoclastic for orthodontic movement) dominate at the alveolar crest when nonaxial or lateral forces are exerted on the tooth in function and parafunction.6 The combination of increased force, lateral direction of stress application, and high area of stress concentration seen with a hanging palatal cusp or non-working interference is the worst combination to have within a parafunctionally susceptible patient who has a reduced resilience of the periodontium to withstand this stress.

References

1. Simontacchi-Gbologah MS, Tamburrino RK, Boucher NS, Vanarsdall RL, Secchi AG. Comparison of Three Methods to Analyze the Skeletal Transverse Dimension in Orthodontic Diagnosis [thesis]. Pennsylvania: University of Pennsylvania; 2010. 2. Vanarsdall RL. Periodontal-orthodontic Interrelationships. In: Graber LM, Vanarsdall RL, Vig KWL, eds. Orthodontics: Current Principles and Techniques. 5th ed. St. Louis, MO: Mosby; 2012: 807-843. 3. Anzilotti CL, Vanarsdall RL, Balakrishnan M. Expansion and Evaluation of Post-Retention Gingival Recession [thesis]. Pennsylvania: University of Pennsylvania; 2002.

5. El-Mangoury NH, Gaafar SM, Mostafa YA. Mandibular anterior crowding and periodontal disease. Angle Orthod. 1987;57(1):33-38. 6. Carranza FA, Newman GA. Clinical Periodontology. 8th ed. Philadelphia, PA: W.B. Saunders Company; 1996. 7. Okeson JP. Management of Temporomandibular Disorders and Occlusion. 5th ed. St. Louis, MO: Mosby; 2003.

9. Hayes JL . In search of improved skeletal transverse diagnosis. Part 2: A new measurement technique used on 114 consecutive untreated patients. Orthodontic Practice US. 2010;1(4);34-39. 10. Ricketts RM. Introducing Computerized Cephalometrics. Rocky Mountain Data Systems; 1969. 11. Andrews LF, Andrews WA. Andrews analysis. In: Syllabus of the Andrews Orthodontic Philosophy. 9th ed. Six Elements Course Manual; 2001.

8. Tamburrino RK, Boucher NS, Vanarsdall RL, Secchi AG. The transverse dimension: Diagnosis and relevance to functional occlusion. Roth Williams International Society of Orthodontics Journal. 2010;2(1):11-20.

4. Amsterdam MA, Vanarsdall RL. Periodontal prosthesis: Twenty-five years in retrospect. Alpha Omegan. 1975;67(3):8-52.

Volume 5 Number 3

Orthodontic practice 53

CONTINUING EDUCATION

Figure 9: Exostosis development on the buccal of the maxillary teeth as a compensatory adaptation to withstand excessive loading

Knowing this, the body is remarkable, and often attempts to adapt to support non-physiologic stresses via development of exostoses along the buccal cortical surfaces of the maxillary posterior teeth and/or lingual cortical surfaces of the mandibular posterior teeth. Coronal cross section cuts through the posterior teeth clearly show this development in Figure 9. However, in dentistry and orthodontics in general, we do not have the ability to test for a patientâ&#x20AC;&#x2122;s adaptive capacity and are unable to predict which patients will be able to develop adaptations to non-optimal situations and who will not. Especially in a population whose adaptive capacity is poor or compromised, continued nonphysiologic stress to the area can lead to tooth mobility, secondary occlusal trauma, and further attachment loss.4 The bottom line is that we do not know which patients can withstand transverse camouflage, and to what periodontal limit they will be able to tolerate a dental compromise. The goal, therefore, is to objectively measure and optimize the skeletal transverse dimension8,9,10,11 in conjunction with comprehensive orthodontic treatment whenever possible.

PRODUCT PROFILE

GALILEOS® Comfort Plus: the most efficient clinical workflow in dentistry

his high-end CBCT unit with HD scan mode guarantees the highest image quality with extremely low dose, large fieldof-view, and integrated FaceScan offers orthodontists and maxillofacial surgeons all the options they need for diagnosis, treatment, and patient consultation. The optional HD mode of GALILEOS® Comfort Plus ensures the highest image quality for a clear and quick diagnosis, even in difficult cases. • 15.4 cm spherical volume with MARS • Lateral and AP/PA cephalometric views • One of the lowest diagnostic doses per volume size available • Stable patient positioning, whether standing or sitting • 14-second scan for minimized patient movement • Seamless workflow integration • Software with superior diagnostic features • Close-up feature with 125μ resolution for endodontic applications At a glance, GALILEOS Comfort Plus offers advanced features that are easy-to-use and provide the optimal workflow for your practice.

Introducing SICAT function For the first time GALILEOS provides true motion in Cone Beam with SICAT Function — only from Sirona. SICAT Function is a revolutionary software solution with an integrated 3D work flow. Through GALILEOS and SICAT Function, you can now utilize the GALILEOS scan with the recorded jaw motions to visualize and accurately diagnose the individual patient’s movements of the lower jaw in 3D with Sirona software. The recorded jaw movement traces can be visualized and reproduced at any location on the dentition or mandible.

Integrated FaceScan The FaceScan plots the patient’s facial surfaces at the same time the X-ray image is taken. With a realistic image of their own face, patients understand and accept treatment recommendations more readily.

Compatible with Dolphin software The Dolphin 3D imaging software is 54 Orthodontic practice

a powerful tool for orthodontists and oral maxillofacial surgeons that make processing 3D data from any Sirona CBCT X-ray system extremely simple. Dolphin 3D features tools for on-screen manipulation and analysis of volumetric datasets. Images are easily oriented and rotated, and tissue density thresholds can be adjusted for detailed views of the craniofacial anatomy. Measurements and digitalization can be performed in both 3D and traditional 2D views. In addition to Dolphin integration, Sirona CBCT systems are also compatible with other popular orthodontic software programs.

Sleep apnea GALILEOS 3D scans can also be used for visualization of the airways. With Dolphin 3D, you can analyze the airway by drawing a border around your selected portion

of the volumetric scan; the program will automatically fill in and display all the airway space within that border, then report back telling you the volume of airway space in cubic millimeters. It will also locate, display, and measure, in square millimeters, the most constricted spot of that airway. A fast 14-second 3D scan from GALILEOS provides 3D data for your diagnostic needs. Its ease-of-use, wide range of functionality, and HD imaging capabilities make the Sirona GALILEOS Comfort Plus perfect for your practice. OP Sirona and GALILEOS takes SCAN, PLAN, and TREAT to another level. To learn more about the GALILEOS Comfort Plus visit Sirona3D.com or contact Sirona at 800659-5977. This information was provided by Sirona. Volume 5 Number 3

Your practice in the palm of their hands

rthodontic practice management leader Ortho2 has announced the release of Practice Connect, an office-specific app that facilitates patient communication, adds powerful marketing features, and greatly expands orthodontists’ practice community. This Android and iPhone app is uniquely branded for each office and allows practices to customize the information seen by their patients, responsible parties, and prospective patients. The app includes many exciting features including patient access to upcoming appointments, images, animations, even reward points and prizes, as well as global messaging and automatic GPS patient sign-in. Amy Schmidt, Ortho2’s Director of Sales and Marketing, says, “Practice Connect was developed from specific customer input that we received over the last year. Many of our orthodontists told us they wanted an app that was designed and customized for their office which they could use to engage their patients, as well as drive new patients to their practice.” Practice Connect lets patients set their

own reminders for appointments at exactly the time they want. In addition, patients can sign in for their appointment via the app’s GPS patient sign-in once they come within a certain distance of your office, and within a certain time before a scheduled appointment. Practice Connect makes referrals simple and rewarding. Patients can easily enter the name and email address of the person they are referring. Your office gets an email, as well as the person being referred. Dr. Tim Dumore, Orthodontist in Winnipeg, says, “I’m very excited to incorporate Practice Connect into our office. What a fantastic way to interact with our patients, as well as for them to see how their treatment is progressing. This marketing tool will greatly help get our name out to those looking for an orthodontist in the area.” Practice Connect runs seamlessly on Ortho2’s Edge cloud platform and is the latest in a series of mobile app development. “The response to Practice Connect has been phenomenal. We are excited to be able

to leverage our cloud-based Edge system by adding a powerful patient-based app which is branded uniquely for each office. Now orthodontists can stay connected with their patients 24/7 by giving them meaningful content and unique mobile functions,” says Dr. Craig Scholz, Ortho2’s Director of Emerging Technologies. Ortho2 products can be found in more than 2,000 orthodontic offices, and the company has been providing orthodontic software solutions for more than 30 years.

placement, and final position. Insignia™ Ai, the enhanced Insignia Advanced Smile Design Approver Interface, combines two occlusion tools into a simultaneous function for clinicians to interact with the patient’s occlusion from multiple angles. The occlusion tool is accompanied by a wizard to easily navigate throughout the entire submission and approval experience. For added personalization, clear precision placement guides (jigs) shipped with each Insignia case provide exact bracket placement on a patient’s tooth before curing.

Unique to orthodontic impression systems, Lythos can provide up to 2.5 million 3D data points per second which results in a rapid single high-resolution scan. Lythos’ open platform format and rebate program ensure the scanner is a sound financial investment.

This information was provided by Ortho2.

Ormco™ Custom

t the 2014 AAO Annual Session, Ormco™ Corporation unveiled Ormco™ Custom — the company’s end-to-end digital suite of products and services. During hysterical in-booth mock debates, Ormco Custom candidates, Senator Tailor and Governor Cash, took the stage to argue which benefit of Ormco Custom is superior — personalization or profitability. If you missed the debates, here is a look at Ormco Custom’s suite of products.

Lythos™ Digital Impression System

Insignia™ Advanced Smile Design™ Insignia — proven to reduce treatment time by 37% with 7 fewer patient visits* — is a fully customized bracket system with an exact calculated per-tooth prescription based on each unique anatomy, bracket Volume 5 Number 3

Helping to make cumbersome PVS impressions a thing of the past, Ormco Custom includes the Lythos Digital Impression System. Lythos allows users to own, store, and send treatment scans to anyone that accepts .stl files — at no cost. The scanner uses AFI technology to capture and stitch together data in real-time, acquiring highdefinition surface detail at all angulations of the tooth surface.

AOA Lab Ormco’s laboratory arm fabricates customized appliances including class II correctors, aligners, splints, retainers, and more. To help streamline the practice workflow, AOA Lab accepts .stl files from a number of scanners but has a unique integration with Lythos to allow for an even easier submission process. Learn more about Ormco Custom at www.ormcocustom.com. *Weber II, Dennis J., Koroluk, Lorne D., Phillips, Ceib, Nguyen, Tung, Proffi t, William R., “Clinical Effectiveness and Efficiency of Customized vs. Conventional Preadjusted Bracket Systems,” Journal of Clinical Orthodontics, Volume XLVII, No. 4 (2013): 261-266.

This information was provided by Ormco Corporation. Orthodontic practice 55

AAO ENCORE

ENCORE

PRODUCT PROFILE

The Victory Series™ adhesive pre-coated Active Self-Ligating Brackets by 3M Unitek

he Victory Series™ brand family of orthodontic brackets from 3M Unitek is known by industry professionals worldwide for its quality. Now, this renowned family has expanded into the self-ligating bracket category, with the introduction of the new Victory Series™ Active Self-Ligating Brackets. Designed using extensive practitioner input, Victory Series Active SelfLigating (SL) Brackets combine industry benchmark performance with APC™ Adhesive, the most efficient bonding system in orthodontics, resulting in an outstanding and unique treatment choice. Victory Series Active SL Brackets bring active door appliances to a higher level of performance, featuring a robust ligating mechanism that provides durability and ease of operation. A full slot-width size door allows optimal rotational control, and no special instrument is necessary to open or close the door, so orthodontists can incorporate the brackets into their practice without changing their technique. Patient comfort is also enhanced with thoughtful design aspects like round, low profile hooks and rounded edges on the bracket body. The design of Victory Series Active SL Brackets allows dynamic interaction between the ligating mechanism and the archwire as treatment phases change, with performance advantages in each stage — passive, interactive, and active. With this design, orthodontists can efficiently progress from the initial leveling and alignment through final finishing and detailing. 3M Unitek recruited orthodontists who were using competitive active self-ligating brackets for design input, and asked them to treat their patients with the brackets in an evaluation phase. Comments received were overwhelmingly positive, including these: 56 Orthodontic practice

• “Dependability, control, and quality are what I get with … Victory Series Active SL Brackets. Doctors using active selfligation should consider this system.” Victory Series Active SL Brackets are available pre-coated with proven APC™ II Adhesive, which reduces bonding steps and variables for added efficiency and convenience. Maintaining the exceptional quality that the Victory Series brand is known for, the brackets are manufactured to strict tolerances and extensively tested to assure reliability. With this combination of bracket and adhesive, orthodontists and their patients can enjoy the unique benefits of the world’s only precoated active self-ligating bracket.

Designed using extensive practitioner input, Victory Series Active Self-Ligating (SL) Brackets combine industry benchmark performance with APC™ Adhesive, the most efficient bonding system in orthodontics, resulting in an outstanding and unique treatment choice. • “I felt I was in control the entire duration of treatment, as I had no loss of the ability to ligate the wire in an active state.” • “What I found most exciting about the Victory Series Active SL Bracket system was the quality finishing I was seeing with a straight wire. Quality engineering led to improved lower anterior alignment.”

For more information, visit www.3MUnitek. com/VSactiveSL.

About 3M 3M captures the spark of new ideas and transforms them into thousands of ingenious products. Our culture of creative collaboration inspires a never-ending stream of powerful technologies that make life better. 3M is the innovation company that never stops inventing. With $31 billion in sales, 3M employs 89,000 people worldwide and has operations in more than 70 countries. For more information, visit www.3M.com or follow @3MNews on Twitter. OP 3M, APC, and Victory Series are trademarks of 3M. © 3M 2014. All rights reserved. This information was provided by 3M Unitek.

Volume 5 Number 3

29.2 μSv

7 μSv

ø20 x 17cm

14.7 μSv

14.4 μSv

• Ultra Low-dose mode for optimal dose based on the ALARA radiation safety principle • Pediatric imaging mode lowers effective dose by 35%, with additional ultra low dose protocols for adults • Multi-bladed collimation focuses radiation to areas of clinical interest • Planmeca Romexis open-architecture software included • Optional SmartPan allows 2D and 3D images to be taken with the same sensor

For a free in-office consultation, please call

1-855-245-2908 or visit us on the web at www.planmecausa.com