s • technology reviews
PROMOTING
EXCELLENCE
Incorporating TADsupported Haas expansion into everyday practice Drs. Ryan K. Tamburrino and Shalin R. Shah
A new regimen of Phase I care applied to potential maxillary canine impactions Dr. John Hayes
Corporate profile Ormco
Dr. Mark Reynolds
ORTHODONTICS
BioDigital Orthodontics: Diagnopeutics with SureSmile technology: part 3 Dr. Rohit C.L. Sachdeva
*Data on file.
Practice profile
IN
•
3D imaging for lower dose than a 2D panoramic * is not magic …it’s
May/June 2013 – Vol 4 No 3
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EDITORIAL ADVISORS Lisa Alvetro, DDS, MSD Daniel Bills, DMD, MS Robert E. Binder, DMD S. Jay Bowman, DMD, MSD Stanley Braun, DDS, MME, FACD Gary P. Brigham, DDS, MSD George J. Cisneros, DMD, MMSc Jason B. Cope, DDS, PhD Neil Counihan, BDS, CERT Orth 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
PUBLISHER Lisa Moler
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Forever a student of orthodontics
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hose of you who know me, or have heard me lecture, know that I have been a lifelong student of orthodontics. The goal to continually improve treatment techniques and final results is what keeps me excited and passionate about our wonderful profession. In fact, I can honestly say that in the past few months, I have worked harder than ever critically evaluating not only where we have been over the past 20 years but carefully analyzing where we need to go to keep improving the Damon System. In February 2013, it was very gratifying to host the 12th Annual Damon Forum in Orlando, which has become the largest privately sponsored orthodontic event in the world. The take-away from my presentation and others was encouraging clinicians to 1) keep it simple by utilizing “torquing couples” in each bracket/archwire interface that gives the clinician true straightwire with three-dimensional control, 2) focus on improving the quality of final results, and 3) to truly have fun. The significance of selecting “torquing couples” on each anterior tooth allows the clinician to gain first, second, and third order control with improved force management, increased patient comfort, and in many situations decrease treatment time for the patient. Today, we all live in a very complicated and busy world. I encourage clinicians to strive to have more fun running their businesses through improved clinical efficiencies and effectiveness. As a profession, we have often evaluated clinical proficiency based on final tooth position and how teeth fit together. Often we hear the comment, “show me the plaster on the table.” With technologies available today, I strongly encourage clinicians to also include treatment planning, clinical case management, and impact on bone and tissue during and after treatment when critically evaluating clinical proficiency. Simply put: straight teeth should not come at a long-term high cost to the periodontium. For highest quality results, clinicians must keep abreast of today’s latest technologies. Unfortunately, it is often human nature to resist and fall into the trap of saying that you are for progress but in reality fear change! My advice: don’t let fear hold you back from cutting-edge treatment mechanics. With the right education, training, mentors, and a proper treatment planning, you can enhance the quality of your patient results while minimizing stress on your clinical life. Lastly, set a goal to have more fun running your business in 2013. It is so much more enjoyable for everyone to be part of a practice and business that strives to create a special, positive environment for patients and staff. The energy and excitement you convey to your patients will have a positive impact on their desire to come in for appointments and also to refer other potential patients. Worldwide, I have observed that happy and energetic offices are usually very busy. I have always been impressed with orthodontists who have passion to continue improving. As you strive to make your practice more successful, continue to expand your knowledge, inspire growth within your staff, and diligently work towards better and better final results. Remember: keep it simple. Focus on quality results. Have fun! Dwight Damon, DDS, MSD, developer of the Damon System, is an industry-leading orthodontist with an office in Spokane, Washington. Widely known for his development of the Damon System — a passive self-ligation braces system that allows for low-friction, low-force orthodontic treatment — Dr. Damon is a pioneer in the field whose passion has been to improve orthodontic patient care worldwide. Dr. Damon has received numerous awards and professional honors including the 2009 Washington State University Regents’ Distinguished Alumnus Award, the highest honor the university confers upon its alumni. He was also elected as a Fellow of the Royal Society of Surgeons of Edinburgh. www.damon-smiles.com.
© 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.
Volume 4 Number 3
Orthodontic practice 1
INTRODUCTION
May/June 2013 - Volume 4 Number 3
TABLE OF CONTENTS Case study
Practice profile Dr. Mark Reynolds: Empowering patients through smiles A focus on patients, family, and continuous learning keeps this orthodontist fulfilled and content
6
Orthodontic technology case report: three-dimensional lingual treatment in combination with a temporary anchorage device (TAD) Dr. Edward Lin treats a case to resolve crowding, straighten teeth, and improve the smile................. 16
Corporate profile Ormco. Your Practice. Our Priority. This leading manufacturer and provider of orthodontic technology and services is dedicated to supporting orthodontic practices in an ever-changing and competitive environment
8
Orthodontic concepts BioDigital Orthodontics: Diagnopeutics with SureSmile technology: part 3 Dr. Rohit C.L. Sachdeva explains his approach to designing a personalized therapeutic solution ................................................... 22
Clinical Dentomandibular sensorimotor dysfunction: what it is and how providing care can benefit orthodontic practices and their patients Dr. Ronald Cohen explores a systematic approach to a painful disorder of the head and neck before orthodontic therapy
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2 Orthodontic practice
Volume 4 Number 3
Virtually everywhere
CS OrthoTrac Cloud
Everywhere your practice needs to be Our CS OrthoTrac Cloud is a powerful practice management and imaging solution that makes data security simple and virtually worry-free. Access it any time, from any location using any computer or tablet device. • Greater flexibility with offsite and HIPAA-compliant storage, always equipped with the latest software • The best of OrthoTrac software with the benefits of a cloud environment • Ideal for single or multi-location practices with wireless Internet access via computer, tablet or iPad® • Minimal upfront cost with simple monthly installments
Call 800.944.6365 or explore it here carestreamdental.com/cscloud © Carestream Health, Inc. 2013. OrthoTrac is a trademark of Carestream Health. iPad is a trademark of Apple, Inc., registered in the US and other countries. 8999 OR OT AD 0513
TABLE OF CONTENTS
TAD-supported Haas expansion
Continuing education Incorporating TAD-supported Haas expansion into everyday practice Drs. Ryan K. Tamburrino and Shalin R. Shah explore appliance design, delivery technique, and expansion protocols as it relates to the TADsupported Haas ............................32 Complete Clinical Orthodontics: treatment mechanics: part 3 Dr. Antonino Secchi summarizes the specific strategies within the CCO System to manage space closure in different anchorage situations .......38
Research A new regimen of Phase I care applied to potential maxillary canine impactions Dr. John Hayes outlines a study of canine impactions to evaluate a regimen of Phase I care.................44
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32
Banding together
Product profile
Hector’s story Dr. Mark Reynolds tells about the many people involved in bringing this novel case to its happy conclusion .....................................................52
Esprit Class II corrector ............58
Education exploration GCARE webinars: inspiration, exploration, and education: part 4 A new webinar program, GAC Clinical Alliance for Research and Education (GCARE), pertains to all stages of the orthodontic community, from residents to practicing orthodontists . .....................................................54
Step-by-step Reliance Orthodontics: Perfect A Smile™ pontic paint An elegant solution to a unique problem with clear aligners ...........60
Book review Orthodontic Pearls: A Clinician’s Guide By Larry W. White, DDS, MSD.......61
Practice management Overcoming technology
“Tech”-nique Accelerated orthodontics through micro-osteoperforation Dr. Jonathan L. Nicozisis explains a new micro-invasive technique .......56
bottlenecks Toby Buckalew discusses how new technology can steer a practice in the right direction and speed up performance..................................62
Materials & equipment.......................64 Volume 4 Number 3
Who Can You Trust to Help Grow Your Practice?
Where Practice Growth Takes Root With an ever-expanding base of benefits for our members, the UOBG is constantly evolving to keep our members ahead of whatever the economy has in store. In the past 12 months alone, we’ve added: The Progressive Orthodontist The Progressive Dentist* (Subscriptions FREE with coupon) Access to Pride Institute Practice Management Solutions Money Saving Benefits of GACPowered Practice Marketing The only thing that hasn’t changed is the price, which remains FREE!
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PRACTICE PROFILE
Dr. Mark Reynolds Empowering patients through smiles
What can you tell us about your background? I grew up in Northwest Ohio in the small village of Bluffton. It is a quaint little college town in a rural, country setting. Like many others in the area, my father worked for Ford’s engine plant in nearby Lima. Early on, I took on jobs in the service sector: mowing lawns, working in an ice cream parlor, and helping to manage a restaurant. After high school, I attended Ohio State University where I was sure that I was destined to be a certified public accountant. (I eventually made my way to the University of Maryland for dental school.)
Why did you decide to focus on orthodontics? After some really crazy overtime as a CPA, I decided that I needed a career change. I realized that what I missed was the personal interactions that I used to have with my regular customers at the restaurant. I looked around for what would give me that kind of interaction again and settled on dentistry. Two years into my dental program, I was approached by one of my orthodontic professors who thought I had potential as an orthodontist. Fortunately, we had a fourth year miniresidency program at school that allowed me to take on some active cases. It was just what I had been missing, and I was hooked. 6 Orthodontic practice
How long have you been practicing, and what systems do you use? I am in my tenth year of private practice. We use Insignia™, the Damon® System and Invisalign®.
What training undertaken?
have
you
Training began in my mini-residency at the University of Maryland, Baltimore. After graduation, I completed an AEGD residency at the Lancaster Cleft Palate Clinic with a great exposure to different craniofacial disorders and the changes those disorders have on normal facial development. I selected my orthodontic residency at the University of Texas, Houston due to its research program as well as its relationship with the oral surgery department. This wellestablished interdepartmental relationship allowed me to continue to be exposed to a wide range of skeletal malocclusions as well as some unique craniofacial disorders. Since graduation, I have continued to learn more about occlusion and facial development from The Dawson Academy, Dr. Jeffery Okeson, the Damon Forum, and recently the Academy of Clinical Sleep Disorder Disciplines.
What is the most satisfying aspect of your practice? Everyone lives for that first time a patient sees his/her teeth at debond and then can’t
stop smiling. I also get a lot of satisfaction with my facial pain patients when I can see that the tension has left their faces, or they are in the office and realize that they feel better.
Professionally, what are you most proud of? Patient education. We work incredibly hard to connect the dots for our patients so that they can truly understand what is going on with their teeth and what they can do about it. Every week we hear, “No one has ever explained that,” or “Now, I get it!” It is a great feeling knowing that we have empowered people to make their lives better. Additionally, it’s incredibly satisfying to be a part of Smile for a Lifetime. We have treated some amazing kids who would otherwise not have access to care.
What do you think is unique about your practice? In addition to spending a lot of time educating our patients, we also spend a lot of time getting to know them and their families. We celebrate milestones in their lives with them, and enjoy relationships throughout their treatment and beyond. I have been known to send a mom our family’s favorite black bean soup recipe or suggest a book that I know they would enjoy. Greensboro, North Carolina, the location of my practice, is a small town, and I love that my patients are always stopping Volume 4 Number 3
PRACTICE PROFILE
me around town to say hi. I really enjoy knowing my patients beyond their teeth.
What has been your biggest challenge? Finding the right people to catch the vision of our practice. Getting people who are personally committed, technically excellent, and technologically savvy, all with a friendly, approachable personality can be challenging. I have been very fortunate to have a great staff supporting me all the way.
What would you have become if you had not become a dentist? There are lots of things that I would like to do, but I think that due to my addiction to HGTV, I would have to be an architect or designer. Helping people design and build their dream home would be a lot of fun.
What is the future of orthodontics and dentistry? Three-dimensional orthodontic treatment planning and diagnosis will soon be the norm. With this technology, we can see so many more things clearly. Soon we won’t know how we ever lived without the information. I think that this will also lead to a better understanding of the interrelationship of facial and occlusal development and overall health. Big strides are already being made in sleep medicine/dentistry, and more are on the way.
world, but it’s not long before the really hard cases come along, and you realize that not everything was covered in class. There is so much information available. Go out there, and keep learning.
TOP 10 FAVORITES 1. Going to movies 2. Cars 3. HGTV
What are your top tips for maintaining a successful practice? Build a great team. Get the best people, and then include them in the decisionmaking processes. A great staff can be full of incredible ideas, and the sense of ownership helps get them implemented quickly. The opposite can also be true — one bad apple can spoil the whole office, and patients can tell the difference.
What advice would you give to budding orthodontists?
What are your hobbies, and what do you do in your spare time? My family is really important to me. One reason I chose orthodontics is because it allows me to spend time with my wife and children. We love to travel, to camp, to hike, and to eat popcorn during family fun nights. Recently, we have begun running 5k races together. We are involved in our church and in our community. I love sharing so many different experiences with my kids and seeing those experiences through their fresh eyes. OP
4. Coffee, lots of coffee! 5. My wife and four kids 6. Crab cakes 7. My Bible 8. Just about any Apple® computer product 9. Getting outdoors 10. My soft tissue laser
Never stop learning. Right out of residency, it is easy to feel on top of the orthodontic Volume 4 Number 3
Orthodontic practice 7
CORPORATE PROFILE
Ormco. Your Practice. Our Priority.
T
oday’s orthodontic specialist is challenged like never before. With many orthodontists facing flat-to-declining patient starts, competition from other dental providers, and a more discerning healthcare consumer, it’s increasingly important to navigate a dramatically shifting marketplace and employ new strategies to truly differentiate your practice. This dramatic shift has been a topic of conversation at Ormco Corp., a leading manufacturer and provider of orthodontic technology and services. That’s why we invite you to learn about the strides Ormco is taking to support your practice in an ever-changing and competitive orthodontic industry. After conducting extensive market research with doctors and healthcare consumers around the world, we’ve been able to better understand your needs as a clinician today. This renewed understanding has led us to a new mission statement designed to truly focus our efforts on meeting your practice and appliance needs. Unveiled by Ormco President Vicente Reynal at our 12th Annual Damon Forum in February, the following mission statement illustrates our commitment to better your practice. Ormco builds trusted relationships with the orthodontists we serve, providing a breadth of innovative products and solutions to enhance their professional lives. Ormco is committed to helping orthodontists achieve their clinical and practice management objectives.
Put more succinctly, “Your practice is our priority.” This new commitment and tagline —“Your Practice. Our Priority.”— is an overarching theme driving our future initiatives, and rooting our programs in customer dedication and support. From product development and educational programs to personalized service and practice marketing support, we’re taking action to serve as your valued practice partner. 8 Orthodontic practice
Ormco’s restructured customer rewards program demonstrates our desire to address popular practice demands. The concept of the program is simple – orthodontists earn points on purchases that can be redeemed for more products. Relaunched in February as the “Ormco Lifetime Rewards” program, customers in North America can now earn points on Ormco and AOA Lab purchases that never expire. In addition to redeeming points for Ormco products and services, members may also benefit from special offers and savings from affiliate companies, including the Gendex GXDP-700™, i-CAT® FLX, CaviWipes™, and Orascoptic HiRes® 2 loupes. Since inception of our rewards program, we’ve awarded $40 million in free product to participating customers.
Innovating for your practice When you think about the year ahead or the next 3 years, do you envision your practice growing, innovating, and adopting new technologies and techniques? For more than 50 years, Ormco has partnered with the orthodontic community to manufacture innovative products and solutions that enhance the lives of clinicians and their patients. Founded in 1960, Ormco— which is an acronym for Orthodontic Research & Manufacturing Company—is one of the few orthodontic suppliers with a fully operational and active research and development department dedicated to design and manufacture new treatment solutions that enhance patient treatment and positively impact practice efficiency. Driven by innovation, we’re proud to have introduced a number of notable “firsts” in the industry, including preformed bands, direct bonding with Optimesh®, computer-aided design (CAD) brackets with Orthos®, Copper Ni-Ti® and TMA™ wires, and the first completely esthetic passive self-ligating bracket with Damon® Clear™. With a focus on product quality, clinical efficiency and esthetics, we released more new products in 2012 than any other year in the company’s history. Last year, our team introduced a new active self-ligating bracket system, Prodigy SL™, which provides maximum rotational control and proven bond reliability. Additionally, the Damon Clear product line — appealing to a
wide consumer base with virtually invisible brackets — expanded to include both upper and lower arch brackets, and is now available in a convenient single-patient kit. We also introduced AdvanSync™ 2, a molarto-molar Class II corrector for simultaneous skeletal and dental corrections, plus a new compact Quad storage system to help organize your inventory.
Digital orthodontics to differentiate your practice Did you know there are approximately 23 million U.S. adults who are interested in improving their smiles? Furthermore, a Boston consulting group study found that patients would pay a premium for treatment that is faster, more esthetic, and more comfortable. As a progressive doctor interested in increasing patient starts, we encourage you to explore today’s advanced digital orthodontic solutions. At Ormco, we’ve dedicated three decades of intensive research and development to create Insignia™ Advanced Smile Design™, an all-inclusive digital solution that combines 3D diagnostic technology and interactive treatment planning with customized appliances to accelerate treatment times and increase precision results.
An advanced technology to differentiate your practice, Insignia is especially appealing to adult patients seeking faster results, fewer appointments, and improved comfort. Today we’re proud to share that Insignia offers the world’s most expansive menu of treatment options, including Insignia Clearguide™ Express, Damon Clear, Damon® Q™, Inspire ICE™, and completely customized self-ligating and traditional twin appliances, making it the natural evolution in appliance choice. With the Insignia Clearguide Express aligner Volume 4 Number 3
Practice development support for your practice How are patients finding you in today’s digital landscape? From teens to adults, the Internet is driving patient engagement, fueling patient referrals, and generating a wealth of new patient leads. Social media trends and web behaviors of digital-savvy consumers have been analyzed and leveraged by Ormco for years. Targeting this growing online community, our consumer websites DamonBraces.com and InsigniaSmile. com offer current and prospective patients an engaging educational resource. Additionally, these sites help consumers find local Damon® and Insignia™ specialists via their popular Doctor Locator search tools that are accessible from the Web,
As a company, we have long advocated the importance of clinical education and facilitate educational opportunities for our clinicians worldwide. Our flagship event in North America, the Damon® Forum, hosts more than 1,300 orthodontic professionals and is the largest privately-sponsored orthodontic event designed for the entire orthodontic team. The Damon Forum is one of many events offered by Ormco’s comprehensive CE program known as the Lifelong Learning Series. Designed to support our customers’ clinical and practice success, regional seminars, inoffice courses, and free online webinars enable doctors and staff to explore clinical innovations and practice management strategies from the industry’s top clinicians and consultants. In June and September
Online doctor locators for practice growth
Practice marketing resources on marketing.ormco.com
the creation of 3D digital treatment plans to custom digitally manufactured, labial, lingual, and clear aligner appliances.” With an easy-to-use, intuitive interface, Lythos streamlines the practice workflow with scans that are complete in less than 12 minutes. Unlike “photo capture” scanners, where feedback is displayed a few seconds after pushing a foot pedal, Lythos scans in real time, which means feedback is displayed as it is captured. The Lythos video uses the occlusal surface to register the position of the data to show in real time. Unique to the industry, Lythos offers a “cash back” rebate system, where customers are credited for every Insignia and/or Insignia Clearguide Express case submitted with a Lythos digital impression. With regular use of Insignia and Clearguide, Lythos scans are virtually free! Volume 4 Number 3
Facebook, and web-enabled mobile devices. Over the past 3 years, our marketing efforts to drive consumers to these websites have yielded a 190% increase in consumer site visits, and a remarkable 360% increase in Doctor Locator searches. This translates into $82 million in potential practice revenue each and every month for our Damon and Insignia doctors. To support our customers’ local practice marketing and patient education campaigns, Ormco provides an online practice marketing resource with a complete range of marketing assets and staff training tools to help increase patient starts. Available 24/7, marketing.ormco. com hosts a library of patient imagery, consultation tools, practice videos, webpage assets, and more for doctors offering the Damon System, Insignia, Inspire ICE, and Prodigy SL.
2013, we invite doctors to attend one of three “Technology Symposiums” hosted in Washington, D.C., Chicago, and Atlanta. With a focus on innovative technologies to advance clinical excellence and efficiency, the day and a half seminars address the latest in passive self-ligation, digital solutions, and Class II correction. Doctors can learn more about Ormco’s supportive CE offerings and register for upcoming events by visiting www.ormco.com/ education. The entire team at Ormco will continue to uphold its commitment to make your practice our priority. We look forward to serving as your trusted partner in 2013 and beyond! For more information, visit Ormco online at www.ormco.com. OP This information was provided by Ormco.
Orthodontic practice 9
CORPORATE PROFILE
system, we’re helping you to address patient image concerns with a sleek, clear aligner tray that goes virtually unnoticed. Building upon Insignia’s advanced digital platform, we’re excited to launch the Lythos™ Digital Impression System this summer. This innovative technology harnesses the power of digital scanning to overcome the inherent challenges associated with traditional impressions. With a small portable device, lightweight wand, and fast scan time, Lythos delivers a comfortable digital impression experience for staff members and patients. Mark Hillebrandt, Vice President of Marketing and Product Management at Ormco, stated, “Ultimately, we envision the orthodontic workflow to be 100 percent digital, from scanning of the patient to
CLINICAL
Dentomandibular sensorimotor dysfunction: what it is and how providing care can benefit orthodontic practices and their patients Dr. Ronald Cohen explores a systematic approach to a painful disorder of the head and neck before orthodontic therapy Abstract Dentomandibular sensorimotor dysfunction (DMSMD) is a frequently painful disorder of the head and neck, temporomandibular joints (TMJ), jaw function, and dental forces. The force distortion causing DMSMD may adversely impact the longterm stability and reliability of dental restorations and adaptations that patients have received for unrelated conditions. A thorough knowledge of the problems and a comprehensive assessment/treatment approach with which to resolve them are pivotal to helping orthodontists and general dentists ensure the integrity of natural teeth and current and future dental work, as well as minimize or eliminate pain and other negative symptoms. This article discusses dentomandibular sensorimotor dysfunction and demonstrates a case in which a systematic approach to its treatment was undertaken prior to initiating orthodontic therapy.
Introduction Dentomandibular sensorimotor dysfunction (DMSMD) is a frequently painful disorder of the head and neck, temporomandibular joints (TMJ), jaw function, and dental forces. It stems from misalignments in the physiology of the skull and mandible that result in problems with bite force, muscle
Ronald Cohen, DDS, MSD, received his DDS from The Ohio State University in 1976. After 5 years as a general practice dentist, 3 years in the USAF, and 2 years running the St. Francis Hospital Neighborhood Dental Clinic in Honolulu, Hawaii, he returned to specialty school at St. Louis University where he attained his Master of Science in Dentistry in 1983. He currently lectures for SureSmile about the advances in technologydriven orthodontics as it relates to such treatments as sleep apnea, TMJ, and advanced orthodontic-surgical procedures. He is also an active Beta test site for SureSmile and a member of the Clinical Advisory Board. Dr. Cohen is not a paid consultant for TruDenta. He can be reached at drcohen@docronsmiles.com.
10 Orthodontic practice
movement, and/or balance of joints, leading patients to experience extreme amounts of force or improper/unbalanced dental forces.1,2 Individuals with force issues — many of whom might not even realize that their conditions stem from DMSMD or that dentists can provide effective treatment for it — suffer from many diverse symptoms. Those that directly impact the teeth and mandible include abfraction, bruxism, tooth erosion, fracture, or damage; instability in the dental arch form; jaw clenching (with or without the formation of a torus); temporomandibular joint disorder (TMD); and clicking and popping of the jaw. Other seemingly disparate, yet highly disruptive symptoms associated with DMSMD, include chronic headaches and migraines, sleep disorders, tinnitus, myofascial pain, poor airway issues, compensatory adaptations in posture, and limited range of motion.1-3 Physiologic interconnections also contribute to complications in understanding, assessing, and treating this complex condition. For instance, although DMSMD is not the sole trigger of migraines — hormones, sleep problems, nutrition, and other factors may play a role as well — its connection to the trigeminal nerve is thought to be a likely contributor to many cases of migraines. The trigeminal nerve generates impulses that cause blood vessels on the brain to swell, thus transmitting pain messages to the brainstem.4 Patients with DMSMD, and dentists seeking to treat the condition’s complications, may encounter other challenges as well. For example, force distortion may adversely impact the long-term stability and reliability of dental restorations and adaptations that patients have received for unrelated conditions. This will necessitate additional treatment to achieve optimal function and to protect dental interventions from irregular forces.1,2
Prevalence of and problems to treating related conditions These often debilitating conditions, outcomes, and complications are not isolated cases affecting a relative few. According to the National Institute of Dental and Craniofacial Research, the number of Americans who suffer from TMJ and associated problems may range from 10 to 45 million individuals,5 and when the number includes those suffering from tinnitus and other conditions, the number rises to an estimated 80 million people. Even more prevalent and impactful, approximately 90% of the U.S. population has headaches, and individuals who suffer from migraines—estimated at more than 29 million Americans — lose between 157 million days of work and school annually.6 Research indicates that up to 80% of headaches result from some type of dental force-related problem. There are many aspects to understanding and treating DMSMDrelated conditions. For effective, longlasting, and predictable results to be achieved, it is imperative that healthcare professionals and their patients understand DMSMD; why it occurs; its not-alwaysreadily-apparent connections to other physiologic components and factors; the importance of properly diagnosing and treating it; the most effective methods/ protocols for assessing and treating it; and who is best equipped to provide such assessment and treatment. Unless DMSMD is properly addressed, a patient’s condition will not improve; rather it will worsen and likely become chronic, and existing and future dental restorations may consequently fail. A thorough knowledge of the problems and a comprehensive assessment/treatment approach with which to resolve them are pivotal to helping orthodontists and general dentists ensure the integrity of natural teeth and current and future dental work, as well as minimize Volume 4 Number 3
CLINICAL or eliminate pain and other negative symptoms. Until recently, healthcare professionals who sought to help patients address their DMSMD-related distress faced numerous obstacles. Many patients, ignorant of the cause of their problems and having exhausted over-the-counter (OTC) and prescription medications, as well as nonpharmacological options, such as physical medicine,6 abandoned their search for solutions and resigned themselves to enduring lives of chronic pain and diminished quality of life. Of those individuals who persisted in seeking help, typically only one in five sought out a physician’s assistance after having no success with OTC remedies.5 Orthodontists and general dentists, in particular, have largely been overlooked in favor of physician-based healthcare providers and chiropractors, who are more likely to be considered “headache/migraine experts” by the public. Additionally, dental professionals and their teams lacked an integrated system and the training necessary to provide complete care for DMSMD-related cases.
assessment, treatment, and resolution of DMSMD conditions, it offers orthodontists and general dentists a Food and Drug Administration (FDA)-cleared, conservative care strategy that can be customized for managing pain and inflammation, restoring range of motion and function, and reestablishing stabilization to the mouth, jaw, and head. Dentists and dental teams who add TruDenta capabilities to their practices are uniquely trained and equipped to offer their existing patients complete care from professionals they already know and trust, as well as attract new patients by establishing themselves as experts in providing a proven assessment and therapy that employs objective and subjective methods and state-of-the-art technologies found in less than 1% of all dental offices in the United States today.10 These combine to enable them to comprehensively assess, treat, and manage/monitor patients’ chronic headache and face, TMJ/D, neck, and other head area pain, as well as other dental force-related conditions.
Why dentists are uniquely suited
The case that follows demonstrates the straightforward manner in which the TruDenta system enables orthodontists and their teams to achieve successful treatment and rehabilitation outcomes through a compelling visual and objective assessment, as well as scientifically based, systematic, and predictable treatment methods and technologies derived from sports medicine to offer a customized pathway of care. A 21-year-old woman presented complaining of soreness of the mouth and jaws due to clenching and grinding. The patient received a complete examination that included a head health, medical, and headache history, and a pharmacological assessment. Dental, periodontal, airway, orthodontic, and occlusal examinations also were undertaken. The patient showed symptoms of muscle pain and headache pains. She claimed pain in the jaw joint, ear, and side of the face. There was a history of popping and clicking, and headaches on the side of the head. She claimed tightness of the jaws in the morning, and that her jaws became tired when chewing. There was history of soreness in the eye and ear areas, as well as neck and shoulder pain. She indicated that she experienced the pain daily, and that she was tired of it. Fortunately, she
Orthodontists and general dentists, recognized experts in oral health, also are knowledgeable about and trained in managing the muscular and nervous components of the jaw, neck, and head, according to the American Dental Association. As such, dental professionals can take a leading role in treating issues relating to DMSMD, TMJ, and associated problems.8,9 Incorporating a system for assessing and treating improper dental forces that cause painful conditions in the mouth, head, face, and neck areas represents an exciting and significant opportunity for dentists to be of service to their patients while also benefiting their dental teams and practices. Those who elect to offer patients assessment and treatment for DMSMD and associated conditions have a competitive edge, distinguishing themselves, their dental teams, and practices as comprehensive providers of an array of overall health services in the convenience of a practice they’re already familiar with. This patient- and practice-enhancing opportunity is possible through the use of a state-of-the-art proprietary system (TruDenta, Dental Resource Systems, Inc., www.DRSdoctor.com). The only comprehensive approach to the 12 Orthodontic practice
Case presentation
had no history of previous treatment for this condition, something that is rare in stomatognathic patients, since many have tried myriad treatments and healthcare professionals prior to seeing orthodontists. The patient reported that she regularly took Excedrin, Tylenol, and Allegra-D to combat her symptoms, but that they were becoming unmanageable with those medications. Upon palpation, the patient showed 6/10 tenderness to palpation of the lateral pterygoinds, masseter muscles, temporalis tendons, and right posterior belly of the temporalis with trigger points. Additionally, she showed 7/10 in the right SCM and bilateral occipital insertion of the trapezius muscles. Her opening range of motion was restricted to 42 mm, with a deviation to the right and a restricted right range of motion as well. Diagnostics included cephalgia 784.0, muscle spasm 728.85, and headache 339.1. Crucial to establishing the severity of sensorimotor dysfunction, any abnormal, excessive, or imbalanced forces were identified objectively using mandibular range of motion (ROM) disability, cervical range of motion disability (digitally), and digital force analysis (TruDenta Scan). The ROM portion of the diagnostic process provides objective data conforming to American Medical Association (AMA) guidelines (Figure 1). The patient’s T-Scan testing showed significant anterior prematurity with heavy force values (Figure 2). This was further confirmed by cone beam CT generated corrected tomograms, which proved distally trapped condyles due to occlusal forces and positions (Figures 3 and 4). Clench T-Scan demonstrated further the
Figure 1: Range of motion (ROM) analysis from the initiation of TruDenta treatment through to completion showing progressive improvement in the patient’s range of motion Volume 4 Number 3
CLINICAL
Figure 2: The initial force analysis (TruDenta Scan) showed significant anterior prematurity with heavy force values
Figures 3 and 4: Cone beam CT generated corrected tomograms showed distally trapped condyles due to occlusal forces and positions
Figure 7: Pre-orthodontic view of the patient’s natural smile
Figure 8: Pre-orthodontic radiograph showing the patient’s tooth alignment Figures 5 and 6: TruDenta scans taken while the patient was clenching further demonstrated the extent of the anterior prematurity and the significance of the resulting condylar position
Figure 9: View of the patient’s teeth following placement of the full fixed orthodontic appliances
extent of the anterior prematurity and the significance of the resulting condylar position (Figures 5 and 6).
Treatment protocol Treatment was planned to achieve relief of the neuromuscular problems as documented, followed by alignment and balancing of the mandible, dentition, and force values, as well as alleviate pain. Treatment recommendations consisted of office visits, manual muscle testing, ROM testing, TMJ ultrasound, applied electrical stimulation, manual muscle therapy, cold laser therapy, therapeutic exercises, home care instructions, occlusal analysis, occlusal orthopedic device (NU modifier), and self-care home management training. Stabilization goals included orthodontic therapy utilizing SureSmile® (OraMetrix) advanced 3D technology once muscle stability was achieved. Diagnostic simulations indicated that lower Volume 4 Number 3
incisor extraction was indicated to allow elimination of anterior dental prematurities and forward positioning of the condyles. Once achieved, equilibration would be undertaken to stabilize the dental forces within the new balanced stomatognathic envelope.
Treatment outcome The patient’s treatment consisted of five weekly in-office visits of therapeutic rehabilitation using cold laser therapy, ultrasound therapy, low-level electrical current stimulation, and manual muscle therapy. A custom rehabilitation orthotic for the mouth was also worn at home until we began the maxillary orthodontic treatment. At 5 weeks, the patient’s condition had improved sufficiently so that orthodontic therapy could begin in order to eliminate the obvious dental deflective interferences (Figures 1, 7, and 8). Extraction of tooth No. 24 and placement of full fixed
Figure 10: The SureSmile therapeutic scan was made in order to virtually finalize the treatment plan
orthodontic appliances occurred in February 2012 (Figure 9). The SureSmile therapeutic scan was made in June 2012 so that the final plan could be fabricated virtually (Figure 10), and the robotic wires were prescribed to finalize her case. A total of three prescription wires were delivered, and the patient was debonded in January 2013, for a total orthodontic treatment time of 11 months (Figures 11 and 12). Dental bite force balance was confirmed at her immediate post-treatment conference in February 2013 with the T-Scan and ROM analysis, which revealed virtually normal ROM measurements and significantly lessened anterior prematurity (Figures 1, 13, and 14). We have equilibrated once so far, and she is scheduled to finalize her equilibration at her next appointment, with additional follow-up T Scans to verify force balance (Figures 15-17). The patient reports a much improved sense of her teeth “fitting together,” no muscle spasms Orthodontic practice 13
CLINICAL
Figure 11: View of the post-orthodontic radiograph following treatment with three prescription wires
Figure 12: Post-orthodontic view of the patient’s smile after debonding
Figure 12: Post-orthodontic view of the patient’s smile after debonding
Figures 13 and 14: Immediate post-orthodontic TruDenta Scans demonstrate that the patient achieved significantly lessened anterior prematurity
Figure 15: Following an initial equilibration, a force analysis was performed
or headaches, and an incredibly positive experience with her treatment.
Conclusion With the acceptance and incorporation of a comprehensive assessment and treatment system, orthodontic practices have the opportunity to expand the scope of services they provide to patients looking to resolve the TMJ/D and head pain issues associated with dental force related problems. The proprietary TruDenta system, which incorporates assessment devices and therapeutic technology derived from sports medicine, uniquely empowers orthodontists to offer a proven, long-term solution and customized pathway to care for DMSMD-related conditions. Treating patients with TruDenta is straightforward; treatments are simple, quick, effective, painless, and require no
Figures 16 and 17: After the initial equilibration, a TruDenta scan was also performed while the patient was clenching
drugs or needles. Many dental practices offering the TruDenta pathway to care — including orthodontic practices — have reported that, within a 10- to 12-week period, their patients experienced lifealtering relief from their chronic pain. Additionally, it now gives us the ability to properly balance our finished orthodontic
cases like never before. The combination of SureSmile virtual diagnostic and robotic treatment, and TruDenta force value detailing finally gives us the tools to perfectly finish our cases for maximum stomatognathic function and stability. It’s a dream that has finally become a reality. OP
References 1. Junge D. Oral Sensorimotor Function. Medico Dental Media International, Inc.: 1998. 2. Sessle BJ. Mechanisms of oral somatosensory and motor functions and their clinical correlates. J Oral Rehabil. 2006;33(4):243-261. 3. Okeson JP. Management of Temporomandibular Disorders and Occlusion. 6th ed. St. Louis, Mo: Mosby; 2008. 4. US News Health. Headache. US News and World Report. 2006. http://health.usnews.com/healthconditions/brain-health/headache. Accessed July 3, 2012.
14 Orthodontic practice
5. Adults. National Institute of Dental and Craniofacial Research Web site. http://www.nidcr.nih.gov/ DataStatistics/ByPopulation/Adults. Accessed December 7, 2012. 6. Migraine. National Headache Foundation Web site. http://www.headaches.org/education/Headache_Topic_ Sheets/Migraine. Accessed July 3, 2012. 7. Ostler GL. Building professional referral relationships with physicians. Dental Economics. 2012. http://www.dentaleconomics.com/articles/print/ volume-96/issue-12/features/building-professionalreferral-relationships-with-physicians.html. Accessed July 3, 2012.
8. Sardella A, Demarosi F, Lodi G, Canegallo L, Rimondini L, Carrassi A. Accuracy of referrals to a specialist oral medicine unit by general medical and dental practitioners and the educational implications. J Dent Educ. 2007;71(4):487-491. 9. Dentists: Doctors of Oral Health. American Dental Association Web site. http://www.ada.org/4504.aspx. Accessed July 3, 2012. 10. TruDenta. http://www.trudenta.com. Accessed January 22, 2013.
Volume 4 Number 3
The Digital Orthodontist Seeing Treatment Differently with suresmile速
For our patients, suresmile is that tool which allows us to plan treatment with greater confidence and predictability than ever before. In turn, this motivates patients to become partners in their treatment.
before Class II, subdivision R.
treatment OraScan performed two months into treatment.
after Total treatment time: 6.5 months.
Jeff Johnson, DDS, MS Dallas, TX
For a detailed case study, please call 888.672.6387 and request suresmile clinical report no. 1.
www.suresmile.com
to be sure.
CASE STUDY
Orthodontic technology case report: threedimensional lingual treatment in combination with a temporary anchorage device (TAD) Dr. Edward Lin treats a case to resolve crowding, straighten teeth, and improve the smile
H
istorically, the United States has lagged behind other countries in the world in regards to offering lingual orthodontics as an option for treatment to our patients. In my opinion, the reason for this discrepancy between the U.S. and other countries for lingual treatment is due to the two main challenges associated with lingual orthodontics: 1) difficult retie appointments for both patient and clinician, and 2) significantly longer appointments. However, I personally see this changing very quickly over the next several years for three main reasons: 1) esthetic orthodontic treatment is something that is highly desirable for our patients, 2) many patients are now aware of lingual treatment and are actively seeking it out, and 3) advances with technologies such as SureSmile® (OraMetrix), cone beam computed tomography (CBCT), and small lingual selfligating brackets have made treatment with lingual orthodontics much easier for both the clinician and the patient. Over the past 4 years, lingual orthodontic treatment utilized in combination with SureSmile/ CBCT has become a big adjunct for me in my practice. In this article, I will review a complex case treated with upper lingual and lower labial fixed appliances.
Dr. Ed Lin is one of two partners at Orthodontic Specialists of Green Bay (OSGB), a private practice in Green Bay, Wisconsin. He is also one of two partners at Apple Creek Orthodontics of Appleton (ACOA). Dr. Lin received both his dental (DDS) and orthodontic (MS) degrees from Northwestern University Dental School. OSGB and ACOA are both completely digital practices and have been utilizing SureSmile (OraMetrix) since February of 2004 at three different practice locations. Both practices have been involved with cone beam computer tomography (CBCT) with the i-CAT (Imaging Sciences International) since 2006. Dr. Lin is an internationally recognized speaker (U.S., Canada, Puerto Rico, Australia, and China), has written several articles that have been published in a wide variety of dental journals, and has lectured at several orthodontic residency programs across the United States. He is a faculty and Clinical Advisory Board member for SureSmile. He also sits on the Clinical Advisory Boards for American Orthodontics and Imaging Sciences International and is on the Editorial Board of Orthotown and Orthodontic Practice US journals.
16 Orthodontic practice
Figure 1: Initial records 5/20/09
Patient information This patient presented at his new patient examination on May 20, 2009 as a healthy 44-year, 1-month-old adult male. He stated that his chief complaint was to resolve his crowding, have straighter teeth, and a nicer smile.
Diagnosis and etiology Intraoral examination revealed a Class III, subdivision right molar and canine malocclusion. He presented with an overbite (OB) of 20% and overjet (OJ) of 1 mm. There was excessive maxillary and mandibular incisal wear present due to this OB/OJ relationship. Arch-length deficiencies were present in both maxillary – 7 mm – and mandibular arches – 7 mm. Both maxillary and mandibular arches were asymmetric and tapered in arch forms. A right posterior crossbite was present for his UR6, UR5, and LR6. An anterior crossbite was also present with his UR3, UR2, LR3, and LR2 as a result of his right Class
III malocclusion. Periodontal evaluation revealed normal and healthy gingival tissue. There was some minor gingival recession present with his UR7, UR6, UL2, UL3, UL6, and LR6 (Figure 1). Frontal facial evaluation revealed a symmetrical and balanced facial pattern for his upper, middle, and lower facial third heights. Profile evaluation revealed a straight profile with normal chin. His nasolabial angle was 110 degrees, and both upper and lower lips were normal and competent at repose. A frontal smile evaluation revealed acceptable upper and lower smile line with buccal corridors present. His maxillary midline was centered with his facial midline. However, his mandibular midline was deviated 3 mm to the right of his facial and maxillary midlines. Cephalometric analysis revealed a Class III skeletal relationship with ANB = -2.6. It also revealed a brachiocephalic facial pattern with a low MPA = 24.7 (Figure 2). Panoramic evaluation revealed all third Volume 4 Number 3
Figure 3: Initial records 5/20/09
molars were present and fully erupted. Alveolar bone height was healthy and within normal limits for both maxillary and mandibular arches. There were no other significant findings (Figure 3).
Treatment summary The patient is a pediatric oncologist, and he requested treatment with lingual brackets in his maxillary arch and labial ceramic brackets in his mandibular arch since esthetics during the course of treatment was a concern for him. The patient was given a non-extraction treatment option, which consisted of full fixed orthodontic appliances in combination with a TAD placed in his lower right posterior quadrant. Due to the amount of crowding present and his Class III relationship, lower posterior interproximal reduction was also recommended. An estimated treatment time of 20 months was given due to complexity of his case. On January 5, 2010, In-Ovation® L Volume 4 Number 3
(Dentsply GAC) lingual fixed appliances were placed for U8-8, and In-Ovation®C (Dentsply GAC) labial fixed appliances were placed for L3-3 in combination with In-Ovation®R (Dentsply GAC) labial fixed appliances for his L5s – L8s using an indirect bonding technique. A 0.013 round CuNiti (G&H) lingual mushroom-shaped wire was placed in the maxillary arch, and a 0.016 round Bioforce® Sentalloy® (Dentsply GAC) labial wire was placed in the mandibular arch. A very active open coil spring was placed between his LR7 and LR6, and a Vector 1.4 mm x 8 mm Vector (Ormco) temporary anchorage device (TAD) was placed just to the distal of the distobuccal root of his LR6. The TAD was tied with a steel ligature tie to his LR6 for indirect anchorage for distalization of his LR7 and LR8. Posterior bite turbos were placed on his LL8, LL7, LR7, and LR8 utilizing Twinky Star (Voco) to open his bite for anterior crossbite correction. Lower posterior interproximal reduction was also
Orthodontic practice 17
CASE STUDY
Figure 2: Initial records 5/20/09
performed between his L8s, L7s, L6s, and L5s due to the amount of crowding present in his mandibular arch and for Class III correction. A 3/16” crossbite elastic with 2.7 oz. of force was instructed to be worn full time from the lingual of his UR6 to the labial of his LR6. A 1/4” Class III elastic with 2.7 oz. of force was also instructed to be worn full time from his UL6 to his LL3. On March 10, 2010, the patient returned for his first retie appointment. The same 0.013 round CuNiti (G&H) lingual mushroom-shaped wire was kept in his maxillary arch to allow for additional leveling and aligning. A new 0.016 round Bioforce Sentalloy labial wire was placed in the mandibular arch. The mandibular arch wire was not placed into the LR8 and was left 3 mm long, and turned over distal to his LR7 so that the wire would not irritate and cause ulcerations of the mucosal tissue on the inside of his cheek. A new very active open coil spring was placed distal to his LR6 to continue distalizing his LR8 and LR7. Indirect anchorage was still present with a steel ligature tied from the TAD to his LR6.The same elastics from his previous appointment were instructed to be worn full time again. On May 10, 2010, the patient returned for his second retie appointment. A new 0.016 round CuNiti (G&H) lingual mushroom-shaped wire was placed in his maxillary arch. A new 0.016 x 0.016 square Bioforce Sentalloy labial wire was placed in the mandibular arch. The mandibular arch wire again was not placed into the LR8 and was left 3 mm long and turned over distal to his LR7 so that the wire would not irritate and cause ulcerations of the mucosal tissue on the inside of his cheek. A new very active open coil spring was placed distal to his LR6 to continue distalizing his LR8 and LR7. Indirect anchorage was still present with a steel ligature tied from the TAD to his LR6. The crossbite elastic was discontinued as the right posterior crossbite had been corrected. The same Class III elastic was instructed to be worn full time. On July 6, 2010, the patient returned for his third retie appointment. The same 0.016 round CuNiti (G&H) lingual mushroomshaped arch wire was kept in his maxillary arch. A new 0.018 x 0.018 square Bioforce Sentalloy labial wire was placed in the mandibular arch. The mandibular arch wire again was not placed into the LR8 and was left 3 mm long and turned over distal to his LR7 so that the wire would not irritate and
CASE STUDY
Figure 4: Progress panorex 8/31/10
Figure 5: Progress 8/31/10 with Dolphin 3D
Figure 6: SureSmile scan 12/08/10
Figure 7: SureSmile scan 12/08/10
Figure 8: Blue SureSmile® 3D CAD/CAM model illustrating malocclusion present created from SureSmile®/i-CAT® scan with supplemental intraoral scan of LR6-LR8 due to amalgam restoration for LR7
Figure 9: White SureSmile® 3D CAD/CAM treatment plan model with correction of malocclusion superimposed over blue SureSmile® 3D CAD/CAM model with malocclusion present
cause ulcerations of the mucosal tissue on the inside of his cheek. A new very active open coil spring was placed distal to his LR6 to continue distalizing his LR8 and LR7. Indirect anchorage was still present with a steel ligature tied from the TAD to his LR6. All elastics were discontinued at this appointment. On August 31, 2010, the patient returned for his fourth retie appointment. A 0.4 voxel, 8 cm field of view (FOV), 10 second i-CAT® scan (Imaging Sciences International) was taken for evaluation prior to repositioning of his lower right TAD to just mesial of the mesiobuccal root of his LR7 (Figures 4 and 5). A closed elastomeric chain (American Orthodontics) was placed from his LL6-LR6 with direct anchorage to the TAD for en masse retraction for right Class III correction. A 3/16” crossbite elastic with 2.7 oz. of force was instructed to be worn for 12 hours per day from the lingual of his UR6 to the labial of his LR6. On September 29, 2010 and
November 10, 2010, the patient returned for his fifth and sixth retie appointments to change his elastomeric chain from his LL7LR6 to his TAD again for his right Class III correction. The same 3/16” crossbite elastic was instructed to be worn 12 hours per day. On December 8, 2010, the patient returned for his seventh retie appointment. We began his transition into SureSmile at this appointment (Figure 6). His arch wires were removed, and the In-Ovation L (Dentsply GAC), In-Ovation C (Dentsply GAC), and In-Ovation R bracket doors were closed. Upper and lower incisal recontouring was performed to give balance and symmetry to his incisal edges. A SureSmile i-CAT scan was taken with a wax bite present with the condyle seated in the glenoid fossa with the maxillary and mandibular dentition slightly separated (~2 mm) at 0.4 voxel, 8 cm FOV, and 10-second settings. Because of the amalgam present in his LR7 and the subsequent metal scatter present with his
SureSmile i-CAT scan, a supplemental intraoral scan was taken with SureSmile’s intraoral scanner of his LR6-LR8 (Figure 7). The intraoral scan data was then merged with his SureSmile i-CAT scan data and was uploaded and submitted to SureSmile for creation of the clinical crown anatomy as well as the root anatomy for the patient’s SureSmile virtual 3D models (Figure 8). The clinician was then able to correct the patient’s malocclusion using SureSmile’s 3D software applications (Figure 9). The patient’s SureSmile plan was completed, and his SureSmile wires were ordered to be bent utilizing SureSmile’s proprietary software and robots (Figure 10). The same 3/16” crossbite elastic was instructed to be worn 12 hours per day. A closed elastomeric chain was placed from his LR7 to his LL6. There was nothing tied to his lower right TAD, and it was left in place to provide mechanical anchorage to prevent the LR7 from drifting forward mesially. Six weeks later, on January 18, 2011,
18 Orthodontic practice
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CASE STUDY
Figure 10: SureSmile wires bent by SureSmile’s robots
Figure 11: Progress 3/16/11
the patient returned for his eighth retie appointment for his SureSmile wire inserts. A 0.017 x 0.025 SureSmile CuNiTi lingual wire was placed in his maxillary arch, and a 0.017 x 0.025 SureSmile CuNiTi labial wire was placed in his mandibular arch. Interproximal reduction was performed in both maxillary and mandibular arches that had been determined from his SureSmile plan (Figure 10). His lower right TAD was removed as anchorage was no longer needed. His right crossbite elastic was discontinued. Clear plastic buttons (ceramic bondable button, Dentsply GAC) were placed on his UR3,UL3, and the patient was instructed to wear trianglevertical 3/16” elastics with 2.7 oz. of force bilaterally for 12 hours per day from his U3s to his L3s and L4s. Closed elastomeric chain was placed from U6-6 and LR7-LL6. On March 16, 2011, the patient returned for his ninth retie appointment. Photos were taken to track treatment progress (Figure 11). His vertical-triangle elastics 20 Orthodontic practice
Figure 12: Progress 5/11/11
were discontinued, and 5/16” with 2.7 oz. of force Class III elastics were instructed to be worn full time on his right side only from his UR6 to his LR3 and UR3. As a result, a clear plastic button was bonded to his UR6 in order for him to wear the new elastic, and the plastic button on his UL3 was removed. Closed elastomeric chain was placed from U6-6 and LR7-LL6. On May 10, 2011, the patient returned for his tenth retie appointment, and photos were taken again to track his treatment progress (Figure 12). Utilizing SureSmile’s proprietary software, virtual wire modifications were submitted for finishing and detailing based upon clinical evaluation of the patient’s occlusion. Finishing SureSmile wires were then ordered to be bent by SureSmile’s proprietary robots (Figures 13 and 14). A closed elastomeric chain was placed from his U6-6. All elastics were discontinued at this time. On June 6, 2011, the patient returned for his eleventh retie appointment, and his
finishing SureSmile wires were placed: maxillary 0.016 x 0.022 lingual CuNiTi and mandibular 0.017 x 0.025 labial CuNiTi. All plastic buttons and elastics were discontinued. Closed elastomeric chain was placed for U6-6 and LR7-LL6. On July 18, 2011, the patient returned to have his fixed appliances removed. He was moved into retention with an Essix ACE® retainer with full-time wear and a L3-3 fixed lingual splint. Three months later, the patient returned for his final records, and retention wear of his Essix ACE® retainer was reduced to bedtime only (Figure 15). Total treatment time for this patient was 18 months and 13 days. The total number of appointments from the initial bonding appointment to his debond appointment was 16, including three emergency appointments.
Summary and conclusions In the early 1980s, lingual orthodontic treatment reached its height in popularity Volume 4 Number 3
CASE STUDY
Figure 13: Maxillary virtual wire modifications
Figure 14: Mandibular virtual wire modifications
Figure 16: Intrusion of his U3’s and extrusion of U2-2 to develop his smile arc
in the U.S. However, its popularity quickly declined as clinicians began to experience the technical difficulties associated with lingual mechanics: 1) visual and working access was significantly less, and ligating the arch wires was much more difficult in comparison to labial resulting in difficult and longer retie appointments, 2) shorter interbracket distances posed problems with being able to place certain bends in the arch wire and engaging the arch wire into the bracket slots, and 3) comfort of the lingual appliances was a problem, and certain patients could not tolerate them, and the appliances had to be removed.1,2 The In-Ovation L bracket has given our profession a small, low profile, selfligating bracket and has helped to make the appliances much more comfortable for the patient. It has also made ligating the arch wires into the bracket slots significantly easier. I chose to utilize the i-CAT, Dolphin 3D, TAD, and SureSmile technologies within my treatment plan because I personally believe that these
four technologies greatly improve my capability to diagnose and treatment plan (i-CAT and Dolphin® 3D), as well as deliver active therapeutic care (TAD, i-CAT, and SureSmile).3 Utilizing SureSmile, I was able to correct his malocclusion to a high degree of precision and accuracy without having to reposition brackets or bend wires by hand, which for lingual, is incredibly challenging. This is clearly illustrated with the development of his upper smile arc, in which I was able to utilize SureSmile’s software to intrude his UR3, UL3 and extrude his UR2-UL2 (Figure 16). The advantages of using SureSmile have been substantiated in two recent and separate studies with SureSmile cases grading better with American Board of Orthodontics (ABO) scores and completing treatment with an average of 25% reduced treatment times in comparison to conventional orthodontics.4,5 In this author’s opinion, the advantages of using SureSmile in combination with i-CAT to create the SureSmile 3-D CAD/CAM mod-
Figure 15: Final 10/19/11
els and to evaluate malocclusion and root positions are invaluable, and I truly believe that I am a better orthodontist today because of them. With SureSmile, treating this patient with lingual appliances is also no longer a daunting task. In the past decade, esthetic orthodontic treatment has exploded with the development of removable, invisible aligners. However, there are limitations with what can be accomplished with aligner treatment.6 As mentioned previously, lingual with SureSmile has become a big adjunct for my practice with my being able to offer esthetic treatment with shorter treatment times and without having to compromise on the finished end result. And as we all know, technology will only continue to get better! OP Give a child fighting cancer a beautiful smile: donate to childhood cancer charities in support of research or financial assistance, offer to provide dental care, or even offer to assist their parents with errands. Thanks to all for this opportunity to raise awareness.
References 1. Keim RG. The resurgence of lingual orthodontics. J Clin Orthod. 2012;46(4):197-198. 2. Stamm, T, Wiechmann D, Heinecken A, Ehmer U. Relation between second and third order problems in lingual orthodontic treatment. J Lingual Orthod. 2000;1(3);5.
Volume 4 Number 3
3. Lin E. Three dimensional orthodontic treatment in combination with TADs: case report. Orthod Practice US. 2011;2(3). 4. Saxe A, Louie L. Mah J. Efficiency and effectiveness of SureSmile. World J Orthod. 2009;11:16-22.
5. Alford T, Roberts E, Hartsfield J, et al. Clinical outcomes for patients finished with SureSmile method compared with conventional fixed orthodontic therapy. Angle Orthod. 2011;81:383-388. 6. Phan X, Ling P. Clinical Limitations of Invisalign. J Can Dent Assoc. 2007;73(3):263-6.
Orthodontic practice 21
ORTHODONTIC CONCEPTS
BioDigital Orthodontics: Diagnopeutics with SureSmile technology: part 3 Dr. Rohit C.L. Sachdeva explains his approach to designing a personalized therapeutic solution Introduction In previous papers , the principles for diagnosis, designing a care plan, communicating with the patient, and evaluating the progress of patient care were discussed. In this article, the approach used by the author in designing a personalized therapeutic solution driven by diagnosis (diagnopeutics) using SureSmile technology is presented. 1,2
Prescribing the Setup (VTS)
Virtual
laboratory technologist to perform the setup. If the need arises, the doctor and the technologist communicate both electronically and verbally to gain a better
understanding of the doctor’s plan for his patient (Figure 1F). The Virtual Targeted Setup is delivered to the doctor within 5 business days.
Target
The design of the prescription is driven by considering six conditions defined by the Sachdeva Virtual Target Prescription Design (SVTPD) guidelines: Midline, Archform, Class of Occlusion, Reference Teeth, Occlusal Plane, and Special Instructions. These are defined by the acronym MACROS and are embedded in the software.3-5 The prescription can be provided in a number of ways, by filling the appropriate conditions in the prescription form, adding to the text field, or providing a simulation. Generally speaking, the “prescriptive” simulation is used in situations where it is difficult to describe the nature of orthodontic tooth movement desired. For patient K.S., the prescription for the virtual targeted setup is shown in Figure 1. The boundary/design conditions prescribed for patient K.S. are seen in Table 1. This prescription is sent to the SureSmile digital laboratory electronically and is used by the orthodontic digital
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.
22 Orthodontic practice
Figures 1A-F: Setup Design Prescription for patient K.S. Virtual Target Setup using the SVTPG framework defined by MACROS. F. Simulation to equilibrate the incisal edges can be performed with SureSmile software and also plan for the restorative needs of a patient Volume 4 Number 3
Boundary Conditions
Prescription
M
MIDLINE
Treat to the upper dental midline
A
ARCHFORM
Treat to lower natural archform
C
CLASS
Treat to a Class I molar and canine relationship
R
REFERENCE TEETH
Treat to the upper and lower right second bicuspid, the upper and lower left canine
O
OCCLUSAL PLANE
Treat to the maxillary functional occlusal plane
S
SPECIAL INSTRUCTIONS
Doctor will polish lower incisal edges as per simulation
Table 1: Sachdeva Virtual Target Prescription Design is used in providing instructions to the SureSmile Digital Laboratory for the Virtual Target Setup. Note that the same guidelines are used for developing the Virtual Diagnostic Simulation (VDS)
Figure 2: Patient K.S. Virtual Target Setup evaluation checklist. Note: as the doctor goes through the checklist, the corresponding images are displayed
Evaluating the Virtual Target Setup This is done by following a comprehensive checklist guide (Figure 2). The purpose of this exercise is to ensure that the setup has not been designed beyond the boundary conditions defined by the doctor’s prescription, and the planned tooth movements are achievable. Complementary tool sets designed in the software, such as registration against the VTM, facilitate the understanding of the planned movements (Figures 3A-3C). Furthermore, an automatic check guide using the ABO grading system can be used to evaluate individual tooth positions and score the setup (Figures 4A and 4B). The doctor has the ability to correct the setup by moving teeth at the practice site or requesting the SureSmile digital laboratory to do so (Figure 4C).
Figures 3A-C: Patient K.S. A. Virtual Target Setup VTS Model registered on the B. Virtual therapeutic model VTM. C. Displacement values VTM, VS, VTS. These provide an indication of the nature of tooth movement planned to achieve the target. Note: It is best to look at the tooth as a whole to determine the nature of tooth movement. The displacement values are best used to gain an appreciation of the type and magnitude of tooth movement
Volume 4 Number 3
Figures 4A-4C: Patient K.S. A. The ABO OGS score shown is measured against a checklist. B. Each of the measurement items defined by this system are automatically identified and measured, and the scores shown. The Virtual Target Setup can also be evaluated by using the automatic ABO OGS grading system. C. The teeth can be moved by the doctor if he/ she chooses to. In this case, the buccal lingual inclination of the lower second molar is being evaluated and corrected. Notice the change in scores of the lower right second molar in B. versus A.
Orthodontic practice 23
ORTHODONTIC CONCEPTS
Sachdeva Virtual Target Prescription Design (SVTPD) guidelines
ORTHODONTIC CONCEPTS Evaluating the final design of the SureSmile precision archwires The SureSmile precision archwire is automatically designed to the Virtual Target Setup. It is best evaluated by reading the archwire bends/geometry against the brackets on the VTM and mentally visualizing the effect of such bends on tooth movement. In other words, bends are consistent with the direction of planned tooth movement (Figure 5).
Figure 5: The design of the SureSmile precision archwire can be read against the therapeutic model to evaluate the nature of the bends designed
Figure 6: Selection of material and cross-section for the fabrication of the SureSmile precision archwires
Designing the virtual prescription for the SureSmile precision archwire SureSmile software provides the orthodontist unprecedented tools to “add or subtract” to the design of SureSmile precision archwires and override the base design driven by the static setup (Please note: No special bends were designed into the precision wire for patient K.S. The
purpose of this part of the discussion is only to inform the reader of the capabilities of SureSmile technology in adding or subtracting bends to affect the geometry of the precision archwire to achieve the target tooth movement.) The doctor may choose both the cross-section and material for archwire fabrication (Figure 6). Furthermore, the expression of the archwires may be
Figures 7A-7E: Patient K.S. wire modifications. Example of the staging of archwire bends. A-E. An entire range of staged archwires can be designed from 0% to 120%, i.e., passive to overcorrected bends for any one region to the entire arch
24 Orthodontic practice
staged from a range of 0% (passive archwire) to 120% (overcorrection) based upon the patient’s needs (Figures 7A7E). Additionally, overcorrection bends to correct for bracket wire slop may be added to the base archwire design to gain better control of tooth movement (Figures 8A8D).
Figures 8A-8D: Patient K.S. addition of torque in archwire. To correct for slop in the archwire, more torque may be added in the archwire. There are two approaches to achieve this. A. First shows the automatic addition of torque based upon slot and archwire dimension. For a .017”x.025” archwire in a .018” slot, this amounts to two degrees. B. For a .016”x.022”, it is five degrees. C. and D. Overcorrection can also be built into archwire. Also, note that tooth movement can be simulated to account for the additional torque in archwire
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ORTHODONTIC CONCEPTS
Also expansion, constriction, reverse Curve of Spee or Curve of Spee may be added to counteract or complement the use of auxiliaries such as elastics, etc. (Figures 9A-9G). The wire may be “straightened” in critical areas where sliding mechanics are needed to close space (Figure 10). Overrides in the distal segments of the archwire may be designed to accommodate for a second molar that erupts later and has not been scanned (Figures 11A-11C). This feature is especially useful in clinical situations where it may be difficult to scan the second molar intraorally, or the doctor does not wish to take an additional CBCT image of the patient. Furthermore, the effect of doctordriven subtractive or additive bends may be simulated to understand the potential displacive effects of these bends (Figure 10). Finally, archwire insertion may be simulated to assess the potential of archwire bracket collisions (Figure 16).
Figures 9A-9G: Designing the virtual prescription archwire. A-C. Reverse Curve of Spee in archwire. A. Initial archwire. C. Note: 4 mm reverse Curve of Spee built into the archwire. C. The effect of this archwire, if allowed to express fully, can be simulated. D-G. Expansion or constriction can be designed into the archwire and simulated. E. Note: 5 mm arch width expansion has been designed into the archwire, and the effect of using this archwire is simulated
Figures 11A-11C: Patient K.S. A-C. Note: the archwire has been distally extended and torque placed on the wire
Overcorrection may also be added by affecting tooth movement in the setup rather than using the “virtual plier.” The choice of either using a tooth-driven approach to affect archwire geometry or virtual plier is dependent upon the doctor’s preference. In patient K.S, .017” x .025” CuNiTi for both the upper and lower were selected to achieve the target treatment.
Figure 10: Archwire modification. Any segment of the archwire can be made “straight” to allow slide to enable space closure without any conflicts arising from bends 26 Orthodontic practice
Volume 4 Number 3
The SureSmile precision archwire is shipped to the practice site within 10 business days of accepting the final design of the virtual prescriptive archwire. It takes 4 business weeks from the time the therapeutic scan is taken to the time the archwire is delivered to the practice (Figure 6). Commonly, the doctor schedules the patient visit for insertion of the SureSmile precision archwires 6 weeks posttherapeutic scan. For patient K.S., this visit was scheduled 4 weeks post-therapeutic scan. The design of the archwire is printed on the box that carries the archwire. This allows the doctor to compare the physical archwire design to the virtual design. Note: The image of the SureSmile precision archwire is also available for viewing in
Figures 12A-12B: Placement of archwire in vivo. Laser marks on the archwire are etched. These are used as guide marks to ensure proper archwire placement. These marks can also be seen on the virtual archwire and on a printout that comes with the box the archwire is shipped in to the practice
Figure 13: Patient K.S archwire insertion. In order to minimize any archwire bends and bracket conflicts, engagement points can be simulated to optimize archwire placement. The blue hash line on the archwire should match with the slot
Figure 14: IPR tracking chart
Volume 4 Number 3
the patient’s SureSmile electronic record (Figure 12A). Accurate placement of the archwire and proper management of tooth constraints is vital to achieve success with SureSmile precision archwires. Visual checkmarks to confirm correct positioning of the archwire are available as a reference for the doctor or staff to place the archwire (Figure 12B). Also guidelines for the tooth best suited to first engage the archwire are available for viewing in the SureSmile patient record (Figure 13). In addition, IPR can be tracked during treatment to ensure tooth collisions do not occur, and excessive enamel is not removed (Figure 14). Orthodontic practice 27
ORTHODONTIC CONCEPTS
SureSmile precision archwire insertion and patient management
ORTHODONTIC CONCEPTS Note: All the archwires may be ordered in a series in advance or later. Additional archwires for refinement purposes during treatment can be ordered by either modifying the setup or adding modifications directly into the archwire. A checklist in the software is embedded to guide the doctor in assessing the potential root cause for misalignment that may be observed during the use of the SureSmile precision archwires (Figure 15). This is often related to mismanagement of the constraints or improper placement of the archwire (Figures 16A-16D). Generally speaking, the SureSmile prescription archwires are allowed to “work out” for 8 weeks before the patient is seen. Upon the patient’s return to the practice at the next visit, the archwire deactivation is matched against the staged virtual target simulation. When the intraoral results match the final VTS, it may be inferred that the archwire has worked out. It is best to view the relative bracket positions to gauge the proximity of the occlusion to the planned target. At the patient check visit (8 weeks post precision archwire insertion), the patient’s response was evaluated against the VTS. Note how closely the planned final position of the brackets on the VTS match patient K.S.’s intraoral condition (Figures 16 and 17). At this visit, it was concluded that most of the tooth movement had been accomplished (Figure 17), and the patient was appointed for a final checkup 4 weeks later. At this appointment, the patient was once again evaluated against the VTS. It appeared clinically that the final target occlusion had been achieved (Figure 16D), and the patient was scheduled for debonding a month later (Figures 17C-17D). In situations where the in vivo positions of the teeth do not match the virtual setup, the checklist guide in the SureSmile software is used to perform a root cause, and then the precision archwire is redesigned with the virtual plier or with simulations to achieve the desired effect match (Figure 14). These refinement precision archwires are generally received within 10 business days or sooner. In most situations, orthodontists will insert the refinement archwire approximately 4 weeks from the time the refinement prescription is ordered. In patient K.S.’s situation, no refinement was required, and the patient was debonded 16-weeks post SureSmile wire insertion. The total active treatment time for patient K.S. was 12 months. 28 Orthodontic practice
Figure 15: Checklist to manage SureSmile precision archwire. Also note refinement in the precision archwire can be made at any point in the care cycle to achieve the desired response. But this is best accomplished by progressing step-wise through this checklist and identifying the root cause of any spurious tooth movement before affecting change in the precision archwire geometry
Figures 16A-16D: Patient K.S. A. and B. The intraoral results match. C. and D. The final target virtual setup. It may be inferred from this that the archwire has worked out
Figures 17A-17D: Patient K.S. Post SureSmile precision archwire insertion progress. A. 8 Weeks. B. 12 Weeks. C. Initial D. Final. The total treatment time was 12 months
Volume 4 Number 3
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ORTHODONTIC CONCEPTS No refinements to the archwires were made, and the patient was debonded a month later.
Conclusions Successful therapeutic management of a patient with SureSmile technology requires thoughtful synchronization of the straightwire technique with use of the SureSmile prescriptive appliance. High risk patients, who require precision control of tooth movement at the onset of treatment, are better served by utilizing SureSmile prescription archwires at the beginning of treatment. Extraction patients are better managed with SureSmile prescriptive archwires post space closure; however, as the orthodontist builds proficiency in the use of SureSmile technology, the prescriptive archwires are commonly used within the first few months of treatment. In future papers, patient histories will be presented to highlight this point. SureSmile technology provides the orthodontist with great flexibility in staging and adapting the prescription of an archwire to suit the patient’s needs as treatment progresses. Such an “adaptive capacity” is not offered by customized brackets.
Figures 17A-17D: Patient K.S. Post SureSmile precision archwire insertion progress. A. 8 Weeks. B. 12 Weeks. C. Initial D. Final. The total treatment time was 12 months
Acknowledgements It is with the deepest sense of gratitude that I wish to thank both Dr. Takao Kubota, DDS, PhD, and Dr. Sharan Aranha, BDS, MPA, for their unconditional and enthusiastic support in the preparation of this manuscript. OP Visit Dr. Sachdeva’s blog on http:// drsachdeva-conference.blogspot.com. All doctors are invited to join the “Improving Orthodontic Care” discussion blog. Please contact improveortho@gmail.com for access information. References 1. Sachdeva RCL. BioDigital orthodontics: Planning care with SureSmile technology: part 1. Orthodontic Practice US. 2013;4(1):18-23. 2. Sachdeva RCL. BioDigital Orthodontics: Designing customized therapeutics and managing patient treatment with SureSmile technology: part 2. Orthodontic Practice US. 2013;4(2):18-26. 3. Sachdeva RCL, Feinberg MP. Reframing clinical patient management with SureSmile technology. Pacific Coast Society of Orthodontists NewsWire. 2009;2(1):1-24. 4. Sachdeva RCL. Integrating digital and robot technologes: diagnosis, treatment planning, and therapeutics. In: Graber LW, Vanarsdall RL, Vig KWL, eds. Orthodontics Current Principles and Techniques. 5th ed. Philadelphia, PA: Elsevier Mosby; 2011. 5. Sachdeva RCL, Kubota T, Hayashi K, Uechi J. Transforming Orthodontics-4: BioDigital Orthodontics (1): Planning care with SureSmile Technology Journal of Orthodontic Practice. 2012;7:83-97.
30 Orthodontic practice
Figures 17A-17D: Patient K.S. Post SureSmile precision archwire insertion progress. A. 8 Weeks. B. 12 Weeks. C. Initial D. Final. The total treatment time was 12 months
Volume 4 Number 3
CONTINUING EDUCATION
Incorporating TAD-supported Haas expansion into everyday practice Drs. Ryan K. Tamburrino and Shalin R. Shah explore appliance design, delivery technique, and expansion protocols as it relates to the TAD-supported Haas Introduction The main goal for palatal expansion is to harmonize the skeletal width of the maxilla to the mandible.1 Ideal orthopedic expansion should involve movements of only the skeletal portions of the maxilla, be stable long-term, and expand at a 1:1 ratio with the amount of opening of the jackscrew as shown in Figure 1. Additionally, in ideal expansion there would not be any dental tipping or other untoward dental effects. Unfortunately, the geometry of the maxilla, the location of the applied expansion force, and the design of most orthopedic appliances all limit the ability to obtain ideal expansion.2 Therefore, palatal expansion will often involve some degree of skeletal change in addition to dental and alveolar changes, often expressed as buccal tipping of the maxillary posterior teeth.3,4 With the advent of temporary anchorage devices (TADs), it is now possible to anchor the expansion appliance directly and only on the palate (a completely tissue-borne appliance). This has shown great promise in improving the effectiveness of orthopedic expansion.
Ryan K. Tamburrino, DMD, co-founder of the Center for Orthodontic Excellence, graduated from Duke University with a double major in biomedical engineering and mechanical engineering/materials science. He attended the University of Pennsylvania for dental school as well as specialty training in orthodontics. Dr. Tamburrino is on faculty as an attending clinician in the graduate orthodontic clinic at the University of Pennsylvania. Additionally, he is on faculty and lectures internationally/nationally with the Complete Clinical Orthodontics (CCO) courses. Shalin Raj Shah, DMD, MS, received his Certificate of Orthodontics and Masters of Science in Oral Biology from the University of Pennsylvania and is a Diplomate of the American Board of Orthodontics. He is also a graduate of the University of Pennsylvania College of Arts and Sciences and School of Dental Medicine. Currently, Dr. Shah is Clinical Associate of Orthodontics at the University of Pennsylvania and is in private practice (Center for Orthodontic Excellence) in Princeton Junction, New Jersey and Philadelphia, Pennsylvania.
32 Orthodontic practice
Educational aims and objectives This article aims to show appliance design, delivery technique, and expansion protocols as it relates to the TAD-supported Haas. Expected outcomes Correctly answering the questions on page 36, worth 2 hours of CE, will demonstrate the reader can: • Realize the benefits of TAD-supported Haas expansion. • Identify and understand TAD-supported Haas expander results. • Understand TAD-supported Haas expander activation protocol. • Identify TAD-supported Haas expander activation and protocol. • Describe the steps of TAD-supported Haas expander removal. • Recognize TAD-supported Haas expander emergencies.
Figures 1A-B: Graphic illustration of “ideal” palatal expansion showing 1B Sutural expansion with the jackscrew and no dentoalveolar or dental tipping Figure 2: The TAD-supported Haas expander
Figure 3: Benefits of TAD-supported expansion
It also enables orthodontists to truly consider it as a treatment modality for older adolescents in addition to younger age groups. For the expansion appliance described in this article and shown in Figure 2, the expansion screw or jackscrew is embedded in acrylic, and the acrylic shelves cover the palatal tissue. The appliance described in this article will be referred to as the TAD-supported Haas expander, which recognizes Dr. Andrew Haas for his contributions to tooth and
tissue-borne expansion.5 This article focuses on appliance design, delivery technique, and expansion protocols as it relates to the TAD-supported Haas. Clinical research comparing its efficacy to other expander types is ongoing, and they are not the focus of this clinical technique report.
Benefits of TAD-supported Haas expansion Unlike traditional expanders that attach Volume 4 Number 3
Figure 5: Illustration of TAD placement variations for two or four TAD appliances
Figure 6: Proper trimming and passive seating of appliance prior to cementation
to or cover the teeth, the TAD-supported Haas expander is anchored directly to the palate and does not engage the dentition. As a result, it offers significant advantages to both the patient and orthodontist (Figure 3). For the orthodontist, the appliance provides another effective option in the expansion of older adolescents, where it is typically thought more dental tipping versus skeletal expansion would occur.6 Additionally, the TAD-supported Haas expander provides a viable treatment approach for adolescents who are further into their skeletal maturation process. Often these individuals would require surgical intervention, but the complete tissue-borne nature of the TAD-supported Haas expander enables the orthodontist to provide an alternative treatment strategy for these patients.7 Another significant advantage of the appliance is the ability to place fixed appliances on all upper teeth at the same time as the expander and without interferences. The patient has less physical material in the mouth with the TAD-supported Haas, compared to both tissue and tooth-borne, and tooth-borne only appliances. The lower profile lends itself to greater comfort Volume 4 Number 3
and better social acceptance. The authors have also found that patients’ speech is often less affected with the TAD-supported Haas expanders.
TAD-supported Haas expansion results The key to the success of this appliance is the direct application of the expansion force onto the maxilla. It has been shown that the maxillary midpalatal suture histologically remains patent on many late adolescent patients, even if radiographic evidence of patency is not conclusive.8 By applying the expansion force directly to the palate instead of indirectly through the teeth, elimination of adverse dental consequences is avoided. Through clinical analysis of preand post-expansion records of patients receiving TAD-supported Haas expanders, the authors have observed midpalatal sutural separation and maxillary skeletal transverse changes (measured at Mx-Mx point) at roughly 60-75% of the amount of expansion placed into the jackscrew. In contrast, the authors have seen approximately 35-50% of the amount of jackscrew activation expressed at the skeletal level in the combined tissue and
Figure 7: Coat cutouts with plastic conditioning material to ensure cement adhesion to the appliance
tooth borne expanders. An example of a 15-year-old male (chronologic age) is shown in Figure 4. The images show the skeletal measurements on pre-treatment and immediate post-expansion CBCT cuts (8 mm jackscrew activation) using the University of Pennsylvania CBCT transverse analysis.9 Of note is the 6 mm of maxillary skeletal change and sutural separation, with negligible dental tipping or alveolar bending. The mandibular images are shown for comparison to ensure no radiologic variations affected the measurement accuracy.
TAD-supported Haas expander insertion protocol A streamlined protocol has been developed where the TADs, as well as the appliance, can be inserted at the same appointment, which has greatly improved patient comfort and clinical efficiency. Additionally, the authors have had equivalent success with placement of two TADs as well as four TADs. With two TADs, there has been less expense for the patient, and clinically, less time was required for placement and retrieval of the expander. Most importantly, all these benefits were accompanied with Orthodontic practice 33
CONTINUING EDUCATION
Figure 4: Pre-treatment and immediate post-expansion CBCT comparison of a 15-year-old male. Note 6 mm of skeletal maxillary change and 6 mm of sutural expansion using an 8 mm jackscrew
CONTINUING EDUCATION
Figure 8: Fill each cutout with light-cure cement prior to insertion
Figure 9: Stabilize appliance with finger while curing the cement
no change in clinical outcomes when compared with expanders that were supported by four TADs. The authors use 1.6 mm (diameter) x 8 mm (length) self-drilling and self-tapping TADs. They are placed in-office, and they typically are inserted between the maxillary first and second premolars. Several drops of local anesthesia (Lidocaine HCL 2% with Epinephrine 1:100,000) or 20% TAC gel are used to provide patient comfort during the insertion process. The authors use a button-top type of head on the TAD, but variations in head shape do not appear to have an effect on the expander retentiveness. When placing palatal TADs, it is important to avoid the branches of the greater palatine artery. It is recommended that a periodontal probe be used to sound the area, and ensure the proposed area for insertion does not encroach upon the artery. Additionally, it is critical to place the TADs as perpendicular to the geometry of the palatal arch as possible to provide stability and resistance to loosening due to the forces of expansion. Figure 5 illustrates the placement of two and four TADs. Once the TADs are placed and secured, the expander can be retrofitted into position by using an acrylic or carbide bur on a high-speed handpiece along with articulating paper. The expander should be reamed out in these areas to allow for complete and passive seating of the entire intaglio surface of the expander against the palatal tissue. After a fit is confirmed, the sides of the expander should be reduced to be at least 4-6 mm apical to the palatal gingival margin. This ensures that the expander will apply more force on basal bone rather than dentoalveolar bone. Once this is completed, the orthodontist should take a lab acrylic bur around the appliance, and 34 Orthodontic practice
ensure no sharp edges are present on the appliance as well as ensuring all corners are rounded and polished. This step is critical in preventing emergencies due to the impingement of the expander into the palatal mucosa. When the expander is ready for insertion (Figure 6), the recessed areas created for passive seating of the TAD heads should be coated with a plastic conditioning material and allowed to air dry as shown in Figure 7. Use of a light-cure, flowable band cement such as Band-Lok速 (Reliance Orthodontics) or flowable acrylic such as Triad速 Gel (Dentsply) is sufficient to hold the expander in place. Each of the recessed areas should be filled completely with the adhesive of choice as shown in Figure 8. However, the orthodontist should take caution not to overfill them excessively as the residual material will spill and cure onto the palatal tissue. At this moment, the clinician should have the patient open, dry the TADs with air, seat the expander in place, and light cure the material (Figure 9). The inserted and cured expander is shown in Figure 10.
TAD-supported Haas expander activation and protocol While there are many different protocols for rapid palatal expansion, they all maintain the same goal of providing an orthopedic level of force to the maxilla. For the TADsupported Haas expander, the authors advocate a protocol of one turn/day for the first week only followed by two turns/day until the desired expansion is completed. This protocol has proven successful in that the one turn/day for the first week allows the expander to fully seat and conform to the palatal tissue for added support prior to more rapid activation. When activating the jackscrew, parents are advised to use the opposite hand to
Figure 10: The completed TAD-supported Haas RPE in place
Figure 11: The wire may be inserted immediately following expansion completion
provide additional support for the expander in order to prevent unnecessary torque to the TADs. Once the desired expansion is completed, the appliance is left in place for 4-6 months to allow for complete osteoid tissue mineralization and stabilization of transverse correction.10 Fixed appliances (bonded brackets) may be placed on the maxillary teeth once expansion is complete as seen in Figure 11. Another alternative is to place fixed appliances on the day of expander insertion, but do not insert a wire until the expansion is complete in order to minimize resistance and potential untoward dental effects.
TAD-supported Haas expander removal Removal of the TAD-supported Haas expander involves two steps: removing the expander and removing the TADs. Unlike the insertion, this step usually does not require local anesthesia. The authors recommend using a flameshaped or football-shaped diamond bur on a high-speed handpiece in conjunction with high-speed suction/evacuation. The orthodontist should remove all the acrylic above the head of the TADs, and relieve Volume 4 Number 3
CONTINUING EDUCATION
Figure 12: Illustration of the TAD-supported Haas RPE sequence, from initial presentation through 2-weeks post-appliance removal
the cement around the TADs. Once the expander is freed from any undercuts on the TADs, it can be removed. Any remaining cement can then be removed from the head of the TAD. If the treatment plan indicates removal of the TAD, the TAD may be removed at that time with the same torque driver used at insertion. Upon removal of the expander and TADs, there will be areas of transient inflammation of the palatal tissues as well as at the sites where the TADs were placed. Patients are encouraged to keep the palatal tissue clean and rinse with warm saltwater two times a day for approximately 1 week. After 7-10 days, the tissue should completely heal with no scarring. The entire sequence from initial presentation through insertion, removal, and healing is shown in Figure 12.
TAD-supported Haas expander emergencies The most common emergency is impingement of the palatal mucosa due to improper steps to smooth the edges of the appliance. Ensuring the expander is smooth prior to insertion can initially prevent this. However, if a sharp or uncomfortable edge is bothering the patient, the problem can be resolved without removing the entire appliance by intraorally relieving the offending edge with a fine carbide bur. Another emergency would be loosening of the expander due to a failed TAD or failed retention to the TAD. While Volume 4 Number 3
this is rare, it is an emergency that can be easily handled. Since the appliance is all acrylic, the expander can be easily removed/retrieved, the TAD replaced (if loose), and the expander repaired and recemented all in the same appointment. Generally, patients have reported minimal discomfort from the TAD-supported Haas expanders. This being said, patients have reported similar soreness following activation as those patients with traditional tooth and tissue-borne expanders. If discomfort from activation persists during the initial few days, patients are advised to take whatever analgesic medication they typically use for minor aches and pains.
Conclusion The TAD-supported Haas expander is a viable method to achieve effective nonsurgical skeletal expansion of middlelate adolescent orthodontic patients. Streamlined methods provide techniques for easy placement and optimal oral hygiene. Furthermore, these expanders are well tolerated by the patient without compromising clinical efficiency and outcomes. It is a revolutionary appliance that should be a part of any modern orthodontist’s armamentarium. OP
References 1. McNamara JA. Maxillary transverse deficiency Am J Orthod Dentofacial Orthop. 2000;117(5):567-70. 2. Araugio RM, et al. Influence of the expansion screw height on the dental effects of the hyrax expander: A study with finite elements. Am J Ortho Dentofacial Orthop. 2013;143:221-7. 3. Chung CH, Font B. Skeletal and dental changes in the sagittal, vertical, and transverse dimensions after rapid palatal expansion. Am J Orthod Dentofacial Orthop. 2004;126:569-575. 4. Garrett BJ, et al. Skeletal effects to the maxilla after rapid maxillary expansion assessed with cone-beam computed tomography. Am J Ortho Dentofacial Orthop. 2008;134:8-9. 5. Haas, AJ. Rapid expansion of the maxillary dental arch and nasal cavity by opening the midpalatal suture. Angle Orthod. 1961;31(2):7390. 6. Baccetti T, et al. Treatment timing for rapid maxillary expansion. Angle Orthod. 2001;71: 343-350. 7. Graber, TM, R. Vanarsdall, KWL.Vig. Orthodontics: current principles & techniques. 4th ed. St. Louis, MO.: Elsevier Mosby; 2005. 8. Knaup B, et al. Age-related changes in the midpalatal suture. A histomorphometric study. J Orofac Orthop. 2004;65:467-474. 9. Tamburrino RK, et al. The transverse dimension: diagnosis and relevance to functional occlusion. RWISO J. 2010:13-2. 10. Lione R, et al. Rapid maxillary expansion: effects on palatal area Investigated by computed tomography. Eur J Paediatr Dent. 2012;13(3):215-8.
Orthodontic practice 35
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Incorporating TAD-supported Haas expansion into everyday practice 1. Unfortunately, ___________ limit the ability to obtain “ideal� expansion. a. the geometry of the maxilla b. the location of the applied expansion force c. the design of most orthopedic appliances d. all of the above 2. With the advent of _______, it is now possible to anchor the expansion appliance directly and only on the palate (a completely tissue-borne appliance). a. temporary anchorage devices (TADs) b. composite resins c. alveolar bending d. light-cure, flowable band 3. Unlike traditional expanders that attach to or cover the teeth, the ______is/are anchored directly to the palate and does not engage the dentition. a. Band-Lok b. TAD-supported Haas expander c. coat cutouts d. Triad 4. For the orthodontist, the appliance provides another effective option in the expansion of _______, where it is typically thought more dental tipping versus skeletal expansion would occur.
36 Orthodontic practice
a. very young children b. older adolescents c. middle aged adults d. seniors 5. Through clinical analysis of pre- and post-expansion records of patients receiving TAD-supported Haas expanders, the authors have observed midpalatal sutural separation and maxillary skeletal transverse changes (measured at Mx-Mx point) at roughly _______of the amount of expansion placed into the jackscrew. a. 30-45% b. 50-55% c. 60-75% d. 80% 6. In contrast, the authors have seen approximately ______of the amount of jackscrew activation expressed at the skeletal level in the combined tissue and tooth borne expanders. a. 15% b. 20-25% c. 35-50% d. 60-75% 7. A streamlined protocol has been developed where the _______ can be inserted at the same appointment, which has greatly improved patient
comfort and clinical efficiency. a. TADs b. the appliance c. bone graft d. both a and b 8. When placing palatal TADs, it is important to avoid __________. a. the maxillary first premolar b. maxillary second premolar c. the branches of the greater palatine artery d. all the above 9. After a fit is confirmed, the sides of the expander should be reduced to be at least______apical to the palatal gingival margin. a. 1-2 mm b. 2.5-3.5 mm c. 4-6 mm d. 7-8 mm 10. Once the desired expansion is completed, the appliance is left in place for ______to allow for complete osteoid tissue mineralization and stabilization of transverse correction. a. 1 month b. 6 weeks c. 2-3 months d. 4-6 months
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CONTINUING EDUCATION
Complete Clinical Orthodontics: treatment mechanics: part 3 Dr. Antonino Secchi summarizes the specific strategies within the CCO System to manage space closure in different anchorage situations Introduction Anchorage management, specifically in extraction cases, is an important concept in clinical orthodontics. Therefore, the main objective of this article is to summarize the specific strategies within the Complete Clinical Orthodontic (CCO) System1 to manage space closure in different anchorage situations. Although the type of anchorage required and used should be determined before treatment starts, the actual space closure mechanics in extraction cases is handled at the working stage, and after the following objectives have been previously and properly achieved: • Complete leveling and alignment • All rotations corrected • Maxillary and mandibular arches coordinated • Maxillary and mandibular occlusal planes flat • Proper maxillary and mandibular incisors inclination achieved Once CCO’s Stage 1 (Leveling and Aligning) is completed, the residual extraction spaces are often smaller
Antonino G. Secchi, DMD, MS, is a clinical assistant professor and former clinical director of the Department of Orthodontics at the University of Pennsylvania. Dr. Secchi received his DMD, Certificate in Orthodontics, and a Master of Science Degree in Oral Biology from the University of Pennsylvania. He is a Diplomate of the American Board of Orthodontics and member of the Edward H. Angle Society of Orthodontists. At the University of Pennsylvania, he has developed and implemented courses on Orthodontic Treatment Mechanics, Straight Wire Appliance Systems, and Functional Occlusion in Orthodontics for postdoctoral orthodontic residents. Dr. Secchi wrote the chapter “Contemporary Mechanics Using the Straight Wire Appliance” for the latest edition of the Graber/Vanarsdall/Vig orthodontic textbook. He also received the 2005 David C. Hamilton Orthodontic Research Award from the Pennsylvania Association of Orthodontists (PAO) and the 2010 Outstanding Teacher Award from the Department of Orthodontics of the University of Pennsylvania. Dr. Secchi is the founder of the “Complete Clinical Orthodontics System” (CCO System™), which he teaches to orthodontists throughout the world. He also maintains an active orthodontic practice in Philadelphia and Devon, Pennsylvania.
38 Orthodontic practice
Educational aims and objectives This article aims to continue to the discussion of the CCO System and to explore strategies within the system to manage space closure in different anchorage situations. Expected outcomes Correctly answering the questions on page 42, worth 2 hours of CE, will demonstrate the reader can: • Identify accurate ways to determine the anchorage requirement by using a visual treatment objective (VTO). • Discuss three types of anchorage requirements: minimum, medium, or maximum.
Figures 1A-1F show an upper and lower first premolar extraction case at the beginning of treatment with the initial 0.014-inch Sentalloy wire. 1C-1D show the same case at the end of Stage 1 and beginning of Stage 2 where all the objectives before starting space closure mechanics have been achieved. Upper and lower teeth are aligned and leveled, all rotations are corrected, upper and lower incisors are uprighted, the overjet and overbite improved, the extraction spaces have decreased, and the maxillary and mandibular occlusal planes are flat. Now, the case is ready for space closure. 1E-1F show the case finished
than at the beginning of treatment. This phenomenon is seen since a portion of the extraction space has been used to unravel the initial crowding and to upright
the maxillary and mandibular incisors, as described in “Complete Clinical Orthodontics: Treatment Mechanics, Part 1”2. Also, the maxillary and mandibular Volume 4 Number 3
occlusal planes should be flat or almost flat, the upper and the lower arches should be coordinated,3 and the six anterior teeth should be consolidated into one unit Volume 4 Number 3
(Figures 1A-1D). At this point, we should be working with rectangular stainless steel (SS) archwires, either 0.019×0.025-inch or 0.021×0.025-inch, depending upon
Orthodontic practice 39
CONTINUING EDUCATION
Figures 2A-2G: 2A-2B show the initial photos of a case treated with extractions. The anchorage was determined based on the VTO. Figure 2C shows the initial cephalometric (black) superimposed with the VTO (blue). Two years of growth were factored in. Torque of the upper and lower incisors was maintained. The anchorage for the maxilla was determined as medium (at least on the right side most of the space would be taken by the ectopically positioned canine). For the mandible the anchorage was determined as minimum since the molars would be moved forward to a Class I relationship. 2D-E show the case at the beginning of treatment with an 0.014-inch Sentalloy wire. Upper first premolars and lower second premolars were extracted. 2F-2G show the case at the end of treatment
the anchorage situation. The archwire selection will be further described in detail later in this article. To efficiently close the remaining spaces, we then need to implement the selected and necessary anchorage modality, which will allow us to move teeth either more mesially or distally to achieve the desired functional and esthetic goals. We believe that one of the easiest and more accurate ways to determine the anchorage requirement is to perform a visual treatment objective (VTO). The VTO is a cephalometric exercise popularized by Ricketts4 where we modify the patient’s cephalometric tracing to achieve the desired “end of treatment” result. When both tracings are superimposed, we can visualize and quantify the movements that need to occur to obtain that result. The VTO is not a formula or equation that will determine or impose a specific type of treatment, but it is an exercise where we can take into account our clinical experience from other similar cases, provide an estimation of the growth the patient will have during treatment, assess the patient’s biotype and soft tissue characteristic, etc. This tool and guide allows the clinician to more accurately treatment plan cases and have a visual representation of the journey and end result. Once the VTO is completed, the anchorage requirements can be defined and be divided into one of three types: minimum, medium, or maximum. It is important to notice that the anchorage requirement is arch specific, and therefore, there are clinical situations where the anchorage will differ from one arch to the other (Figures 2A-2G). Before describing each one of these anchorage situations, it is important to indicate the wires and auxiliaries used at this stage as well as the goals to be achieved (Table 1). In the CCO system, straight archwires with hooks and Sentalloy® coils (GAC International) are used. The wire is stainless steel and can be either 0.019×0.025-inch or 0.021×0.025inch, depending upon the anchorage situation. The hooks are crimpable hooks that are usually crimped into the archwire distal of the canine. The Sentalloy coils can be light (100 gr), medium (150 gr), or heavy (200 gr). The most common coils used are medium (150 gr) and heavy (200 gr). They work very well in all kinds of anchorage situations. When the anchorage situation calls for it, additional auxiliaries may be utilized to enhance the posterior
CONTINUING EDUCATION
Figures 3A-3C: 3A shows an extraction case at the beginning of the space closure. Notice the crimpable hook distal of lower canine and the Sentalloy coil attached from first molar to the surgical hook. 3B shows the same case after the space has been closed. During space closure, the Sentalloy coils were moved from the first molar to the second molar to adjust the anchorage as required by the case. Figure 3C shows the case finished
Figure 4A-4C: 4A shows a case with a missing lower first molar. The treatment plan was to move the second and third molars forward to close the space. The Sentalloy coil was attached from the second molar to the hook of the first premolar. Notice that all anterior teeth are tied with an elastomeric chain, so they can act as one unit in this minimum anchorage case. 4B shows the space already closed with the molars in Class I. Now the coil is extended to the third molar to move it forward. 4C shows the case with all the spaces closed and the case ready to be finished
anchorage. For example, the clinician may choose to use auxiliaries like transpalatal bars (TPB), temporary anchorage devices (TAD), or extraoral anchorage such as headgear (HG).
Sentalloy coil activation As pointed out before, Sentalloy coils come in different strengths, 100 gr (blue dot), 150 gr (yellow dot), and 200 gr (red dot). These coils deliver the same force independent of the amount of activation or length the coil is stretched. In the CCO mechanics, a surgical hook is crimped distal of the canine where the Sentalloy coil is engaged. The other end of the coil is connected to the elastic hook of either the first or second molar (Figures 3A-3B); the molar choice depends upon the anchorage 40 Orthodontic practice
required. If a surgical hook is not available, the Sentalloy coil could also be attached to the hook of the canine or premolar’s bracket. This situation requires the six or eight front teeth to be tied together with either an elastomeric chain or a stainless steel ligature so they act as a unit (Figures 4A-4B).
Medium anchorage This is the most common anchorage situation encountered. Medium anchorage means that the remaining spaces are closed reciprocally. For this situation, we use a 0.019×0.025-inch SS wire. The activation of the Sentalloy coils for minimum anchorage requirement is often to the elastic hook of the first molar (Figures 5A5B). However, it can also be done from the
second molars depending on how the case is progressing. The bone and attachment apparatus is not the same for every patient, and therefore, the response to the closing mechanic could differ between cases. A clinical examination of the overbite/ overjet, canine and molar relationship, and facial esthetics should be done at each visit to evaluate any changes in activation that may be required. This should take minimal additional chairtime, since the management of the Sentalloy coil is in itself an easy procedure. At this point, we ask the patient to wear short, 3/16” 4 oz Class II elastics at nighttime.
Maximum anchorage In a maximum anchorage situation, most of the remaining space left after leveling and aligning is closed due to distal movement of the anterior teeth. We use a 0.019×0.025-inch SS wire. The Sentalloy coil is activated from the second molars (Figures 6A-6B). Also, at this point, we ask the patient to wear short, 3/16” 4 oz or 6 oz Class II elastics at nighttime as well as during daytime if needed. Although not frequently required, auxiliaries to enhance posterior anchorage such as TPB, TADs, or HG can be used. Volume 4 Number 3
CONTINUING EDUCATION
Figures 5A-5B show the diagram of a medium anchorage situation. Crimpable, surgical hooks placed distal of the canines and Sentalloy coils attached from the surgical hook to the elastic hook of the first molars. It is important to remember that the Sentalloy coils should not be extended more than five times their passive length. Therefore, depending on how long is the distance from the hook to the molars, the coils can be extended using stainless steel ligatures.
Figures 6A-6B shows the diagram of a maximum anchorage situation. Usually first premolars are extracted, the wires are 0.019×0.025-inch SS, and the coils are attached from the second molars to the surgical hook
Figures 7A-7B show the diagram of a minimum anchorage situation. Usually second premolars are extracted, the wires increased in stiffness to an 0.021×0.025-inch SS, and the coils are activated from the first molars
Minimum Anchorage In a minimum anchorage situation, molars are moved mesially to close the remaining extraction spaces. The use of a 0.021×0.025-inch SS wire facilitates this type of movement more efficiently. This wire will not only help to maintain the buccal crown torque of the maxillary incisors and the mesial tip of the maxillary and mandibular canines, but even more important, this wire will prevent the collapse of the occlusal plane because of its stiffness. This is typically seen in the lower arch; when the the molars are moved mesially/forward, the Curve of Spee becomes deep, the incisors tip back, the molars tip mesially, and a lateral open bite develops. Round wires of any kind and/or any flexible wire are not stiff enough to overcome the collapse of the occlusal plane when protracting molars. The activation of the Sentalloy coils must be done from the elastic hook of the first molars in minimum anchorage situations (Figures 7A-7B). As a reminder, molar Volume 4 Number 3
tubes are essentially passive attachments with a very low resistance to sliding (even lower than most passive brackets5) and therefore sliding and control of molars are both possible when using such large SS wire as the 0.021×0.025-inch SS wire. After the first molar is moved mesially/ forward to its desired location, the second molar can subsequently be activated and moved mesially/forward. Most often, this is not required since the second molars will travel mesially/forward with the first molars. The residual space remaining between the first and second molars is very small and can be easily closed with an elastomeric chain. At this point, we ask the patient to wear short, 3/16” 4 oz Class II elastics at nighttime. In summary, understanding anchorage requirements and management is of paramount importance, especially in extraction cases. Completing a VTO helps to determine the specific anchorage requirements for a particular case. Anchorage requirements can be divided in minimum, medium (the most common),
and maximum. Each one of these three types of anchorage requires the use of specific archwires and auxiliaries such Sentalloy coils and crimpable hooks. It is very important to remember that before closing extraction spaces, all the objectives of Stage 1 are accomplished. The CCO System has a simple but accurate and predictable protocol to manage the anchorage requirements as well as space closure in extraction cases. OP
References 1. Secchi AG. CCO Manual on Treatment Mechanics. 2nd ed. Islandia, NY: Dentsply/GAC; 2012. 2. Secchi AG. Complete clinical orthodontics: treatment mechanics: part 1. Orthodontic Practice US. 2013;4(1):28-35. 3. Secchi AG. Complete clinical orthodontics: treatment mechanics: part 2. Orthodontic Practice US. 2013;4(2):28-32. 4. Ricketts RM, Bench RW, Hilgers JJ, Schulhof R. An overview of computerized cephalometrics. Am J Orthod. 1972;61(1):1-28. 5. Garcia-Baeza J. Resistance to Sliding of Different Molar Bracket Tubes/Archwire Couples at Different Angulations [master’s thesis]. Philadelphia, PA: University of Pennsylvania, Department of Orthodontics; 2011.
Orthodontic practice 41
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ORTHODONTIC PRACTICE CE Approved PACE Program Provider FAGD/MAGD Credit Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 12/1/2012 to 11/30/2016 Provider ID# 325231
REF: OP V4.3 SECCHI
CONTINUING EDUCATION BROUGHT TO YOU BY
Full Name
Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 16 CE credits for only $99. To receive credit, complete the 10-question test by circling the correct answer, then either: n Post the completed questionnaire to: Orthodontic Practice US CE 15720 N. Greenway-Hayden Loop. #9 Scottsdale, AZ 85260 n Fax to (480) 629-4002.
AGD REGISTRATION NUMBER
LICENSE NUMBER
ADDRESS
CITY, STATE, AND ZIP CODE
To provide feedback on this article and CE, please email us at education@orthopracticeus.com Legal disclaimer: The CE provider uses reasonable care in selecting and providing accurate content. The CE provider, however, does not independently verify the content or materials. Any opinions expressed in the materials are those of the author and not the CE provider. The instructional materials are intended to supplement, but are not a substitute for, the knowledge, skills, expertise and judgement of a trained healthcare professional.
TELEPHONE/FAX
Please allow 28 days for the issue of the certificates to be posted.
Complete Clinical Orthodontics: treatment mechanics: part 3 1. Once CCO’s Stage 1 (Leveling and Aligning) is completed, the residual extraction spaces are often ______ than at the beginning of treatment. a. smaller b. larger c. rounder d. more rectangular 2. To efficiently close the remaining spaces, we then need to implement the selected and necessary anchorage modality, which will allow us to move teeth either more ______to achieve the desired functional and esthetic goals. a. lingually b. mesially c. distally d. either b or c 3. We believe that one of the easiest and more accurate ways to determine the anchorage requirement is to perform a _________. a. passive attachment b. visual treatment objective (VTO) c. proper coil activation d. positive ligature connection 4. The VTO is not a formula or equation that will determine or impose a specific type of treatment, but it is an exercise where we can_______. a. take into account our clinical experience from other similar cases b. provide an estimation of the growth the patient will have during treatment
42 Orthodontic practice
c. assess the patient’s biotype and soft tissue characteristic d. all of the above 4. a. b. c. d.
In the CCO system, _________ is(are) used. straight archwires with hooks Sentalloy® coils bent archwires both a and b
5. a. b. c. d.
The Sentalloy coils can be _________. light (100 gr) medium (150 gr) heavy (200 gr) a, b, or c
6. When the anchorage situation calls for it, additional auxiliaries may be utilized to enhance the posterior anchorage. For example, the clinician may choose to use auxiliaries like _______. a. transpalatal bars (TPB) b. temporary anchorage devices (TAD) c. extraoral anchorage such as headgear (HG) d. all of the above
8. The Sentalloy coil could also be attached to the hook of the canine or premolar’s bracket. This situation requires the _____front teeth to be tied together with either an elastomeric chain or a stainless steel ligature so they act as a unit. a. two or three b. four or five c. six or eight d. no less than nine 9. The activation of the Sentalloy coils for minimum anchorage requirement is often to the elastic hook of the ______. a. first molar b. maxillary incisor c. lateral incisor d. third molar 10. It is very important to remember that before closing extraction spaces, all the objectives of ______ are accomplished. a. maintaining the residual space b. Stage 1 c. Stage 2 d. opening remaining spaces
7. In the CCO mechanics, a surgical hook is crimped _____ of the canine where the Sentalloy coil is engaged. a. lingual b. mesial c. distal d. sagittal
Volume 4 Number 3
RESEARCH
A new regimen of Phase I care applied to potential maxillary canine impactions Dr. John Hayes outlines a study of canine impactions to evaluate a regimen of Phase I care Abstract Objective: The purpose of this pilot study was to evaluate a new regimen of Phase I care applied to potential maxillary canine impactions. Materials and Methods: The data were drawn from the Williamsport Orthodontic Study, which is part of the University of Pennsylvania, School of Dental Medicine, Orthodontic Department’s practice-based research network (PBRN). Ten cases were evaluated (20 canine impactions), all of which underwent a new regimen of “Phase I only” care. All patients were diagnosed as maxillary deficient based on Harmony criteria and also based on the center of alveolar crest (CAC) measurement technique, both of which were previously reported. Results: A new regimen of Phase I care may be helpful for potential canine impactions. Conclusions: Early Phase I diagnosis and RPE correction of maxillary transverse deficiency, by way of Harmony criteria and the CAC measurement technique, may be helpful for potential maxillary canine impactions. More study is recommended with control and treatment groups matched for maxillary deficiency determined by Harmony criteria and measured by the CAC technique.
Introduction Helpful intervention for potentially impacted canines is problematical. Most researchers recommend early detection by way of palpation and/or films and/or dental cast
John L. Hayes, DMD, MBA, received an AB and MBA from the University of Michigan. After graduating from the Boston University H. M. Goldman School of Dental Medicine, he completed his orthodontic residency at the University of Pennsylvania where he is a Clinical Associate in the Department of Orthodontics. Dr. Hayes is on the Editorial Review Board of Orthodontic Practice US. He continues to research and lecture on the advantages of early interceptive treatment and on the etiology of malocclusions. Dr. Hayes is in private practice in Pennsylvania, with his wife, Sharon, who is also an orthodontist.
44 Orthodontic practice
Figure 1
Figure 2
Figure 3
measurement.1-8 However, even with early detection, prevention of impacted canines has been uncertain. The extraction of primary canines has been recommended.7, 9-11 However, extraction has not been a significant advantage over no extraction.12 The supplemental use of space gaining cervical pull headgear has been shown to be more effective than primary canine extraction alone.12 Maxillary expansion for space gaining for prevention may not be warranted if the maxilla is deemed sufficient by some criteria. It should be fair to say that the particular criteria used to diagnose a deficient maxilla will determine whether or not a maxillary deficiency is deemed to exist. Accordingly, there can easily be disagreement regarding the need for
maxillary transverse treatment.13-17 The purpose of this pilot study was to evaluate a new regimen of Phase I care applied to potential maxillary canine impactions. This manuscript suggests a new method of diagnosis of a transverse deficient maxilla. Specific treatment is then directed in a new regimen of Phase I care to normalize the maxilla and gain intra-arch Harmony.
Materials and methods The “Phase I only treatment–no braces” Williamsport Orthodontic Study (WOS) provided the patients. The WOS is part of the University of Pennsylvania School of Dental Medicine, Orthodontic Department’s practice based research network (PBRN).13 The WOS was a 10-year retrospective and Volume 4 Number 3
RESEARCH
Figure 4
Figure 5
Figure 7
Figure 9
longitudinal study; it used before and after dental casts and films from one private practice. Patients in the WOS were diagnosed with maxillary deficiency. Patients were then treated with a new regimen of Phase I care with RPE to eliminate the maxillary deficiency; all cases started in mixed dentition; after Phase I care, the cases that were judged to require 9 months or less care in a future Phase II of braces were retained in the data base. The present maxillary canine impaction Volume 4 Number 3
Figure 6
Figure 8
Figure 10
study used 10 consecutive case studies (20 impacted canines) [four male and six female] from the WOS (Figures 1-10). It may be important to note that the cases chosen for this study were culled from hundreds of other potentially impacted canine cases – we attempted to evaluate the most severe cases of potential canine impactions that we could find at T1. All the patients exhibited maxillary deficiency as defined by Harmony criteria. Harmony was defined: when the skeletal transverse maxilla was at least as wide as
the skeletal transverse mandible (measured by center of alveolar crest [CAC]) and up to 5 mm wider. Thus, there was a range of Harmony. For example, a maxilla that was narrower than the mandible (measured by CAC) would be considered maxillary deficient and not in Harmony. The studies undertaken to propose new Harmony criteria have been previously reported. It was evident from those studies that maxillary deficiency is more common than previously thought.13-16 The new center of the alveolar crest Orthodontic practice 45
RESEARCH
case/
WOS
Figure
ref#
Sex
CAC
T1
T2
T1 CAC
T1 CAC
T2 CAC
T2 CAC
Age
Age
maxilla
mandible
maxilla
mandible
maxilla
mm
mm
mm
mm
mm
(T2 less T1) RPEs
T1 canine
T2 canine
T1
impactions
impactions
gingival
T1 central fossa
T2
gingival
T2 central fossa
intermolar mm
intermolar mm
intermolar mm
intermolar mm
1
1
F
8y 1m
14y 9m
39.3
42
48.2
44.1
8.9
2
2
0
29
40.8
36.3
48.2
2
2
F
8y 4m
13y 11m
43.3
44.6
50.8
46.4
7.5
2
2
0
32.2
44.9
37.3
50.3
3
5
M
7y 1m
10y 11m
44.6
42.8
51.9
46.3
7.3
2
2
0
32.8
45.2
41.3
52.1
4
18
F
9y 3m
12y 0m
43.6
42.8
50.1
44.8
6.5
1
2
0
34
46.6
37.6
50.3
5
19
F
7y 2m
10y 1m
39.9
44.5
47.1
45
7.2
2
2
0
28.7
40.5
35.8
47.1
6
28
M
6y 3m
11y 7m
42.1
44
48.6
44.2
6.5
1
2
0
30.8
43.2
35.3
49.1
7
46
M
8y 0m
13y 1m
38.8
42.6
48.3
44.6
9.5
2
2
0
28.3
42.6
36.1
48.3
8
50
M
8y 0m
12y 1m
41
45.3
47
45.3
6
1
2
0
30
43.5
35.3
48.5
9
54
F
5y 9m
11y 6m
36.1
41.4
47.2
42.5
11.1
2
2
0
26.1
37.5
35.9
46.6
10
55
F
9y 6m
13y
40.2
43
48
45.5
7.8
2
2
0
28.9
41
36
48
Table
Figure 11
(CAC) measurement technique may be the most reliable and meaningful transverse skeletal measurement available at this time, as it does not rely on less reliable dental landmarks12,13-16 (Table and Figure 11). For reference, maxillary intermolar dental measurements (taken both at central fossa and at gingival margins of the 6-year molars) are also shown (Table and Figure 12). 46 Orthodontic practice
Most patients in the study presented with a malocclusion: at T1 all patients were judged to feature future dental crowding; three patients had a posterior crossbite (Figures 5,7 and 9); five patients exhibited an anterior open bite (Figures 3, 5, 7, 9 and 10). Dolphin cephalometric software was used with the cephalometric analysis. OrthoCad™ (Cadent, Inc.) software was
used for analysis of the dental casts and for measurements. Phase I appliances were constructed by Great Lakes Orthodontics, Ltd.: RPE (Great Lakes SD1017 turnbuckle)-Haas style (modified with the classic buccal wire struts removed for improved appliance flexibility); lower lingual holding archfor lower leeway space maintenance; Hawley retainer–also for Phase I space maintenance, and modified Hawley retainers. No active appliances, such as appliances with finger springs, were used. To be included in the present study, the following criteria were used to help ensure that the study reduced bias to a minimum: 1. A new “Phase I only” regimen was used; all patients were diagnosed with maxillary deficiency defined by Harmony criteria and CAC measurements;16 “potential/ certain future” impactions of canines were diagnosed from panoramic films; canines were to appear completely blocked out with frank or incipient impingement at roots of adjacent teeth; cases were consecutively chosen; no braces were used; no active treatment was used, post RPE, such as finger Volume 4 Number 3
Figure 12: Two dental intermolar measurements used in the Table: central fossa and gingival margin
springs on retainers. 2. No surgical exposure of the impacted canines; no extraction of primary canine or primary molar; no cyst present; no trauma from a primary tooth; no problem with root resorption of a primary tooth; no iatrogenic factors; no absent maxillary lateral incisors; no ankylosis of the permanent canine; no early loss of the primary canine; no tooth size discrepancy; no known endocrine problem; no genetic dental malformation; no known genetic condition; no palatal cleft. This pilot study controlled for: age, sex, and maxillary deficiency as defined by CAC and Harmony criteria. Confounding variables (listed above) were avoided. This is the first study of potentially impacted canines to use CAC measurement of the skeletal transverse and to use Harmony criteria goals to help determine whether or not a maxillary deficiency was present. When a maxillary deficiency was determined to be present, RPE was used to normalize the maxillary transverse, and the effects on potentially impacted canines were noted. Many manuscripts have used dental measurements to diagnose maxillary skeletal situations. The problems with dental measurements used as proxy for skeletal measurements have been discussed previously.14 Some studies have attempted to get to the skeletal level using Ln-Ln or J-J or Mx-Mx, which are far away from the alveolar ridges – this has also been discussed previously.15 This study is our third study using CAC for skeletal measurement of the skeletal transverse along with Harmony criteria — the first being the WOS13; the second, a study of AOB correction.17 Volume 4 Number 3
The new regimen of Phase I orthopedic care consisted of: 1. Diagnosis and treatment to address maxillary deficiency ages 6 to 10 years. For example, Case No. 1, an 8-year-old, featured a maxillary skeletal deficiency of 7.7 mm at presentation: the mandibular CAC was 42 mm plus 5 mm for a total maxillary goal of 47 mm – less the actual T1 maxillary CAC of 39.3 = 7.7 mm maxillary skeletal transverse deficiency. Actual expansion achieved was 8.9 mm, which was not overexpansion but was near ideal because the mandibular CAC increased spontaneously from 42 mm to 44.1 mm (a mandibular transverse width increase occurs at the 6-year molars in one out of five patients in our research). Thus, some patients present a moving target when it comes to the needed amount of maxillary expansion. Spontaneous transverse expansion of the mandibular CAC interarch dimension is not new information13 (Table). 2. Very slow RPE expansion (one turn/ every other day) was used. The amount of recommended skeletal expansion varied for each patient depending in individual patient needs (Table). 3. An expanded and torqued lower lingual holding arch was also used to simultaneously upright posterior mandibular molars as the maxillary deformity was normalized. 4. Prior to removal of RPE, adequate maxillary midline suture maturation was achieved by waiting 6 weeks after completing the very slow expansion.13,14,17 5. The RPE was then removed; no retention was used to allow the posterior dentition time for “settling relapse.” At least 6 weeks is needed for this critical transverse stability to be introduced.17 7. A Hawley retainer was then used for maintenance of maxillary leeway space. 8. Phase I active care duration was 12 months or less.
9. Post Phase I, periodic (6- to 9-month) follow-up visits were planned until eruption of some 12-year molars, or as necessary. 10. Progress records were taken at T2. Disclaimer: These steps are presented to help distinguish the newly proposed orthopedic regimen of Phase I care, used in this research from the typical definition of “Phase I care.” The above information is not designed to take the place of a seminar course given to certified orthodontists. Due to the severity of maxillary deficiency (defined by CAC and the Harmony criteria) at presentation, seven patients (Figures 1, 2, 3, 5, 7, 9, and 10) required a second, sequential RPE to gain the needed skeletal CAC expansion to gain Harmony (Table). Although the turnbuckle featured a maximum of 12 mm turnbuckle expansion, actual skeletal expansion attainable, as confirmed by CAC measurement of dental casts, was typically 6 mm with the remaining 6 mm seen in unwanted increased posterior proclinations. The unwanted additional proclinations were allowed to dissipate on their own — back to pretreatment inclinations after removal of the RPE, as discussed above.13,14 It is important to emphasize that the expansion was not measured by turnbuckle or by dental landmarks but rather by CAC measurements taken from dental casts as skeletal improvement of a skeletal deficiency was the objective.
Results The new regimen of Phase I care helped address maxillary deficiency and was helpful to gain de-impactions of 20 canines. Results of this study are shown in Figures 1-10 and Table. An advantage of such studies is apparent: the cases can be visually evaluated by way of before and after dental casts and panoramic films. Accordingly, individual case results were not lost in averages or statistical inferences.13,17 At T1 (initial presentation), all 10 patients presented with impacted canines; three patients had posterior crossbite; five patients had an anterior open bite. At T2 (after eruption of the 12-year molars), all 10 cases showed de-impacted canines; occlusions were without crossbite and without anterior open bite (Table 1). Skeletal RPE expansion (for all cases, ranged from 6.0 mm to 11.1 mm, as measured by CAC (Table). Nonsurgical Orthodontic practice 47
RESEARCH
• Records were taken at T1 (presentation); ages ranged from 5 years, 9 months to 9 years, 6 months (Table). • Records were taken again at T2 (during the eruption of 12-year molars); ages ranged from 10 years, 1 month to 14 years, 9 months (Table). The T2 dental casts comprised a portion of the orthodontic progress records.
RESEARCH maxillary skeletal expansion with RPE beyond 6 mm has been previously reported in the literature.13,17 Additional ancillary results of the new regimen of Phase I care in addition to the effect on canines: • Patients showed spontaneous improvement in dental alignments from T1 to T2 as evidenced by their casts and panoramic films (Figures 1-10). • Maxillary archforms change from constricted to then assume the classic (horseshoe-shaped) morphology of normal non-orthodontic subjects, as described by Lundstrom.18 • The RPE allowed reduced inclination of posterior teeth for improved periodontal stability — more study is recommended. • Additionally, and anecdotally, the parents noted improvements in their children’s overall health by way of improved nasal respiration — more study is recommended. • CL II and CL III patterns changed without orthodontic care to a CL I pattern; anterior open bites resolved; results remained stable. • It should be fair to say that the new regimen of Phase I care would have been an advantage for these patients even if the potential canine impactions had not resolved.
Discussion The strategy of triangulation was used to help understand the complex problems of canine impaction and to see if insights could be gained that would lead to helpful interventions: Simply put, triangulation, as defined here, is the use of three different methods to arrive at a conclusion. Method No. 1: Gain insight from highly respected research and experience: A. Regarding etiology: 1. Peck, Peck, and Kataja wrote in 1994: “…facial and palatal displacement – are actually very different phenomena, although they seldom have received separated consideration in the studies of impacted teeth. Facial displacement of the maxillary canine is usually due to inadequate arch space, and it eventually results in eruption in most cases. In contrast, palatal displacement of the maxillary canine is a position anomaly [of genetic basis] that generally occurs despite adequate arch space.” Peck, 48 Orthodontic practice
et al., wrote further: “The genetic basis for palatal displacement of the maxillary canine does not rule out the occasional influence of environmental and adventitious factors in the genesis of this positional anomaly.”11 2. Peck, Peck, and Kataja wrote in 1995: “A mode of genetic transmission often cited in the genesis of dental developmental disturbances is multifactorial inheritance. This type of heritability indeed denotes the presence of important non-genetic environmental and individual factors in addition to gene loci, that all interplay in establishing the occlusal and dental phenotype.”19 3. Becker wrote in 1995: “It is quite clear that the deciduous canine or the lack of space in these cases is obstruction and displacing (guiding) the canine....”20 4. Sajnani and King wrote in December 2012: “It is hypothesized [from their study of 533 patients] that both buccally and palatally impacted canines have similar etiological factors leading to impaction. While the intrinsic genetic mechanisms form the core of this hypothesis, the influence of environmental factors such as guidance from the lateral incisor (or lack of it) plays a vital role in the mechanism. It is suggested that the genetic mechanisms strongly influence the potential of the maxillary canine to be impacted, and the guidance from the lateral incisor and the stage of development plays a vital role [the sequential hypothesis] in determining the ultimate position of the impacted canine (buccal or palatal).” Sajnani and King also wrote further: “The sequential hypothesis provides a sequence, in which the two most commonly accepted theories, i.e., the genetic theory and the guidance theory, might act at different stages during the development of the maxillary canine and surrounding structures. It postulates that both buccally and palatally impacted maxillary canines share similar aetiologies.”8 Comments: Some experts emphasize the genetic theory of impaction, and while other experts emphasize the guidance theory of canine impaction, Sajnani and King meld the two theories together. When multifactorial genetics is the etiology of a condition, a perfect genetic road to a cure is likely elusive. Side roads may
need to be taken. B. Regarding arch length, transverse deficiency, crowding: 5. Jacoby wrote in 1983: “In this study 85 percent of the palatally impacted canines had sufficient space for eruption in the dental arch. Only one of these cases had to be treated by upper first premolar extractions.”21 6. Mew wrote in 1984, re: Jacoby21 “…most of us associate palatally impacted canines with a degree of arch shortening. Indeed, in all but the first unusual case, the illustrations shown in the article would suggest that the permanent canines were slightly short of space…”22 7. Becker wrote in 1995: “...when we mechanically reopen space in the arch for the canine by moving the posterior teeth distally and gathering up anterior spacing (the incisors are usually small and spaced), we may often be rewarded with the spontaneous eruption of the canine, close to its normal position. This scenario may be even more pronounced following the remedial extraction of a maxillary premolar in the rarer instances when actual crowding exists.”20 8. McConnell, et al., wrote in 1996: “Data from this study indicated that patients with impacted maxillary canines demonstrate transverse maxillary deficiency. This deficiency exists in the anterior portion of the arch.”23 9. Langberg and Peck wrote in 2000: “Maxillary interpremolar arch width and intermolar arch width comparisons between the PDC (palatally displaced canine) sample and the reference sample showed no statistically significant difference in their means. Therefore, there is no statistically significant difference in the anterior and posterior arch width between PDC subjects and the control subjects.”24 10.Saiar, et al., wrote in 2006: “This study does not corroborate the conclusions of McConnell, et al., but supports the hypothesis of Peck and Langberg that maxillary skeletal width is not a primary contributory factor in PDC [palatally displaced canine].” Saiar, et al., further: “...the recommendation of McConnell, et al., for expansion therapy solely based on decreased intercanine arch widths might lead to unnecessary treatment.” And Saiar, et Volume 4 Number 3
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RESEARCH al., further: “Further investigation into the etiology of PDC is needed before clinical recommendations can be made to prevent PDC.”25 Comments: Too little space causes canine impactions? — enough space or too much space causes canine impactions? — those are the questions. It is interesting to note that lack of arch length was discussed through the 1980s, while some time later on the transverse deficient maxilla was referenced. McConnell, et al., believed that the skeletal transverse was deficient; however their method of measurement of deficiency has been called into question. Saiar, et al., were concerned that expansion might be unnecessary treatment presumably because of the particular transverse diagnostic criteria used. C. Regarding possible early diagnosis and preemptive treatment for impacted canines: 11.Peck, Peck, and Kataja wrote in 1994: “At present, the best interceptive procedure for a palatally developing, unerupted canine involves early extraction of the associated maxillary deciduous canine tooth at the time of diagnosis in the mixed dentition.”11 12. Olive wrote in 2002: “In the majority of 10- to 13-year-olds, extraction of an overlying primary canine may be the only form of treatment necessary to prevent impaction of an ectopic canine.”10 13. Leonardi, et al., wrote in 2004: “The use of headgear in addition to the extraction of the deciduous canine induced successful eruption in 80% of the cases (compared to 50% successful with extraction of primary canines alone).”12 14. Sambataro, et al., wrote in 2005: “The closer the canine crown is to the midfrontal line at age 8 years, the higher the probability of eruption disturbance.” Sambataro, et al., also wrote in 2005: “From a clinical point of view, the role of prognosis of canine impaction represented by a deficiency in the distance between the crown of the canine and the midsagittal plane, in the absence of a deficiency in the posterior width of the maxilla, suggests the use of techniques to widen the anterior part of the maxilla without increasing the posterior part of the upper jaw, if 50 Orthodontic practice
not needed for therapeutical purposes. Methods to expand the palate at an early age in a sectorial way (such as a specifically activated quad-helix or rapid maxillary expanders incorporating a “fan” screw) could be viable options.”3 15. Baccetti, et al., wrote in 2009: “…it can be stated that maxillary expansion is effective as an interceptive procedure to prevent final impaction of maxillary canines with palatal displacement in the early mixed dentition. The mechanism involved in the favorable outcome of RME on the eruption process of a PDC can only be speculated.” And Baccetti, et al., wrote further: “When the pretreatment maxillary width of our subjects was contrasted with data in the literature for subjects with normal occlusal relationships, it appears that those with PDC had no transverse maxillary deficiency at the skeletal level (J-J).”1 16. Sajnani and King wrote in July 2012, “…our findings suggest that early radiographic examination (by panoramic film) aided by geometric measurement can provide substantial information on the eruption pattern of a maxillary canine, thus allowing early detection of an impaction.”8 Comments: Extraction of a primary canine may not be a reliable cure for canine impaction. Note that Leonardi, et al., wrote that cervicalpull headgear helped with impacted canines (presumably by increasing space). Sambataro, et al., among other measurements, performed maxillary transverse skeletal measurements (NcNc and J-J) and suggested a “fan” type RME expansion of the anterior portion of the maxilla. Baccetti, et al., also performed maxillary transverse skeletal measurements (J-J); then made a bold and insightful case for RME to help with the skeletal maxillary transverse for potential canine impactions — regardless that the data in the literature was not supportive of the need for expansion. Method No. 2: Gain insight from unsuccessful canine impactions treatment reports. Leonardi, et al, wrote in 2004: “The removal of the deciduous canine as an isolated measure to intercept palatal displacement of maxillary canines showed a prevalence rate of 50% success, which was not
significantly greater than the success of untreated controls.”12 Comments: A success rate of 50% is not a success. Early diagnosis of impending canine impaction is possible, according to many authors. However, the tools to intervene with the impactions have been inadequate. When, in the future, the multifactorial genetic variables for the etiology of canine impaction can be identified, the hope for human genetic modification can follow. Method No. 3: Gain insight from successful canine impactions treatment. 1. Headgear has been shown to importantly improve eruption of canines – presumably by creating more space by way of distalization of the posterior dentition.12 2. Expansion of the anterior maxilla has been proposed to create space.3 3. And maxillary expansion has been proposed to gain space, even though some criteria would argue against expansion.1 4. Given the above, it is not a stretch to suggest a rethinking some of the criteria used to diagnose whether or not a maxilla is deficient in the transverse. It may be time for a new measurement technique using skeletal landmarks along with a Harmony goal as first hypothesized by Lundstrom.18 5. In this study, it should be fair to say that — without treatment — given the severity of the transverse skeletal arch deficiency, diagnosed by CAC and Harmony criteria, and also with the radiographic appearance, some type of canine displacement would have occurred. Removal of primary canines would likely have been a futile effort. 6. Without enough space to erupt properly, the final resting place of the canines could leave them: 1) impacted in the palate, 2) impacted facially, 3) impacted while centered within the alveolar ridge — neither favoring the palate nor the labial, 4) ectopically positioned to the facial. For the 10 case studies shown, it would not have been possible for them to erupt into a proper position. The reader will note that the T2 cases spontaneously corrected. And after skeletal expansion, few interdental spaces were created; enough space was created to allow well-aligned teeth and well-shaped arches. Our considered opinion is that the Volume 4 Number 3
part of the solution to a serious orthodontic concern.13,17 There can be shortcomings with different research designs, and the present pilot study research is no exception. For this investigation, it would have been better to randomly place the patients into two groups (treatment and control), while also controlling for degree of skeletal deficiency, age, and sex). One group would be treated while the other group waited. At a later time, approximately age 12 or 13, data would be collected and analyzed to compare effectiveness of the treatment. This would then constitute a prospective, randomized, clinical trial — the research of choice. In the future, with insight from this study and outside of a private practice, groups could be studied in a prospective, randomized, clinical trial; it is possible that such a study could likely be completed in less than 10 years given a high enough volume of young patients – with the understanding that some patients would act as controls and would be required to forgo intervention. This study’s simple design helped minimize research biases. No braces or active retainers were used for canine deimpactions. Treatment involved:
1. The elimination of maxillary deficiency by way of RPE; new skeletal transverse criteria were used to help define maxillary deficiency. 2. Preservation of leeway space. 3. Treatment biases were minimized. In our experience, the 10 case studies and the canine treatment results presented in this manuscript were not exceptional — they were, in fact, representative of hundreds of other similar potentially impacted canine cases that received the same Phase I care regimen.
Conclusions 1. Early Phase I diagnosis and RPE correction of maxillary transverse deficiency, by way of Harmony criteria, and the CAC measurement technique may be helpful for potentially impacted maxillary canines. 2. A deficient maxilla may be more prevalent than previously thought as determined by CAC measurement and Harmony criteria. 3. More study is recommended with control and treatment groups matched for maxillary deficiency determined by Harmony criteria and measured with the CAC technique. OP
References 1. 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. 2. Fernández E, Bravo LA, Canteras M. Eruption of the permanent upper canine: a radiologic study. Am J Orthod Dentofacial Orthop. 1998;113(4):414-420. 3. Sambataro S, Baccetti T, Franchi L, Antonini F. Early predictive variables for upper canine impaction as derived from posteroanterior cephalograms. Angle Orthod. 2005;75(1):28-34. 4. Schindel RH, Duffy SL. Maxillary transverse discrepancies and potentially impacted maxillary canines in mixed-dentition patients. Angle Orthod. 2007;77(3):430-435. 5. Shapira Y, Kuftinec MM. Early diagnosis and interception of potential maxillary canine impaction. J Am Dent Assoc. 1998;129(10):1450-1454. 6. Warford JH Jr, Grandhi RK, Tira DE. Prediction of maxillary canine impaction using sectors and angular measurement. Am J Orthod Dentofacial Orthop. 2003;124(6):651-655. 7. Williams BH. (1981) Diagnosis and prevention of maxillary cuspid impaction. Angle Orthod. 1981;51(1):30-40. 8. Sajnani AK, King NM. Early prediction of maxillary canine impaction from panoramic radiographs. Am J Orthod Dentofacial Orthop. 2012;142(1):45-51.
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9. Ericson S. Kurol J. Early treatment of palatally erupting maxillary canines by extraction of the primary canines. Eur J Orthod. 1988;10(4):283-295. 10. Olive RJ. Orthodontic treatment of palatally impacted maxillary canines. Aust Orthod J. 2002;18:6470. 11. Peck S, Peck L, Kataja M. The palatally displaced canine as a dental anomaly of genetic origin. Angle Orthod. 1994;64(4):249-256. 12. Leonardi M, Armi P, Franchi L, Baccetti T. Two interceptive approaches to palatally displaced canines: a prospective longitudinal study. Angle Orthod. 2004;74(5);581-586. 13. Hayes JL. The Williamsport Orthodontic Study. Practice Based Research Network, Univ. of Pennsylvania, School of Dental Medicine, Orthodontic Department; 2008. 14. Hayes JL. A clinical approach to identify transverse discrepancies. Presentation at: Pennsylvania Association of Orthodontists; March 2003; Philadelphia, PA. 15. Hayes JL. In search of improved skeletal transverse diagnosis. Part 1: traditional measurement techniques. Ortho Prac US. 2010;1(3);34-39. 16. Hayes JL. In search of improved skeletal transverse diagnosis. Part 2: A new measurement technique used on 114 consecutive untreated patients. Ortho Prac US. 2010;1(4):34-39.
17. Hayes JL. A new regimen of phase I care applied to anterior open bite—10 case studies: an etiology proposed by the strategy of triangulation. Ortho Prac US. 2012;3(3):18-26. 18. Lundström AF. Malocclusion of the teeth regarded as a problem in the connection with the apical base. Stockholm: A. B. Fahlcrantz; 1923. 19. Peck S, Peck L, Kataja M. Sense and nonsense regarding palatal canines. Angle Orthod. 1995;65(2):99102. 20. Becker A, Peck S, Peck L, Kataja M. Palatal canine displacement: guidance theory or an anomaly of genetic origin? Angle Orthod. 1995;65(2):95-102. 21. Jacoby H. The etiology of maxillary canine impactions. Am J Orthod. 1983;84:125-132. 22. Mew JRC. Re Jacoby: Etiology of maxillary canine impactions [letter to the editor]. Am J Orthod. 1983;84:125-139. 23. 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. 24. Langberg BJ, Peck S. Adequacy of maxillary dental arch width in patients with palatally displaced canines. Am J Orthod Dentofacial Orthop. 2000;118(2):220-223. 25. Saiar M, Rebellato J, Sheats RD. Palatal displacement of canines and maxillary skeletal width. Am J Orthod Dentofacial Orthop. 2006;129(4):511-519.
Orthodontic practice 51
RESEARCH
normalization of the previously deformed arches somehow caused improvement in canine guidance as in the guidance theory of canine impaction, and that the skeletal expansion also somehow “reset or overcame” some of the genetic disturbances as in the genetic theory of canine impaction. Comments: Gaining space to help with canine impactions is not a new idea.1,3,12 Accordingly, based on triangulation, a new Phase I regimen can be helpful for potential canine impactions. By way of normalization of the maxillary skeletal transverse, potentially impacted canines were able to erupt into good position. A new definition of what constitutes maxillary deficiency -determined by a new center of alveolar crest (CAC) skeletal measurement technique and by Harmony criteria — was helpful.13,14,16 It may be important to note again that we chose the most severe cases we could find at T1. This new regimen of Phase I care is likely not a perfect answer to canine impactions – it is not a perfect world. However, we do believe that this study and other similar studies confirm that CAC measurement and Harmony criteria can be
BANDING TOGETHER
Hector’s story Dr. Mark Reynolds tells about the many people involved in bringing this novel case to its happy conclusion
T
he first time I heard anything about Hector was from my dentist who knew both his family and him. She had referred them to our chapter of Smile for a Lifetime and suggested that he apply. When his application arrived, I was somewhat prepared, but shocked to see both the complexity of his case and his passion and heart. Hector has agenesis, the absence of permanent teeth, and is missing 10 teeth. When a primary tooth would fall out, there was nothing to replace it. This left him with many gaps, oddly shaped teeth, and holes where teeth were absent. And while he was definitely self-conscious about his smile, he didn’t act like a victim or have any less passion for life. “When the dentist told my mom the first time that I had agenesis, it was in my presence. I felt so sad that I cried all the way back home. I was 7 years old and did not understand why that was happening to me. I prayed for months asking God to let my teeth grow,” said Hector on his application. Although Hector definitely had significant need, our board initially declined his application due to the complexity of his case. We knew we could put braces on him, but he needed so much more to make his smile. We used the next quarter to investigate resources and to determine what we could provide to him beyond the braces. After meeting Hector face to face, we learned that he is missing 14 of his permanent teeth, and several of the teeth that he does have are either small or misshapen. Our initial treatment plan was to close the gaps in his upper arch mesially, to the extent possible with his undersized teeth, and replace his missing premolars with four implants. His mandibular arch required not only the replacement of his premolars but also his central incisors. I met with Dr. Luis Benitez, a local periodontist. He was excited about the case. He mentioned to me that he had wanted to get involved in some pro bono work but found it difficult to identify where he could use his specialized skills. Hector provided him with a need within his 52 Orthodontic practice
specialty as well as a significant challenge. Amazingly, Dr. Benitez worked with Astra Tech, and they graciously agreed to provide all 10 of the implants that Hector will need once we are able to position his existing teeth properly. In addition, Dr. Ed Martinez, a prosthodontist, and the lab that he works with, have volunteered their services to restore the implants as teeth once a proper time for healing has passed. By the time Hector is finished, he will have received more than $50,000 in dental care, but I am confident his smile will look like a million bucks! “Now I am grown,” says Hector, “but I still believe in miracles. I believe that people like you are used by God to make those miracles, and make this possible with people like me. Currently, I am in a relationship, and I would like to be and feel more comfortable and confident with myself.” It has been amazing to see Hector’s smile change, but more significant is the change I have seen in him. When he first came to my office, his mother brought many pictures of him throughout his childhood. What started as a happy, smiling boy quickly turned into a child who smiled without showing his teeth, and the twinkle in his eye slowly disappeared as he grew older. Even with only the initial alignment of his teeth, that twinkle has returned. Hector has graduated from high school and is in the dental assisting program at our local community college. He plans to continue to hygiene school and possibly pursue dental school. He married a wonderful girl and has many, many reasons to show off the smile that is constantly improving. Smile for a Lifetime offers a wonderful structure to provide care to those in our community who really need it but are without the resources to make things happen on their own. Cases like Hector’s have also provided a way to work with other dental professionals for the good of a common patient. By the time we reach the end of Hector’s treatment, at least six dental professionals will have worked together on this case. We have truly
banded together, and the results are visibly life-changing.
Dr. Luis M. Benitez, periodontist, tells his chapter of Hector’s story Partial anodontia or oligodontia is a condition characterized by the partial absence of certain permanent teeth, which could include one or both of the jaw bones. As a consequence of having undeveloped teeth, these patients frequently suffer from malpositioned teeth and underdeveloped bone where the tooth is supposed to erupt. The latter is mainly due to the lack of “bone stimulus” during the tooth bud development. Since this condition is frequently diagnosed during childhood, it becomes imminent to involve several dental specialists who will focus not only on tooth alignment, but also in the adequate tooth replacement. Following orthodontic treatment, the missing teeth need to be replaced in order to maintain the arch integrity and a balanced bite during adulthood. As a periodontist, my involvement requires the reassessment of the bone of the empty spaces to determine what kind of treatment best suits the patient’s condition to replace his teeth. I have evaluated Hector, and he will require some bone regeneration to accept dental dental implants, which are considered the gold standard in these cases. I will donate the regenerative materials and the time involved to deliver the implants that were donated by Astra Tech. Once the implants heal, Dr. Ed Martinez will be the one in charge of restoring the implants with crowns as the final restoration. OP
Volume 4 Number 3
EDUCATION EXPLORATION
GCARE webinars: inspiration, exploration, and education: part 4 Interviews by Orthodontic Practice US Managing Editor Mali Schantz-Feld explore how a new webinar program, GAC Clinical Alliance for Research and Education (GCARE), pertains to all stages of the orthodontic community, from residents to practicing orthodontists
Ali Oromchian, Esq., Managing Partner at Dental & Medical Counsel, PC Four years ago, in dentistry, employment lawsuits surpassed malpractice litigation for the first time. In the past 10 years, I have seen the number of lawsuits by employees against their orthodontic practices increase at an alarming rate. My 1-hour webinar, “Employment Law: How To Keep An Orthodontic Practice Compliant In 2013”, was designed to address compliance issues that can save orthodontists from the stress and frustration of an HR lawsuit. Many issues occur when the orthodontist needs to terminate an employee. Three main scenarios in the orthodontic office can spur a lawsuit if proper precautions are not followed: if the employee is older, injured or pregnant. The type of lawsuit centered on age discrimination can occur, for example, when a young orthodontist purchases a practice and updates the office with brand new equipment and software that the older employee struggles with. If an older employee is unable to keep up with the new technology, and the dentist decides that he/she should be terminated, that could lead to trouble, if the correct documentation regarding the termination is not in place. There are similar concerns pertaining to an injured and pregnant employee, which we cover during the webinar including strategies to avoid liability. This webinar is not just focused on strategy but also on avoiding legal liability from any and all HR threats through compliance. At HR for Health, we provide the steps that lead to achievement of that goal. The HR for Health software was devised so the doctor becomes HR compliant on a daily basis. We establish expectations so that the employees 54 Orthodontic practice
understand what the doctor anticipates from them, and that leads to success. The “secret sauce” to terminating an employee is to have proper documentation. Documentation is often lacking in a busy practice. There isn’t enough time to properly attend to patients, their families, referral sources, and staff members. Since my wife is a pediatric dentist, I see how busy her office is, so I have gained a unique prospective on how difficult it is to spend time on HR on a day-to-day basis. When we designed and built HR for Health, we consulted many dentists and specialists and always kept their busy practices in mind. Other lawsuits develop because of lunches and breaks. Many states have specific rules about the minimum amount of time that an employee should be assigned for lunch and breaks throughout the day. Typically, a busy practice has many employees and patients, often involved in constant activity. The doctor needs to focus on treating patients. It becomes impossible to keep track and manage employee breaks each day. The HR for Health software provides some really smart, simple, and easy to implement strategies to avoid these problem areas. Another pitfall concerns overtime. State rules differ regarding how much an employee is scheduled to get paid once he/ she exceeds 40 hours in a week or 8 hours in a day. We discuss the issues that occur in these scenarios. Some orthodontists think that if they are not open 5 days a week, they are safe from the 40-hour rule, but unfortunately, that is not the case. In the webinar, we cover situations that can cause the employee to go over 40 hours that may not be so obvious. If orthodontists don’t pay overtime, trouble awaits. We also provide the pathway for orthodontists to take the necessary steps
to protect themselves. When I speak to the lawyers involved in lawsuits against our doctors. I ask, “What made you jump in on this litigation?” Many times the answer is: “If the doctors do not have an employment manual in place, they are an easy target.” There is never a good reason not to have an employment manual in a practice. HR for Health includes an office manual as part of our software package at no extra cost. The manual is easy to update, and since no two offices are the same, the manual can be customized to address each individual office’s needs. My webinar is about empowering doctors and their staff to act, by working together on a plan that creates compliance and opens up a level of communication that is appreciated by everyone in the office. As President, CEO, Managing Attorney for Dental and Medical Counsel and creator of HR for Health, our mission is simple: “To keep you compliant always.” Rules and regulations change constantly — federally and state to state. Our doctors are busy enough already. With HR For Health, they don’t have to become HR experts. That’s our job; to become experts in this area; to become a part of your team, ensuring you peace of mind. I look forward to presenting my webinar at the GCARE site, and hope it will bring you knowledge and awareness.
Rachel Mele, Director of Business Development for Sesame Communications As Internet search engines and social media play an ever-increasing role in social interactions and marketing, orthodontic practices can no longer rely solely on traditional forms of advertising and Volume 4 Number 3
Volume 4 Number 3
Attendees can also receive, “Twenty Ways to Grow Your Facebook Likes.” It is great to post on Facebook regularly, but if you do not have enough likes, no one will see those posts. YouTube statistics show that over four billion videos are viewed each day, with more than 800 million unique users worldwide per month.3 The webinar will discuss how to effectively use YouTube to drive patients into the practice. With 57% of companies having acquired a customer from their company blog4, it’s important to discuss the impact a blog can make on the success of an orthodontist’s online presence. If a practice is successful with its search engine optimization and social media strategy, but it does not have a patient-centric website; all that work is wasted. An unprecedented study conducted by Sesame Communications revealed that you have less than 90 seconds to engage a prospective patient and persuade them to explore your site further. Based on these eye-opening findings, the Sesame User Experience Team has developed a Top Patient Appeal Rated™ system that evaluates 25 factors the research determined make the difference between your website bringing new patients into your practice or sending them to someone else’s. The webinar will detail these findings. Being successful online includes more than just being on Facebook and having some YouTube videos posted. Today, prospective patients expect a great user experience. This means the prospective patient should be able to view a practice website on whatever device they are using, be it an iPhone®, Android™, Kindle, iPad® etc. This webinar will include a review of the benefits surrounding Responsive Website design and its ability to ensure your website is optimized for viewing different devices as well as helping your site see improved rankings on search engines like Google. Return on investment (ROI) is an important aspect for any practice. Having a strategic search optimization, social media and website plan should drive results. At Sesame Communications, on average, a practice with an effective search engine optimization, social media, and pay per click advertising strategy should expect to generate about 93 calls per month, with 21 of those calls specifically identifying themselves as new patients.5 This webinar will show you how these types of results
are possible within your practice. Practices using the In-Ovation bracket system from GAC can educate their prospective patients about the types of orthodontics available at your practice. The webinar will provide information on having up-to-date content specific to InOvation brackets. This content will help prospective patients understand the types of braces offered. It should include up-todate logos, before-and-after photos with full face shots, testimonials, and FAQs. In-Ovation content can also help improve search engine optimization. An effective online strategy also includes electronic communications. The webinar will provide tips on how to effectively communicate with patients via email and newsletters. Research conducted by Sesame Communications, analyzing attendance rates on more than 21 million appointments, found that in the first 36 months of implementing automated appointment reminders, no-shows were reduced by 21.83% in orthodontic practices. These significant changes in schedule compliance drove, on average $105,322.80 for orthodontic practices — revenue that would otherwise be lost to appointment no-shows.6 The webinar, “Fifteen Ways To Get More In-Ovation Patients” will be highly educational. Orthodontic practices will learn about effective online techniques to drive patients into their practice. Implementing the fifteen techniques including search optimization, social media and web strategies will help practices better engage with their patient and prospective patients and will increase practice production. OP
References 1. Thomson Data. Why outbound marketing is on the wane. http://www.thomsondata.com/article/whyoutbound-marketing-is-on-the-wane.php. Accessed April 18, 2013. 2. Fox S. Health topics. Pew Internet and American Life Project. 2011. http://www.pewinternet.org/Reports/2011/ HealthTopics.aspx. Accessed April 18, 2013. 3. Bullas J. 35 Mind numbing youtube facts, figures and statistics – Infographic. http://www.jeffbullas. com/2012/05/23/35-mind-numbing-youtube-factsfigures-and-statistics-infographic/. Accessed April 18, 2013. 4. Hubspot. The 2012 State of Inbound Marketing. 2012. http://www.slideshare.net/HubSpot/the-2012-state-ofinbound-marketing. Accessed April 18, 2013. 5. Sesame Communications, April 11, 2013. Proprietary data on file. 6. Sesame Communications Inc. Breakthrough study shows impact of automated patient appointment reminders on practice production. 2013. http:// www.sesamecommunications.com/news/2013/01/ breakthrough-study-shows-impact-of-automated-patientappointment-reminders.php. Accessed April 18, 2013.
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EDUCATION EXPLORATION
marketing communications to connect with their patients. This is the age of digital technology. More than half of all U.S. residents and 75% of adults are online.1 Promotion and market communications are no longer an option; they are a necessity. To help practices better position themselves in this Internet world, I’ve developed a webinar on the “Fifteen Ways To Get More In-Ovation® Patients.” This webinar will be helpful for orthodontic practices especially those wanting to spotlight their use of InOvation brackets from GAC. Last month, 2.7 million searches were completed on Google for the word “braces.” That does not include the millions of other orthodontic-related terms completed such as “clear braces,” or “orthodontists.” Therefore, we know orthodontists can benefit from search engine optimization tips on how to improve their websites and rank better. One of the strategies reviewed in this webinar includes easily implemented suggestions for improving website search engine ranking. For example, if practices want to show up in their city and state for the term “braces,” yet their home page doesn’t include the word braces (it happens often), it is unlikely that website will rank at all. Search engine optimization techniques also apply to the management of the practice’s Google+ Local listing, the map listing which shows up on a Google search. Google+ Local is a 100% free to set up. It is important to optimize the listing with the right information including reviews, quotes, hours, graphics, and videos. An orthodontic practice without an online presence is virtually invisible, considering that 80% of adult Internet users look for health information online.2 A simple online search is now the easiest way for potential patients to find you. The financial success of your orthodontic practice depends on your patient base. This means you must attract new patients to the practice while staying connected with your existing patients to ensure they remain engaged and active. Consumers today expect orthodontic practices to embrace social media, ingraining themselves within their various social networks. Three out of the fifteen tips within this webinar will specifically focus on social media. Attendees of the webinar can receive a complimentary copy of, “365 Days of Facebook Posts,” specifically geared towards orthodontics. With this vast collection of Facebook posts, orthodontists don’t have to spend time or energy thinking about what to post.
“Tech”-nique
Accelerated orthodontics through microosteoperforation Dr. Jonathan L. Nicozisis explains a new micro-invasive technique
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atients’ number one concern before starting orthodontic treatment is how long treatment will take. In the past 20 years, new devices and modalities have made the orthodontic process more efficient, but not faster. Many innovations have been introduced to improve bracket design and treatment protocols; however, the only effective techniques to increase the speed in which teeth move through alveolar bone involve extensive surgery. The challenge has been how to locally accelerate bone remodeling in a noninvasive manner. Treixeira, et al., has shown that biological principles can be activated to accelerate bone remodeling using microosteoperforations (MOP). In particular, by increasing the local levels of cytokine activity around a tooth, the rate of tooth movement during orthodontic therapy can be increased.1 Increased cytokine activity has been well documented to increase bone remodeling. In animal studies1 when clinicians create micro-osteoperforations in
Jonathan Nicozisis, DMD, MS, has been in the specialty practice of orthodontics since 1997. He completed his dental education at the University of Pennsylvania before attending Temple University for his orthodontic residency. While at Temple University, Dr. Nicozisis received his specialty certificate in orthodontics and a master’s degree in oral biology. During his training, he also completed an externship at the Lancaster Cleft Palate Clinic in Lancaster, Pennsylvania, where he was involved with the care of patients with craniofacial syndromes. Dr. Nicozisis is a member of Invisalign® National Speaker’s Bureau and Clinical Research Network where he helps conduct research and development of new technologies and improvements to the Invisalign technique. Dr. Nicozisis is also the founding orthodontist and a scientific advisory board member of BAS Medical (now Corthera), a developmentstage company founded in 2003 with a mission to develop and market a novel technology to accelerate and improve the stability of orthodontic treatments. Dr. Nicozisis’ master’s research is the basis for BAS Medical innovative research. In February of 2010, Corthera was acquired by Novartis. Dr. Nicozisis has been awarded membership to the Edward H. Angle Society of Orthodontists. He is a member of the American Association of Orthodontists, Middle Atlantic Society of Orthodontists, New Jersey Dental Association, Mercer County Dental Society and the Greater Philadelphia Society of Orthodontists. Dr. Nicozisis is a paid lecturer, but not a consultant, for PROPEL Orthodontics.
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the alveolar bone, the cytokine cascade is activated, resulting in a marked increase in osteoclast activity. When any type of orthodontic force is applied immediately following micro-osteoperforation, the teeth will move easily through the treated area (Figure 1).1 Micro-osteoperforation (MOP) is the only micro-invasive option able to accelerate orthodontics. MOP creates predictable orthodontic treatment results, improves finishes with braces, and reduces or eliminates refinements with clear aligner therapy. MOP can be completed chairside in minutes, and does not require any advanced training; therefore, any trained clinician can perform it. Additionally, the treatment yields very little discomfort to the patient. There is zero recovery time, and the patients are able to immediately return to their normal daily routine. The procedure is indicated for approximately 80% of patients receiving orthodontic treatment and can be used in conjunction with any treatment modality, including but not limited to, TADs, Invisalign® (Align Technology), SureSmile® (OraMetrix), and conventional braces. The ideal treatment device for microosteoperforation should be able to provide ergonomic control by the using clinician, and remain sharp through multiple perforations, and have a depth limiter to ensure penetration to the minimal effective depth. Temporary anchorage devices, miniplants, and burs are not viable alternatives to performing micro-osteoperforation in a private practice setting. Recently, a new device by PROPEL Orthodontics has become available which seems to show promise (Figure 2). Studies at major universities have been conducted with devices that demonstrated the feasibility and predictability of MOP being used chairside.2 Today, increasing numbers of adults are seeking orthodontic treatment to enhance the social, psychological, and functional status of their lives. Treatment of these patients is complicated by the fact that the correction of their malocclusion,
Figure 1
Figure 2
Figure 3
orthodontically, is limited to the dentoalveolar element, since adult patients have no growth and development. With an increase in age, tissues are less biologically active, and the ability to adapt diminishes. As a result, tooth movement may not only be more uncomfortable for adults but also move at a slower rate.3 Previous animal studies demonstrate that by delivering micro-osteoperforation in the bone near the teeth, bone remodeling enables a greater rate of tooth movement.3 Based on the referenced animal studies, it was demonstrated that this highly invasive surgical procedure can be simplified and replaced with minimal, shallow, small micro-osteoperforations in alveolar bone without the need for soft tissue flaps, bone grafting, or any suturing.4 As with any medical intervention, the longer treatment takes, the higher the possibility for side effects and poor outcomes. By shortening treatment time Volume 4 Number 3
“TECH”-NIQUE
Clinical examples of micro-osteoperforations
with MOP, patients avoid the pervasive complications of long-term orthodontic treatment. There is less likelihood for decalcifications due to extended banding times leading to “white lesions.” Root blunting is reduced, as treatment duration is shortened.5 Shorter treatment time will allow patients to return to their normal oral hygiene routine and maintain clean teeth.
Clinical examples osteoperforations
of
Figure 5: MOP was performed and correction of open bite was completed in 35 weeks
Figure 6: Significant leveling and aligning of the maxillary anterior segment in 4 weeks
Figure 7: MOP was performed and extrusion was completed in 16 weeks
micro-
LL 4 and 5 were treated for 8 weeks without MOP with little correction. MOP was performed, and correction was completed in 8 weeks. Significant leveling and aligning of the maxillary anterior segment.
Micro-osteoperforation’s clinical uses • Molar uprighting • Lower anterior crowding • Canine impactions • Forced eruption • Difficult aligner movements • Space closing • Rotations • Intrusion • Correction of Curve of Spee • Pre-surgical orthodontics • Pre-esthetic (prosthetic) orthodontics • Avoid surgical intervention A rapidly growing segment of the orthodontic market is adult relapse cases. This population of patients’ chief complaint is often lower anterior crowding. MOP is uniquely able to quickly address this issue and help this population of patients achieve their desired result quickly without the need for long term treatment. Besides the orthodontic and tooth position issues, accelerating treatment will allow adults and teens with busy schedules and limited time for long term treatment with multiple appointments the option of orthodontic care. Micro-osteoperforation makes orthodontic treatment a realistic option for many that up until now could not commit to extended treatment. Micro-osteoperforation harnesses the body’s own biology to create a cytokine effect that induces bone remodeling and allows teeth to be moved into the clinically desired position in a more predictable Volume 4 Number 3
Figure 4: LL 4 and 5 were treated for 8 weeks w/o MOP with little correction. MOP was performed and correction was completed in 8 weeks
and faster manner. The induction of the cytokine cascade is modulated and controlled by the design of the device itself. Basic bone biology research, animal studies and controlled clinical trials have demonstrated the safety and efficacy of the MOP treatment.6 In fact, the results of both animal and clinical studies have demonstrated that micro-osteoperforation decreases orthodontic treatment in combination with any type of orthodontic force (Figure 3).2 There are multiple benefits of using the MOP in the office including reducing treatment time, economic benefits, and greater patient satisfaction with orthodontic treatment. Reducing treatment time for patients has been an industry goal due to patient and orthodontist demand. Besides the cost of treatment, patients take time from work and school to attend multiple appointments. These appointments incur significant indirect costs. The average patient spends an additional $654 dollars travelling to and from their appointments during a 2-year treatment.7 Reducing the number of these multiple office visits will save both time and money. Orthodontists are looking for ways to efficiently treat more patients. Finishing cases faster and with more predictability will allow a larger percentage of the population to be treated. There is currently a shortage of orthodontists, which is only predicted to worsen in the next 20 years.8 Adult patients exhibit a greater
incidence of mutilated dentitions with missing teeth. As these adult patients seek prosthodontic treatment, a costeffective option to implants often involves orthodontic closure of the edentulous region. Adult patients do not want orthodontic treatment for an extended period of time. Micro-osteoperforations can significantly shorten the duration of treatment, making orthodontics a more acceptable option. OP References 1. Teixeira CC, Khoo E, Tran J, Chartres I, Liu Y, Thant LM, Khabensky I, Gart LP, Cisneros G, Alikhani M. Cytokine expression and accelerated tooth movement. J Dent Res. 2010;89(10):1135-1141. 2. Khoo E, Tran J, Abey M, Raptis M, Teixeira CC, Alikhani M. Accelerated Orthodontic Treatment [research paper]. New York: New York University; 2011. 3. Proffit WR, Fields HW Jr, Moray LJ. Prevalence of malocclusion and orthodontic treatment need in the United States: estimates from the NHANES III survey. Int J Adult Orthodon Orthognath Surg. 2008; 13(2):97-106. 4. Garlet TP, Coelho U, Silva JS, Garlet GP. Cytokine expression pattern in compression and tension sides of the periodontal ligament during orthodontic tooth movement in humans. Eur J Oral Sci. 2007;115(5):355-362. 5. Apajalahti S, Peltola JS. Apical root resorption after orthodontic treatment—a retrospective study. Eur J Orthod. 2007;29(4):408-412. 6. Shackelford JF, Alexander W. CRC Materials Science and Engineering Handbook. 3rd ed. Boca Raton, FL: CRC Press; 2000. 7. Richmond, S. Guest Editorial: The need for costeffectiveness. J Orthod. 2000;27(3):267-269. 8. American Dental Association. The Future of Dentistry. http://www.ada.org/sections/ professionalResources/pdfs/future_execsum_ fullreport.pdf. Accessed July12, 2005.
Orthodontic practice 57
PRODUCT PROFILE
Esprit Class II corrector
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pal Orthodontics proudly introduces Esprit, a revolutionary Class II corrector designed specifically to address the overwhelming demand for everything missing in other Class II correctors on the market today. Developed with the innovative and cutting-edge technology that Opal Orthodontics has consistently built its reputation upon, Esprit finally answers the call for an easier-to-install, more comfortable, highly durable Class II corrector. The comfort and strength Esprit provides will assuredly please patients with a more pain-free orthodontic experience, and reduce emergency appointments and frustration for clinicians and staff. Esprit is the result of over 3 years of design and development. Developed and tested by Opal Orthodontics — in collaboration with industry leaders such Drs. Richard McLaughlin, Terry McDonald, and Robert Miller — Esprit is undoubtedly the most technologically advanced corrector on the market. Esprit’s unique features include a CNC-machined body that is smooth and durable, and a new innovative, patented clip that is a breeze to install and remove, but stays in place without disengaging during treatment. Esprit also features a mesial hook that prevents rolling into the occlusion. The hook is smooth for patient comfort and can also be removed with ease — no cutting required. Esprit’s enclosed stainless steel spring prevents painful pinching and unhygienic trapping of food. This unique enclosed spring also resists deformation and maintains consistent force throughout the patient’s wear. Esprit’s dual telescoping feature increases range of motion, and its distal body opening prevents bottoming out and allows liquid flow to keep it clean. The entire corrector is laser welded, allowing it to withstand even the toughest treatment from any patient — 100% guaranteed. Opal Orthodontics will unveil Esprit at the American Association of Orthodontists’ trade show in Philadelphia on May 3–7. To learn more, visit opalorthodontics.com/ esprit or call 888-863-5883. OP
Class II to Class I in 4.5 months. Clinical photos courtesy of Dr. Robert Miller
Esprit full body
Esprit mesial hook
Esprit distal clip
This information was provided by Opal Orthodontics.
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Volume 4 Number 3
TM
Innovative clip design allows easy placement
Smooth CNC-machined body for patient comfort and durability
Comfortable mesial hook is easy to install and remove Enclosed spring prevents painful pinching
Laser-welded components hold up to the toughest conditions
Now Aligned COMING SOON Visit our website at opalorthodontics.com/esprit or call 888.863.5883 to learn more about Esprit. Innovative machined clip design allows easy placement with predictable locking
Comfortable machined mesial hook enables smooth gliding, prevents rolling, and reduces the need for push-rod bends
When we asked doctors what they wanted in a Class II corrector, the response was clear: More comfort. More durability. Easier placement.
Photos courtesy of Dr. Robert Miller
So we developed Esprit. The breakthrough appliance that offers everything your Class II corrector is missing.
Class II to Class I in 4.5 months
opalorthodontics.com | 888.863.5883 Š 2013 Ultradent Products, Inc. All rights reserved.
STEP-BY-STEP
Reliance Orthodontics Perfect A Smile™ pontic paint An elegant solution to a unique problem with clear aligners
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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. These items include: bonding an attachment to an aligner, creating a hole or “window” in the aligner to clear an attachment bonded to the tooth, or the issue of maintaining patient esthetics if a tooth is missing or lost during treatment. Many resourceful solutions have been used to create a missing tooth in the aligner, but they have met with limited success. The most popular solutions devised include using a tooth-colored wax or trying to bond a plastic pontic tooth into the aligner socket. The problem is that this was a short term solution at best since neither “filling” would stay anchored in the aligner socket for long. Reliance Orthodontics has introduced an elegant and simple solution to this problem. 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 vita shades – A1, A2, and B1. It cures and bonds directly to the aligner plastic. Three coats are typically applied to the facial, mesial, and distal area of the socket to achieve the proper color and coverage. Each coat is light cured. Perfect A Smile™ is the simple, fast, inexpensive solution for maintaining patient esthetics while wearing their aligners. A side benefit is that patient will be more inclined and motivated to wear the aligner to avoid an embarrassing “toothless” grin. For more information, please contact Reliance Orthodontic Products at 800-323-4348 or visit the website at relianceorthodontics.com. OP
A typical example of a patient with missing laterals.
Same patient with aligner laterals finished with Perfect A Smile™.
1) To apply: Simply clean aligner socket if needed, and dry with compressed air. Paint a coat of Perfect A Smile™ using a bristle or microbrush. Cover the facial, mesial, and distal of the inside of the tooth socket. Light cure for 10 seconds.
2) Apply two additional coats of Perfect A Smile™, light curing each coat.
3) Finished aligner ready for insertion and immediate wear.
This information was provided by Reliance Orthodontics.
60 Orthodontic practice
Volume 4 Number 3
BOOK REVIEW
Orthodontic Pearls: A Clinician’s Guide By Larry W. White, DDS, MSD
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rthodontists, like people in many professions, are constantly looking for ways to make things easier, quicker, more efficient, and more affordable. One of the best ways to figure out these things is to converse with other orthodontists and share ideas. In the book, Orthodontic Pearls: A Clinician’s Guide, the author, Larry W. White, DDS, MSD, brings together many of these different ideas from around the world. Dentists will tell you that they learned the basics in school, and then learned a lot more through their experience in practice.
book are. One pearl that sticks out in my mind is that by Dr. Eric Liou of Taipai, Taiwan. He demonstrates a technique in which an .018 nickel-titanium wire is tightly ligated to the lingual surfaces of the lower anterior teeth and bonded with composite. This technique can be used to greatly correct relapse that has occurred due to a patient not wearing a retainer as directed. Relapse is one of the most common problems in orthodontics, if it is not the top one. As soon as I looked at that technique, I thought that I will definitely try to use it in my practice.
This book will help the clinician skip many steps in the learning curve and become aware of many techniques that can be used in everyday practice.
This book will help the clinician skip many steps in the learning curve and become aware of many techniques that can be used in everyday practice. Overall, I would say there are absolutely some very valuable “pearls” in this book. At the same time, some should almost be common sense to an orthodontist. However, everyone’s training and experience is different, so it is difficult to say what the best “pearls” in this Volume 4 Number 3
Those relapse patients frequently want to try anything, except putting braces back on the teeth. This will give me a valuable, easy, and affordable option to offer these patients. It also looks like it will likely be more effective than a spring retainer, which would commonly be used in those situations. The only slight negative about this book is that a few of the images seem
blurry. I realize this is due to the fact that the ideas come from so many different doctors, and the author had to rely on those doctors for the illustrations. This book is a quick read, for sure. I would recommend that this book be read and/or owned by every orthodontist out there. I would be shocked if an orthodontist who has not read this book could say that he/she had already seen everything in this book. Dr. Larry White did an excellent job putting together this book. He has been an orthodontist since 1968 and has been a faculty member at both The University of Texas Health Science Center and Baylor Dental College. In the table of contents, he notes that he did not write this to tell everyone about the pearls that he has developed. He wrote this to bring together the best pearls from around the world for all orthodontists to share. OP
Review by Brian M. Bivens, DMD, MS Bivens Orthodontics www.bivensortho.com 12950 Race Track Rd #107 Tampa, FL 33626 813-443-5050
Orthodontic practice 61
PRACTICE MANAGEMENT
Overcoming technology
bottlenecks
Toby Buckalew discusses how new technology can steer a practice in the right direction and speed up performance
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ttempting to drive 80 miles per hour through a congested downtown street during rush hour is not conducive to speedy travel. Crowded streets, poorly timed stoplights, and other factors create bottlenecks, through which traffic cannot move, slowing everything down. The network in your practice works in the same manner – when there is a data bottleneck, everything behind it suffers, and perhaps it shows as slow performance or sluggish Internet access. As with automobiles, computers do not age gracefully. In fact, as users, we demand more and more from them in the form of new features in the software we use. We want to take advantage of seeing our data anywhere, everywhere, at any time. However, all these items require some horsepower in the form of higher processing performance and memory. The first hurdle in improving performance is to ensure your computers are up to speed. They may have been great 6 or more years ago, but when they reach the age of 5, you may want to start looking at trading them in for newer models. Those computers normally generate printed information at some point in time. There is a good chance many of you have an assortment of printer models throughout the office, each with different features. When you need to print something specific, but that printer is on
Toby Buckalew, CIO of OrthoSynetics, is an experienced technology and operations executive with over 24 years of experience in military retail, financial, and healthcare markets. Starting his technology and operations career servicing U.S. military facilities in Europe, Mr. Buckalew returned to the U.S. to continue his work after the end of the cold war. Working and consulting in the healthcare field in both Cardiovascular Practice Management and Convenient Care industries, Mr. Buckalew specialized in the evaluation and implementation of technology, designing staffing and technology solutions for unique business needs. Serving as the previous CIO of GET Marketing, a military retail broker, and as the Vice President of HealthStop in the convenient care industry, Mr. Buckalew brings a strategic and varied view of technology and its focus on healthcare to OrthoSynetics. Mr. Buckalew studied Technical Management with a minor in Logistics at Embry Riddle Aeronautical University.
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another computer, a workflow bottleneck ensues. There is a good chance they are connected directly to the computer, and they may or may not be shared. Having a computer network and not implementing network-attached printers simply increases your costs and complexity. When it is time to replace one or more of those printers, look at a network model – one that can be used by any computer on the network. Printers strategically placed in the office make workflows more efficient, and overall printing costs drop (fewer printers, fewer consumables, hopefully only one or two different models). Things were pretty good for a few years, then you implemented digital X-Rays, and now things seem to crawl at times – it must be that new machine! Actually, it is. It is the new machine pushing large amounts of data down an old dirt road — in this case, the network connecting everything together. Ironically, the convenience of wireless leads many to lower their office cabling costs by simply not pulling cable to each workstation – using wireless instead – usually with problems down the road. Wireless signals are not as fast as wired signals – they are also prone to interference from things such as other wireless networks, remote control toys, cordless phones, and other wireless devices. For the cabled computers, the units that connect everything together are switches and hubs. Each has its limitations – both in terms of how much data they can process and move, and how fast they can do it. If the units are more than a few years old, there is a good chance they are not capable of handling the higher speeds of today’s computers – so everything slows down to meet the speed the hubs/switches can handle. In the end, just remember that switches handle more than hubs (although they look the same), and linking switches and hubs together slows everything
connected to them down. As business services move off of local servers and into the cloud (data and services hosted via the Internet), our connection to the Internet becomes ever more important. Service providers constantly advertise their high-speed performance for downloading information (as that is what casual users do most often) – but usually not for uploading information. Your connection to the Internet is a twoway street. Data is downloaded to your office via the Internet and also uploaded from your office back to the Internet. Providers offer differing speeds for down/ up service – with download speeds usually faster as most people simply browse web sites and download content. If you regularly send information via the Internet, or use a hosted service for anything from email to digital imaging – plan on spending a bit more to obtain greater upload speeds. You should ask what the best upload speed your provider can offer you. Technology bottlenecks lie also with users on your network. Today, users can stream music, movies, video, and more from the Internet. The convenience and flexibility is amazing. However, those streams of data last for long periods of time – occupying the data road and taking a lane or two all itself. If your network is already experiencing performance issues, and data is being streamed, that leaves little for the rest of the business to operate. Bottlenecks on your network are not insurmountable. They should be viewed simply as roadblocks needing removal or streets needing to be widened. If a complete overhaul is needed, list your objectives and requirements, price what it will take, and then plan a roadmap to implement each of the items to ensure a smooth ride down your technology road. OP
Volume 4 Number 3
MATERIALS lllllllllllll & lllllllllllll EQUIPMENT 3D Systems 3D Systems has introduced a low cost, easy-to-use, color medical modeling solution for oral surgeons, orthodontists, and dentists who have their own CB scanner. They can either purchase a ZPrinter and print their own models, or sign up for a monthly subscription service and send the models out to be printed. This model takes less than 5 minutes to create including uploading the DICOM data set. Contact Scott Bender at 803-554-3466 for more information.
Ortho2 announces the release of two new software suites, Edge 3 and ViewPoint 10 Edge 3 delivers the ideal all-comprehensive practice management, imaging, and communication system with powerful new features including: the ability to publish animations and custom playlists to Facebook, utilize pre-recorded and background audio in animations, and morph between image timepoints to seamlessly show progress through treatment. You’ll love the Sooner if Possible scheduling option, Light Bar in Patient Tracker, as well as an ever-expanding library of new reports and integrations. ViewPoint 10 comes equipped with a Patient Reward System, giving patients accolades for compliance, a Google Map Scatter Plot to visually see where patients and referrers are coming from, and E-mail Correspondence for sending receipts, appointment cards, and statements directly from ViewPoint. Also included is the Office Contact Manager, which is the clinician’s hub for vendor contacts, and the ability to schedule appointments with professionals through the office calendar. For more information call 800-678-4644; email sales@ortho2. com or visit at www.ortho2.com
Sunstar GUM® announces new size and re-design of Proxabrush® Go-Betweens® cleaners The new Proxabrush is ideal for healthier patients with tighter contacts, and features several new design elements to improve use. Proxabrush Go-Betweens are clinically proven to remove plaque as well as string floss and are convenient, reusable, and easy-to-use. In addition, Sunstar will be applying the new design elements to each of the existing Proxabrush Go-Betweens cleaners sizes: tight, moderate, and wide. These redesigned Proxabrushes will be available in June. For more information, visit www.US-Professional.GUMbrand. com.
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J. Morita announces TwinPower Turbine Basic The new TwinPower Turbine® Basic handpiece offers several of the unique features of the original TwinPower product line, above and beyond those in its class. Cutting efficiency remains equal to the standard head with the same double-impeller rotor design that produces high power and torque, up to 22 watts. A pressurized air system prevents suck back in the air line resulting in superior infection control. The body of the handpiece is chrome with a convenient push-button chuck. Other features include: ceramic bearings, rapid braking within 2 seconds, and a four-hole connection. For more information, visit www.morita.com/usa/ twinpower or call 1-888-JMORITA (566-7482).
Kaleidoscope digital marketing tool that captures attention in the waiting/reception area with a stunning visual display Kaleidoscope’s key benefits are: • Customization that gives the flexibility and control to present your practice as you wish • Builds and strengthens relationships, which encourages customer referrals and retention • Clients will discover new services that they never knew you had Kaleidoscope has possibilities to promote your special offers, client testimonials, and showcase the unique qualities/services only you can provide. Kaleidoscope is visually appealing and sets you apart from the competition. Not to mention it makes the wait more enjoyable and lessens any apprehension about their appointment. It also increases the chance of customers choosing an additional product or service that they may discover on your Kaleidoscope display. For more information call 415-766-2017, email info@ theKaleidoscope.com, or visit the website www.theKaleidoscope. com.
Stratasys launches the Objet30 OrthoDesk at IDS; first 3D printer designed especially for smaller orthodontic labs and clinics The Objet30 OrthoDesk now makes digital orthodontics accessible for facilities of all sizes. Affordable and simple-to-use, Objet30 OrthoDesk conveniently fits on a desktop in any lab, and with industry-leading precision, it enables orthodontists to create accurate, smooth, orthodontic models more easily than ever before. Now orthodontists can automate the entire workflow from CAD file to model fabrication, significantly accelerating production times and increasing capacity. The Objet30 OrthoDesk combines accurate, precise 3D printing technology with a small desktop footprint. It comes with specialized dental printing materials in convenient sealed cartridges. Stone models, orthodontic appliances, delivery and positioning trays, clear aligners, retainers, and surgical guides can all be produced significantly faster and much more accurately than before. For more information, see www.StratasysDental.com.
Volume 4 Number 3