Orthodontic Practice US - October 2013 - Vol 4 No 5 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews October 2013 – Vol 4 No 5

PROMOTING EXCELLENCE IN ORTHODONTICS

Dr. Rohit C.L. Sachdeva

A golden opportunity for dentists: dental sleep medicine: part I Dr. Harold F. Menchel

Practice profile Drs. Shalin Shah and Ryan Tamburrino

PAYING SUBSCRIBERS EARN 24 CONTINUING EDUCATION CREDITS PER YEAR!

The frontal cephalometric analysis – the forgotten perspective Dr. Bradford Edgren

Treating digitally and the new orthodontic practice

Go to page 3 and just say “OM.”

BioDigital Orthodontics: part 5

Dr. Randall Moles

to be sure.

On Both Arches

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INTRODUCTION October 2013 - Volume 4 Number 5 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

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Investing in your legacy I’ve been practicing orthodontics for more than 40 years, and one of the most important things I’ve discovered is that your practice and the patients whose lives you change are your legacy. The ability to provide patients with enhanced self-esteem, build lifelong relationships, and create an environment that nurtures a “practice family,” is a gift that we have the opportunity to take advantage of. I run a high-tech practice where we treat with Ormco’s Damon® System, Insignia™ Advanced Smile Design™, and Lythos™ Digital Impression System. The progressive technology helps us deliver patients the best possible care with comfort and speed, but, our treatment philosophy extends far beyond straightening teeth. Our mindset is wholehealth treatment. I encourage all to consider this approach. From breathing habits to sleep concerns and tongue thrust, we’re looking to improve each patient’s quality of life. Yes, we all need to make a living (there is no denying that!), but not all decisions can be driven by the bottom line. I’m an advocate for treating patients and team members like family, which requires investing time. At our office, we start every day with a morning huddle and end it with a prayer. Our objective is to keep the truth that we are here to serve our patients and our community top-of-mind. Our motto is “Enriching lives and smiles.” It’s all about investing in the people around you. As my team says, “We’re not saving lives here, but we are changing them!” The profit/loss numbers cannot be ignored, but what stays with you is how you’re able to change lives in a profoundly positive way. My advice: take the time to be involved in your community, be a mentor, and care deeply about your team and your patients — it will be your legacy. Dr. Jim Lyles

Dr. Jim Lyles has been practicing orthodontics for more than 40 years and treats patients at Smiles by Lyles Orthodontics in Spring, Texas. Dr. Lyles assembled a group of exceptional restorative dentists and dental specialists with the purpose of continued growth and education in the field of dentistry. He served with the Air Force Reserve and spent 4 years with a MASH unit, completing military service with the rank of Major. Dr. Lyles began college at the age of 17 with two scholarships and majored in predental medicine at the University of Texas. After completing undergraduate studies at University of Texas, Dr. Lyles continued with 4 years of dental school at the University of Texas Dental Branch in Houston. He is an active member of the American Association of Orthodontists and a past-president of the Houston Regional Society of Orthodontists. You can visit Dr. Lyles’s website at: http://www.smilesbylyles.com.

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MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Fax: (480) 629-4002 Toll-free: (866) 579-9496 Web: www.orthopracticeus.com SUBSCRIPTION RATES 1 year (6 issues) 3 years (18 issues)

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© FMC 2013. 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.

2 Orthodontic practice

Volume 4 Number 5

surezen.

The anticipation is the reality. Dr. Melisa Rathburn Atlanta, GA

May 2011 Initial intraoral

July 2011 Planned result

May 2012 Actual result

To learn more about NEW suresmile 7.0 or request Clinical Report No. 2, call 877.787.7645

suresmile.com

to be sure.

TABLE OF CONTENTS

Case study Bite turbos Drs. Nathan Yetter and Donald J. Rinchuse discuss the pros and cons of bite turbos............................... 16

Practice profile

Drs. Shalin Shah and Ryan Tamburrino: Center for Orthodontic Excellence These analytical, intellectual, and business-savvy clinicians have found their purpose in serving their patients and their community.

Orthodontic concepts BioDigital Orthodontics: Management of Class I non extraction patient with “Fast– Track”© – 6-month protocol: part 5 Dr. Rohit C.L. Sachdeva discusses a treatment for Class I non-extraction patients....................................... 18

Corporate profile

Carestream Dental A history of proven technology, a future dedicated to innovation. ON THE COVER Cover photo courtesy of Dr. Bradford Edgren. Article begins on page 28.

4 Orthodontic practice

Volume 4 Number 5

It’s amazing what a great image can do for your practice. The CS 9300C Select is ready to work hard for your practice. This technologically-advanced system will finally give you clarity, flexibility and, most importantly, complete control of your image quality and dosimetry. It will also show your patients how dedicated you are to their dental health. • One system with superior 3D exams with multiple fields of view, 2D panoramic imaging and optional one-shot cephalometric imaging • Optimize your image quality and dosimetry • Cut treatment time by 30% with SureSmile certification • Make accurate assessments and diagnoses • Experience seamless integration

To learn more about what a great image can do for your orthodontic practice, visit carestreamdental.com/3DOP or call 800.944.6365 today. © Carestream Health, Inc. 2013

9438 OR 93 AD 0713

TABLE OF CONTENTS Book review Treating digitally and the new orthodontic practice

Orthodontics, Volumes I, II and III By Dr. Chris Chang and Dr. W. Eugene Roberts.............................58

In memoriam Continuing education The frontal cephalometric analysis – the forgotten perspective Dr. Bradford Edgren delves into the benefits of the frontal analysis .......28

Dr. Craig Andreiko, noted innovator and educator .....................................................59

Technology

A golden opportunity for dentists:

Treating digitally and the new orthodontic practice Dr. Randall Moles illustrates how the digital world has changed his role as an orthodontist..............................46

dental sleep medicine: part I Dr. Harold F. Menchel offers a wakeup call to clinicians to explore an evolving niche in dentistry .............36

The art of orthodontic efficiency Dr. Neil Warshawsky discusses the speed factor in orthodontics..........54

Research

Product profile

TMD/orofacial pain survey of orthodontic residents in the U.S.

Reliance Orthodontic Products addresses today’s problems with effective solutions......................56

and Canada Drs. Amanda Guess, Mark Causey, John Stockstill, Donald Rinchuse, and Eladio DeLeon explore dental students’ education regarding occlusion, TMD, and orofacial pain .....................................................42 6 Orthodontic practice

H4™ Self-Ligating Bracket System .....................................................57

Practice development Apply current tax laws to improve patient care Bob Creamer explains Section 179 and Bonus Depreciation ...............60

Practice management New office or major renovation? Andrew Greene offers some tips to take the stress out of planning a new office ............................................62

Industry news ...........63 Materials & equipment .....................63 Volume 4 Number 5

Trusted Products Powering Practice Growth

FROM START

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PRACTICE PROFILE

Drs. Shalin Shah and Ryan Tamburrino Center for Orthodontic Excellence What can you tell us about your background? Shalin Shah (SS): Although my wife brought me to settle down in New Jersey, I am a true Philadelphian at heart. Having grown up in the suburbs of Philadelphia and gone to the University of Pennsylvania for all my education (where I also met my future wife), I am a die-hard fan of all things Philadelphia, especially the sports teams. Ryan Tamburrino (RT): I am a Pittsburgh boy who still holds a strong allegiance for my Pittsburgh sports teams, even though my wife brought me to the eastern part of Pennsylvania. I traveled out of the state for a brief period to complete my undergraduate training at Duke University, but I eventually returned to the Keystone State for my dental and orthodontic education at the University of Pennsylvania. Remarkably, we both agree on almost everything that we jointly undertake, but neither of us is willing to give in that the other’s city has the best sports fans!

Why did you decide to focus on orthodontics? Our love of orthodontics stems from a variety of passions. The most important to us is giving each person the ability to love his smile. The profession as a whole has many opportunities and challenges, which allows us to draw upon our non-traditional backgrounds and interests while keeping us excited at the same time. Orthodontics is unique in that every case allows us to continue to hone our analytical skills, develop our intellectual curiosities, and fine-tune our business skills from marketing to IT to negotiations. Every day is a true joy!

How long have you been practicing, and what systems do you use? The Center for Orthodontic Excellence looks to bring patient service, peer education, and orthodontic solutions together to provide patients with the best possible care utilizing the latest technology. All three areas are interests of ours, and we view the merger of the three as synergistic. We also look to effectively integrate Shalin’s 8 Orthodontic practice

Dr. Tamburrino (left) and Dr. Shah (right) took their friendship and mutual aspirations to the next level by partnering to provide the highest quality of orthodontic care at the Center for Orthodontic Excellence

focus in the basic sciences with Ryan’s passion for clinical application to develop novel methods and products. The practice has been operational out of two major locations for the last 2 years. The systems we use include the In-Ovation® bracket system (Dentsply GAC), i-CAT® FLX (Imaging Sciences International), topsOrtho™, AD2 articulators, Quick Ceph® (Quick Ceph Systems, Inc.), and Anatomage, among many other products and systems. We remind ourselves, as well as our students, that it is not the system that makes a great orthodontist. Rather, it is a comprehensive understanding of how to use what you have (strengths and limits) to meet the needs of your diagnoses and treatment plan.

What training undertaken?

have

you

We bring a unique educational background to the Center for Orthodontic Excellence. Both of us completed our dental school and orthodontic training at the University of Pennsylvania. While in orthodontic residency, we also both pursued additional training in functional occlusion through a 2-year program in Detroit, Michigan

(Advanced Education in Orthodontics), as well as completing both Andrews’ Six Elements of Orofacial Harmony and Tim Tremont’s Four Faces of Orthognathic Surgery courses. Ryan attended Duke University for his undergraduate education. His extensive background in Biomedical Engineering and Mechanical Engineering/Material Science has led him to new innovations and research in the field of orthodontics. Additionally, he has leveraged this extensive education to develop two patent pending devices to date and author several manuals and articles, as well as a textbook chapter. Shalin attended University of Pennsylvania for his undergraduate education. His passion for basic science research led him to pursue a Masters of Science in Oral Biology while completing his orthodontic residency. Additionally, while at Penn, he achieved his board certification from the American Board of Orthodontics, which made him the second person in the history of the department to complete such a feat. Shalin’s interest in research led him to accept a position as Abstracts Editor for a peer-reviewed orthodontic journal. Volume 4 Number 5

PRACTICE PROFILE

Between Ryan and Shalin, they have earned 12 additional certifications in pursuit of excellence in diagnosis, treatment planning, and care for their patients.

Who has inspired you? We are very fortunate to come from loving and supportive families. They are the base of our success and everyday happiness. They challenge us to be better people and practitioners while accepting our long workdays dedicated to orthodontics and our patients. We both are also very fortunate to have been the students of Dr. Robert L. Vanarsdall, the Penn Faculty, the Advanced Education in Orthodontics faculty, Drs. Lawrence and Will Andrews, and Dr. Timothy Tremont. Each milestone reached, The exterior of the office is in harmony with the heritage of the building’s rich history

The doctors blended the rustic feel of the old barn with modern decor for a warm, unique feel

The private treatment area still offers spacious comfort and views of the barn’s old stone walls

each concept learned, and each novel thought/product developed is a result of the unparalleled dedication and interest these people have had in our personal and professional growth. Henry Brooks Adams once said, “A teacher affects eternity; he never knows where his influence stops.” We can say that what they have taught us will continue to influence throughout our careers.

of Orthodontics teaching alternate weeks (one day/week). Our primary responsibilities include overseeing orthodontic cases treated by residents, lecturing to orthodontic residents, lecturing to dental students, and mentoring orthodontic resident research. We view teaching as a privilege and a way to be involved with the future of the orthodontic and dental professions. It is truly a humbling experience.

What is the most satisfying aspect of your practice? Coming to work every day knowing we are making a real and tangible difference Volume 4 Number 5

in our patients’ lives and doing something we love to do, which doesn’t feel at all like work. We have found our purpose to serve our patients and the communities within which they operate, and nothing can be more professionally satisfying.

Professionally, what are you most proud of? Although we are honored to be orthodontists serving the community and profession, we are most proud of being on the Penn Orthodontic faculty and lecturing/growing to/with their peers. We are Clinical Associates in the Department

What do you think is unique about your practice? Although, we have two practices (Philadelphia and Princeton Junction), our Orthodontic practice 9

PRACTICE PROFILE

At the Princeton Junction train station, the office’s signature orange color and striking ads from 7Group signify a different and wonderful experience awaiting future patients

Princeton Junction office is a practice that was truly built from scratch. Below are a few facts about our Princeton Junction office that make it unique: 1) Green technology, including a floor made of 30% recycled material that possesses antibacterial and antiviral properties. 2) Built in a building pre-dating 1929. It was initially a potato barn and then sold/ leased to an exotic car photo shoot studio. In fact, the garage door that served as the entrance into the building was present until November 2011. Thereafter, it was leased to a hard rock entertainment label company. We like to say that is now inhabited by the two most exciting guys, the orthodontists! 3) The office includes a lecture area with future plans to have live video feed and TVs at each chair for teaching purposes. 4) Music is customizable in different areas of the office per patients’ requests. 5) The entrance area features a life-size wine barrel from the Napa Valley (empty of course). 6) Patients experience an audiovisual 10 Orthodontic practice

experience during their consults via a 52-inch LED TV that also has 3D capabilities. 8) The main treatment bay includes a wave architectural piece that is almost 30 feet in length and suspended from the high ceilings. The wave is comprised of the three horizontal lines representing the company’s three lines of business – lines also seen in the Center for Orthodontic Excellence logo.

What has been your biggest challenge? As mentioned above, we love what we do every day. The biggest challenge is for us to remember to maintain balance with all of the things we have going on in our lives both personally and professionally. There has been many a time that our spouses (who are equally career-oriented) have reminded us to come home for dinner!

What is the future of orthodontics and dentistry? The future of orthodontics and dentistry is rooted in innovation, and being lifelong

learners and critical thinkers. Innovation extends to the way we diagnose and treatment plan to actual treatment modalities. Our efforts should lead to reduced treatment time while providing longevity, stability, and predictability in the smiles we create. Collecting long-term data points will help better understand effective treatment. It is also remiss of us not to look to history for answers to future questions. Being lifelong learners and critical thinkers enables us to draw upon successful thoughts and techniques to better what we do and can deliver to our patients.

What are your top tips for maintaining a successful practice? In today’s ever busy and hectic world, our patients and their caregivers are busier than ever. We are figuring out ways to give patients an amazing and convenient experience while still giving them the right solution. It is a difficult balancing act but a very important one nonetheless. Also, in today’s “all things digital and mobile age,” there are so many ways to reach your patients and prospective patients, Volume 4 Number 5

PRACTICE PROFILE

Dr. Tamburrino and his wife, Shazia

so embrace technology in your marketing efforts, patient experience, etc. Our vision statement sums up our goals for the future of the practice: Excellence defines us! Our vision is to always exceed expectations and the standard of care by passionately delivering orthodontic treatment with outstanding service and a personalized touch. It is our goal to get to know our patients and make them feel excited about the benefits of orthodontics. Through advanced training and technology, we strive to provide individualized care and achieve functional and esthetic goals for each patient. We diagnose the entire orofacial system...we go beyond simply straightening teeth. Orthodontics is a team effort. With our support and through our best efforts, both adults and children will actively participate in their care, maintain a lifelong interest in their long-term health, and enthusiastically refer friends and family. We work in concert with a community of professionals who mutually seek out and demand the highest caliber of treatment, service, and results for their patients and loved ones. Everything that we do makes a difference.

In this recovering economy, what are you doing to grow the business side of your clinical practice? In a time of challenging economics, it’s been important for to us to grow our visibility by creating a strong brand identity, which differentiates us from our competitors. As others decrease their marketing budgets, it opens opportunities for us to expand our 12 Orthodontic practice

Dr. Shah and his wife, Neha, along with their two boys, Aidyn and Kaayan

market share. Being creative and innovative in terms of our messaging and use of new marketing channels was a very high priority for us. We wanted to think outside the box to add the element of surprise. So far, the feedback from the community has been very positive.

What advice would you give to budding orthodontists? Always invest in your knowledge and skills to remain at the cutting edge of the profession, and most importantly, to allow yourself to give the best solution to your patients. We don’t believe in cutting corners and always think about the longterm consequences of our actions.

What would you have become if you had not become a dentist? SS: Professional snowboarder, DJ, or breakdancer, but my wife wouldn’t allow any of it! I enjoy hitting the slopes, listening to tunes, and “throwing down” a couple of freezes. Although parenthood has tamed all these interests into the “safe zone,” I do still enjoy dabbling in each when I have a moment. I hope my children will embrace these hobbies as well, so they can be integrated into family time! RT: Professional golfer. Shalin describes my drives as sounding like a shotgun blast. You can ask me to play golf in any weather and any temperature, and my answer is always a resounding “Yes!” (Comment from SS): It should also be noted that at a recent team-building event, Ryan did demonstrate amazing bowling skills! He was a varsity letter recipient for bowling and golf all 4 years in high school, but when asked he undeniably says golf is his true passion!

What are your hobbies, and what do you do in your spare time? RT: I love to golf, cook, and spend time with my wife and two cats. I am also an expectant father so I am getting in my extra sleep right now! SS: I love to snowboard and play most sports (the more extreme the better) as well as spending quality time with my wife and two young boys (ages 3 and 1). I also enjoy being an amateur DJ, a hobby I started during my college days at UPENN. OP

Top 10 favorites 1) Seeing our patients with happy and perfect smiles! 2) Fun, fun, fun! We love to integrate humor and practical jokes in everything we do! 3) Hanging out with our families and friends. 4) Music – listening to it, dancing to it, and making it. 5) RT: Cookies – if it’s a good tasting cookie, it must be eaten. Although, I love the traditional chocolate chip, there is no cookie I won’t try (and enjoy)! SS: Jimmy Johns’ sandwiches – a new location opened near our Princeton Junction office, and I cannot get enough. 6) Sharing our learning with our professional peers throughout the world. 7) Kids! Our patients as well as our own! 8) Pizza - especially fresh made Brooklyn pies! Come visit, and we will make sure you get to enjoy as well! 9) Talking about orthodontics all the time! 10) Hearing young people say they want to be orthodontists! Volume 4 Number 5

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CORPORATE PROFILE

A history of proven technology, a future dedicated to innovation

ith roots that can be traced back to the 19th century, Carestream Dental certainly has a long history of innovation when it comes to dental specialties — including orthodontics. This legacy still carries on, as the company continues to develop imaging systems and software and enter new markets. It’s because of this proud tradition that more than 800 million images are captured each year on products from the company’s imaging portfolio. Today, Carestream Dental is focused on providing orthodontists with the products they need to facilitate treatment planning and improve patient care.

History of Carestream Dental The Carestream Dental of today was built on the shoulders of major industry leaders of the past — starting in 1896 when Eastman Kodak introduced the first photographic paper designed specifically for dental X-rays. As technology improved and became more digitalized, Trophy Radiologie filed a patent for the world’s first digital intraoral sensor in 1983. Already known for producing intraoral X-ray generators, the digital intraoral sensor earned Trophy a reputation as the world’s leader in dental digital radiography. On the practice management front, OrthoTrac became the first practice management software developed specifically for orthodontists in 1982. In 2000, PracticeWorks emerged as a dominant dental software company when it acquired several other software companies. PracticeWorks went on to acquire Trophy Radiologie in 2002 and was purchased the next year by Eastman Kodak to expand their presence in the dental business. With the integration of PracticeWorks/Trophy, Eastman Kodak built the industry’s leading portfolio of film, digital imaging systems, and practice management software. Then, in 2007, Onex Corporation purchased Kodak’s Health Group, and Carestream Dental was born.

The Carestream Dental Factor “We exist to make your practice better,” 14 Orthodontic practice

CS 9300C panoramic image

said Marc Gordon, Carestream Dental’s General Manager, U.S. Equipment and Software. “Our number one goal is to make user-friendly, yet sophisticated, technology to put our customers’ practices at the forefront.” Carestream Dental’s dedication to advancing orthodontics can be summed up by the Carestream Dental Factor; three pillars on which the company bases all of its products and services. Incorporating the key elements at the heart of Carestream Dental’s philosophy, the company’s main focus is on delivering workflow integration, humanized technology, and diagnostic excellence. Workflow integration: Administrative tasks cut into time that can be better spent communicating with and treating patients. For this reason, Carestream Dental designs systems and software to enhance treatment planning and fit seamlessly into busy orthodontic practices. Ensuring that every link in the chain fits and contributes to the workflow as a whole allows orthodontists to increase productivity and efficiency. Intuitive technology and software are the hallmarks of Carestream Dental. By developing imaging systems that can be

CS 9300C Autotracing image

quickly utilized by practitioners — and are even compatible with third-party products — users can eliminate time that would have been spent troubleshooting problems and instead focus on patients. Humanized technology: Patients are an integral part of every orthodontic practice, so Carestream Dental is committed to providing solutions that facilitate communication between the orthodontist and patient. When communication is optimized, patients are happier and healthier — allowing them to make better, more informed decisions regarding their proposed treatment plan and, in turn, increasing case acceptance. Diagnostic excellence: Details are everything when it comes to planning orthodontic treatments. To facilitate faster, more reliable treatment planning, Volume 4 Number 5

Technology developed for clinicians, by clinicians The Carestream Dental Factor isn’t the only thing driving user-focused and innovative products and services — the clinicians at the heart of the company also play a large role. Through meetings and forums with doctors in the field, Carestream Dental is better able to understand the needs of orthodontists in order to develop — and modify — products. In fact, the voice of the customer (VOC) is critical throughout the development process. To ensure quality, Carestream Dental also manages every aspect of the products they develop. “We are the only company that is designing its own practice management software and imaging equipment,” said Mr. Gordon. “By controlling every step in the process — from development and manufacturing all the way to support — we make it easier for orthodontists to deliver better patient outcomes.”

Innovative products to facilitate orthodontic treatment planning

cephalometric imaging technology provides orthodontists with an exclusive full cranial option as well as addresses all orthodontic diagnostic and tracing needs through autolandmark detection. The system is also certified for use with SureSmile technology to proactively develop effective treatment plans. CS 3D Imaging software: Included with Carestream Dental’s CBCT imaging units, CS 3D Imaging software allows practitioners to view images slice by slice in axial, coronal, sagittal, cross-sectional, and oblique views to enhance diagnostic interpretation. In addition, the images can be saved to a CD/DVD or USB drive with a complimentary copy of the software to share with the referring doctor — improving the colleague collaboration process. CS OrthoTrac Cloud: For over 30 years, OrthoTrac has helped orthodontists build and maintain productive and efficient practices. Now, with the Cloud version of this practice management software, orthodontists gain 24/7 access to their patient files and 2D images from any web-connected location or device — including PCs, Macs®, iPads® and tablets—while eliminating many of the costs associated with IT infrastructure and server maintenance. In addition, all patient information storage is HIPAA compliant and backed by Carestream Dental, ensuring that the data is protected.

Orthodontists require high-resolution images to evaluate the trajectory of the teeth and identify any unexpected pathologies during treatment planning — something that Carestream Dental certainly delivers. The following is just a sample of the imaging products Carestream Dental has designed to meet the specific needs of orthodontic practices: CS 9300C: As a three-in-one unit, the CS 9300C allows users to select from panoramic, cone beam computed tomography (CBCT), and true cephalometric imaging. Users can also choose from seven selectable fields of view (ranging from 5 cm x 5 cm to 17 cm x 13.5 cm), or four selectable fields of view for the Select model (5 x 5 cm to 10 x 10 cm), to tailor their image based on the specific clinical application. And, the system features Intelligent Dose Management for greater control over patient exposure. The CS 9300C’s one-shot Volume 4 Number 5

Comprehensive education When orthodontists understand how to fully maximize their imaging capabilities, they are better able to get the most out of their equipment. For this reason, Carestream Dental is committed to providing thorough training and education to ensure their customers have the skill and knowledge necessary to use their imaging products and software. In addition to providing web-based and in-person training, Carestream Dental

holds a dedicated Orthodontic Users conference each year featuring a number of hands-on classes as well as a 3D Symposium, where practitioners can learn how to use 3D imaging equipment in their daily practice. This event features leaders in the industry who share advice and insights, as well as information on the latest industry trends in 3D to make participants’ practices more efficient and successful.

Next steps With the launch of CS Solutions, a oneappointment CAD/CAM restoration system, Carestream Dental will once again enter an entirely new market — and it certainly will not be the last. As an integrated, openarchitecture system, practitioners can scan an impression with a CBCT unit, design the crown, using the CS Restore software, and mill the crown in-office with the CS 3000 milling machine. CS Solutions also features an intraoral scanner — the CS 3500. Handheld and truly portable, the CS 3500 requires no trolley, external heater, or powder to capture true-color 2D and 3D image scans. In addition, the scanner’s light guidance system lets practitioners know when scanning is successful, so they can focus more on their patient and less on the monitor. As always, Carestream Dental will continue to focus on customer service. “Our number one goal is to provide superior customer experience through best-in-class products and best-in-class support,” said Mr. Gordon. To learn more about Carestream Dental’s portfolio of imaging products and software for orthodontic practices, please call 800-944-6365 or visit carestreamdental.com. OP This information was Carestream Dental.

provided

Orthodontic practice 15

CORPORATE PROFILE

Carestream Dental has created a number of cutting-edge diagnostic tools that enable orthodontists to capture sharp, high-quality images quickly. From industry-leading 3D imaging systems to comprehensive imaging software, Carestream Dental offers a range of solutions that allows orthodontists to identify areas of concern and determine the best course of action.

CASE STUDY

Bite turbos Drs. Nathan Yetter and Donald J. Rinchuse discuss the pros and cons of bite turbos

he use of “bite turbos” to help maintain bite opening during aspects of orthodontics has become a relatively routine aspect of treatment. Bite turbos can have some orthodontic biomechanical advantages when using elastic wear during Class II or Class III correction. In addition, there are some claims that by “unlocking” the occlusion, teeth move more freely and this, thereby, shortens treatment time. From a practical viewpoint, they can facilitate bonding both the upper and lower arches, and help prevent the patient from shearing off brackets. Bite turbos can be placed on the lingual surface of the upper incisors, or they can be placed on the posterior teeth. Using the posterior teeth to open the bite can be achieved by using stainless steel crowns or by bonding resin material to the occlusal surface. While posterior “bonded resin” bite turbos have become very common among orthodontists, there are a few side effects and cautions that one needs to be aware of. First, discluding the posterior teeth will make chewing very difficult. In rare instances, this can create a choking hazard for younger patients as well as potential digestive problems. Second, when placed on posterior teeth, bite turbos can cause fremitus and pain due to traumatic occlusion. Third, it may be a contributing factor to exacerbation of TMD in a patient who may be sensitive in the TMJ. Fourth, they can cause unwanted tooth intrusion, and depending on where the bite turbo is placed on the posterior tooth surface, unwanted root movement can occur. The following cases demonstrate that placing bite turbos can cause unwanted tooth movement. In case No. 1, bite turbos were placed on the mesial aspect of the

Nathan Yetter, DDS, is senior orthodontic resident at Seton Hill University, Greensburg, Pennsylvania. Donald J. Rinchuse, DMD, MS, MDS, PhD, is Professor and Graduate Orthodontic Program Director, Seton Hill University, Greensburg, Pennsylvania.

16 Orthodontic practice

Case No. 1 (Figures 1A and 1B)

Figure 1A

Figure 1B

Case No. 2 (Figures 2A-2E)

Figure 2B

Figure 2A

Figure 2D

Figure 2C

Figure 2E

lower first molars and caused unwanted distal root movement into the mesial root of the lower second molar. The taller the bite turbo, the more adverse movement one can expect. Case No. 2 shows an intrusive movement of a posterior single-rooted tooth. Generally, bite turbos should be reserved for posterior molars, but in this case, they were placed on the second

bicuspids due to missing posterior molars on the lower left side. While this movement can be corrected, we question the added stress placed on the root or roots of the affected teeth. Ultimately, bite turbos do have many positive effects and are an important tool for orthodontists, but clinicians must be aware of the adversities that may present when using posterior bite turbos. OP Volume 4 Number 5

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ORTHODONTIC CONCEPTS

BioDigital Orthodontics: Management of Class I non–extraction patient with “Fast–Track”© – 6-month protocol: part 5 Dr. Rohit C.L. Sachdeva discusses a treatment for Class I non-extraction patients Introduction In previous articles, the science, the philosophy, and principles of BioDigital Orthodontics developed by the author have been discussed.1-7 It is defined by a systematic, processdriven approach for planning and providing care within a framework of a personalized, empathic, and safe care environment, more aptly described by Berwick as “a practice of one.”8 In addition, the application of SureSmile technology in enabling reliable and “high touch” care has been discussed.9-14 Clinical Practice Guidelines (CPGs) developed by the author for the management of orthodontic patients are described. When followed, these guidelines provide both efficient and effective pathways to provide quality care.15-19 It should be noted that these guidelines are constantly reevaluated in order to continuously improve clinical performance and outcomes. It must also be emphasized that the application of these guidelines, although very useful, should be complemented with professional judgment to suit the individual care needs and preferences of the patient. Furthermore, successful outcomes require that the

Rohit C.L. Sachdeva, BDS, M Dent Sc, is the cofounder 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.

18 Orthodontic practice

practice is committed to a proactive approach to care delivery. In this article and the next, the treatment of Class I non-extraction patients will be discussed. Patient and Practice characteristics (Table 1) and Clinical Practice Guidelines developed by the

author for completing treatment of Class I non-extraction patients with a “Fast– Track”© – 6-month protocol (Table 2), and the “Standard-Track”© 9-month protocol are described with the aid of patient histories.

Table 1: Patient and practice characteristics that encourage the successful implementation of “Fast-Track” care are defined by the author

PATIENT

PRACTICE

Patient

Doctor and Team

• High orthodontic IQ, very cooperative, receptive to shared decision making, and participates in care

• Dedicated to tenets of high performance and learning organizations, and obsessed about delivering on time care and personalized care

• Oral hygiene excellent, high threshold to discomfort

• Care and treatment schedule is proactively planned and followed with rigor with the aid of CPGs

• Values timely care and is motivated to have a short treatment time

• Practice is well designed to prevent or minimize both active and latent errors

• Desires few visits and is open to extended visits

• Zero tolerance policy for bracket failure, misplacement of archwires

• Adaptive scheduling to accommodate the patients’ needs

Volume 4 Number 5

Class I non-extraction “Fast Track” © Protocol A CPG 6 months treatment (Sachdeva)

APPT 1 (Week 0)

• Initial consultation. • Diagnostic records. • Take supplementary impressions for auxiliary appliances such as quad helix if needed. • Bond teeth. • Diagnopeutic scan (OraScan or CBCT scan taken post bonding). • Place posterior molar turbos, check for height and balance. • Perform IPR prn. • Insert initial archwire. - .016” preformed SE NiTi Af 35ºC or .017” x .025” SE NiTi Af 35ºC if minimal crowding or torque control and deep bite correction needed. - Place auxiliary appliances, e.g., tipback springs, ART springs, etc.

APPT 2 (Week 4) SureSmile Therapeutic Phase

• Perform IPR prn. • Place auxiliary devices such as quad helix if needed. • Adjust posterior molar turbo height, as needed. • Insert SureSmile Precision Archwire (SSPA) (full expression or partial expression). Note: For .018”/.022” bracket either .016” x .022” or .017” x .025” SE NiTi Af 35ºC are crossections of choice. • Check archwire placement against bracket archwire image.

APPT 3 (Week 12)

• Review progress against the Virtual Therapeutic Simulations (VTS). • Review expression of SSPA against bracket archwire image. • Perform selective IPR prn. • Check turbo for height/balance. • Replace current archwire with: - 100% staged SureSmile precision archwire. - For .018” bracket step up to pre-ordered SureSmile .017” x .025” if needed. - For .022” bracket step up to pre-ordered SureSmile .019” x .025” arch.

APPT 4 (Week 18)

• Review progress against VTS. • On-demand debonding, if schedule allows.

APPT 5 (Week 24)

• Debond. • Take final records for outcome evaluation.

Patient 1: “Fast-Track” Protocol A (6 months)

Figures 1A and 1B: Patient 1. 1A. “Fast-Track” presents with a Class I occlusion with minimal upper crowding and moderate lower arch crowding. A non-extraction approach to treatment was chosen. IPR was planned among the lower anteriors to relieve crowding. 1B. Initial cephalometric and panoramic radiographs

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Orthodontic practice 19

ORTHODONTIC CONCEPTS

Table 2: Clinical pathway guidelines developed by the author for “Fast-Track” care. Protocol A for both users of .018” and .022” brackets systems

ORTHODONTIC CONCEPTS

Figure 2: Patient 1. Initial visit. 7-7 upper and lower arch bonded with .0I8” bracket system. Upper .017”x.025” SE CuNiTi Af 35°C engaged. Lower posterior first molar turbos placed to disengage anterior occlusion. Lower IPR 3-3 initiated and .016” SE CuNiTi Af 35°C wire inserted. Power chain placed

Figures 3A-3D: Patient 1. 3A. Diagnopeutic scan. This scan was taken immediately post bonding and post IPR at the first visit with an in-vivo OraScan. 3B. Virtual Diagnostic Model (VDM) derived from the Diagnopeutic model by turning off the bracket objects. The advantage of the Diagnopeutic scan is that it provides for both the Virtual Diagnostic and Therapeutic models. 3C. Virtual Diagnostic Simulation (VDS) non-extraction 3D. VDS superimposed on VDM

Figure 4: Patient 1. The therapeutic scan has also been derived from the diagnopeutic scan. The bracket and archwires are shown. The Virtual Therapeutic Model (VTM) derived from this scan may be used to plan definitive care for the patient as well as the SureSmile Precision Archwire (SSPA)

20 Orthodontic practice

Volume 4 Number 5

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ORTHODONTIC CONCEPTS

Figure 5: Patient 1. SureSmile Virtual Prescription Form completed with the Treatment Objectives. These are defined by “MACROS.” For this patient, the following objectives were selected. Treat to the upper midline, lower archform, Class I occlusion, the upper and lower first premolars as reference teeth, upper functional occlusal plane, IPR of 2.5 mm in the lower 3-3, and esthetic contouring of the upper central incisors

Figure 6: Patient 1. Virtual Therapeutic Simulation (VTS)

Figures 7A and 7B: Patient 1. 7A. Initial. 7B. Note the planned recontouring of the upper central incisors

Figure 8: Patient 1. SureSmile Precision Archwire (SSPA). Design evaluated against the Virtual Therapeutic Model (VTM)

22 Orthodontic practice

Figure 9: Patient 1. SSPA engaged 4 weeks from start, upper and lower archwires SE 0.17” x 0.25” CuNiTi. Selective IPR performed around the mesial distal surfaces of the lower left lateral incisor

Volume 4 Number 5

Figure 11: Patient 1. 12 weeks post SSPA insertion and 16 weeks from the start of treatment

Figures 12A-12C: Patient 1. 12A. “Fast–Track” debonded 5 months from the start of treatment. 12B. Final cephalometric and panoramic radiographs. 12C. Virtual Final Models (VFM)

Patient 2: “Fast-Track” Protocol A (6 months)

Figures 13A-13B: Patient 2. 13A. “Fast-Track” presents with a Class I occlusion with minimal upper crowding and moderate lower arch crowding. Patient has a deep bite with retroclined upper incisors, peg lateral incisors, and a midline diastema; a non-extraction approach to treatment was chosen. IPR was planned among the lower anteriors to relieve crowding. 13B. Initial cephalometric and panoramic radiographs

Volume 4 Number 5

Orthodontic practice 23

ORTHODONTIC CONCEPTS

Figure 10: Patient 1. Progress 8 weeks post SureSmile precision archwire insertion and 12 weeks from start of treatment

ORTHODONTIC CONCEPTS

Figure 14: Patient 2. Initial visit. 7-7 upper and lower arch bonded with .022” DAMON® bracket system. Upper .017” x.025” SE CuNiTi Af 35°C engaged. Lower posterior first molar turbos placed to disengage anterior occlusion. Lower IPR 3-3 initiated and .017”x.025” CuNiTi Af 35°C wire inserted. .017”x.025” TMA tipback springs placed in upper and lower arch to facilitate deep bite correction. Patient was scanned (Diagnopeutic scan) intraorally post bonding with the OraScan prior to placing the turbos and tip-back springs

Figures 15A-15C: Patient 2. 15A.Virtual diagnostic model derived From the Diagnopeutic model by turning off the bracket objects. The advantage of the Diagnopeutic scan is that it provides for both the Virtual Diagnostic and Therapeutic models. 15B. Virtual Diagnostic Simulation (VDS) for anterior space closure. 15C. VDS superimposed on Diagnopeutic model

Figure 16: Patient 2. The therapeutic scan has been derived from the Diagnopeutic scan. The brackets and archwires are shown. This Virtual Therapeutic Model (VTM) may be used to plan Virtual Therapeutic Simulation (VTS) for definitive care of the patient as well as the SureSmile Precision Archwire (SSPA)

Figure 18: Patient 2. Virtual Therapeutic Simulation (VTS)

24 Orthodontic practice

Figure 17: Patient 2. SureSmile Virtual Prescription form completed with the Treatment Objectives. These are defined by “MACROS.” For this patient, the following objectives were selected. Treat to the upper midline, lower archform, Class I occlusion, the upper and lower first premolars as reference teeth, upper functional occlusal plane, IPR of 1.5 mm in the lower 3-3 and selective spacing among the upper anteriors with veneers planned for upper 2-2

Volume 4 Number 5

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ORTHODONTIC CONCEPTS

Figure 20: Patient 2. SureSmile Precision Archwire (SSPA) Design evaluated against the Virtual Therapeutic Model (VTM)

Figure 19A-19B: Patient 2. 19A. Virtual Therapeutic Simulation (VTS) without brackets and wire. 19B. Note the planned veneers for the upper anteriors Figure 21: Patient 2. SSPA engaged 4 weeks from start, upper and lower archwires SE 0.17” x 0.25” CuNiTi. Note upper ART spring placed to provide additional torque control on the upper anteriors

Figure 22: Patient 2. Progress 8 weeks post SureSmile precision archwire insertion and 12 weeks from start of treatment

Figure 23: Patient 2. 12-weeks post SSPA insertion and 16 weeks from the start of treatment

Figures 24A-24B: Patient 2. 24A.“Fast-Track” debonded 5 months from the start of treatment. 24B. Final cephalometric and panoramic radiographs

26 Orthodontic practice

Volume 4 Number 5

Conclusions The “Fast–Track”© – 6-month protocol (Table 2), enabled with the use of SureSmile technology developed by the author, offers the practitioner both an effective and efficient approach to providing patient care.15-19 Many of these efficiencies reside in effective management proper selection of the patient as shown in Table 1 and using sound principles developed by Sachdeva

References 1. White L, Sachdeva R. Transforming orthodonticsPart 1 of a conversation with Dr. Rohit Sachdeva, Cofounder and Chief Clinical Officer of Orametrix Inc. by Dr. Larry White. Orthodontic Practice US. 2012;3(1):1014. 2. White L, Sachdeva R. Transforming orthodonticsPart 2 of a conversation with Dr. Rohit Sachdeva, Cofounder and Chief Clinical Officer of Orametrix Inc. by Dr. Larry White. Orthodontic Practice US. 2012;3(2):610. 3. White L, Sachdeva R. Transforming orthodonticsPart 3 of a conversation with Dr. Rohit Sachdeva, Cofounder and Chief Clinical Officer of Orametrix Inc. by Dr. Larry White. Orthodontic Practice US. 2012;3(3):6-9. 4. Sachdeva R. BioDigital orthodontics: Planning care with SureSmile Technology: Part 1. Orthodontic Practice US. 2013;4(1):18-23. 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):22-30.

Volume 4 Number 5

such as Condition Based Scheduling, Timely Constraint Management, and Concurrent Mechanics. Future articles in this series will discuss an alternative pathway to manage the treatment of a Class I non–extraction patient.

Acknowledgements

that the author wishes to thank Drs. Takao Kubota (Yame City, Japan), Kazuo Hayashi (Sapporo, Japan), Jeff Johnson (Dallas, Texas), and Sharan Aranha (Richardson, Texas) for their unconditional and enthusiastic support in the preparation of this manuscript. Without their effort, it would be impossible to write and prepare this paper in a timely fashion. OP

It is with the deepest sense of gratitude

7. Sachdeva R. BioDigital orthodontics: Outcome evaluation with SureSmile technology: Part 4. Orthodontic Practice US. 2013;4(4):28-33.

14. Mah J, Sachdeva R. Computer-assisted orthodontic treatment: the SureSmile process. Am J Orthod Dentofacial Orthop. 2001;120(1):85-87.

8. Berwick DM. What ‘patient-centered’ should mean: confessions of an extremist. Health Aff (Millwood). 2009;28(4):w555-565.

15. Alford TJ, Roberts WE, Hartsfield JK Jr, Eckert GJ, Snyder RJ. Clinical outcomes for patients finished with the SureSmile™ method compared with conventional fixed orthodontic therapy. Angle Orthod. 2011;81(3):383-388.

9. Sachdeva RCL, Feinberg MP. Reframing clinical patient management with SureSmile technology. PSCO Newswire. 2009;2(1):1-24. 10. Sachdeva R, Frugé JF, Frugé AM, Ingraham R, Petty WD, Bielik KL, Chadha J, Nguyen P, Hutta JL, White L. SureSmile: A Report of Clinical Findings. J Clin Orthod. 2005;39(5):297-314,315. 11. Sachdeva RCL. Digital Care Solutions for the Orthodontic Industry. The Orthodontic CYBER Journal. Available at: http://orthocj.com/2001/06/digital-caresolutions-for-the-orthodontic-industry/. Accessibility verified August 23, 2013. 12. Sachdeva RCL. SureSmile Technology in a Patient-Centered Orthodontic Practice. J Clin Orthod. 2001;35(4):245-53. 13. Sachdeva R, White L. Dr. Rohit C.L. Sachdeva on A Total Orthodontic Care Solution Enabled by Breakthrough Technology. J Clin Orthod. 2000;34(4):223-232.

16. Saxe AK, Louie LJ, Mah J. Efficiency and effectiveness of SureSmile. World J Orthod. 2010;11(1):16-22. 17. Sachdeva R, Aranha S, Egan ME, Gross HT, Sachdeva NS, Currier GF, Kadioglu O. Treatment time: SureSmile vs conventional. Orthodontics: The Art and Practice of Dentofacial Enhancement. 2012;13:72-85. 18. Groth C. Compare the Quality of Occlusal Finish Between SureSmile and Conventional [thesis]. Ann Arobor, MI: University of Michigan; 2012. 19. Rangwala T. Treatment Outcome Assessment of SureSmile Compared to Conventional Orthodontic Treatment Using the American Board of Orthodontics Grading System [thesis]. Bonx, NY: Albert Einstein College of Medicine, Department of Dentistry; 2012.

Orthodontic practice 27

ORTHODONTIC CONCEPTS

Figures 25A-25B: Patient 2. 25A. Final veneers 2 months post debonding. 25B. Virtual Final Models (VFM)-post veneer placement

CONTINUING EDUCATION

The frontal cephalometric analysis – the forgotten perspective Dr. Bradford Edgren delves into the benefits of the frontal analysis

hen greeting a person for the first time, we are supposed to make direct eye contact and smile. But how often when you meet a person for the first time do you greet them towards the side of the face? Nonetheless, this is generally the only perspective by which orthodontists routinely evaluate their patients radiographically and cephalometrically. Rarely is a frontal radiograph and cephalometric analysis made, even though our first impression of that new patient is from the front, when we greet him/her for the first time. A patient’s own smile assessment is made in the mirror, from the facial perspective. It is also the same perspective by which he/she will ultimately decide if orthodontic treatment is a success or a failure. So why don’t orthodontists utilize the frontal analysis more? B. Holly Broadbent is credited with developing the cephalometric procedure in 1931 when he simultaneously took frontal and lateral radiographs on his patients to evaluate the craniofacial skeleton in all three dimensions, including the posterioranterior dimension. Interestingly, even though Broadbent took both frontal and lateral radiographs simultaneously, orthodontists are generally trained to use the lateral cephalometric analysis on all patients, but only encouraged to use the frontal analysis when an asymmetry is suspected or a dental crossbite is clinically observed. Accordingly, many orthodontists rarely assess a patient with a frontal

Bradford Edgren, DDS, MS, earned both his Doctorate of Dental Surgery, as Valedictorian, and his Master of Science in Orthodontics from University of Iowa, College of Dentistry. He is a Diplomate, American Board of Orthodontics and an affiliate member of the SW Angle Society. Dr. Edgren has presented to numerous groups on the importance of cephalometrics, CBCT, and upper airway obstruction. He has been published in AJODO, American Journal of Dentistry, as well as other orthodontic publications. Dr. Edgren currently has a private practice in Greeley, Colorado.

28 Orthodontic practice

Educational aims and objectives This article aims to discuss the frontal cephalometric analysis and its advantages in diagnosis. Expected outcomes Correctly answering the questions on page 34, worth 2 hours of CE, will demonstrate the reader can: • Understand the value of the frontal analysis in orthodontic diagnosis. • Recognize how the certain skeletal facial relationships can be detrimental to skeletal patterns that can affect orthodontic treatment. • Realize how frontal analysis is helpful for evaluation of skeletal facial asymmetries. • Identify the importance of properly diagnosing transverse discrepancies in all patients; especially the growing patient. • Realize the necessity to take appropriate, updated records on all transfer patients.

cephalometric analysis. Since all orthodontic patients are threedimensional, they should be evaluated three-dimensionally, and the frontal analysis provides valuable information that should be part of the diagnostic process1. Additionally, with the increasing use of Cone Beam Computed Tomography (CBCT) scans in orthodontics, a frontal analysis should be made for all patients receiving a CBCT scan; making use of the volume of information obtained. CBCT scans provide the opportunity for adjusting the orientation of the patient’s head, improving the reliability of the cephalometric measurements, and simulating Broadbent’s cephalometric procedure. Skeletal facial asymmetries are more the rule than the exception, and the frontal analysis is an excellent instrument to use for their evaluation. However, skeletal asymmetries are not always readily visible clinically nor do skeletal lingual crossbite patterns reveal themselves with obvious posterior dental crossbites. It can be challenging to determine the presence of a skeletal lingual crossbite pattern when it appears that there is a normal transverse relationship between the upper and lower jaws without a frontal analysis. Many patients who appear to have normal transverse skeletal relationships have skeletal lingual crossbite patterns2 that can negatively affect orthodontic treatment

outcomes. Furthermore, skeletal lingual crossbite patterns are not just limited to a narrow maxilla. Posterior skeletal lingual crossbites can also be the result of wide mandibles, which are further exacerbated by future, excessive lower jaw growth1. True dental asymmetries can be treated by orthodontics alone. However, prior to the initiation of treatment, the etiology of the dental asymmetry should be determined. If that dental asymmetry is the result of a skeletal issue, an orthopedic or surgical approach will be necessary because orthodontic treatment alone would likely result in an unfavorable outcome. So, what about those skeletal asymmetries? It’s not uncommon for the orthodontist to miss a skeletal asymmetry in a severely crowded and maligned malocclusion that only becomes obvious after the leveling and alignment phase of treatment3. At this stage in treatment, it may be more difficult to address the skeletal asymmetry and, therefore, more difficult to salvage. But, diagnosing the skeletal asymmetry initially, prior to the start of treatment, provides informed consent to the patient and reduces the unintended consequences of poor treatment planning. Perfectly symmetrical faces are largely theoretical concepts that seldom exist in living organisms4. Minor facial asymmetries are relatively common. In a study by Severt and Proffit of 1,460 patients, 34% had a Volume 4 Number 5

CONTINUING EDUCATION

Figure 1: Posterior-anterior image demonstrating rightsided lateral and vertical facial asymmetries (CBCT images taken with i-CAT [Imaging Sciences International])

clinically apparent facial asymmetry. Of the facial asymmetries that were present, the upper face was only affected in 5%, the middle third (primarily the nose) in 36%, and the lower third in 74% of cases. Vertical asymmetries were present in 41% of cases5. Moreover, facial asymmetries are more frequently associated with Class II and Class III malocclusions than with Class I malocclusions4. The frontal cephalometric analysis is useful in diagnosing skeletal asymmetries and skeletal crossbite patterns for both jaws. It also aids in the evaluation of: occlusal cants, nasal widths, turbinate enlargements, dental arch widths, buccolingual angulation of first molars, angulation and position of impacted canines, location of the maxillary incisors to the skeletal midline, location of the mandibular incisors to the mandibular midline and skeletal midline, and the morphology of the maxilla and mandible. The frontal analysis can also aid in determining if an off-centered dental midline is due to a tooth-size discrepancy, a mandibular functional shift, or skeletal dysplasia. Significant skeletal asymmetries can be congenital, developmental, or acquired. Hemifacial microsomia is a congenital birth defect where the lower half of the face is typically unilaterally, or rarely bilaterally, underdeveloped. This common facial birth defect, second only to clefts, most frequently affects the ears, mouth, and lower jaw6. In this case, the patient has a significant unilateral dentofacial asymmetry to the right. Complete diagnostic records were taken, including a CBCT scan, followed by lateral and frontal cephalometric analyses. The frontal image and the corresponding cephalometric analysis demonstrate the effects of the hemifacial microsomia on the right side of the patientâ&#x20AC;&#x2122;s face (Figures 1 and 2). The Volume 4 Number 5

Figure 2: Frontal cephalometric analysis demonstrating significant dentofacial asymmetry to the right and occlusal cant

lateral radiographic image alone does not display the degree of the lateral and vertical asymmetries that could easily be passed off as poor patient positioning (Figure 3). The panoramic radiograph demonstrated a hypoplastic right ramus and condyle (Figure 4). The maxillary canines and lateral incisors were ectopically erupting due to an anterior maxillary constriction. Early interceptive treatment included rapid maxillary expansion followed by upper and lower fixed appliances. Following the removal of the fixed appliances at the end of early interceptive treatment, a CBCT scan was taken. The scan revealed an improvement in the facial asymmetry and significantly improved permanent tooth eruption and root parallelism (Figures

Figure 3: Lateral CBCT image

Orthodontic practice 29

CONTINUING EDUCATION

Figure 4: Panoramic image demonstrating a hypoplastic right condyle and ramus, and ectopic maxillary canines

Figure 5: Posterior-anterior image following early interceptive treatment

Figure 7: Note, in the lateral radiographic image, the difference in the borders of the left and right sides of the mandible. When the borders of the mandible present this large of a difference, and the orbits are aligned, a facial asymmetry should be suspected

Figure 6: Panoramic image following early interceptive treatment. The anterior maxillary constriction has been resolved, and the maxillary canines have erupted nicely

5 and 6). This patient will be monitored until the eruption of the permanent dentition is complete. Second phase treatment will include full fixed appliances and orthognathic surgery to correct the remaining asymmetries. Condylar hypoplasia is the unilateral or bilateral underdevelopment of the mandibular condyle(s). Condylar hypoplasia can be either congenital or acquired, and is often associated with head and neck syndromes as in the previous case7. Bilateral condylar hypoplasia is considerably less common than unilateral involvement, even though both can lead to significant facial deformities. In acquired cases, the extent of the facial deformity is dependent upon the severity of the injury that caused the disruption in condylar growth, the duration of that injury, and the age that it occurred.8 30 Orthodontic practice

This case of acquired condylar hypoplasia was a transfer into my office. She had had previous Phase I treatment, including the extraction of the maxillary first premolars. At her clinical exam, a rightsided facial asymmetry was noted. After taking progress records, which included a CBCT scan (Figures 7 and 8), both lateral and frontal cephalometric analyses were made. A frontal analysis revealed a severe mandibular asymmetry to the right, a right vertical asymmetry, as well as a skeletal lingual crossbite pattern due to both jaws (Figure 9). The mandibular asymmetry amounted to a total of 8 mm to the patientâ&#x20AC;&#x2122;s right. The source of the asymmetry was a hypoplastic right condyle. The patientâ&#x20AC;&#x2122;s right ramus was also significantly shorter and comparatively broader when compared to the left. Since this patient still has several years left to grow, the facial asymmetry will

Figure 8: Posterior-anterior image revealing the significant right-sided vertical and lateral asymmetries

most likely become more pronounced. The best solution for this patient is maxillary expansion, leveling and aligning, and eventually orthognathic surgery to correct the facial asymmetry. Note, this is a case where the significant facial asymmetry and the skeletal lingual crossbite were not documented until a frontal analysis was made. Consequently, this case is a perfect example of where a facial asymmetry Volume 4 Number 5

Figure 9: Posterior-anterior image revealing the significant right-sided vertical and lateral asymmetries

Figure 11: Initial panoramic image exhibiting severe crowding and multiple impacted teeth

went undiagnosed until the frontal analysis was made, after irreversible orthodontic treatment had been already initiated, including extractions of permanent teeth. It only disputes the myth that the frontal analysis should only be made if an asymmetry is suspected. Obviously, significant facial asymmetries do exist and can be missed without a posterioranterior radiograph and subsequent analysis. Routinely taking a posterioranterior radiograph reduces the chances of missing an asymmetry. Even this patient’s panoramic image illustrates the extent of the right condylar hypoplasia, shortened ramus, and noticeable asymmetry (Figure 10). This case also illustrates why it is necessary to take appropriate, updated records on all transfer patients. I have found previously undiagnosed tumors, severe facial asymmetries, cysts, supernumeraries, and other pathologies Volume 4 Number 5

that required attention before continuing orthodontic treatment in patients already in orthodontic appliances. Like facial asymmetries, skeletal lingual crossbites due to either the maxilla and/or mandible are more the norm than the exception. Transverse maxillary constrictions frequently result in significant crowding and impacted teeth. This 7.3-year-old Caucasian female presented with loss of arch length in both arches due to premature loss of the deciduous lateral incisors. The left maxillary molar was ectopically erupting and had resorbed the distal root of the left maxillary second deciduous molar, blocking out the eruption path of the second premolar (Figure 11). But, it was the patient’s overall preexisting maxillary deficiency, including the transverse constriction, that was the original source for the loss of maxillary arch length, severe crowding, disruption of the eruption of the maxillary laterals,

Figure 12: Initial posterior-anterior image. Note the significant rotation of the right maxillary incisor

and subsequent impaction of the maxillary canines. A posterior-anterior image taken from the diagnostic CBCT scan of the patient demonstrates the significant rotation of the maxillary lateral incisors and severe maxillary anterior crowding (Figure 12). The frontal cephalometric analysis not only illustrated a dental lingual crossbite pattern Orthodontic practice 31

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Figure 10: Panoramic image exhibiting condylar hypoplasia of the right condyle and subsequent widening of the ramus. The patient’s maxillary first premolars were extracted to aid in the eruption of the maxillary canines. If expansion had been performed on this patient initially, it may have been unnecessary to extract the maxillary first premolars to make room for the eruption of the canines

CONTINUING EDUCATION

Figure 13: Initial frontal cephalometric analysis

Figure 14: Progress panoramic image exhibiting improved eruption of the maxillary canines and the erupted lateral incisors with complete root formation. Also, note maxillary right third molar blocking the eruption of the maxillary right second molar

due to both arches but also a skeletal lingual crossbite pattern due to the maxilla and mandible (Figure 13). After distalization of the maxillary left first molar, the patient was expanded with a bonded expansion appliance to correct the dental and skeletal lingual crossbite patterns. After 29 months of Phase I treatment, the maxillary and mandibular lateral incisors have erupted into proper position, and the maxillary canines are erupting appropriately (Figures 14 and 15). Early extraction of the maxillary deciduous canines was not necessary, nor was it indicated. Studies have suggested that impacted canines are a result of maxillary constriction, and rapid maxillary expansion can aid in the proper eruption on maxillary canines.9,10,11 32 Orthodontic practice

Orthodontic treatment without expansion, when a transverse maxillary constriction exists, does not address the root of the problem. Extraction of permanent teeth in a growing patient, to promote eruption of the maxillary canines, may result in future crossbite patterns when the patient becomes an adult and dentofacial growth is complete. A case that appears to be treated to proper balance may indeed become a significant malocclusion years later because future growth and the skeletal lingual crossbite patterns were never addressed, nor treated.8 This adult case exemplifies the importance of properly diagnosing transverse discrepancies in all patients and especially in the growing patient.

Figure 15: Progress posterior-anterior image. Note the significantly improved angulation of the maxillary canines and lateral incisors

This 30-year-old Caucasian female patient presented with a chief complaint of myofascial pain disorder (MPD) and an anterior open bite. Her maxillary first premolars were extracted as a child as part of her orthodontic treatment. However, what may have been a well-treated case at the finish as an adolescent became a significant problem as an adult. Because her skeletal lingual crossbite pattern was never initially diagnosed, extraction of the first permanent premolars negatively enhanced her transverse discrepancy. Additional facial growth only intensified her transverse discrepancies. Over time, this patient developed an anterior open bite and crossbite, bilateral posterior crossbites, gingival recession, and MPD (Figures 16 Volume 4 Number 5

Figure 16: Panoramic image demonstrating anterior open bite

Figure 18: Cephalometric tracing revealing a skeletal lingual crossbite pattern due to the maxilla and mandible, and a lingual crossbite due to both arches

and 17). The frontal analysis made from her CBCT scan revealed a significantly narrow maxilla and a wide mandible (Figure 18), indicating that rapid maxillary expansion would have been a more appropriate treatment regimen than extraction of teeth. The patient is currently being treated for her myofascial pain disorder. Future treatment will focus on improving her periodontal condition and a combined surgical orthodontic approach to address her orthodontic problems. The use of the frontal analysis should be more the norm than the exception. Many facial asymmetries and skeletal lingual crossbite patterns go undiagnosed, only becoming apparent later and adversely affecting the quality of care. Performing a frontal analysis may take more time, but it is in the best interest of the patient. Volume 4 Number 5

Remember, the patient will be making his/ her own quality assessment of the final

orthodontic result, using a frontal analysis called the mirror. OP

References 1. Edgren BN. The combined value of the frontal analysis and growth prediction. Orthotown. 2013;56-57. 2. Miner RM, Al Qabandi S, Rigali PH, Will LA. Conebeam computed tomography transverse analysis. Part 1: Normative data. Am J Orthod Dentofacial Orthop. 2012;142(3):300-307. 3.Ricketts RM, Grummons D. Frontal cephalometrics: practical applications, part I. World J Orthod. 2003;4(4):297-316. 4. Cheong YW, Lo LJ. Facial asymmetry: etiology, evaluation, and management. Chang Gung Med J. 2011;34(4):341-351. 5. Severt TR, Proffit WR. The prevalence of facial asymmetry in the dentofacial deformities population at the University of North Carolina. Int J Adult Orthodon Orthognath Surg. 1997;12(3):171-176. 6. The National Craniofacial Association. Hemifacial Microsomia. http://www.faces-cranio.org/Disord/Hemi. htm. Accessed August 19, 2013.

7. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology. Philadelphia, PA: W.B. Saunders; 1995:16. 8. Edgren BN. Upper airway obstruction - poor function becomes poor form. Orthodontic Practice US. 2013;4(2):34-37. 9. McConnell TL, Hoffman DL, Forbes DP, Janzen EK, Weintraub NH. Maxillary canine impaction in patients with transverse maxillary deficiency. ASDC J Dent Child. 1996;63(3):190-195. 10. Schindel RH, Duffy SL. Maxillary transverse discrepancies and potentially impacted maxillary canines in mixed-dentition patients. Angle Orthod. 2007;77(3):430435. 11. Baccetti T, Mucedero M, Leonardi M, Cozza P. Interceptive treatment of palatal impaction of maxillary canines with rapid maxillary expansion: a randomized clinical trial. Am J Orthod Dentofacial Orthop. 2009;136(5):657-661.

Orthodontic practice 33

CONTINUING EDUCATION

Figure 17: Posterior-anterior image demonstrating bilateral posterior crossbites and anterior open bite

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The frontal cephalometric analysis â&#x20AC;&#x201C; the forgotten perspective 1. Many patients who appear to have normal transverse skeletal relationships have ______ that can negatively affect orthodontic treatment outcomes. a. skeletal lingual crossbite patterns b. minor facial asymmetries c. occlusal cants d. tooth-size discrepancies 2. If that dental asymmetry is the result of ______, an orthopedic or surgical approach will be necessary because orthodontic treatment alone would likely result in an unfavorable outcome. a. a tooth-size discrepancy b. a skeletal issue c. enlarged turbinates d. missing teeth 3. Itâ&#x20AC;&#x2122;s not uncommon for the orthodontist to miss a skeletal asymmetry in a severely crowded and maligned malocclusion that only becomes obvious after the _______of treatment. a. final stage b. leveling phase c. alignment phase d. both b and c

34 Orthodontic practice

4. But, diagnosing the skeletal asymmetry initially, prior to the start of treatment, ______. a. provides informed consent to the patient b. reduces the unintended consequences of poor treatment planning c. shortens treatment time d. both a and b 5. The frontal analysis can also aid in determining if an off-centered dental midline is due to a ______. a. tooth-size discrepancy b. mandibular functional shift c. skeletal dysplasia d. all of the above 6. ______ is a congenital birth defect where the lower half of the face is typically unilaterally, or rarely bilaterally, underdeveloped. a. Myofascial pain disorder b. Cleft lip and palate c. Hemifacial microsomia d. Root parallelism 7. This common facial birth defect, second only to _____, most frequently affects the ears, mouth, and lower jaw. a. tooth-size discrepancies b. clefts

c. condylar hypoplasia d. impacted canines 8. In acquired cases (of bilateral condylar hypoplasia), the extent of the facial deformity is dependent upon ________. a. the severity of the injury that caused the disruption in condylar growth b. the duration of that injury c. the age that it occurred d. all of the above 9. Routinely taking _______reduces the chances of missing an asymmetry. a. a posterior-anterior radiograph b. digital photographs c. a full mouth series d. cephalometric tracings 10. Many _______ go undiagnosed, only becoming apparent later and adversely affecting the quality of care. a. facial asymmetries b. skeletal lingual crossbite patterns c. supernumeraries d. both a and b

Volume 4 Number 5

CONTINUING EDUCATION

A golden opportunity for dentists: dental sleep medicine Part I: Introduction Dr. Harold F. Menchel offers a wake-up call to clinicians to explore an evolving niche in dentistry Introduction The dental profession is becoming more aware of its unique position in relationship to identifying and managing patients with sleep disordered breathing — Obstructive Sleep Apnea (OSA).1 As primary care providers, many dentists have thousands of patient visits a year with both dentist and hygienist, and are in a position to evaluate and screen patients for OSA. Orthodontists are in a particularly advantageous position to evaluate patients during growth and development and can be integral in interceding to benefit these patients. By screening these patients, we are becoming the primary source of referral of new patients to sleep physicians. Part I of this article will review the background of sleep medicine and dentistry, pathophysiology of OSA, related disorders, basic diagnosis, the role of the dentist, and where to get information about sleep dentistry for your practice. Part II will discuss implementation of a sleep program in your dental office and discuss controversies in this field.

Background The history of sleep medicine dates back to 18802, however, it was not until the latter half of the 20th century that sleep medicine came into its own. The following events are significant: 1953: REM sleep discovered.

Harold Menchel, DMD is a dentist in Coral Springs, Florida, who limits his practice to TMD, orofacial pain, and sleep disordered breathing. Dr. Menchel teaches undergraduate and graduate education in TMD and orofacial pain at Nova Southeastern School of Dental Medicine in Fort Lauderdale, Florida. He is the director of orofacial pain at Larkin Teaching Hospital in Miami, and lectures both nationally and internationally. He is a fellow of the American Academy of Orofacial Pain, a Diplomate of the American Board of Orofacial Pain, and a member of the American Academy of Dental Sleep Medicine.

36 Orthodontic practice

Educational aims and objectives This article aims to discuss sleep dentistry, its origins, symptoms, and various methods available for treatment. Expected outcomes Correctly answering the questions on page 40, worth 2 hours of CE, will demonstrate the reader can: • Identify some background of sleep medicine and dentistry. • Recognize pathophysiology of OSA and related disorders. • Realize some basic diagnosis of sleep disorders. • Understand the role of the dentist. • Know where to get information about sleep dentistry.

1970: Stanford University established the first known sleep center. The beginnings of the AASM (American Academy of Sleep Medicine) are formed. 1980: The first reports of an oral appliance are reported (tongue retaining device). 1981: CPAP introduced. 1987: Home testing reveals that 31% of all men tested have OSA. 1991: The first dental sleep medicine group is organized, Sleep Disorders Dental Society (SDDS). 1994: The AMA recognizes sleep medicine as a subspecialty. 1995: The journal Sleep published parameters for dental sleep appliances. 2000: The SDDS becomes the Academy of Dental Sleep Medicine (ADSM) followed by establishment of the American Board of Dental Sleep Medicine (ABDSM) in 2004. Today most dentists get their training in sleep medicine at a continuing education level, although dental schools are implementing sleep dentistry into both their undergraduate and graduate curriculums. Although many sleep disorders are diagnosed and managed by sleep physicians (insomnia, parasomnias, narcolepsy, central apneas, etc.), dentist involvement is increasing exponentially with the approval of dental appliances for mild to moderate OSA by the AASM, NIH, and Medicare.

The gold standard for treating patients with OSA is CPAP (Continuous Positive Airway Pressure) to force air under pressure into the mouth and maintain airway. CPAPs have greatly improved in the past decade as far as patient comfort and noise; however, there are still problems with compliance and tolerance of the masks. There is some new evidence that for mild to moderate OSA, dental appliances may have equal efficacy versus CPAP.3 There are also concerns about changes in growth and development with CPAP use in growing children and adolescents.4,5 Certain patients are candidates for dental appliances that advance the mandible and open the blocked airway. This is a wonderful opportunity for all concerned — patients, sleep physicians, and dentists — to benefit.

Pathophysiology of OSA (a brief overview) The pathology of OSA is related directly to circulatory hypoxia.6 These patients have decreased blood oxygen level, which is responsible for the tiredness. Other than the global symptom of excessive sleepiness of OSA from hypoxia, this can also result in oxidative stress on commencement of reperfusion of oxygen to the blood vessels. Direct tissue damage can result as well from increased circulatory damage from inflammation. These patients often have increased CO2 blood levels and increased vasoconstriction responsible for the cardiovascular consequences. There are Volume 4 Number 5

Table 2

also endocrine disturbances linked to OSA (See Table 1 above).6,7,8,9,10 OSA is the second most common cause of single car motor vehicle accidents after driver distraction!

Diagnosing OSA (what dentist needs to know)

every

State dental practice acts only allow dentists to screen, not diagnose or treat OSA, without coordination with a sleep physician. Most states allow dentists to make the primary referral to a sleep laboratory or to do home sleep testing, even though they cannot diagnose. All dentists should learn to include OSA screening in their comprehensive examination including a brief observation and oral questions:11,12 • Is the patient obese? • Is the patient retrognathic? • Does the patient have a thick neck? (size 17 or more in males) • Snoring? • Hypertension? • Excessive daytime sleepiness (fall asleep in front of the TV, while reading a book, at a social occasion, drowsiness while driving, etc.) • GERD Although Epworth Sleepiness Scale (ESS) has been the standard for screening patients with OSA, a newer scale, STOP BANG, has been shown to be more effective in screening patients and13 easier to use (Table 2). Dentists who are inserting dental sleep appliances should know the basics of sleep physiology, know how to read polysomnograms (PSG), and know how to communicate with sleep physicians and Volume 4 Number 5

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Table 1

insurers.14,15,16 They should understand airway evaluation and be familiar with all management approaches to treatment of OSA. It is appropriate for dentists to have nutritional, weight loss, and exercise information, and programs available for their OSA patients. The above are basic essentials for dentists who are supplementing their practice with sleep dentistry. The question of who is responsible for titration and monitoring of a dental appliance needs to be addressed. Ideally, the patient should be returned to the sleep physician for this part of the evaluation. In reality, however, patients would prefer to avoid further laboratory PSG, and since many insurers will not cover second sleep studies, recall is often lacking. Many dentists use Home Sleep Testing (HST) to titrate and follow their patients, and others use high-resolution pulse oximeter. Any results should be forwarded to the sleep physician. Some dentists have transitioned their entire practices to just treating OSA and have more complete education in sleep physiology and sleep medicine.

Treatment of OSA Most common treatments of OSA are listed in Table 3. These are for obstructive sleep apnea, not central apneas (CNS). One of the central apnea treatments ASV (adapto-servo ventilation) is also used for OSA. This is a computer that monitors your breathing pattern and automatically uses airflow pressure to prevent pauses in breathing. One of the common and dangerous central apneas is SIDS (sudden

infant death syndrome).17 The use of surgical versus nonsurgical methods for OSA is controversial.18 Orthognathic surgery for advancement of the mandible and maxilla has been predictable and successful, although it is a major decision for OSA patients

The role of the dentist in treating OSA Dentists do not want to practice medicine without a license; therefore, they must understand their limits in managing OSA patients. We also need to get remuneration for our work and our knowledge. Dentists, sleep physicians, educators, the government, and insurers are in the process of defining this new area of sleep dentistry. Many things are still unclear, and laws do vary from state to state. Insurance reimbursement is very inconsistent for dental sleep appliances. The following decisions are needed before you begin making oral appliances. (Remember that many continuing education presenters lecture nationally and may not be aware of your particular state’s practice act, specific insurance guidelines, etc. Every patient’s policy is different. It is your responsibility to check with your state dental board.)

How does one learn how to practice sleep dentistry? More and more resources are becoming available for education in sleep dentistry. A good starting point is the AADSM website (http://www.aadsm.org/). An online search will also identify dental school programs teaching evidenced-based sleep dentistry. There are also individual lecturers not Orthodontic practice 37

CONTINUING EDUCATION Table 3

Table 4

Treatment for OSA Treatment

Comments

Treatment for OSA (self management) Nasal decongestants

CPAP

Gold standard for treatment of OSA: there are partial coverage and full coverage masks available. Comfort and noise have been greatly improved.

Dental appliance

Less effective than CPAP, better compliance indicated, for mild to moderate OSA.

UPPP (Uvulopalatopharyngoplasty)

Procedure that removes excess tissue in the throat to make the airway wider. Long-term effectiveness questionable.

Stopping smoking

Expiratory Positive Airway Pressure EPAP Provent®

Devices placed in the nostril with valves that block expiration. They may be helpful if other devices are not tolerated or in combination.

Decreasing caffeine

Tongue retention devices

These hold the tongue forward to open the airway. Effectiveness is questionable.

Orthognathic surgery

This is the most effective surgical technique.

Pillar technique

Plastic struts are surgically placed into the palate with local anesthesia to open the airway. This is only for mild to moderate OSA. It is not effective for everyone.

associated with recognized programs who are selling training and implementation of sleep dentistry in practices. Some of these programs can be costly (up to $25,000 with equipment). The validity of some of these devices are in question, so do your research.

Controversies As with all new areas of knowledge, unfortunately some misinformation is being disseminated about OSA. The following are FAQs. 1. Is there a relationship between sleep bruxism and OSA? There is confusion in the field of sleep dentistry about sympathetic arousals associated with bruxism and with arousals causes by airway blockage in OSA.19 While the former is associated with bruxism, there is no evidence to support the latter. The truth is that both in children and adults, there is no difference in bruxism between controls and patients with OSA, and it is a mistake to assume that patients who 38 Orthodontic practice

exhibit tooth wear have apnea.20 2. Is Gastro Esophageal Reflux Disease (GERD) associated with OSA? There is a high prevalence of GERD associated with OSA both in children and adults. Some researchers have indicated that the negative esophageal pressure during apneic events results in acid reflux. Others have postulated that acid reflux PH itself stimulates laryngeal spasm. This is still very controversial. No direct causal relationship between GERD and OSA has been established. These disorders are also associated with, and have a higher correlation with, BMI, alcohol, and smoking.21 There is no question that gravitational effects of body position along with weakness and size of the esophageal sphincter also directly influence GERD. In bruxers with GERD, tooth wear is accelerated, but there is no evidence that GERD either causes or is associated with bruxism.

Weight loss

Decreasing alcohol before bedtime

Promote side sleeping over back or stomach Promote proper sleep habits and environment (regular sleep hours, blackout curtains, cold room temperature etc.)

How valid are clinical airway 3. measurements? One absolute truth in sleep medicine is that “narrowed airways can be maintained, and large airways can collapse.” Although it may be useful information to observe “static” airway with CT, or acoustic pharyngometer/ rhinometer as an initial screening, this type of study does not show what is actually happening during sleep. Many CTs are taken in an erect position, and the airway may be very different in a supine position. This further questions the validity of CT for airway evaluation. PSG is still gold standard for diagnosis of OSA. The validity and reliability of CT measurement, as well as the other airway measuring devices, has been questioned.22 Insurers consider these measuring devices as “experimental,” and do not provide coverage. 4. Is unattended home sleep testing (HST) as valid as laboratory PSG? If done properly, HST can be valid when Volume 4 Number 5

5. Is Pulse Oximetry (PO) an effective screening method for OSA? High-resolution pulse oximetry can be an effective and economical screening device for OSA. The limitations are that although the PO is most valid for severe OSA, it does not detect mild to moderate OSA accurately, and these patients often are diagnosed as normal. In sleep dentistry, this is the exact population that we want to treat. In addition, patients with medical conditions affecting the blood oxygen level, e.g., hemoglobin, poor circulation, can affect the accuracy of the test. Body and limb movement can cause false positive readings. Tissue optics in obese patients can also invalidate the readings.24,25 Pulse oximetry will miss any type of sleep disorder that does not involve O2 blood desaturation such as Upper Airway Resistance Syndrome (UARS), Respiratory Effort Related Arousals (RERAs), or pure central sleep apnea. Discussion of these syndromes is beyond the scope of this article. 6. Is pulse oximetry acceptable in titration of a sleep appliance? As previously stated, PSG, or at the minimum HST, is needed to evaluate the benefit of the dental appliance. Pulse oximetry has limitations as previously stated and is far from ideal in monitoring patients. Volume 4 Number 5

7. Can airway blockage in children lead to neurological deficit? Studies have clearly shown that undiagnosed OSA in infants and children can lead to learning disabilities, irritability, and children with airway blockage have been misdiagnosed with ADD (ADHD). Standard of care in most of these cases is tonsillectomy and adenoidectomy (T&A). Once the airway is treated, these children show great improvement, in most cases returning to normal.26 OP

Next issue: Part II – Implementing sleep dentistry into your practice. Acknowledgements: I would like to thank Drs. Barry Glassman, Don Malizia, and Steven Bender for their assistance with this article. It is greatly appreciated.

References 1. Kushida CA, Morgenthaler TI, Littner MR, Alessi CA, Bailey D, Coleman J Jr, Friedman L, Hirshkowitz M, Kapen S, Kramer M, Lee-Chiong T, Owens J, Pancer JP; American Academy of Sleep. Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances: an update for 2005. Sleep. 2006;29(2):240– 243. 2. Schmidt-Nowara W. A review of sleep disorders: The history and diagnosis of sleep disorders related to the dentist. Dent Clin North Am. 2001;45(4):631-642. 3.White DP, Shafazand S. Mandibular advancement device vs CPAP in the treatment of obstructive sleep apnea: Are they equally effective in short term health outcomes? J Clin Sleep Med. 2013;9(9):971-972. 4. Hammond RJ, Gotsopoulos H, Shen G, Petocz P, Cistulli PA, Darendeliler MA. A follow-up study of dental and skeletal changes associated with mandibular advancement splint use in obstructive sleep apnea. Am J Orthod Dentofacial Orthop. 2007;132(6):806–814. 5. Kobayashi T, Izumi N, Kojima T, Sakagami N, Saito I, Saito C. Progressive condylar resorption after mandibular advancement. Br J Oral Maxillofac Surg. 2012;50(2):176180. 6. Fuller PM, Lu J. Neurobiology of sleep. In: Amlaner CJ, Fuller PM, eds. Basics of Sleep Guide. 2nd ed. Westchester, IL: Sleep Research Society; 2009:53–62. 7. Lopez-Jimenez F, Sert Kuniyoshi FH, Gami A, Somers VK. Obstructive sleep apnea: implications for cardiac and vascular disease. Chest. 2008;133(3):793–804. 8. Penzel T, Riedl M, Gapelyuk A, Suhrbier A, Bretthauer G, Malberg H, Schöbel C, Fietze I, Heitmann J, Kurths J, Wessel N. Effect of CPAP therapy on daytime cardiovascular regulations in patients with obstructive sleep apnea. Comput Biol Med. 2012;42(3):328–334. 9. Kono M, Tatsumi K, Saibara T, Nakamura A, Tanabe N, Takiguchi Y, Kuriyama T. Obstructive sleep apnea syndrome is associated with some components of metabolic syndrome. Chest. 2007;131(5):1387–1392. 10. Meslier N, Gagnadoux F, Giraud P, Person C, Ouksel H, Urban T, Racineux JL. Impaired glucose-insulin metabolism in males with obstructive sleep apnoea syndrome. Eur Respir J. 2003;22(1):156–160. 11. Shepherd KL, James AL, Musk AW, Hunter ML, Hillman DR, Eastwood PR. Gastro-oesophageal reflux symptoms are related to the presence and severity of obstructive sleep apnoea. J Sleep Res. 2011;20(1 Pt 2):241–249. 12. American Academy of Sleep Medicine. The AASM Manual for the Scoring of Sleep and Associated Events. Westchester, IL: American Academy of Sleep Medicine; 2007.

14. Kushida CA, Littner MR, Morgenthaler T, Alessi CA, Bailey D, Coleman J Jr, Friedman L, Hirshkowitz M, Kapen S, Kramer M, Lee-Chiong T, Loube DL, Owens J, Pancer JP, Wise M. Practice parameters for the indications for polysomnography and related procedures: an update for 2005. Sleep. 2005;28(4):499-521. 15. Lipsey MR. Medical insurance for dental sleep medicine. Dent Clin North Am. 2012;56(2):475–484. 16. Chan AS, Lee RW, Cistulli PA. Sleep-related breathing disorders. In: Lavigne GJ, Cistulli PA, Smith MT, eds. Sleep Medicine for Dentists. A Practical Overview. Hanover Park, IL: Quintessence Publishing Co, Inc.; 2009:35–40. 17. Adams SM, Good MW, Defranco GM. Sudden infant death syndrome. Am Fam Physician. 2009;79:870-874. 18.Ravesloot MJ, de Vries N. Reliable calculation of the efficacy of non-surgical and surgical treatment of obstructive sleep apnea revisited. Sleep. 2011;34(1):105– 110. 19. Lavigne GJ, Kato T, Kolta A, Sessle BJ. Neurobiological mechanisms involved in sleep bruxism. Crit Rev Oral Biol Med. 2003;14(1):30-46. 20. Maluly M, Andersen ML, Dal-Fabbro C, Garbuio S, Bittencourt L, de Siqueira JT, Tufik S. Polysomnographic study of the prevalence of sleep bruxism in a population sample. J Dent Res. 2013;92(7 suppl):97S-103S. 21. Morse CA, Quan SF, Mays MZ, Green C, Stephen G, Fass R. Is there a relationship between obstructive sleep apnea and gastroesophageal reflux disease? Clin Gastroenterol Hepatol. 2004;2(9):761-768. 22. Alsufyani NA, Flores-Mir C, Major PW. Threedimensional segmentation of the upper airway using cone beam CT: a systematic review. Dentomaxillofac Radiol. 2012;41(4):276-284. 23. Gagnadoux F, Pelletier-Fleury N, Philippe C, Rakotonanahary D, Fleury B. Home unattended vs hospital telemonitored polysomnography in suspected obstructive sleep apnea syndrome: a randomized crossover trial. Chest. 2002;121(3):753-758. 24. Niijima K, Enta K, Hori H, Sashihara S, Mizoue T, Morimoto Y. The usefulness of sleep apnea syndrome screening using a portable pulse oximeter in the workplace. J Occup Health. 2007;49(1):1-8. 25. Netzer N, Eliasson AH, Netzer C, Kristo DA. Overnight pulse oximetry for sleep-disordered breathing in adults: a review. Chest. 2001;120(2):625-633. 26. Hansen DE, Vandenberg B. Neuropsychological features and differential diagnosis of sleep apnea syndrome in children. J Clin Child Psychol. 1997;26(3):304-310.

13. Vasu TS, Doghramji K, Cavallazzi R, Grewal R, Hirani A, Leiby B, Markov D, Reiter D, Kraft WK, Witkowski T. Obstructive sleep apnea syndrome and postoperative complications: clinical use of the STOPBANG questionnaire. Arch Otolaryngol Head Neck Surg. 2010;136(10):1020-1024.

Orthodontic practice 39

CONTINUING EDUCATION

compared to laboratory PSG, although PSG is still the gold standard. It is also more cost effective and has been approved by insurers. It is accepted for just limited diagnosis of OSA only.23 The limitations are as follows: • Often home testing is not set up properly or equipment leads unplugged. This invalidates the study. This has been reported up to 25% in some journals versus 5% for laboratory PSG. • Although home testing reports OSA, it does not measure periodic limb movement (PLM), bruxism, or central apneas. • If a dentist provides HST equipment for his/her patients, the results still need to be read by a sleep physician. It may be considered below standard of care if there is no face-to-face contact between the patient and the sleep physician. • In complex patients with medical issues, L-PSG is indicated.

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A golden opportunity for dentists: dental sleep medicine Part 1 1. The pathology of OSA is related directly to ______. a. circulatory hypoxia b. muscular problems c. decreased CO2 levels d. chronic cough 2. State dental practice acts only allow dentists to screen, not ______OSA without coordination with a sleep physician. a. diagnose b. treat c. educate about d. both a and b 3. Although Epworth Sleepiness Scale (ESS) has been the standard for screening patients with OSA, a newer scale, _____has been shown to be more effective in screening patients and easier to use. a. polysomnography b. STOP BANG c. pulse oximetry d. adapto-servo ventilation 4. It is appropriate for dentists to have _______, and programs available for their OSA patients. a. nutritional

40 Orthodontic practice

b. weight loss c. exercise information d. all of the above 5. The truth is that both in children and adults, there is no difference in bruxism between controls and patients with OSA, and it is a mistake to assume that patients who _____ have apnea. a. chew gum b. sleep with an open mouth c. exhibit tooth wear d. wear braces 6. In bruxers with GERD, tooth wear _____, but there is no evidence that GERD either causes or is associated with bruxism. a. is unaffected b. is slowed c. is accelerated d. none of the above 7. Although home testing reports OSA, it does not measure _____. a. periodic limb movement (PLM) b. bruxism c. central apneas d. all of the above

8. If a dentist provides HST (home sleep testing) equipment for his/her patients, the results ______by a sleep physician. a. do not need to be read b. will probably be invalidated c. still need to be read d. should be sent to the insurance company 9. As previously stated, PSG, or at the minimum HST, is needed to evaluate ______. a. the benefit of the dental appliance b. upper airway resistance c. tissue optics d. positional sleep habits 10. Studies have clearly shown that ______in infants and children can lead to learning disabilities, irritability, and children with airway blockage have been misdiagnosed with ADD (ADHD). a. excessive body and limb movement during sleep b. undiagnosed OSA c. large airways d. bruxism

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RESEARCH

TMD/orofacial pain survey of orthodontic residents in the U.S. and Canada Drs. Amanda Guess, Mark Causey, John Stockstill, Donald Rinchuse, and Eladio DeLeon explore dental students’ education regarding occlusion, TMD, and orofacial pain Abstract Objective: The purpose of this study was to investigate the teaching of occlusion, temporomandibular disorders (TMDs), and orofacial pain (OFP) as viewed by current orthodontic residents. Methods: An email invitation from the American Association of Orthodontists, AAO Partners in Education, was sent to all student members of the AAO in the U.S. and Canada (n=1,151), requesting participation in an 18-question online survey (Survey Monkey). Results: The online survey was emailed on two different occasions, yielding a response from 116 residents. Like previous studies, results of this survey suggest there are instances where the curriculum being taught is not evidence-based, and the materials and methodologies for teaching these disciplines are diverse and lack standardization. There are still aspects of the traditional dental-based model of TMD and OFP being taught. For instance, 87.9% of the residents stated that they are taught principles of neuromuscular dentistry, and 61.2% said that understanding gnathology is important in orthodontic diagnosis and treatment. Conclusions: In general, there are aspects of the traditional, historic, dental-based approach to teaching TMD and OFP,

Amanda Guess, DMD, is a graduate orthodontic resident, Seton Hill University Center for Orthodontics, Greensburg, Pennsylvania. Mark Causey, DMD, is a former graduate orthodontic resident, Georgia Regents University, Augusta, Georgia. John Stockstill, DDS, MS, is Section Chief – Orthodontics Temporomandibular Disorders/Orofacial Pain at East Carolina University, Greenville, North Carolina. Donald J. Rinchuse, DMD, MS, MDS, PhD, is Professor and Graduate Orthodontic Program Director, Seton Hill University Center for Orthodontics, Greensburg, Pennsylvania. Eladio DeLeon, DMD, MS, is Goldstein Chair of Orthodontics, Georgia Regents University, Augusta, Georgia.

42 Orthodontic practice

including gnathology, still being taught in graduate orthodontic residency programs.

Introduction Temporomandibular joint disorders and orofacial pain have received a considerable amount of attention throughout the history of dentistry. Temporomandibular disorder (TMD) was once considered a single disease/dysfunction/disorder (TMJ pain dysfunction syndrome) with a single cause, i.e., stress and/or occlusion.1,2 Later on, the position of the condyles in the glenoid fossa (i.e., centric relation) became thought of as the primary etiological factor in the diagnosis and treatment of TMD.3 TMD is now considered a collection of disorders/sub-disorders that embrace a number of clinical conditions that involve the masticatory muscles, joints, and associated structures.1,2 There appears to be a multifactorial etiology of each of the half-dozen or so subclasses of TMD and not the general, single category of TMD.1 The contemporary view of the etiology, diagnosis, and treatment of TMD is based on a biopsychosocial model rather than the historical, dental-based model.4-10 The biopsychosocial model integrates the host of biologic, behavioral, and social factors to the onset and maintenance of TMD. A medical orthopedic approach for TMD management is recommended that focuses on the biomedical sciences and musculoskeletal therapies comparable to those of most chronic pain. Cognitivebehavioral therapies (CBTs) and biofeedback (BFB) are modern TMD treatment modalities.11 The present biopsychosocial evidence-based view does not imply that occlusion has no relevance at all to the etiology of TMD. The gross examination of the occlusion is still important in the diagnosis and management of TMD to identify and mitigate major occlusal discrepancies. The relationship of orthodontics to TMD and orofacial pain has been disputed and is often labeled as being “controversial” in spite of the evidence-

based information that orthodontics is generally TMD “neutral,” i.e., does not cause or cure TMD.12-18 Malocclusion is not typically a precipitating factor in TMD. Early orthodontic treatment for the prevention of future TMD in young patients has little to no evidentiary support.2,11 Because the topics of occlusion, condyle position, and TMD (orofacial pain) have had a controversial, and at times a marred, history, this makes it important that what is taught in our dental schools and postdoctoral dental programs is evidencebased and organized in progressive patterns. Prior to the publication of the American Dental Association’s President’s Conference on the Examination, Diagnosis and Management of Temporomandibular Disorders in 1983,1 there was minimal information available to dental schools regarding TMDs. In 1990 and 1992, the Association of University Teachers of Orofacial Pain Programs held two conferences in an attempt to generate guidelines for the management of TMD and OFP. Curriculum standards were published and suggested as guidelines to be incorporated into the curricula at the predoctoral, postdoctoral and continuing education levels.19-22 However, no attempt was made by the American Association of Dental Schools to officially adopt and implement the proposed curricula. In 2001, the Association of University Teachers of Orofacial Pain Programs held a third conference, with its main objective being to “enhance the teaching of TMD and OFP to predoctoral dental students and to postdoctoral students in this field.”23 Several didactic changes were proposed, including the need for TMD management guidelines supported by evidence-based concepts. Additionally, the conference stressed the critical importance of clinicallybased training to supplement these didactic changes to the curriculum.24-28 In 2007, Klasser and Greene conducted a survey of U.S. and Canadian dental schools regarding the teaching of topics related to TMD and OFP at the predoctoral Volume 4 Number 5

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orthodontic faculty in the institution to teach the subjects of static and functional occlusion as opposed to orofacial painTMD specialists.31 The authors stated, “If orthodontists are providing most of the information about these relationships rather than having TMJ and TMD experts address those matters, graduate orthodontic students might not be learning about the more current concepts of TMD and the diminishing role of occlusion, occlusal interferences, and jaw relationships in the etiology of TMD.”31 Furthermore, only 87% of programs reported formal teaching of TMD and OFP.¹ Not only are the didactic portions of the curriculum important, but also the application of the concepts in the clinical setting. Most programs reported screening for TMD signs and symptoms during the initial exam, but there seems to be lack of consistency regarding the management of these patients. Timing of TMD treatment and the contraindications to orthodontic treatment varied widely among respondents.¹ Another subject under constant debate is the definition of centric relation. According to the survey, the definition for CR is unclear, or programs are presenting outdated information. Responses for CR ranged from anterior-superior to posteriorsuperior to individualized for each patient.31 Overall, dental schools need “qualitative and quantitative standards” for the teaching of occlusion, TMJs, and TMDs. Parenthetically, based on the information gleaned from this survey, as well as other data, a curriculum proposal for teaching TMD and OFP in postgraduate orthodontic programs was recently published.32 A follow-up and the next step to the survey of graduate orthodontic program directors was a survey of U.S. and Canadian orthodontic residents on the teaching of occlusion, temporomandibular disorders, and orofacial pain as a means of comparing and contrasting the perceptions of residency program directors with those of residents relative to the teaching of this curriculum. By intentionally asking similar questions regarding the content and dispersion of concepts of occlusion, temporomandibular disorders, and OFP as the earlier survey of program directors, it was expected that similarities and differences may emerge relative to the curriculum at the residency level, and thus lead to more refined and standardized guidelines.

Materials and methods A survey was used to obtain information concerning how the topics of occlusion, TMJ, and TMD, and OFP are taught in advanced education programs in orthodontics (postdoctoral). More specifically, how these topics are taught from the viewpoint of orthodontic residents throughout the U.S. and Canada. Using a previous study31, questions were modified for applicability for orthodontic residents versus program directors, and several other questions were added. The questions were then compiled and reviewed by each investigator. The survey was then presented to a group of residents from one residency program not used in the study, after which the final version of the survey was adopted. An email invitation from the AAO Partners in Education was sent to all the student members of the AAO in the U.S. and Canada (n=1,151), requesting participation in an online survey (Survey Monkey). The residents were asked to respond based on their previous educational and clinical experience associated with the topics of occlusion and TMD (OFP). The introductory letter informed the residents that the study was to “better define the established occlusion and TMD-related educational and clinical protocols currently being taught at the orthodontic residency program level.” The online survey was posted from September 12 to November 10, 2012. The survey was emailed to residents on two separate occasions. The survey questionnaire included 18 single-response, multi-response, and open-end questions, which allowed the residents to write explanatory answers. Parenthetically, the questions are summarized as per the table.

Results Of the 1,151 emails sent to current residents, 116 participated in the survey. The programs from which the residents are enrolled were not specified. Important findings from the survey are listed in the Table. Most residents (90%) are not pretested on their understanding of TMD/ orofacial pain upon entering residency. The majority of residents disagree (59.5%) or strongly disagree (25.9%) that occlusion is the primary cause of TMD. Secondly, 58.3% of residents disagree, and 22.6% of residents strongly disagree that certain orthodontic appliances or techniques (Class III mechanics, chin cups, and Orthodontic practice 43

RESEARCH

level.29 They found that a significant number of dental schools were either presenting outdated and inappropriate information or simply not presenting much information. They also found that few schools had any clinical exposure for predoctoral dental students. These authors concluded that there is a need to establish standards for teaching this subject in predoctoral and postdoctoral dental schools.29 Now specifically related to postdoctoral, graduate orthodontic education, and the topics of occlusion, TMD, and OFP, there is limited information available. Nonetheless, what is clear is that orthodontists should be competent in diagnosing and managing patients’ pretreatment TMD and orofacial pain as well as managing instances in which patients may develop TMD symptoms during treatment. This is in agreement with the American Dental Association’s Commission on Dental Accreditation standards for Advanced Specialty Education Programs in Orthodontics and Dentofacial Orthopedics, in which they have stated that postdoctoral, orthodontic residents should be educated to “manage patients with functional occlusal and temporomandibular disorders.”30 Therefore, the educational standard of care mandates that orthodontic residents should receive appropriate and evidencebased training to become proficient at identifying and managing such problems (ADA CODA Standard 4, item 54G-Manage functional occlusal/TMD).30 Of note, the ADA CODA recommends orthodontic residents should be proficient rather than familiar with managing occlusion/TMD, so this is a higher level requirement. The ADA does not suggest any specific ways these topics should be taught. The majority of dental schools assign TMD and OFP to various departments, which suggests that there is little uniformity in the curriculum.31 A recent survey was sent to orthodontic residency program directors in the U.S. and Canada, related to the teaching of occlusion, TMJ, TMD, and OFP in order to help “…ascertain where the orthodontic teaching community stood on the topics of occlusion, the TMJs, and TMDs, because their teachings will have a significant effect on future practitioners.”31 Results of this survey suggest that the materials and methodologies for teaching this discipline are diverse and lack standardization. Not surprisingly, there were various concepts being taught with little evidentiary support. The survey found that most programs use

RESEARCH Table: TMD/orofacial pain survey summary results

TOPIC

RESULTS

1. Have dental school (NOT “stand alone” program)

80% come from school with a pre-doctoral dental school

2. Pre-testing

89.7% not pre-tested on TMD/orofacial pain knowledge

3. Didactic component taught when?

55.3% TMD/orofacial pain taught in first year of residency

4. Cases finished to ABO standards

50% said that it is very important to finish cases to ABO Phase III standards. 43.1% said that is somewhat important

5. Mounted models

5.2 % always mount; 32.8% never mount; 62.1% case dependent

6. Articulator type

62.3% indicated using semi-adjustable articulators

7. Deprogramming splints

55% never use deprogramming splints prior to mounting; 43.2% sometimes; 1.8% always

8. Bite registration

51.4% always use a particular type bite registration; 25.2% sometimes; 23.4% never

9. Type bite registration

50% indicated the mandible manipulated posteriorly; 49% maximum intercuspation; 28.8% power bite; 22.1% leaf gauge

10. Essentials for records

87.9% neuromuscular dentistry principles; 18.2% chewing cycle kinematics; 12.1% EMG activity (*83 respondents skipped question)

11. Recommended occlusal scheme

74.6% canine guidance; 50% anterior guidance; 20.2% no particular scheme; 19.3% finished in centric relation; 15.8% group function; 14.9% balanced occlusion

12. Occlusion - the primary cause of TMD?

59.5% disagreed; 25.9% strongly disagreed; 14.7% agreed

13. Orthodontics - the cause of TMD?

58.3% disagree; 22.6% strongly disagree; 18.3% agree

14. TMD - related to biopsychosocial factors?

56.9% agree; 36.2% strongly agree; 6% disagree

15. Orthodontics - the cause of TMD when gnathologic goals are NOT met?

55.7% disagree; 27% strongly disagree; 17.4% agree

16. Gnathology - important in diagnosis/ treatment?

61.2% agree; 26.7% strongly agree; 10.3% disagree

17. Length of residency program

39.1% 36 months; 29.6% 30 months; 20.9% 24 months; 10.4% 27 months

18. Time period in program

25.4% 1 year completed; 24.6% 6 months completed; 18.4% 1 ½ years completed; 15.8% 2 years completed; 8.8% 2 ½ years completed; 7.0% more than 2 ½ years completed

44 Orthodontic practice

extractions) directly cause TMD. The majority of residents also strongly agree (36.2%) or agree (56.9%) that TMD is related to biopsychosocial factors. Lastly, residents disagree (55.7%) or strongly disagree (27%) that orthodontic treatment causes TMD when gnathologic goals are not met (i.e., canine protected occlusion, anterior guidance, MI=CRO). Overall, there is a wide variety of views on the subjects of occlusion, TMD, and OFP being taught in graduate orthodontic residency programs in the U.S. and Canada.

Discussion Consistent with previous studies31, it is apparent that postgraduate teaching concerning occlusion, OFT, and temporomandibular disorders is diverse. Since many of these topics are initially presented in undergraduate dental curriculum, most postgraduate orthodontic residents have a variety in background training and experiences. Therefore, it might prove useful for programs to establish a baseline of the residents’ backgrounds in these subjects in order to improve their education. However, our survey indicates that most residents (90%) are not pretested on their understanding of TMD/ orofacial pain upon entering residency. The results reported from our survey of current orthodontic residents are comparable to the results obtained from orthodontic program directors in a previous study.³¹ Of the residents surveyed, 80% are attending programs associated with a dental school; similarly, 78% of responding program directors are associated with a dental school. Nearly 90% of residents report not being formally pre-tested on TMD/orofacial pain knowledge, which correlates with only 13% of program directors reporting formal pretesting. According to our survey, 50% of orthodontic residents believe that it is very important to finish cases to ABO Phase III standards. When program directors were asked the same question, 61% agreed that ABO Phase III standards are very important for finishing orthodontic cases. Despite the lack of standardization in graduate orthodontic curriculum, many of the responses from residents are consistent with current literature. More than half of the respondents, 59.5%, report that occlusion is not the primary cause of TMD, and 58.3% do not believe that orthodontics cause TMD. However, there remains to be some principles still being taught that Volume 4 Number 5

the responses of 116 of 1,151 residents surveyed. This response rate was lower than we expected; nonetheless, it reflected the findings of the previous survey of program directors.31 In retrospect, it may be beneficial to offer an incentive to motivate the residents to respond to the questionnaire. Informing the potential respondents that they could be eligible for some sort of prize by way of a lottery may have prompted more responses. Another thought would be to launch the questionnaire in a different manner. Rather than a survey, the researcher(s) could have brought the questionnaire to an AAO Meeting, or GORP (Graduate Orthodontic Residency Program), and had the questionnaire completed by residents on site. Another possibility would have been to reduce the number of questions used in the present study. The next step could be to study the opinions of practicing orthodontics related to TMD/orofacial pain and stratify the sample in a number of ways such as to older versus younger orthodontists, ABO Boarded versus non-Boarded, or those who have faculty appointments versus those who do not. It would also be interesting to survey other graduate specialty programs such as prosthodontics, oral surgery, periodontics, and pediatrics to learn how the TMD/orofacial pain curriculum of these

programs might differ from orthodontic residency programs.

Conclusions There are a number of conclusions that can be drawn from this survey investigation of the teaching and beliefs of orthodontic residents on the topic of TMD/orofacial pain. As mentioned above, despite the lack of standardization of TMD and OFP curriculum, many of the residents’ responses were consistent with current literature concerning TMD and OFP associated with orthodontics. However, there are aspects of traditional, historic, dentistry, still being taught in graduate orthodontic residency programs. • 62.1% of the respondents stated that they would mount casts on an articulator only for certain cases; 5.2% always; and 32.8% never. • 55.0% stated that their programs never use deprogramming splints prior to articulator mountings; 43.2% sometimes; and 1.8% never use. • Interestingly, 87.9% stated that they are taught principles of neuromuscular dentistry principles. • 61.2% said that understanding gnathology is important in orthodontic diagnosis and treatment. OP

References 1. Griffiths RH. Report of the president’s conference on the examination, diagnosis, and management of temporomandibular disorders. J Am Dent Assoc. 1983;106:7577.

11. Rinchuse DJ, Kandasamy S. Chapter 11-Orthodontics and TMD. In: PG Miles, DJ Rinchuse, DJ Rinchuse, eds. Evidence-Based Clinical Orthodontics. Hanover Park, IL: Quintessence Publishing; 2012: 157-166.

2. McNeill C, Mohl ND, Rugh JD, Tanaka TT. Temporomandibular disorders: diagnosis, management, education, and research. J Am Dent Assoc. 1990;120(3):253,255,257.

12. Reynders RM. Orthodontics and temporomandibular disorders: a review of literature (1966-1988). Am J Orthod Dentofacial Orthop. 1990;97(6):463-471.

3. Rinchuse DJ, Kandasamy S. Centric relation: a historical and contemporary orthodontic perspective. J Am Dent Assoc. 2006;137(4):494-501. 4. Fernandez E, Turk DC. The utility of cognitive coping strategies for altering pain perception: a meta-analysis. Pain. 1989;38(2):125-135. 5. Flor H, Birbaumer N. Comparison of the efficacy of electromyographic biofeedback, cognitive-behavioral therapy, and conservative medical interventions in the treatment of chronic musculoskeletal pain. J Consult Clin Psychol. 1993;61(4):653-658. 6. Gardea MA, Gathel RJ, Mishra KD. Long-term efficacy of biobehavioral treatment of temporomandibular disorders. J Behav Med. 2001;24(4):341-359. 7. Mishra KD, Gatchel RJ, Gardea MA. The relative efficacy of three cognitive-behavioral treatment approaches to temporomandibular disorders. J Behav Med. 2000;23(3):293309. 8. Rudy TE, Turk DC, Kubinski JA, Zaki HS. Differential treatment response of TMD patients as a function of psychological characteristics. Pain. 1995;61(1):103-112. 9. Turk DC, Zaki HS, Rudy TE. Effects of intraoral appliance and biofeedback/stress management alone and in combination in treating pain and depression in patients with temporomandibular disorders. J Prosthet Dent. 1993;70(2):158-164. 10. Turk DC, Rudy TE, Kubinski JA, Zaki HS, Greco CM. Dysfunctional patients with temporomandibular disorders: evaluating the efficacy of a tailored treatment protocol. J Consult Clin Psychol. 1996;64(1):139-146.

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13. Kim MR, Graber TM, Viana MA. Orthodontics and temporomandibular disorders: a meta-analysis. Am J Orthod Dentofacial Orthop. 2002;121(5):438-446. 14. McNamara JA Jr, Seligman DA, Okeson JP. Occlusion, orthodontic treatment, and temporomandibular disorders: a review. J Orofac Pain. 1995;9(1):73-90. 15. Rinchuse DJ, Kandasamy S. Myths of orthodontic gnathology. Am J Orthod Dentofacial Orthop. 2009;136(3):322330. 16. Macfarlane TV, Kenealy P, Kingdon HA, Mohlin BO, Pilley JR, Richmond S, Shaw WC. Twenty-year cohort study of health gain from orthodontic treatment: temporomandibular disorders. Am J Orthod Dentofacial Orthop. 2009;135(6):692693. 17. Luther F. Orthodontics and the temporomandibular joint: where are we now? Part 1. Orthodontics and temporomandibualr disorders. Angle Orthod. 1998;68(4):295304. 18. Luther F. Orthodontics and the temporomandibular joint: where are we now? Part 2. Functional occlusion, malocclusion, and TMD. Angle Orthod. 1998;68(4):305-318. 19. Greene CS, Stockstill JW, Clark GT. Predoctoral education for TMD and orofacial pain: a philosophical overview. J Craniomandib Disor. 1992;6(2):111-112. 20. Stockstill JW. Curriculum outline for adjunctive predoctoral education in TMD and orofacial pain. J Craniomandib Disord. 1992;6(2):117-122. 21. Curriculum guidelines for the development of predoctoral programs in temporomandibular disorders and orofacial pain. J Dent Educ. 1992;56(9):646-649.

22. Curriculum guidelines for the development of postdoctoral programs in temporomandibular disorders and orofacial pain. J Dent Educ. 1992;56(9):650-658. 23. Mohl ND, Attanasio R. The third educational conference to develop the curriculum in temporomandibular disorders and orofacial pain: introduction. J Orafac Pain. 2002;16(3):173175. 24. Glaros AG. Teaching evidence-based approaches to orofacial pain. J Orofac Pain. 2002;16(2):89. 25. Sessle BJ. Orofacial pain: an educational focus. J Orofac Pain. 2002;16(3):169. 26. Sessle BJ. Integration of basic sciences into predoctoral curriculum to study temporomandibular disorders and orofacial pain. J Orofac Pain. 2002;16(3):181-184. 27. Fricton JR. Development of orofacial pain programs in dental schools. J Orofac Pain. 2002;16(3):191-197. 28. Gonzales YM, Mohl ND. Care of patients with temporomandibular disorders: and educational challenge. J Orofac Pain. 2002;16(3):200-206. 29. Klasser GD, Greene CS. Predoctoral teaching of temporomandibular disorders: a survey of U.S. and Canadian dental schools. J Am Dent Assoc. 2007;138(2):231-237. 30. American Dental Association - Commission on Dental Accreditation. Accreditation Standards for Advanced Specialty Education Programs in Orthodontics and Dentofacial Orthopedics- Clinical Standard 4-3.4(g). http://www.ada.org/ sections/educationAndCareers/pdfs/ortho.pdf. Accessed January 30, 2013. 31. Stockstill J, Greene CS, Kandasamy S, Campbell D, Rinchuse D. Survey of orthodontic residency programs: teaching about occlusion, temporomandibular joints, and temporomandibular disorders in postgraduate curricula. Am J Orthod Dentofacial Orthop. 2011;139(1):17-23. 32. Greene CS, Stockstill J, Rinchuse D, Kandasamy S. Orthodontics and temporomandibular disorders: a curriculum proposal for postgraduate programs. Am J Orthod Dentofacial Orthop. 2012;142(1):18-24.

Orthodontic practice 45

RESEARCH

are not evidenced-based, such as the position of centric relation. Exactly half of the residents surveyed report manipulating patients’ mandibles posteriorly to record a centric bite registration. Interestingly, question No. 10, “Are chewing cycle kinematics, EMG activity, and/or neuromuscular dentistry principles taught as being essential for your records appointments? Select all that apply,” was skipped by 83 residents and only answered by 33 residents. Of the 33 residents that answered the question, 87.9% indicated that neuromuscular dentistry principles were taught, 18.2% indicated chewing cycle kinematics were essential, and 12.1% felt EMG activity was essential. Due to the high percentage of residents that skipped the question, it might be concluded that none of the above principles are essential to their records’ appointment. “None of the above” could have been included as an answer choice. Another possibility for the low response rate for this question could have been due to the ambiguity or lack of understanding of the techniques listed. There were several limitations of this survey study. The data from this study is based on the assumption that answers were an accurate and honest representation of what is being taught in postgraduate programs. As noted earlier, our survey results are based on

TECHNOLOGY

Treating digitally and the new orthodontic practice Dr. Randall Moles illustrates how the digital world has changed his role as an orthodontist

Figure 1: Initial photos

e have all been digitized. The process began in the early 1980s when our profession began to digitize cephalometric head films, and the first computerized management systems were introduced. More recently, we have witnessed the introduction of custom treatment systems with the advent of custom brackets (Insignia™, Ormco), custom wires (SureSmile®, OraMetrix), and treatment without braces (Invisalign®, Align Technology, Inc.). Having graduated in the 1970s, I’ve had the pleasure and the pain of experiencing many changes. Being a senior member of our specialty, along with being somewhat of a “tech junkie,” gives me what I think is a unique perspective on orthodontic practice. With that in mind, I can now state that the stage is set for a revolution in the delivery of orthodontics that will impact virtually every aspect of our profession. What we today consider an orthodontic practice is changing, and our

Randall Moles, DDS, MS, graduated from Marquette University and practices in Milwaukee and Racine, Wisconsin. He served in the U.S. Coast Guard Division of the United States Public Health Service and as an associate professor of orthodontics at Marquette. Dr. Moles is board certified and for many years has been actively involved in research for a number of orthodontic companies, having three U.S. patents to his credit. He is an original member of the Ormco “Insiders,” which developed the lingual appliance. Dr. Moles has written a book on TMD, numerous orthodontic articles, and lectures both nationally and internationally on digital orthodontics, TMD treatment, and practice management.

46 Orthodontic practice

Figure 2: Initial pan

Figure 3: Initial ceph

role as the orthodontist is going to be very different. The important point I want to make here is that these changes are taking place as you read this article. They are profound, they are irreversible, and they are exciting for those willing to embrace the new paradigm! They most assuredly will affect each practitioner, and I see no way to escape their impact. I must admit that I am approaching this discussion from the aspect of someone who practices in a suburban practice so these changes may have affected me differently than they might a rural practice or one in the heart of the city. However, what is occurring has the potential to impact any practice in any location.

don’t think we have fully appreciated the impact that these things are having and will have in the near future. In many ways, this is because we are still burdened by our traditional view of what an orthodontic practice looks like. While there is nothing inherently wrong with the traditional office, which has served our profession admirably over the years, the evolving digital office will be quite different and very likely will have a number of distinct advantages. At this point many might say “So what?” But, instead, I submit that they should be asking, “How will this affect me and my practice?,” since it most certainly will.

Defining digital The term “digital” has been liberally applied to describe a great deal of the world around us. While it’s possible to apply the term to most of what happens on a day-to-day basis in our offices, I’m going to focus on patients and their experience with an explanation of the digital delivery of treatment. I feel this is a useful way to approach the subject, since it will give you a perspective and a framework to evaluate how this paradigm shift may affect you. So let’s explore a bit, and I will first define “digital” as I am going to use it. It’s “the application of computer technology to the clinical delivery of orthodontic treatment.” Sounds pretty simple, doesn’t it? Many of us are already doing this with bracket placement systems, custom brackets, custom wires, and aligners. However, I

Digital versus traditional treatment In discussing the new digital orthodontics, I often mention my own experience. I tell people, “I have been practicing most of my orthodontic career with mittens on my hands and Vaseline® in my eyes because I have not been able to translate my thoughts on treatment accurately into the patient’s mouth!” By that, I meant that despite my best intentions, it was a constant struggle to get the teeth where I wanted them (and I felt I was pretty good at it). This is because I was doing it without adequate visualization: I could not accurately preplan movements, and I was handicapped by the imprecise art of bending wires by hand. The net effect of this was that, as we have all experienced, some cases went well, and some did not. It was because I was “guesstimating” in order to treat the case. By “guesstimating,” I was guessing Volume 4 Number 5

treatment times were inherent to practicing in a traditional non-digital system. Another important consideration in the traditional therapy model is that the diagnostic and clinical therapeutic aspects of treatment are intimately related and intertwined. At most treatment visits, therapeutic decisions need to be made immediately at the chair, and these decisions are based on what is evident in the mouth, where visibility is limited. In effect, the clinician reacts to what limited information he/she has as to where the teeth are and makes a decision on where

plan, but also the therapeutic appliance at his or her leisure. The therapeutics can be applied in the office under the doctor’s supervision, but without the stress of planning every step at every visit, in a process of what I would call constant rediagnosis. It’s a process that can lead to inefficient treatment and tends to consume valuable time better spent communicating with the patient and/ or parents.

Figure 4: New patient education lingual view

Figure 5: NP education showing how we can see and position roots

Figure 6: NP education show how we can see how the teeth fit with occlusal contacts

Figure 7A: Presurgical in SureSmile with roots anterior

Figure 7B: Presurgical in SureSmile with roots left

Figure 7C: Presurgical in SureSmile with roots right

This “guesstimation” also had a significant effect on the practice itself. As much as I hate to admit it, cases would get out of control. A side effect of this was the stress — for both my staff and myself — caused by one or more of these cases arriving during the afternoon rush. There I would sit at 4:15 with an office full of patients, trying to figure out why the patient’s teeth were not going where I wanted them to go! Moreover, the patient was impacted with additional appointments and extended treatment times. I think I was pretty good at what I did, and overall, I had very respectable treatment times and a fairly large practice. However, the fact remains that higher stress and longer

to go from there. It’s a very inefficient and imprecise way of doing things, much like driving a car looking in the rear view mirror. This repetitive rediagnosis is often, stressful, time-consuming, and fraught with potential inaccuracies. Wouldn’t it be much more efficient to thoroughly diagnose the case once and build the therapeutics on the spot, which will carry the case to completion? This interconnection of diagnostics and clinical therapeutics, which up until now has been inescapable, has finally been unraveled with digital technology. Diagnostics and clinical therapeutics are now separate and distinct entities, allowing the clinician to develop not only a treatment

digital solutions available today: the one that I find to be the most accurate and comprehensive is the SureSmile system. SureSmile allows me to fully utilize CBCT scanning (including roots and bone relationships) and, most importantly, it gives me the ability to modify the appliance as needed at any time during treatment. This last point is very important, since no system achieves 100% predictability, and when teeth do not move as planned, it’s important to have a way to make changes with forethought and precision. The SureSmile system allows me to work with any bracket system on both the labial and lingual. In addition, the software gives the clinician the ability to export STL

Volume 4 Number 5

The digital application differences As mentioned, there are many new

Orthodontic practice 47

TECHNOLOGY

where the teeth might move. I was estimating how much torque I’d need. I was guessing where the roots were…and so on. As I practiced orthodontics, I got better and better at “guesstimating,” but I was still engaged in a continual process of guessing and estimating, which is the fundamental dilemma facing the nondigital orthodontist. That doesn’t mean that excellent results aren’t possible with traditional non-digital treatment. It’s just the non-digital orthodontist has to work much harder to get the same result.

TECHNOLOGY files. From those STL files, a commercial lab prints models from which we fabricate our own aligners in-house. So for the first time in the history of our profession, we now have the ability not only to treat patients with labial appliances, lingual appliances, or aligners, but also to mix these modalities on the same patient with precision and accuracy. We are just beginning to explore the possibilities of this advance. Even so, I have found that all of these advantages have had an extremely powerful impact on the outcome of my cases and the overall operation of the office. Since becoming a completely digital practice (all full orthodontic cases), we have treated over 2,000 finished cases with an average treatment time of 14.1 months. This has been done with low stress and finishes that

overall are better than I was able to achieve conventionally. A revolutionary part of the SureSmile system is that it has now become cloudbased and is not connected to any system or in-house server. This even more effectively separates the diagnostics from the therapeutics. I can now work on patient diagnostics and “set up” from literally anywhere in the world (in the morning before skiing or before breakfast at the beach?). Once the case has been diagnosed and set up, I have little to do in the clinic except to say “hello” to the patient and observe that the case is on track. If a tooth or teeth are not moving as needed, I can easily go back into the computer to see what has been put into the case in the initial set-up and then order a wire set with the needed modifications. The reduction in

Figure 8A: Estimated surgical movements

stress and the freedom that this provides is remarkable. Let’s now follow a patient through treatment in the digital practice.

The new patient experience The website has become the new reception room of the digital office. Because it now has such great influence on the patient’s first impression, we find that it must be inviting, informative, and provide ample reason to choose our office. Patients today are better informed consumers, and in an era of multiple opinions, we want the website to be attractive enough that they will want to check us out even if they have already visited other offices. When patients call, we always direct them to our website if they haven’t already visited it (many already have done so). There they have

Figure 8B: Postsurgical simulation anterior

Figure 8C: Postsurgical simulation left

Figure 8D: Postsurgical simulation right

Figure 8E: Simulated facial changes in Dolphin Imaging

Figure 9: Ideal bracket position set up to make IDB trays

Figure 10: Maxillary spaces closed and patient is scanned into SureSmile using a CBCT

Figure 11: Tooth movements can be separated from surgical movements

48 Orthodontic practice

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Figure 12A: Lower oclusal presurgical wire

philosophy of treatment, and why we do things differently. I go over the concept of digital orthodontics using SureSmile. I show him/her how it allows me to better see what’s going on (Figure 4), how I can see the initial and target position of the roots (Figure 5), and exactly where we want the teeth to fit when we are finished (Figure 6). I discuss how this technology can reduce the guesswork inherent in orthodontic treatment. We then discuss the impact that I feel it has on his/her long-term dental health and the stability of treatment. I note that these are targets, and we may not get these exact positions: however, the more precise the target we have, the better the chance of achieving it. This is a short, but impactful discussion. I find that the majority of patients “get it” and, because I take the time to explain what I feel are the advantages of our digital approach, they

Figure 12B: Presurgical wires anterior

Figure 12D: Presurgical wires right

Figure 13A: Postsurgical wires anterior

Volume 4 Number 5

Figure 13B: Postsurgical wires left

are more willing to invest in treatment. It’s only after this discussion takes place that the TC takes over.

Co-diagnosis/treatment planning This 21-year-old patient presented with a Class III skeletal malocclusion (Figure 3). Since she was very concerned with cosmetics, we discussed the possibility of clear aligners, but recommended the option of lingual treatment (lingual upper, ceramic lower brackets) for improved control, which she readily accepted. Since, we had already discussed the need for surgery, we now engaged the oral surgeon and the restorative dentist with the patient. I term this the co-diagnosis and treatment planning, since it’s important for all the members of the treatment team to provide their individual diagnostic input in mutually developing a treatment plan. Using the

Figure 12C: Presurgical wires left

Figure 12E: Upper occlusal presurgical wire

Figure 13C: Postsurgical wires right

Orthodontic practice 49

TECHNOLOGY

the opportunity to see in more detail what we are all about. Moreover, they can fill out their forms online or print them to bring to the new patient visit. When they arrive, they are cordially greeted, offered refreshments, and taken for a brief tour of the office. Before the actual examination, I perform a quick evaluation and tell the technician which records will be needed. After the examination, we bring up the patient’s records on a large, wall-mounted monitor where we go over the conditions I see and then discuss my recommendations for treatment (Figures 1, 2, and 3). This is where most offices would pass the patient over to the treatment coordinator to go over the financials to ask if the patient wants to start — and where we deviate from the typical exam protocol. I take the time to personally discuss my

TECHNOLOGY

Figure 14: .016 x .016 robotically formed CuNiti and Class II elastics

Figure 15: Patient is ready for surgery

robust treatment planning tools of Dolphin Imaging and in the SureSmile program, we can quickly and easily explore multiple treatment options by emailing images or in real time using a web based program like GoToMeeting (Figures 7 and 8). While bimaxillary surgery was an option, after discussion with all involved, a mandibular set back was decided upon. This would be followed with the placement of implants in the lower buccal segments.

Lingual surgical treament with SureSmile Lingual SureSmile Lingual has truly made lingual treatment easy. The main problems traditionally associated with lingual therapeutics are: 50 Orthodontic practice

1. Tying in the wire - due to limited access 2. Bending wires - due to variable lingual tooth morphology 3. Difficulty seating the wire - due to small interbracket distances 4. Arch coordination - when only upper lingual is used. These challenges have all been overcome with SureSmile Lingual. Because the system is not bracket-specific, we are able to use a SL bracket (In-Ovation速 L, GAC) and avoid the hassle of tying-in on the lingual. Since the wires are bent robotically, in all three dimensions, the issue of wirebending is eliminated. Moreover, SureSmile provides a wide selection of materials and sizes for these robotically-bent wires. The option of using a custom robotically-

bent CuNiTi wire greatly reduces difficulty seating the wires. Coordinating the arches is no longer an issue with the SureSmile system, since we can use labial brackets on the lower and lingual on the upper arch, and easily coordinate the two. As was previously mentioned, the software even gives us the ability to combine limited aligner therapy on one arch with brackets on the opposing arch, easily coordinating the two. After the treatment plan was agreed upon and insurance coverage had been preauthorized for the surgery, the treatment was begun on April 19, 2011 by placing .018 ceramic brackets on the lower arch. We then placed a .016 x .016 NiTi. Chain was used to begin space consolidation and Volume 4 Number 5

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TECHNOLOGY

Figure 16: Finished treatment

Figure 17: Posttreatment cephalogram

Figure 18: Posttreatment pan

also to begin rotating the severely rotated right second bicuspid.

a very exact set of movements both preand post-surgery, and both pre- and postsurgical wires can be designed (Figures 12 and 13). While there are few, if any, of these movements in most BSSO surgeries, there can be many of them in a three-piece LaForte which, if not removed, can create serious problems in finishing the case. You will notice that the mandibular right second bicuspid does not have a bracket on the virtual models, as that tooth was still being rotated. Once rotated, a bracket will be placed and a local scan of three teeth will be taken to determine bracket position. Any further wires ordered will contain bends for that tooth. On September 6, 2011, the first SureSmile wires were placed: a .016 round CuNiTi robotically-bent wire on the lingual of the upper arch and a .016 x .022 robotically-bent CuNiTi labially on the lower arch. They were both bent to the pre-surgical dimensions. On December 6, 2011, the lower right second bicuspid was sufficiently rotated to allow for bracket to be placed. A quick three-tooth scan was done to pick up that tooth and new .016 x .022 wire was ordered. On January 9, 2012, the new .016 x .022 roboticallyformed CuNiTi was placed in the lower arch: enough movement had occurred on the upper to allow the placement of the next larger wire, which was a .016 x .016 robotically-formed CuNiTi. At this time, the patient was wearing Class II elastics to achieve the incisor positions that were planned in the virtual set-up (Figure 14). On April 10, 2012, the upper arch was ready for the insertion of the roboticallybent .016 x .022 CuNiTi. The patient was ready for surgery in June (Figure 15). However, her schedule dictated that it be done on August 15th. In order to facilitate intermaxillary fixation, buttons were bonded to the buccal of the maxillary teeth for elastics post-surgery. The postsurgical

occlusion was so good that no additional wires were needed to finish this patient’s treatment (Figures 16, 17, and 18).

Simulation for lingual bracket positioning Since most of our patients have lingual upper and ceramic lower brackets, our usual protocol is to place the lower appliances first, and at the same visit, scan the patient using the intraoral scanner or scanned study models. It’s extremely important in lingual treatment to get the brackets placed so that bends are minimized in the arch wire. SureSmile Lingual gives me the ability to create a simulation with ideal tooth positions. I can then place virtual brackets on the teeth, position them to minimize wire bends and then create bonding trays to get perfect bracket positions (Figure 9). On May 24, 2011, the patient’s upper lingual appliances were bonded, and a .016 NiTi mushroom arch was placed with chain from molar-to-molar to initiate space consolidation. On July 20, 2011, a CBCT was taken to create the virtual models so that all movements — both dental and surgical — could be planned and built into the robotically-bent arch wires (Figure 10). In our digital practice, this is the time when I do most of my work on the case. I complete a detailed prescription checklist, which the digital lab technician at OraMetrix uses to design the therapeutic set-up. I will then check it and make any needed modifications. Once that is completed, and I am satisfied with the set-up, I will order the initial wires. If time is taken at this step to get it right (approximately 15 to 20 minutes), the treatment is effectively on “auto-pilot,” and it’s is just a matter of checking progress and visiting with the patient. Since surgery was to be performed, two set-ups would be created, one presurgical and one postsurgical, removing any special movements needed prior to surgery, from the postsurgical set-up (Figure 11). This provides 52 Orthodontic practice

Conclusion The total treatment time for this patient was 20 months, 2 months of which the patient was in holding pending the scheduling of her surgery. While the patient spent time in the chair, the majority of my work as the orthodontist was done at a different time and place. Of particular note is that there were no brackets repositioned, nor did I ever pick up pliers to adjust a wire during treatment! In effect I now have two practices, a digital practice and a clinical practice. Our systems had to be adjusted to accommodate this new practice model, and the result of this effort has been more than worth it. This is exemplified in the patient experience. The digital systems facilitate information transfer so much more easily and effectively. Treatment proceeds quicker (there is no need to reposition brackets) and more easily for both them and us. Along the way, they can see our proposed targets and even be involved in their development. Finally, after appliance removal, we can create digitally-formed retainers, which are also aligners, to make any post-treatment adjustments. We are just beginning to see the changes these new technologies are bringing to the practice of orthodontics. Digital technology enhances our ability to engage the patient in the treatment process at a much higher level. It creates the opportunity for more effective communication and clearly established goals. As a clinician, it empowers me to achieve these goals more precisely, efficiently, and comfortably than ever before. In addition, it provides a unique opportunity to better differentiate our practice. Change is good! OP Volume 4 Number 5

New to Digital? It’s not new to us.

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Choosing the right digital solution doesn’t have to be complicated. Great Lakes will get you up and running with an intraoral scanner, 3D printer, or desktop scanner that’s right for your orthodontic practice. We’ve done the homework for you. We know digital. For years, Great Lakes has been immersed in digital technology– from appliance fabrication to offering digital lab services. We are confident we’ve selected the best digital solutions for our customers. One source for everything Great Lakes is the only distributor to offer a full-line 3D solution for orthodontic practices and labs. We represent products from industry leaders including the 3Shape TRIOS® Intraoral Scanner with Ortho Analyzer™ software and the Objet30 OrthoDesk printer from Stratasys. We also carry the 3Shape R700™ and Maestro desktop scanners.

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igital technology is rapidly changing the orthodontic landscape, offering new opportunities for improved patient care and efficiency in a competitive market. More and more orthodontists are investing in digital impression systems to increase efficiency and to offer patients a positive experience that fosters referrals. However, faced with this huge commitment and investment, many orthodontists are feeling the pressure of making the right decisions for their practice. Devoting the time to sort through the growing number of technology options can be daunting.

Complete 3D resource One company that is simplifying the process for orthodontists is Great Lakes Orthodontics, Ltd. In fact, they are the only distributor to offer a full-line 3D solution for orthodontists and labs. According to company President James R. Kunkemoeller, Great Lakes has been using digital technology since 2006. Volume 4 Number 5

“We’ve been digitally fabricating appliances for almost 8 years, and also offer comprehensive digital lab services to our customers,” says Kunkemoeller. “We know digital. We’ve done the homework and are confident that we’ve selected the best digital solutions for orthodontists and their labs.” According to Kunkemoeller, Great Lakes represents 3D solutions from industry leaders including the 3Shape TRIOS® Intraoral Scanner with Ortho Analyzer™ software and the Stratasys Objet30 OrthoDesk printer. The company also carries Maestro and 3Shape R700™ orthodontic desktop scanners. “There are a lot of choices out there. We systematically narrowed those choices for our business, and now we’ve done it for our customers,” comments Kunkemoeller. “The digital technology we recommend is the technology we use. It’s the best of the best.”

Your digital solutions partner

Total assistance from selection through installation Great Lakes’ knowledgeable staff works closely with each customer to understand their goals and ensure their digital needs are met. Once the appropriate equipment is selected and delivered, an on-site technical team gets customers up and running, quickly and smoothly. According to Kunkemoeller, transitioning to digital requires a substantial commitment and investment for doctors and labs. “We want to help our customers succeed. We are here for them through every step of the process,” says Kunkemoeller.

Digital hands-on seminars Great Lakes is bringing their digital product line to major U.S. cities to provide orthodontists and labs with a hands-on learning experience. The schedule can be viewed at www.digitalortholive.com. OP To learn more about this digital technology, visit www.digital-ortho.com This information was provided by Great Lakes Orthodontics, Ltd. Orthodontic practice 53

TECHNOLOGY

The art of orthodontic efficiency Dr. Neil Warshawsky discusses the speed factor in orthodontics

a Vinci would be proud of my palette — and I don’t mean the one attached to my teeth. I can honestly say that nothing that I do today on a regular basis is what I learned when I was in residency. I trained in .018 twin brackets with no pre-programmed movements; now I’ve migrated to a .022 system that is self-ligating with an MBT-like prescription. Over the years, I started to develop “my style” and honed it to make my practice stand apart from others. I made sure that our facilities were modern, clean, and architecturally open. I then focused on technique and made it my priority to learn esthetically desirable mechanics to attract a crowd that would demand no less than the best for themselves or their children. I focused on efficient bracketing systems from the labial as well as the lingual, in addition to offering a multitude of clear aligner choices. The key to success in this business is having a palette of choices to choose from, as not everyone will be able to fit one mechanical solution or within a certain price range for their orthodontic needs. I have always been an early adopter and have been fortunate that most of my decisions have been favorable. I practice in the highly competitive Chicago area, and between the 2008 economic downturn and increased competition from local orthodontics and dentists, I realized that it was time to reinvent our team’s image to give patients a

Neil M. Warshawsky, DDS, MS, PC, is a Diplomate, American Board of Orthodontics. He attended the University of Illinois where he earned five college degrees in 9 years, concluding with his certificate in orthodontics. Dr. Warshawsky has over 20 years of experience working with cleft lip and palate patients and is an Associate Professor of Orthodontics at the University of Illinois Craniofacial Team. He sees a high percentage of adults and is an advocate for team dentistry in multidisciplinary cases. He speaks worldwide on various topics including but not limited to lingual braces, integrating technology and esthetics, and aligner therapy. He has been interviewed in numerous journals and newspapers, contributed to a variety of national and international dental journals, and has presented over 130 programs to dental groups all over the world. Dr. Warshawsky is a key opinion leader and a consultant for OrthoAccel Technologies, Inc.

54 Orthodontic practice

Initial

4 Weeks

strong reason to choose my practice, “Get It Straight Orthodontics,” for their needs. As the economy declined, I invested in upgrading equipment and facilities, as well as taking the opportunity to train my staff to be practice “ambassadors.” Truth be told, we are not perfect; however, we have created a caring atmosphere that is both supportive for the patients’ needs as well as nurturing for the staff’s ability to grow and mature. It was about this time that I started to realize that our patients were reinventing how they found us as well. I always ask patients how they find my practice, and many say they were referred by their dentist or a friend. The Internet also plays a large role in how patients choose our practice, specifically for those who I call “digital omnivores,” (those who own a smartphone, tablet, and/or computer) who I look for to choose our practice. This new breed of patient records their orthodontic experience and broadcasts it on channels like YouTube, Facebook, and LinkedIn. They praise as well as criticize using sites such as Yelp, which never happened in orthodontic school! If I do a great job for someone, he/she will advertise my practice for free, and that type of exposure is immeasurable.

The speed factor: an analysis of alveocentesis, accelerated osteogenic orthodontics, and AcceleDent® So, we have now altered our approach to selling orthodontics, which includes

9 Months

enhancing our listening skills. I ask a lot of questions and take several pictures to quickly convey to patients the importance of orthodontics. Utilizing visual treatment objects, we hone our treatment objectives to ensure we do what our patients ask of us. With this in mind, I have broken my consultation down into four areas: esthetics, comfort, cost, and speed. I am concentrating on the speed factor for this article and will provide analysis of some of the options we offer patients to shorten treatment time up to 40%: customized brackets and wires, minimally invasive procedures, full periodontic surgery, and a new medical device called AcceleDent.

Alveocentesis Invasive procedures change the actual physiology of the bones surrounding the Volume 4 Number 5

Accelerated Osteogenic Orthodontics (AOO) aka “Fast Ortho” and Wilckodontics AOO is full periodontic surgery and involves a full flap thickness to expose the area in question, surface trauma to get the area to respond in the desired manner, and demineralized freeze-dried bone graft to augment the area of surgical interest.4 This procedure certainly is not for everyone. However, my palette of choices allows me to combine multiple techniques such as custom-made braces with AOO to get more efficient results than using braces alone to accelerate a case.

AcceleDent® AcceleDent by OrthoAccel® Technologies, Inc., is an FDA-cleared, Class II medical device that offers an attractive choice for patients who want to accelerate their

orthodontic treatment. Unlike the other options mentioned above, AcceleDent is simple in that it is not permanent, has no negative side effects, and has the ability to work with any type of orthodontics. Patients are only required to gently bite on the mouthpiece for 20 minutes daily. This approach has led to some wild success stories for our practice. One patient in particular was referred to me for a second opinion consultation by both his dentist and wife, who was a former patient of mine as well. The husband is congenitally missing teeth Nos. 7 and 10, and in addition to his anodontia, his remaining teeth are mildly undersized. His true complaint was his conscientiousness about his smile because he hardly shows any teeth. His original orthodontic recommendation was to close the spaces where tooth Nos. 7 and 10 were congenitally missing and to have a dental substitution placing the canine in the lateral incisor position. The treatment plan that my patient opted for was to return the canines to their correct position and create two implant sites. Due to the nature of his job, my patient said it was necessary to have lingual treatment; however, given the difficult nature of that task, I convinced him to augment mechanics with bilateral TADs and AcceleDent.

After almost 3 months of movement with AcceleDent, the pontic spaces were evident but not completed. I was impressed that the teeth moved back as quickly as they did. I understood that the canine roots still had a mild amount of movement left, but what I was not prepared for was my patient telling me that he had no discomfort at all because the AcceleDent device also relieved his sensitivity. After approximately 9 months, the spaces were generated for proper and safe implant placement. It was tight but acceptable, and the periodontist informed me that he could place the fixtures. The patient is currently awaiting final integration of his implants. The image on the previous page shows him initially on the left, 4 weeks into treatment and then 9 months after the treatment initiation when the implants were placed.

Conclusion Today’s patients are very different from those two decades ago. They come into our offices with preconceived notions and want to dictate the mechanics and the speed at which it runs. As a result, I feel that today’s progressive orthodontist should possess an array of choices so that he or she can customize the work to the patient’s desires. Products such as AcceleDent by OrthoAccel Technologies enable professionals, including myself, to not only provide service that the patient desires, but to do so in a manner that exceeds both the doctor’s and the patient’s expectations. In today’s economic climate where competition is high and many dental professionals are now offering orthodontics, this could well be the game changer you have been looking for to both set yourself apart from your competition and to continually grow your practice in the future. OP References 1. Frost HM. The regional acceleratory phenomenon: a review. Henry Ford Hosp Med J. 1983;31(1):3-9. 2. Frost HM. Vital biomechanics: proposed general concepts for skeletal adaptions to mechanical usage. Calcif Tissue Int. 1988;42(3):145-156. 3. Shih MS, Norrdin RW. Regional acceleration of remodeling during healing of bone defects in beagles of various ages. Bone. 1985;6(5):377379. 4. 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.

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teeth. Alveocentesis is the process in which bone is locally traumatized specific to an area where you desire to facilitate tooth movement. The process produces a regional acceleratory phenomenon, aka “RAP” zone1, causing the bone to soften in response to the attraction of cytokines and the activation of bone remodeling.2,3 The process effectively stabs the bone in a transmucosal manner and is repeated approximately every 8 weeks.

PRODUCT PROFILE

Reliance Orthodontic Products addresses today’s problems with effective solutions An effective solution to a common problem with pontics in orthodontics

ith an increasing number of orthodontic offices implementing or currently using CAT (Clear Aligner Therapy) with selected patients, many unique but minor problems have been discovered. How can you maintain patient esthetics if a tooth is missing or lost during treatment? Various solutions have been used to create a missing tooth in the aligner, but they have met with limited success.

Reliance Orthodontic Products has introduced an effective and simple solution to this problem – Perfect A Smile™ Developed by Orthodontist Dr. Laurel Martin of Longmont, Colorado, Perfect A Smile is a “pontic paint” that is applied to the inside of the aligner tooth socket of the missing tooth. Perfect A Smile is a light-cured pontic paint that comes in three popular generic shades – light, medium, and dark. It cures and bonds directly to the aligner plastic. Typically, three coats are applied to the facial, mesial, and distal surface of the tooth socket to achieve the proper color shade and coverage. Each coat is light cured. Perfect A Smile can completely change the way you address retention and esthetics of missing teeth in your practice. It can provide a simple, efficient solution for patients going through grafting and implant procedures. Oral surgeons and restorative dentists will be pleased with the lack of adjustment and pressure on grafting sites. For patients who have discolored, fractured, or worn teeth, Perfect A Smile will provide the esthetic solution they’ve been looking for. Additionally, patients will be more inclined and motivated to wear their aligner to avoid an embarrassing “toothless” grin.

Yes, you can successfully bond attachments to aligner plastics! If you use clear aligners in your practice,

56 Orthodontic practice

Before and after: Clear aligner painted with Perfect A Smile

you may find the need to bond attachments directly to the aligner, which, up to now, has been very difficult. Bond Aligner™ from Reliance Orthodontics is the answer!

Bond Aligner will bond all attachments to any clear aligner materials, including Essix® ACE®, Invisalign®, Invisalign® Smart Track,™ and Tru-Tain™ material, excluding Essix C+®, Invisacryl™C, and Biocryl C®. Perfect A Smile bonds to thermoplastic aligners with no primers or matrix preparation needed! The low modulus of elasticity allows Bond Aligner to flex with the plastic, assuring a secure bond without failures. Plus, bonding attachments to aligners opens up many new tooth moving capabilities that weren’t previously possible with clear aligners. Bond Aligner is available in 1.5 g syringes and includes five disposable tips.

Finally – nickel-free wire for bonded permanent retention with Retainium RETAINIUM™ from Reliance Orthodontics takes bonded lingual retention to a new level. Made from a single flat rectangular (.010 x .028) titanium wire, RETAINIUM is nickel-free, strong, takes bends in both horizontal and vertical dimension with ease, and is comfortable for the patient. RETAINIUM addresses today’s requirements for the ideal lingual retention wire with Reliance innovation and value. Each tube contains 10, 6-inch wires.

For more information, please call 800323-4348 or visit Reliance Orthodontics’ website, relianceorthodontics.com. OP This information was provided by Reliance Orthodontic Products.

Volume 4 Number 5

PRODUCT PROFILE

H4™ Self-Ligating Bracket System

uilt from the ground up, the H4™ is Ortho Classic’s new Self-Ligating Bracket System that has been designed to be efficient and predictable for the clinician, as well as comfortable and hygienic for the patient. Ortho Classic® and its parent company, World Class Technology™, have been designing and manufacturing orthodontic products in America for over 22 years. Advancements in technology have given them the opportunity to produce some of the highest quality and consistent brackets possible. These years of experience have resulted in the next generation of selfligation; the H4™ bracket system. The H4™ bracket is a one-piece base metal injection molded (MIM) part. The benefit of a bracket that has been produced using MIM technology is twofold. Ortho Classic’s® MIM process has a +/- tolerance of .0008; meaning that every part is near perfect and consistent to the design and mold. For the doctor, this translates into a bracket that will provide reliable and predictable results for each and every case, reducing the amount of “finishing” work that needs to be done. The second benefit of a one-piece base MIM bracket is that the clinician will have zero pad-to-body separation or inconsistences. This leads to optimum pad-to-tooth fit and bond strength. The overall design of the H4™ bracket has been calibrated to provide optimum results. A precise slot depth provides improved three- to four-point rotational and torque control. The H4’s™ patent pending door slides and locks into both open and closed positions. Minimal mesialdistal width on the door and slot adds an increased interbracket span to fully express the wire. There is a scribe line molded into the door and bracket body for improved visual bracket placement. The need to support early elastics has also been taken into consideration for the H4™ bracket system. It has been designed to have an excellent tie-wing area that can support early elastics, ligatures, metal ligatures, and power chain. The smooth, rounded contours and tight tolerances of the H4™ bracket are clinically proven to be more hygienic and repel plaque. The smoothness of the bracket and its Volume 4 Number 5

Built from the ground up, the H4™ is Ortho Classic’s new SelfLigating Bracket System that has been designed to be efficient and predictable for the clinician, as well as comfortable and hygienic for the patient.

low-profile has also proven to be more comfortable for the patient. Ensuring full control, torque is built into the base of each H4™ bracket and anatomically contoured (mesial-distal/ occlusal-gingival) for accurate placement on each tooth. The H4™ brackets have been engineered with precise angulation, placing the long axis of the root distal to the occlusal portion of the crown and all roots to align parallel. The anatomically contoured design permits precise bracket placement with all slots aligning at the end of treatment. The one-of-a-kind, patent pending, Treadlok™ pad is a completely new and exciting improvement of pad retention technology. Not unlike the tread of a quality car tire, the Treadlok’s™ open flowing channel design allows air bubbles to escape, promoting maximum bond strength and multidirectional sheering protection. By utilizing the Treadlok™ pattern, the H4™ brackets adhere easier, with a stronger bond, minimizing bond failures. The Treadlok™ pad makes repositioning of the bracket easier than ever too. A debonded bracket will leave the majority of the adhesive on the tooth minimizing enamel fracturing and eliminating the need for micro-etching the bracket. OP This information was provided by Ortho Classic. Orthodontic practice 57

BOOK REVIEW

Orthodontics, Volumes I, II and III by Dr. Chris Chang and Dr. W. Eugene Roberts

rs. Chris Chang and W. Eugene Roberts have combined their unique and distinctive talents to produce the most remarkable and extraordinary texts orthodontists have ever seen or profited from. By using the e-publishing software iBooks® Author developed by Apple, they have combined narratives, photos, videos, video interviews, and illustrations into an instrument of learning that not only informs and astonishes the reader but supplies professional knowledge that is fun to absorb. For example, it is one thing to read about, and dread the placement of, a Zygomatic Temporary Anchorage Device or even see isolated photographs of a technique, but it is an altogether magnified experience to see a clinician complete the procedure in a video in less than 1 minute. These graphic illustrations, supplemented by a live video of the clinical procedure, mitigate any doubts and confusions one might have about the method. Ad executive Fred Barnard first published in the San Antonio Light in 1918 the well-known aphorism, “A picture is worth a thousand words.” Barnard later attributed the aphorism to Confucius because he thought people would pay more attention to it, and, of course, they did. If that epigram is true, then the publications Drs. Chang and Roberts have developed must be worth millions of words. These volumes provide orthodontic clinicians with the most lively and responsive features yet produced in orthodontic literature. The excellent therapies displayed in these interactive productions must have taken enormous skill, patience, and exquisite judgment. No current orthodontic tome can equal the unsurpassed illustrations, clinical photos, and a myriad of video sequences collected in these three books. It is nothing less than a professional triumph of publication imagination and creativity, and they deserve inclusion in every orthodontic library. These iBooks are also available in hard copy editions with familiar photos, narratives and illustrations, but these lose the interactive energy, liveliness, and 58 Orthodontic practice

portability the iBooks offer on an iPad®. Nevertheless, for those who prefer holding a book and turning pages, that option is accessible. However, by just using a swipe of the finger on an iPad to move from written narrative to illustration and then to video or to bibliography offers a completely up-todate and boosted learning experience. Volume I is intended as a clinical atlas that demonstrates innovative approaches to diagnosis, treatment, and evaluation of treatment outcomes. The first three chapters describe the use of the American Board of Orthodontics’ prescriptions for evaluating the complexity of malocclusions and gauging the treatment outcomes. All of the included therapies of this book are subjected to the ABO evaluations, which makes them even more impressive. Following chapters deal with palatally impacted canines, scissor bites, bimaxillary protrusions, high maxillary canine impactions, treatment of high angle malocclusions, low angle malocclusions, anterior crossbites, and Class III skeletal malocclusions. Volume II’s first four chapters deal with various Class III malocclusions and their successful therapies. The next two chapters deal with treatments for open bites, while the next four chapters offer therapies for Class I and Class II deep overbites. Four chapters offer readers detailed descriptions of soft tissue treatments for subperiosteal grafts and impacted teeth. The final two chapters furnish users with more applications of TADs.

Each chapter is accompanied with ample bibliographies and tests at the conclusion of the chapters to give feedback regarding the learning accomplished. Volume III has additional authors, Drs. John Lin and Johnny Liao, and this volume dedicates itself exclusively to the diagnosis, treatment planning, and therapy for Class III malocclusions. The first chapter wisely contributes a most practical and useful recommendation for accurately diagnosing and treatment planning for Class III patients. This is followed by treatments for Class III siblings and therapies for twins with skeletal Class III malocclusions. Succeeding chapters deal with Class III open bites, asymmetries, hyperdivergent mandibles, retraction of molars in all four quadrants, early interventions in Class III patients, and the paradigm shift that TADs now offer the profession, among other topics. The astounding therapies in these books are nothing short of staggering and set a new standard for orthodontic clinicians and their patients. Jacob Bronowski once said in The Ascent of Man, “The strongest power in the ascent of man is his pleasure in his own skill. He loves to do what he does well, and having done it well, he loves to do it better.” Drs. Chang, Roberts, Lin and Liao have certainly shown the profession how to do it better. OP Review by Larry W. White, DDS, MSD For more information on these books, email info@newtonsa.com.tw. Volume 4 Number 5

IN MEMORIAM

Dr. Craig Andreiko, noted innovator and educator, dies at 63

ith the death of Dr. Craig A. Andreiko on Sunday, August 25, 2013, the orthodontic profession lost a gifted innovator who transformed orthodontics. His career at Ormco Corporation spanned 43 years, lastly as Technical Director, New Product Development. He was 63 years old. With 74 assigned or pending patents, Dr. Andreiko’s inventions are mainstays in today’s orthodontic practices: anatomically-based arch forms, early lightforce wires, braided archwires, and brazed mesh for weld-free pads on direct-bonded brackets, which so greatly improved bond strength that clinicians felt comfortable switching from banded to direct-bonded brackets. According to Dr. David Sarver, “Eliminating bands meant we could treat crowding without having to account for the 7 mm or so of space that bands created, expanding exponentially the option for treating cases in a nonextraction manner. Mesh was a game changer, and it was Craig’s vision that made it happen.” He also invented Orthos®/Titanium Orthos® and Insignia™ Advanced Smile Design™, a comprehensive digital treatment solution with customized brackets, wires and placement trays. He was intimately involved in early lingual appliances, the T.A.R.G. setup method, and the development of the rhomboid shape for brackets. He revolutionized heart therapy by writing the code for and developing a catheter for Edwards Lifesciences. Vicente Reynal, Ormco President, witnessed Dr. Andreiko’s value firsthand saying, “I feel honored to have worked alongside such an amazing person. I will never forget brainstorming new technological advances. More importantly, I will never forget how incredibly humble he was. I know that Craig’s spirit and determination will always be with us.” Dr. Larry White, clinician and past editor of the Journal of Clinical Orthodontics, commented: “My friend Craig had the passionate intensity of a pioneering savant Volume 4 Number 5

“He was a giant in the profession whose intellectual capacity was matched only by the size of his heart.” that fueled his imagination and creativity and which, subsequently, resulted in a myriad of inventions that benefited us all.” Dr. Steve Tracey’s sentiments summed up the general consensus of opinions about Dr. Andreiko, “The thing I admired most about him was his selflessness. Of all the amazing things he did, I never saw him worry about getting credit. He was a giant in the profession whose intellectual capacity was matched only by the size of his heart.” After receiving his dental and orthodontic education at Loma Linda University, Dr. Andreiko served as assistant

clinical professor there from 1994. He was the author of numerous research studies and papers, was inducted into Omicron Kappa Upsilon in 2010, and was a PADI Master Scuba Diver who produced underwater adventure videos. Dr. Andreiko is survived by his wife of 39 years, Jean; son, David; daughter, Sarah; father, Andy, former President of Ormco; brother, Scott; and sister, Jody. A celebration of his life was held in late September. Charitable gifts can be made to the USC Norris Comprehensive Cancer Center, Office of Development, 1441 Eastlake Avenue, Room 8302, Los Angeles, CA 90033. OP Orthodontic practice 59

PRACTICE DEVELOPMENT

Apply current tax laws to improve patient care Bob Creamer explains Section 179 and Bonus Depreciation

hriving dental practices understand that patients are the lifeblood of the dental practice. Indeed, without patients, a dental practice does not exist. Success is therefore determined by the quality of patient care provided and the overall patient experience. In the last decade, we have seen many important and amazing advancements in dental equipment that have assisted dentists in the delivery of ultimate patient care. One of the newest, but well-proven advancements is with 3D CBCT technologies. Investing in equipment and technology upgrades can provide a number of benefits for your practice – a competitive advantage, expanded services, improved efficiency, and overall patient comfort. These advantages can certainly make a difference to your bottom line, especially when you incorporate significant tax incentives for investing in your practice and yourself. In recent years, we have enjoyed a series of tax laws enabling dentists to take accelerated tax deductions when purchasing equipment and technology. A couple of tax code provisions that have been very beneficial to dentists are known as Section 179 and Bonus Depreciation. Both provisions allow for accelerated deductions even when purchases are financed. These laws are so advantageous that I am often asked, “Should I purchase some new equipment this year to help reduce taxes?” I trust their true objective in upgrading their practice is not to simply create a tax deduction, but rather to provide better services and improved care. Patients recognize and appreciate the dentist who makes patient care the focal point of the practice. During the recent

Bob Creamer, CPA, is president of the accounting firm Creamer & Associates, PC, specializing in financial and retirement planning, dental transitions, practice enhancement, wealth creation, tax savings and related services. He is also a founding member of the Academy of Dental CPAs. Bob can be reached at 800-248-1120 or Bob@bestcpas.com.

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struggles in our country’s economy, I witnessed that dentists who invested in their practices to improve the quality of care they provided, attracted a loyal patient following and a market share that continued to increase even while others struggled. It is with these practices that patients were willing to spend their precious dental dollars. However, investing in the practice provides a reward for dentists far beyond income and tax deductions – the peace of mind of knowing that they are delivering the highest level of patient care possible.

Section 179 and Bonus Depreciation Section 179 of the IRS Tax Code was introduced as a way to stimulate the economy by allowing business owners to deduct the full cost of a qualified asset in the year it is acquired, rather than spreading deductions over the normal depreciable life or many years. During its early years, Section 179 allowed a maximum accelerated tax deduction of $10,000 to $24,000. This amount has varied as needed to spur

Volume 4 Number 5

economic growth, and was increased to a very generous $500,000 maximum deduction in 2010 and 2011. That amount dropped to a $139,000 deduction for 2012, but was retroactively raised after the first of this year back to $500,000 for tax calculation purposes for 2012. Additionally, the maximum deduction for Section 179 for 2013 was originally set at $25,000. However, during Congressional wrangling early in the year to address the ominous “fiscal cliff” predictions, Congress adjusted the law to again allow a maximum Section 179 deduction in the amount of $500,000, with a spending cap of $2,000,000 before phase-outs begin. Looking ahead, the law as currently written (as of the writing of this article) has deduction limits scheduled to drop all the way down to $25,000 for 2014, unless Congress acts to change the law and keep the deduction limit elevated. Therefore, there may be a drastic reduction in deduction limits for those who wait until next year to make their purchases. Section 179 provides tax incentives for purchasing both new and used equipment and technology. The complementary

Bonus Depreciation provides incentives for new purchases only. For new equipment and technology purchases in 2013, a dentist can take a 50% Bonus Depreciation deduction on all purchases without purchase limitation. While Section 179 has a $2,000,000 cap with a dollar phase-out for every dollar spent over the cap, Bonus Depreciation has no spending cap. Unlike Section 179, which is scheduled to simply be reduced, Bonus Depreciation is currently scheduled to end on January 1, 2014. Today’s tax laws allowing accelerated deductions have led many dentists to rightfully consider them as a key aspect of their yearly tax and financial planning. As the tax rates continue to increase, there is greater incentive to invest in yourself and your practice. In addition to tax laws that make practice investments attractive and accessible, historically low interest rates on equipment loans have made it easier to incorporate practice upgrades that may have seemed out of reach just a few years ago. While today’s accelerated tax

deductions can be highly advantageous from a business perspective, they are not permanent as I have already illustrated. When considering the forthcoming expiration or reduced deduction laws, and the recent significant tax rates increases for those making $250,000 or more, it certainly makes sense to invest in equipment and technology where needed. When you couple this with low interest rates, which may soon be on the rise, there seems to be a window of opportunity for dentists to make their purchases during 2013. I strongly advise my doctors to invest in their practices and purchase equipment and technology, provided it’s for the right reasons. After all, it is not tax rates, accelerated tax deductions, or even low interest rates that determine whether or not you need to invest in your practice, it’s the need to continually take extraordinary care of your patients. So if you need to invest to deliver the care you desire, why wouldn’t you take advantage of Section 179 and Bonus Depreciation to help you accomplish your professional goals? It only makes great sense! OP

Volume 4 Number 5 Orthodontic practice 61

PRACTICE DEVELOPMENT

Patients recognize and appreciate the dentist who makes patient care the focal point of the practice. During the recent struggles in our country’s economy, I witnessed that dentists who invested in their practices to improve the quality of care they provided, attracted a loyal patient following and a market share that continued to increase even while others struggled. It is with these practices that patients were willing to spend their precious dental dollars. However, investing in the practice provides a reward for dentists far beyond income and tax deductions – the peace of mind of knowing that they are delivering the highest level of patient care possible.

PRACTICE MANAGEMENT

New office or major renovation? Andrew Greene offers some tips to take the stress out of planning a new office

his article will provide some guidelines to keep in mind when planning to construct a new office or approaching a major renovation, as there are so many variables that need to be taken into consideration and addressed prior to making such a significant decision. Remember, real estate deals and construction projects are unique and usually have to go through a strenuous and detailed process to obtain a successful result. This article will highlight a number of items and tasks that should be addressed by you prior to launching into such a daunting project. They range from site selection, the hiring of architects and engineers, whether or not to use an interior designer, bidding out and selecting a contractor, and determining and purchasing the appropriate office equipment that best suits your needs. Let’s start with site selection. There are many wide-ranging issues that need to be considered from demographics to building type to rental rate to tenant improvement allowance. Keep in mind that as the real estate market fluctuates so does the rental rate, as well as the extent to which, if any, for the landlord to provide a tenant improvement allowance. As real estate markets change, it is important to keep in mind that while a large tenant improvement allowance is attractive (and quite helpful with the build-out of any project), one must be careful to analyze the real estate deal as a whole, taking term and rental rate into consideration. In some cases, it may be more beneficial for you, as the tenant, to take the space asis and borrow the money for your tenant improvements from an outside lender at a cheaper rate, because the landlord will amortize his tenant improvement costs and add to your rent payment. Once you have selected a location, it Andrew Greene currently serves as the Real Estate Manager at OrthoSynetics and has been with the company since 2012. He currently works and plays an active role in all aspects of the Real Estate Department, including lease administration, facilities management, and construction project management. Mr. Greene has over 5 years of real estate experience ranging from brokerage to property management. He received his Bachelor of Science in Marketing from the University of Kansas in 2007.

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is vital to hire the right people to assist you in the process. That ranges from architects and engineers to interior designers to contractors. All of these people will bring their specialty to the project and should be able to provide valuable insight. The right people will provide invaluable assistance to you in assessing the feasibility and associated costs of the project. The architects and engineers can work through a variety of items, including space planning, and working with the cities and states on codes and/or ordinance issues. This is an aspect of the project that is constantly changing, and it is important to be surrounded by a team with the required

experience and skill set to help you successfully manage the process. This will be illustrated in next issue’s article entitled, “Hard-piped Filtered Water System vs. Self-Contained Bottled Water System.” That article will explain how the code has evolved, and what processes and solutions have been put in place to satisfy certain requirements. It will also provide details about an issue that we have experienced as offices have flooded due to the manner in which they were originally set up. Interior designers can play an important role in keeping the branding of your practice in alignment with the marketing/advertising you chose in which to engage. There are many ways to incorporate this into the office, and with the help of an interior designer fresh ideas can be brought to the table. While marketing and advertising may be constantly changing, it is important that your branding remain consistent throughout your practice and within your office. You would be well served to select an interior designer who can work hand-inhand with your contractor in order to create a seamless transition from the design phase into the finished product. There are many contractors and construction companies available to you,

and it is critical to select the right one for you, taking into consideration price, scheduling, and specialties. Many jobs can be bid out to find the most competitive price to do the work. If and when doing this, it is very essential to have the contractors bid on exactly the same things (an apples to apples scenario). This can usually be achieved by providing architectural drawings and specific instructions. If the bids are inconsistent, you must determine where the differentiation occurred. Also, keep in mind that the cheapest bidder may not do the best work and that the most expensive bid may not meet your expectations. Remember to request references, and if possible, visit past projects they have done to appreciate the work they do. You will likely be in this office for a long time, considering the associated costs, and it is important that is done right the first time. The more you can learn about your options, the more successful your project will be. The equipment, both new and old, you will need for your office requires your careful attention when planning construction. How and where will all of your files, dental chairs, and particularly new X-Ray machine fit and be located? Consider carefully the size of the room, electrical needs, appropriate server and electrical configuration for your computer system, to name a few. Also, if you think you will be purchasing new equipment, you must keep that in mind during the planning phase and maybe incorporating those specifications into your plans. The list is long of doctors who have purchased new and often larger equipment such as X-ray machines only to discover they must spend thousands of dollars on renovation in order to have them fit in the proposed space. In conclusion, thoughtful and thorough planning, including site selection, lease terms, tenant improvement choices, financing, and choosing the most appropriate construction professions will maximize the result the new or renovated office will work best for you, your staff, and your patients. Failure to do so often results in a finished product you will have to put up with for years, and you could regret every day you walk through the door. OP Volume 4 Number 5

INDUSTRY NEWS

OrthoBanc makes Inc. 5000 fastest growing companies list for 5 consecutive years OrthoBanc, LLC, has been selected to be on Inc. 5000’s list of Fastest Growing Companies for the 5th year in a row. The Inc. 5000 list represents the most comprehensive look at the most important segment of the economy - America’s independent entrepreneurs. OrthoBanc provides payment management for thousands of orthodontists nationwide via monthly checking account or credit card drafting and also handles all follow up with the responsible party regarding failed payments, expired credit cards, etc. OrthoBanc, LLC, also owns two more brands – DentalBanc and PaymentBanc. DentalBanc provides payment management for dentists in the same way that OrthoBanc does for orthodontists. PaymentBanc is set up to handle any other industry that needs outsourced management of monthly, recurring payments – and is primarily serving the veterinary industry at this time. “Not all the companies in the Inc. 500 | 5000 are in glamorous industries, but in their fields they are as famous as household name companies simply by virtue of being great at what they do. They are the hidden champions of job growth and innovation, the real muscle of the American economy,” says Inc. Editor Eric Schurenberg. OP

MATERIALS lllllllllllll & lllllllllllll EQUIPMENT OrthoAccel® Technologies issued key patent for groundbreaking AcceleDent® technology that accelerates orthodontic treatment up to 50% With rapid adoption of new technology, AcceleDent is now available in 1,000 U.S. locations The U.S. Department of Commerce’s United States Patent and Trademark Office (USPTO) issued OrthoAccel Technologies, Inc., a patent for its hands-free AcceleDent, an FDA-cleared, Class II medical device designed for faster orthodontic treatment with only 20 minutes of daily use. AcceleDent was introduced to the U.S. market in 2012 and is now offered at over 1,000 orthodontic locations nationwide. A prescription-only medical device, AcceleDent is recommended by orthodontists who tout the device’s SoftPulse Technology™ that enhances movements directed by orthodontics and accelerates tooth movement. Orthodontists and staff members interested in learning more about AcceleDent Aura or how to offer the technology at their practice can locate an OrthoAccel sales representative at AcceleDent.com/ orthodontists or call 866-866-4919.

Introducing Hu-Friedy’s Clear Collection: a new line of clear aligner instruments Hu-Friedy announced the North American launch of the Clear Collection, a new line of Orthodontic Clear Aligner Instruments. Set to launch globally later this year, the Clear Collection, offers orthodontists four instruments that help accent, individualize, and optimize the biomechanics of clear aligners in the office. Due to the recent clear aligner trend in Orthodontics, Hu-Friedy in partnership with Hu-Friedy Thought Leader, Dr. S. Jay Bowman, DMD, MSD, designed the Clear Collection to help streamline the treatment process. Each instrument within the collection has a unique function that, when properly applied to clear aligners, allows for easier in-office adjustments and tweaks. Instruments include: • The Tear Drop - An instrument that creates a notch at the gingival margin of clear aligners where elastic hooks are required within the arch. It also provides a reservoir to hold the elastics in place, permitting easy manipulation of elastics by the patient. • The Vertical - Focuses on the over-correction of rotations by producing an indentation at the mesial or distal angles of a tooth. • The Horizontal - Creates an indentation to accent individual root torque. Retention of either the clear aligners or retainers is enhanced by placing this indent into a tooth’s undercut or below a bonded attachment. • The Hole Punch - Creates a half-moon cutout for relief of clear aligners around bonded buttons used for elastics. It also can nip away plastic to provide soft tissue clearance to prevent aligner impingement of tissue. For more information about Hu-Friedy’s Clear Collection, please call 1-800-HU-FRIEDY.

Volume 4 Number 5

Orthodontic practice 63

MATERIALS lllllllllllll & lllllllllllll EQUIPMENT Ormco Corporation reaches sales milestone of Lythos™ Digital Impression System

Products from Great Lakes Orthodontics, Ltd. ACU-flow™ Putty Impression Material ACU-flow™ Putty Impression Material is a dimensionally stable silicone material used for taking bite registrations, impressions, matrixes for temporary bridges, and indirect bonding of orthodontic brackets. This advanced formula technology hydrophilic vinyl poly siloxane can also be used to create a matrix for bondable lingual retainers. ACU-flow Putty Impression Material is easy to use, and has convenient mixing consistency with problem-free removal and perfect elasticity after setting. Includes Putty Catalyst (420g), Putty Base (420g), and two plastic scoops.

Ormco Corporation, a leading manufacturer and provider of advanced orthodontic technology and services, has reached a significant sales milestone for its Lythos™ Digital Impression System, which became commercially available in May 2013 and began shipping in late July. To date, the company has shipped more than 100 Lythos systems in North America and plans to start shipping to Europe and other parts of the world in the coming months. Ormco’s Lythos Impression System effectively harnesses the power of digital scanning to capture intraoral data with accuracy and ease of use. For increased patient and staff comfort, the lightweight and compact Lythos wand is ergonomically designed for the operator and allows for easy, painless access to the posterior of the mouth. Similarly, the unit weighs less than 30 pounds for convenient transport from operatory to operatory and features an easy-toclean touch screen for flexible viewing of models on screen and when entering patient data.

Invisacryl Ultra™ invisible retainer material Invisacryl Ultra™ is ultra clear, strong, durable, and stain resistant. Invisacryl Ultra is ideal for fabricating invisible retainers, and offers fast fabrication, uniform thickness, and consistent high quality. BPA and phthalate free, Invisacryl Ultra comes in 1 mm thickness round sheets, and is available in either 25 or 100/package quantities.

To learn more about Lythos hands-on demonstrations, please visit www.ormco.com/lythos.

Ultradent Products announces new whitening product: Opalescence Go Opalescence Go comes in an innovative, ready-made UltraFit™ tray that adapts instantly and comfortably to the teeth for a better fit and improved whitening experience. Opalescence Go provides powerful, professional whitening for the on-the-go lifestyle. The Opalescence Go 10% hydrogen peroxide gel allows for a 30-60 minute wear time with flavor choices of mint, melon, or peach. The 15% hydrogen peroxide gel is available in mint flavor and allows for a 15-20 minute wear time.

For more information, contact Great Lakes product customer service at 800-828-7626 or visit www.greatlakesortho.com.

The unique UltraFit tray material easily conforms to any patient’s smile and offers molar-to-molar coverage, ensuring that the gel comes into contact with more posterior teeth than before. For more information, call 800-552-5512 or visit www.ultradent. com.

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Volume 4 Number 5

ProMax® 3D 3D pan/ceph

Low-dose ProMax 3D Max image (21 uSv) *

Low-dose radiation • Using the ALARA (As Low As Reasonably Achievable) radiation safety principle as a key design concept, ProMax enhances patient safety with features that minimize radiation dosage: - Horizontal and vertical segmenting tool and multi-bladed collimation focus radiation only to areas of interest - Pediatric mode reduces radiation by 35% • Pulsed radiation further lowers dose verses continuous exposure • Adjustable kV and mA to limit your patient radiation dose

Innovative technology • Patented SCARA arm allows unlimited movement to accommodate complex and unique jaw shapes

For a free in-office consultation, please call

• Delivered with feature-rich Romexis imaging software, or able to integrate with Dolphin, Ortho II, and other TWAIN compliant ortho imaging programs

1-855-245-2908

• Advanced imaging program includes improved interproximal pan program for better spacing and root positioning for TAD placement • Upgrade to 3D at any time and add functionality as you need it: - Impression scanning module - ProFace 3D facial photo option - And many more • Mac OS and DICOM compliant

or visit us on the web at www.planmecausa.com

PLANMECA® * Romexis 3.2 required

ORTHOPHOS XG 3D The right solution for your diagnostic needs.

Implantologists

Endodontists

Orthodontists will benefit from highquality pan and ceph images for optimized therapy planning.

will enjoy instantly viewable 3D volumetric images for revealing and measuring canal shapes, depths and anatomies.

will appreciate the seamless clinical workflow from initial diagnostics, to treatment planning, to ordering surgical guides and final implant placement.

General Practitioners will achieve greater diagnostic accuracy for routine cases.

ORTHOPHOS XG 3D

â&#x20AC;&#x153;With my Sirona 3D unit, I can see the anatomy of canals, calcification, extent of resorption, fractures, and sizes of periapical radiolucencies, all of which influence treatment plans for my patients. Combine that with the metal artifact reduction software that reduces distortions from metal objects, my treatment process is a lot less stressful. My patients benefit from the technology and my referrals appreciate the value.â&#x20AC;? ~ Dr. Kathryn Stuart, Endodontist - Fishers, Indiana

The advantages of 2D & 3D in one comprehensive unit ORTHOPHOS XG 3D is a hybrid system that provides clinical workflow advantages, along with the lowest possible effective dose for the patient. Its 3D function provides diagnostic accuracy when you need it most: for implants, surgical procedures and volumetric imaging of the jaws, sinuses and other dental anatomy.

For more information, visit www.Sirona3D.com or call Sirona at: 800.659.5977 www.facebook.com/Sirona3D