Orthodontic Practice US - August/September 2013 - Vol 4 No 4

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s • technology reviews August/September 2013 – Vol 4 No 4



Dr. Rohit C.L. Sachdeva

Treating vertical maxillary excess without surgery Dr. Stuart Frost

Instrument sterilization Dr. Nelson S. Slavik


Go to page 9 and just say “OM.”

BioDigital Orthodontics Part 4:


Practice profile Dr. Robert Sheffield


to be sure.



a PVS Impression is Eliminated Rapid and accurate impressions to streamline your practice Capture Data with Speed and Ease Quickly transition your practice to digital impressions while keeping chair time to a minimum. A single high resolution scan captures a dual-arch scan in an average of 7 minutes.

A Comfortable Experience for Patients and Staff Lightweight, ergonomic and compact, the Lythos wand is comfortable for repeated use throughout the day and easily reaches the posterior of the mouth, maximizing patient comfort.

Do More with Lythos Lythos provides freedom with open transfer of data and no fees! Use Lythos data within the Ormco digital suite of products including Insignia™ Advanced Smile Design, AOA lab appliances and more.

A Smart Investment that Works for You Economically-priced without storage, maintenance or click-fees, Lythos is paired with a unique rebate program that reimburses you when scans are taken. Bundle Lythos with Insignia™ for greater savings and accelerated treatment times.

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Dimensions: Height (with screen extended): 30" | Height (with screen collapsed): 15" Depth: 11" | Width: 13" | Weight: Approx. 25 lbs.

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tnempoleveD ecitcarP seirailixuA latigiD sniwT © 2013 Ormco Corporation seriwhcrA sdnaB/sebuT srengilA noitagiL fleS

EDITORIAL ADVISORS Lisa Alvetro, DDS, MSD Daniel Bills, DMD, MS Robert E. Binder, DMD S. Jay Bowman, DMD, MSD Stanley Braun, DDS, MME, FACD Gary P. Brigham, DDS, MSD George J. Cisneros, DMD, MMSc Jason B. Cope, DDS, PhD Neil Counihan, BDS, CERT Orth Eric R. Gheewalla, DMD, BS Dan Grauer, DDS, Morth, MS Mark G. Hans, DDS, MSD William (Bill) Harrell, Jr, DMD John L. Hayes, DMD, MBA Paul Humber, BDS, LDS RCS, DipMCS Laurence Jerrold, DDS, JD, ABO Chung H. Kau, BDS, MScD, MBA, PhD, MOrth, FDS, FFD, FAMS Marc S. Lemchen, DDS Edward Y. Lin, DDS, MS Thomas J. Marcel, DDS Andrew McCance, BDS, PhD, MSc, FDSRCPS, MOrth RCS, DOrth RCS Mark W. McDonough, DMD Randall C. Moles, DDS, MS Elliott M. Moskowitz, DDS, MSd, CDE Atif Qureshi, BDS Rohit C.L. Sachdeva, BDS, M.dentSc Gerald S. Samson, DDS Margherita Santoro, DDS Shalin R. Shah, DMD (Abstract Editor) Lou Shuman, DMD, CAGS Scott A. Soderquist, DDS, MS Robert L. Vanarsdall, Jr, DDS John Voudouris (Hon) DDS, DOrth, MScD Neil M. Warshawsky, DDS, MS, PC John White, DDS, MSD Larry W. White, DDS, MSD, FACD CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day BDS, VT Julian English BA (Hons), editorial director FMC Dr. Paul Langmaid CBE, BDS, ex chief dental officer to the Government for Wales Dr. Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-in-chief Private Dentistry Dr. Chris Potts BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon

PUBLISHER | Lisa Moler Email: lmoler@medmarkaz.com

Tel: (480) 403-1505

MANAGING EDITOR | Mali Schantz-Feld Email: mali@medmarkaz.com

Tel: (727) 515-5118

ASSISTANT EDITOR | Kay Harwell Fernández Email: kay@medmarkaz.com

Tel: (386) 212-0413

EDITORIAL ASSISTANT | Mandi Gross Email: mandi@medmarkaz.com

Tel: (727) 393-3394

DIRECTOR OF SALES | Michelle Manning Email: michelle@medmarkaz.com

Tel: (480) 621-8955

A new practice transition model


n the year 2013, practice transition is more challenging than in previous periods for many reasons. Orthodontic residents are graduating with greater student loan debt, corporate dentistry is hiring many residents, financing of practice sales can be difficult, and many practicing orthodontists’ retirement plans won’t allow them to sell, retire, and leave the practice. These same problems can be managed with forward-thinking ideas. An experienced orthodontist can start the transition process earlier, giving young residents an opportunity to learn how to run a successful practice; orthodontists can keep retiring practices in the hands of orthodontists, and we can invest in what we know best to keep our own retirement safe and predictable. Graduating residents with large loan debts may find themselves trapped in the corporate dentistry model of practice as their debt needs to be serviced with current income. Their large debt may make it difficult to borrow more money to buy or start a practice. These orthodontic jobs do not teach a young orthodontist the skills necessary to run a quality, profitable private practice. Many older doctors have put off selling their practices because their retirement plans have been hurt in the last 5 years of recession/ depression. These practices are typically not on the leading edge of clinical and management technology and offer little learning opportunity for young orthodontists. A new model would have successful orthodontists at the peak of their practice lives get involved when they usually would just be enjoying their well-earned success. With good back office support and a professional management team (I use OrthoSynetics), a successful orthodontist could find practice opportunities, arrange financing, and offer long-term opportunities to young orthodontists. In this model, the practice owner should have little trouble arranging financing as there is a long track record for running a successful practice. The new graduate will be learning good cutting-edge clinical and management techniques and work with an energized and growth motivated staff! There will be ample new income to pay the new orthodontist as the new office will increase cash flow such that there is little or no loss of income to the owner doctor. The benefits to this model are multifold. If structured correctly, all three doctors benefit, the retiring doctor gets a fair secure price for the practice, the owner buys a practice that with excellent clinical and management practices will increase in value very quickly, the new doctor gets immediate income with valuable education and a pathway to ownership of a successful private practice. Best of all, orthodontics stays in the hands of orthodontists!

NATIONAL SALES/MARKETING MANAGER Drew Thornley Email: drew@medmarkaz.com Tel: (619) 459-9595 NATIONAL SALES REPRESENTATIVE Sharon Conti Email: sharon@medmarkaz.com Tel: (724) 496-6820 PRODUCTION/DIGITAL MARKETING MANAGER Greg McGuire Email: greg@medmarkaz.com Tel: (480) 621-8955 PRODUCTION ASST./SUBSCRIPTION COORD. Lauren Peyton Email: lauren@medmarkaz.com Tel: (480) 621-8955

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

Jack Devereux, Jr., DDS, MS Diplomate of The American Board of Orthodontics Member of the local, state and national Dental and Orthodontic Associations Past president of the Louisiana Association of Orthodontists Invisalign Premier Provider

$99 $239

© 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 4

Orthodontic practice 1


August/September 2013 - Volume 4 Number 4

TABLE OF CONTENTS Clinical The “therapeutic” Class II and Class III first molar relationship Drs. Donald J. Rinchuse, Dara L. Rinchuse, and Ethan Drake share perspective on first molar arch relationships................................ 14

Practice profile


Dr. Robert Sheffield: Changing smiles and lives through orthodontics An uncompromising dedication to quality care brings smiles to this orthodontist’s patients.

Preventive Eruption Guidance® and the gummy smile in 6- to 8-year-olds Dr. Earl O. Bergersen discusses a technique to prevent the development of the gummy smile ................................................... 16

Case study Treating vertical maxillary excess without surgery Dr. Stuart Frost presents a nonsurgical adult case for treating vertical maxillary excess and mild crowding with VectorTAS™ and Damon® Clear™........................... 24

Corporate profile Reliance Orthodontic Products A legacy of 31 years of support and commitment to quality orthodontics.

2 Orthodontic practice



Volume 4 Number 4

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

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

9438 OR 93 AD 0713


Practice development

Best of class


Pride Institute’s “Best of Class” Technology Awards Winners of these prestigious awards are recognized for impacting clinicians and demonstrating excellence ......26


Legal matters

Orthodontic concepts

Efficacy of a fluoride sealant and a fluoride varnish on demineralization around orthodontic brackets: in vitro

The doctor-patient relationship Dr. Laurance Jerrold discusses the legal aspects of the dentist-patient connection....................................56

BioDigital Orthodontics: Outcome evaluation with SureSmile technology: part 4 Dr. Rohit C.L. Sachdeva describes some of the tools he uses in evaluating treatment outcomes......28

study Drs. Cintia Santana Dias, Thais Aglaet Miranda, André Gasparetto, Adilson Luiz Ramos, and S. Jay Bowman explore the effects of a fluoride sealant and fluoride varnish ..........44

Continuing education


Instrument sterilization: the case for high velocity hot air sterilization in the orthodontic


office Dr. Nelson S. Slavik delves into a sterilization method that can effectively sterilize instruments while increasing instrument life span ......34 Impacted premolar — conservative management Dr. Runa Mowla-Copley details a case study requiring conservative management of an unerupted premolar during orthodontic treatment .....................................................40 4 Orthodontic practice

Integrating technology in orthodontic practice for pain relief, TMJ/D, and headache Dr. Sheila Birth uses a systematic therapy approach for life-changing care...............................................50

Product profiles Lythos™ Digital Impression System .....................................................53

Practice management Maximizing practice profits Terri Zeringue explores ways to effectively manage office expenses .....................................................58

Practice development The removable orthodontic market is alive and kicking Dr. Neil M. Warshawsky discusses MTM® In-Office Minor Tooth Movement.....................................60

Materials & equipment.......................64

OrthoAccel Technologies .........54 Dentronix LED 3000 ...................55

Volume 4 Number 4

Bright Ideas Generating Brilliant Results With an ever-expanding base of member benefits, the UOBG is constantly evolving to keep you in-the-know and on-the-go! UOBG member benefits now include access to: Flexible pricing options that enable you to personalize your membership with a plan that makes the most sense for you. HR for Health’s web-based human resource software Online and print forum, The Progressive Orthodontist, that teaches the business of orthodontics The Practice Management Solutions of the Pride Institute The Online Expertise of Sesame Communications Money-Saving Benefits of GACPowered Practice Marketing Best of all, membership in the UOBG remains FREE!

Come and see what you’ve been missing. www.UOBG.org


In addition to member-only discounts, a complimentary CE course and access to the UOBG Preferred Partner Program, you can earn UCash to redeem for FREE products and practice building opportunities. Join over 3,000 orthodontists and start saving on the products you already use by becoming a UOBG member today!


Dr. Robert Sheffield Changing smiles and lives through orthodontics What can you tell us about your background? I am a solid Northern Californian! I was born and raised in the Bay Area. My mother was a teacher and high school counselor, and my father was an engineer. My parents encouraged me to explore new things, instilling within me the desire for continual learning that stays with me today. I journeyed to Southern California for college earning a B.A. in Political Science at UCLA. I followed my childhood dream and continued at UCLA for Dental School. I stayed in LA because I could still qualify for student tickets to the UCLA football and basketball games. We ended up winning our 11th National Championship in basketball in my senior year of dental school. I continued my specialty training at UCLA, completing a combined residency in pediatric dentistry and orthodontics.

Why did you decide to focus on orthodontics? To be frank, all the orthodontists I met were awesome people who loved what they did. They had a passion for life and no regrets about their chosen profession, so I figured it was a great place to start. The mechanics of orthodontics, the precision and perseverance required to achieve a spectacular result, the knowledge needed to effect growth and development with proper force application, and the opportunity to make a difference in people’s lives ultimately sealed the deal.

How long have you been practicing, and what systems do you use? I began practicing 15 years ago. For my first 2 years in practice, I practiced both pediatric dentistry and orthodontics. I purchased an orthodontic practice in 2001 and have practiced primarily orthodontics since then. I’ve used the Damon System® exclusively since 2004. We use Damon metal and clear as well as Invisalign® and Invisalign Teen. We also have begun ramping up our use of Insignia™ custom braces and now have nearly 150 finished or in progress cases. 6 Orthodontic practice

“My family remains the best thing in my life.” (Kaitlyn, Courtney, Ryan, and Cristie)

What training undertaken?



In keeping with my upbringing I make a point to regularly attend CE courses on a wide range of topics from orthodontics to restorative dentistry. With interdisciplinary care becoming more and more complex, it is critical that orthodontists understand, at least at a basic level, what our restorative colleagues are doing. The Seattle Study Club offerings have been spectacular. I regularly attend the Damon forum; always coming away with something new. I belong to the Ormco Insiders and the Pitts Progressive Group, which allow me to interact with exceptional orthodontists two to three times a year. Learning from colleagues who continually strive to be at the forefront of our specialty and turn out consistently exceptional results pushes me to deliver the best for my patients.

Who has inspired you? Wow! This is like giving an acceptance speech at the Oscars and not wanting to forget anyone. Dr. Peter Silcher was a career day advisor in high school, so I must give him credit for starting me down this path as well as my orthodontist Dr.

George Redmond. The faculty at UCLA all deserve credit for inspiring me. Without their constant instruction and expectations of excellence, I would not be where I am today. Dr. Dwight Damon’s passion for excellence and overall patient care ranks at the top of the list, and I can’t thank him enough. Many others deserve mention; Dr. Tom Pitts for challenging me to be better with every case, Dr. David Sarver for taking the time to teach us to look at more than just the teeth, and Dr. Bob Smith for sharing his passion for orthodontics, providing insight on running a business and reminding me to live life to its fullest. All the docs in my study clubs inspire me every time I listen to their lectures or pearls. I am definitely a better orthodontist and person because I have the opportunity to know them all.

What is the most satisfying aspect of your practice? I know it’s somewhat cliché in orthodontic practices, but I have to say the day the braces come off, and we celebrate with photos, candy, balloons, and cheers ranks at the top. We make a point of having fun with our patients whether in the clinic or during our regular patient appreciation parties. Volume 4 Number 4


Reception area in the main office

Fun outside the office with patients

Dr. Sheffield’s team brings hospitality to patients and their families every day

Also, having people come to our practice because they were told we’d treat them like our own family lets me know my team and I succeeded in living our vision and mission.

Professionally, what are you most proud of? Starting a chapter of Smile 4 a Lifetime has, without a doubt, been the accomplishment I am most proud of. The opportunity to provide the gift of smiles to patients who believe orthodontics remains beyond their grasp is immensely fulfilling. To have a group of patients whose best day is getting braces on, not off, reaffirms the impact we can have on the lives of others. We really do have the opportunity to change lives, one smile at a time.

Volume 4 Number 4

What do you think is unique about your practice? In our community, we are known for our honesty, integrity, and customer service. We strive every day to live up to those ideals. Additionally, we lead the way in adopting new technology in treating our patients; self-ligating brackets, soft tissue lasers, TADs, and digital orthodontics like Insignia. We’ve also just ordered an intraoral scanner, and I’m hoping we can become a nearly impression-free office! I think that will be awesome.

What has been your biggest challenge? I would say assembling a team that’s committed not only to outstanding clinical care and customer service but recognizes that each member of the team is also a

Making patients feel special

customer who must be treated well has been my biggest challenge. I also enjoy the challenge of being the good leader that my team deserves.

What would you have become if you had not become a dentist? Since I announced to my family I would be a dentist at the age of 6, I really never gave another career much thought. Upon reflection, since I am somewhat obsessive regarding analyzing the numbers and statistics of my practice and the ROI on various aspects of the practice, I suspect I would have gone into business. I do think being an astronaut would be really cool!

What is the future of orthodontics and dentistry? I see digital orthodontics and customized Orthodontic practice 7


Ryan in slalom race

Awesome day outdoors with Dr. Sheffield’s children and his dog Bode

Kaitlyn in giant slalom race

treatment options becoming commonplace. The ability to use technology to improve quality care and make treatment even more patient-friendly in terms of overall treatment time, and more importantly the number of visits, will be a game changer in my opinion.

What are your top tips for maintaining a successful practice? • Always put your family first. The last thing you want to do is sacrifice time with your kids and spouse for your work. • Be committed to finding the right people for your team. This is easier said than done, but having a team who believes in your vision and thinks of others first is critical to success. • Pay attention to the numbers! You must know them at all times. • Be honest with your patients always, no exceptions. • Treat patients as if they were members of your family. • Try very hard to see your patients on time for their appointments, and finish their treatment on time. • Remember that it’s called an orthodontic practice for a reason. You can always get better. 8 Orthodontic practice

Oldest daughter Courtney celebrating victory at home mountain Super G race

What advice would you give to budding orthodontists? Be steadfast in your commitment to quality results. Try very hard not to compromise your principles. Read as much as you can about leadership, service, and business. In most cases, it is best to try new things in an incremental fashion. Respect your team, and always try to show them you care because they will be a big part of your success. Learn from others, and be willing to share your knowledge. Be a giver not a taker.

What are your hobbies, and what do you do in your spare time? Right now I’m at a stage in life where my kids’ activities and sports consume most of my free time. We all enjoy skiing, and we are on the slopes every weekend during the winter as my kids train or race. I enjoy hunting with my kids and spending time in the outdoors. A good book remains a true pleasure for me. The occasional getaway with my wife remains at the top of the list. OP

Top 10 favorites list 1. Time with family and friends 2. Tahoe-winter skiing/summer golf 3. Wine 4. Steaks on the grill 5. ESPN and Fox News 6. Damon Braces (Ormco Corporation) 7. Insignia™ custom braces (Ormco Corporation) 8. Transbond™ XT for bonding (3M Unitek) 9. Herbst appliance 10. Orthodontext — software to send custom reminders for elastics, Invisalign trays, etc. Volume 4 Number 4

To see the future you must first look into it. Dr. Bruce Goldstein Scottsdale, AZ

May 2008 Initial intraoral

July 2008 Planned result

August 2009 Actual result

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


to be sure.

Š 2013 OraMetrix, Inc. All rights reserved. suresmile is a registered trademark of OraMetrix.



Reliance Orthodontic Products

Reliance Orthodontic Products® was established in 1982, with the sole purpose of providing innovative adhesives at a fair price with the most comprehensive technical support. Founded by Paul Gange and his wife Sharon, Reliance set up offices in a small 1,000-square-foot facility in Itasca, Illinois, with five employees. Paul’s background in orthodontics included 11 years of experience, starting with Ormco® and later with Lee Pharmaceuticals®, where he developed the first no-mix orthodontic adhesive. When Reliance entered the market as a company solely dedicated to orthodontic adhesives, the consensus was that they could not survive with adhesives as their sole product line. Reliance persevered with the philosophy that when customers purchase a product, they will receive continuous technical support. Paul worked closely with Dr. Byoung Suh, a renowned PhD polymer chemist and educated himself on every aspect of each product he sold — from design through final sale — to guarantee that he could answer any question presented to him. Each customer has access to product education, training, and technical support, either by phone, email, or in person. With a limited budget, Paul traveled over 300 days a year visiting doctors’ 10 Orthodontic practice

offices, and establishing the Reliance name by offering his expertise in orthodontic bonding and listening to the situations that doctors faced daily. These open conversations with respected clinicians generated a deep interest to solve the bonding problems orthodontists and staff face each day and has been the main focus of Reliance since its inception.

Fair pricing and consistent quality Without a large sales force to drive up costs and a firm belief that a good adhesive sells itself, Paul dedicated himself to providing a consistent and quality product at a fair cost to all orthodontists. That philosophy continues as evidenced by the fact that Reliance has raised prices only three times in 31 years. Equipped initially with two chemical cure adhesives, Phase II® (two paste system) and Rely.a.Bond® (single paste system), along with Light Bond™ (light cure system), Reliance attracted a dedicated group of customers who spread the word about the quality of their adhesives. However, what has distinguished Reliance from other orthodontic companies and accelerated their growth, is the technical support each customer receives, even to the point of developing adhesive products

to correct the problems they may be experiencing. In 1983, Dr. James McNamara, of Ann Arbor, Michigan, was having difficulty bonding acrylic Herbst appliances. After many months of tweaking and perfecting, Excel®, a chemical cure adhesive with a thinner viscosity paste and an extended working time was born. Today, it is still the product of choice for these appliances. With bonding being a highly sensitive technique that is often delegated, questions can arise during procedures that require a timely response. Reliance does not utilize a voice recognition telephone system like many companies. Every customer is greeted by a customer service representative and is immediately provided a comprehensive answer, or for complex questions, is provided follow-up with an expert technical support staff member.

Experienced, professional team While Sharon maintained her position as Vice President, she handled day-today customer service and warehouse distribution, and as the customer base increased along with the customer service team, Marsha Acuna was brought in from a California-based orthodontic company to supervise and manage the expanding Volume 4 Number 4


Bonding attachments to clear aligners.


Bond Aligner™* Place Bond Aligner™ on attachment

Place attachment on aligner

Cure the Bond Aligner™

Bond Aligner™ from Reliance Orthodontics was developed by Orthodontist Dr. Laurel Martin. Bond Aligner™ features include:

• Will bond any attachment to most aligner materials including Essix ACE®, Invisalign®, Invisalign® Smart Track™ and Tru-Tain® material.

• A clear light cure paste for excellent aesthetics. • Bonds to plastic aligners without plastic preparation, primers or conditioners.

• Low modulus of elasticity- Bond Aligner and will not crack or separate

flexes with plastic

* Patent Pending

Bonded Aligner

For more information, contact…

(800) 323-4348 • (630) 773-4009 • Fax (630) 250-7704 www.relianceorthodontics.com

CORPORATE PROFILE customer service team. In 1989, Reliance added an International Sales Manager, Scott Hudson, who took over sales and distribution of 10 international accounts. In addition to his duties as International Sales Manager, Scott is a member of the technical support team, is a published author, and has lectured at universities in the Southeast U.S., Europe, and at European conferences. Scott brought to Reliance years of experience in the orthodontic lab business and helped to expand the worldwide distribution channels. Reliance now has product representation in over 80 countries with 300 distributors worldwide. John Cady joined Reliance in 1993 as Product Manager of ancillary products and Eastern Regional Manager, after many years with Great Lakes Orthodontic Products. Judy Mis was hired as Quality Systems Manager in 1991 as the product line continued to grow along with the number of employees. In 1993, Halina Chojnowskii relieved an overburdened accounting department and assumed the position as Chief Financial Officer. Steve Bogart came on board as National/International OEM Production Manager in 1998 when distribution outgrew its facility once again. Arlo and Verdell Westmiller, Sharon’s parents, have been instrumental from day one, and relentless in their dedication to the success of Reliance and still are active today in the day-to-day business. The philosophy of immediate customer service and technical support will continue to separate Reliance from its competitors with Paul Gange Jr. In 2009, after completing his studies at DePaul University in Chicago, Reliance was proud to have Paul Jr. join the Reliance team, under Paul Sr.’s tutelage. He found that he shares the same passion for excellence in orthodontics and the desire to help the profession through technical support. Paul Jr. is a published author and has been a speaker at meetings and universities, following the path that Paul Sr. has mastered. His sister Nicole is currently a second-year dental student at Midwestern University, with plans to continue her education in orthodontics, and hopes to one day assist with testing and developing new and exciting products for the industry.

Knowledgeable insights Over the years many clinicians have been responsible for some of Reliance’s finest products. Dr. James Hilgers is responsible 12 Orthodontic practice

Paul Gange, Sr., Sharon Gange, and Paul Gange, Jr. in front of corporate headquarters

for OVS™ (a veneer system for peg laterals), Bond.a.Braid® and Retainium™ (lingual retention systems), and C&C™ Composite and Chain (an extrusion system). Dr. David Musich developed Ortho Flex Tech® and Stainless Steel Ortho Flextech® (lingual retention systems), and currently, Reliance is partnering with Dr. Laurel Martin who developed an aligner adhesive, Bond Aligner™, which will adhere to any clear thermoplastic aligner, and Perfect.a.Smile™, a pontic paint that can be painted onto any clear aligner to temporarily mask any missing or compromised teeth. Also instrumental to our success is Dr. Robert Gange, Paul’s brother, whose relentless testing and retesting of products have led to the perfect formulas and Dr. Robert French of Laguna Beach, California for being a constant inspiration and mentor. Currently, Paul Sr. holds several patents, is a published author, has lectured worldwide on bonding, and considers himself to be very fortunate to be able to interact with the doctors and their assistants and students on a daily basis, fulfilling his passion. Over the years, Reliance’s innovation produced the first fluoride-releasing orthodontic adhesive, one- and two- paste band cements (Ultra Band Lok® and Band Lok®), hydrophilic primer for enamel, composite, and metal (Assure® Universal Bonding resin), and enamel protective sealant (Pro Seal®).

of its customer service and production teams have been with them for 10 years or more and love working with orthodontists worldwide. Reliance appreciates the effort and commitment each and every one of them possesses. Paul and Sharon maintain that no one works for them, they work with them to ensure success. Today, Reliance products are sold worldwide, thanks to a fully compliant US FDA and ISO Certified facility and thanks to Paula Wendland our Internal Regulatory Affairs Manager, with 18 years experience in the medical device industry. Reliance boasts a spotless compliance record, both with ISO and FDA. It is Reliance Orthodontic Products’ quality system policy “to provide the highest quality orthodontic products by using qualified, reliable suppliers, providing quick and effective technical support\customer service, and ensuring all employees are committed to the quality system, adhering to regulatory requirements and meeting the needs of our customers.” Through this policy, they are proud to ship over 99% of all orders on the same day that the customer’s order is placed. The Reliance team would like to thank their customers for 31 years of support and commitment to their vision of quality orthodontics. For more information, visit www.relianceorthodontics.com or call 800-323-4348. OP

Loyal and service

This information was provided by Reliance Orthodontic Products.



The Reliance team is proud that 80% Volume 4 Number 4

• Get the precise adaption that typical vacuum units can’t deliver, resulting in better fitting appliances. • Easy-to-use barcode programming system helps speed production and minimize materials waste. • Variable, electronically-controlled operating pressure of up to 6 bars (87 psi) and verticallyforming design help insure consistent results. • Fabricate not only aligners and retainers, but a wide range of high-quality removable appliances — without long waits or lab fees.

To find out what the Drufomat Scan can do for your practice, call today to schedule a consultation.

1-800-883-8733 www.essix.com




Drufomat and Dreve are not trademarks of DENTSPLY.


The “therapeutic” Class II and Class III first molar relationship Drs. Donald J. Rinchuse, Dara L. Rinchuse, and Ethan Drake share perspective on first molar arch relationships


ngle1 and Andrews2 established criteria for “optimal” static occlusion. In addition, there have been classification systems for malocclusion,1,3,4,5 which help orthodontists glean and distinguish optimal from non-optimal occlusions. From a juxtaposition comparison of over 1,150 welltreated American Board of Orthodontics cases with 120 non-orthodontic treated ideal occlusions, Andrews2 developed his six keys to optimal occlusion. The six keys to optimal occlusion deal with: 1. molar relation, 2. angulation, 3. inclination, 4. no rotations, 5. no spacing, and 6. flat Curve of Spee. Andrews’ six key measurements were taken from the clinical crowns of the teeth and not from the long axes of the teeth (roots). The key characteristic of Angle’s “optimal/normal” occlusion (i.e., key # 1)

Donald J. Rinchuse, DMD, MS, MDS, PhD, graduated from the University of Pittsburgh School of Dental Medicine in 1974 with degrees in Dentistry (DMD) and Pharmacology/Physiology (MS). He received his certificate and MDS degree in orthodontics in 1976 and a PhD in Higher Education in 1985 from the University of Pittsburgh. He is a Diplomate of the American Board of Orthodontics. In addition, Dr. Rinchuse is on the editorial review board of many professional journals including the American Journal of Orthodontics and Dentofacial Orthopedics. He has published over 100 articles, several book chapters, a book, and has made many presentations. Dr. Rinchuse is presently Professor and Graduate Orthodontic Program Director at Seton Hill University, Center for Orthodontics, Greensburg, Pennsylvania. He can be reached at rinchuse@setonhill.edu. Dara L. Rinchuse, DMD, graduated from the University of Pittsburgh School of Dental Medicine (DMD) in 2008 and Jacksonville University School of Orthodontics (Certificate) in 2010. She is a Clinical Faculty, Graduate Orthodontic Program, Seton Hill University, Greensburg, Pennsylvania and is in private orthodontic practice in Belle Vernon, Pennsylvania. She has authored several papers, including several in the American Journal of Orthodontics and Dentofacial Orthopedics. She can be reached at dararinchuse13@gmail.com. Ethan Drake, DMD, MS, is a former orthodontic resident at Seton Hill University, Greensburg, Pennsylvania and is currently in orthodontic practice in Chambersburg, Pennsylvania.

14 Orthodontic practice

Figure 1: Andrews key #1- molar relation- note distal angulation (about +5% tip) of maxillary first molar so that this cusp occludes in the embrasure between the distal of the mandibular first molar and the mesial of the mandibular second molar

Figure 2: Case under orthodontic treatment in which there was single arch extractions of maxillary bicuspids to mitigate a Class II (1) malocclusion and final occlusion will end up with a Class II interarch (therapeutic) molar relationship, with the canines and incisors in a Class I/ normal occlusal relationship

was that the maxillary and mandibular molars should be in an interarch, saggital relatationship such that the mesiobuccal cusp of the upper molar occludes in the buccal groove of the lower molar (the mesiolingual cusp of the upper first molars occludes in the central fossa of the lower first molars).1 Andrews expanded on the thinking of Angle concerning the optimal first molar interarch relationship by discussing the proper distal angulation (“tip”) of the maxillary first molar and its interarch contact relationship with the mandibular second molar. He wrote: “The distobuccal cusp of the upper first permanent molar should make contact and occlude with the mesial surface of the mesiobuccal cusp of the lower second molar.”2 Based upon Andrews, the maxillary molars should have approximately +5 degrees distal angulation (Figure 1).6 It should be pointed out that there are many instances where a first molar interarch relationship can be judged ideal from Angle’s perspective but not from Andrews.2

set in a “therapeutic Class II” relationship; however, the incisors, canines, and most of the rest of the dentition is in a “normal”/Class I relationship (Figure 2).7 Or perhaps, lower bicuspids are extracted (no extractions in the upper arch) to address an Angle’s Class III malocclusion, and the final first molar occlusion results in a “therapeutic Class III relationship.”

Discussion There are instances in orthodontic treatment when single arch extractions are performed to address Class II or III malocclusions,7,8,9,10 and the final occlusions end up with Class II/III first molar occlusion, but the remaining occlusion is Class I/normal. That is, when upper first bicuspids are extracted (no lower teeth removed) to mitigate an Angle’s Class II malocclusion, the first molars will be

Therapeutic Class II and Class III molars – clinical implications An issue that can arise based on Andrews’ key #1, maxillary first molar angulation, is: should orthodontically treated cases with single arch extractions and treatment planned to end up in a therapeutic Class II or Class III relationship have maxillary first molars with approximately a +5 degree distal angulation, as discussed by Andrews for optimal Class I/normal, interarch molar relationships? There is some literature that has briefly addressed this issue and suggests that “therapeutic Class II molars” should have an upright angulation/slant; 0 degrees, not +5 degrees as for Class I/ normal molars (Figure 2). 7 For orthodontically treated cases with “therapeutic Class II molars” having the maxillary molars angulated +5 degrees as for Class I occlusions (i.e., distal aspect of the molar tipped down), could cause several possible adverse effects. That is, having “therapeutic Class II molars” with +5 degree angulations as in Class I/normal occlusions can produce a situation where Volume 4 Number 4


Figure 3A: Class II interarch relationship in which the maxillary first molars have distal crown angulation as per Andrews key #1 Class I/normal relationship instead of a more upright angulation as for a therapeutic Class II molar relationship. The photo illustrates a consequence of the distal angulation of a Class II molar; i.e., plunger cusp with dental open bite

the marginal ridges of the maxillary first molars in conjunction with the teeth mesial (bicuspids) and distal (second molars) will not be at the same height levels. This could result in a plunger cusp-type relationship of the maxillary first molar as the distal tipped part of the maxillary first molar lies in the buccal groove of the mandibular first molar, and when contacting the central fossa of the lower first molar (as in a Class II relationship) could possibly result in a posterior/anterior dental open bite (Figures 3A and 3B). To a lesser extent, the mesial aspect of the upper first molar will be tipped upward to cause an open bite of only the mesial aspect of this tooth (Figure 3B). Parenthetically, when an orthodontic case has more inclination of the incisors and/or more angulation of the posterior teeth (then discussed in Andrews’ six keys), it makes sense that the first molar angulation for all molars Classes, i.e., I, II, and III, would be greater than what Andrews found for his sample of 120 naturally occurring normal (optimal) occlusions. So, for example, where a case has protrusive

Figure 3B: Orthodontic case in treatment with single arch extractions (maxillary) and Class II “plunger” cusp molar relationship due to maxillary first molars with distal tip as of an Andrews Class I relationship rather than “0” degrees (no tip) for ideal Class II therapeutic molar relationship. Notice dental open bite most likely the result of the distal tip of the maxillary molar acting as a plunger cusp

inclination of the incisors and more distal angulation of the posterior teeth, and these parameters are not deemed in need of corrected/changed, the optimal first molar inclination values may be say +10 degrees rather than +5 degrees for Class I molars. Likewise, the values might be +5 degrees rather than 0 degrees for therapeutic Class II molars.7,11 Therapeutic Class III angulation values are positive and distal but less than those found in the Class I first molar relation, approximately +2 degrees.11 In addition, Andrews’ values considered only the clinical crowns of the teeth and not the long axes of the teeth (roots). His measurements did not also consider how the teeth and dental arches are related to the palatal plane, and/or the Frankfort plane.12 Hence, if maxillary first molar angulation is compared and calculated based upon the above mentioned references, there should be a modification of the angulation values of Andrews.10,11,12 In his/her quest for excellence, the savvy orthodontic clinician must take

into account situations where the basic principles of Andrews’2 six keys do not apply, and changes in thinking must occur. This is true for single arch extraction cases which finish in “therapeutic Class II or III” first molar relationships.

Conclusions • The Angulation2 (“tip”) values of Andrews (based on his six keys) for the clinical crowns of the maxillary first molars should be adjusted by the orthodontic clinician for cases when one arch extractions are performed and the final occlusion ends in a therapeutic Class II or Class III first molar interarch occlusal relationship. • When angulation adjustments are not considered by the clinician for therapeutic Class II or Class III patient case situations, there is the possibility of developing “plunger cusps” with resulting creation of open bites and uneven marginal ridges. OP

References 1. Angle EH. Classification of malocclusion. Dent Cosmos. 1899;41:248-264, 350-357. 2. Andrews LF. The six keys to normal occlusion. Am J Orthod. 1972;62(3):296-309. 3. Dewey M. Classification of malocclusion. Int J Orthod. 1915;1:133-147. 4. Ackerman JL, Proffit WR. The characteristics of malocclusion: a modern approach to Classification and diagnosis. Am J Orthod. 1969;56(5):443-454. 5. Katz MI. Angle Classification revisited. 1: Is current use reliable? Am J Orthod Dentofacial Orthop. 1992;102(2):173-179.

Volume 4 Number 4

6. Andrews LF. The Straight-Wire Appliance: Syllabus of Philosophy and Techniques. Michigan: LF Andrews; 1975. 7. Nangia A, Darendelilier MA. Finishing occlusion in Class II or Class III molar relation: therapeutic Class II and III. Aust Ortho J. 2001;17(2):89-94. 8. Burrow SJ. The impact of extractions on facial and smile aesthetics. Semin Orthod. 2012;18(3):202-209. 9. Erdinc AE, Nanda RS, Dandajena TC. Profile changes of patients treated with and without premolar extractions. Am J Orthod Dentofacial Orthop. 2007;132(3):324-331.

10. Janson G, Maria FR, Barros SE, Freitas MR, Henriques JF. Orthodontic treatment time in 2- and 4-premolar-extraction protocols. Am J Orthod Dentofacial Orthop. 2006;129(5):666-671. 11. Drake E. Beyond Andrews’ Six Keys: Angluation of Class II and Class III Molars. [master of science research project]. Greensville, PA: Seton Hill University; 2012. 12. Paquette DE. Importance of the occlusal plane in virtual treatment planning. J Clin Orthod. 2011;45(4);217-221, 236.

Orthodontic practice 15


Preventive Eruption Guidance and the gummy smile in 6- to 8-year-olds 速

Dr. Earl O. Bergersen discusses a technique to prevent the development of the gummy smile Abstract The study of 17 patients treated with the preventive Nite-Guide速 procedure was compared to a control sample of 20 longitudinal individuals from the Denver Growth Sample. Measures of deciduous and permanent maxillary central incisal edges to the palatal line were made to determine if early treatment could restrict eruption of these teeth and prevent the development of an excessive overbite, and in turn, could reduce or eliminate a gummy smile. Results indicated that the appliance could prevent the excessive eruption of the incisors, and at the same time, limit overbite development while these two variables in the control sample increased significantly. Formulae were presented to predict the development of a gummy smile.

The factors not associated with gummy smiles are:3 a) A short upper lip; and b) A steep mandibular plane angle and a steep palatal line. The most attractive smile is when the entire crowns of the maxillary permanent incisors are displayed during a high smile,1 although a small amount of gingival tissue

Figure 1: An adult patient with a gummy smile present during a high smile

Review of literature The gummy smile (Figure 1), commonly referred to an excessive gingival display during a high smile, is present in about 23% of adults,1 and the majority are in females.2 The high incidence in females is due to their increased ability to elevate the upper lip more than males.3 The male lip offers more resistance to excessive gingival display because of thickened tissue and the presence of a beard. The most frequent reasons for a high smile gingival display are2,3,4: a) Increased distance between the maxillary incisal edges to the palatal line (ANS-PNS); b) Excessive overbite (and overjet); c) Greater muscular response to elevate the upper lip; d) Short clinical crown height of the upper incisors; e) Excessive interlip distance; and a f) Short ramus height.

Earl O. Bergersen, DDS, MSD, is former assistant professor, Northwestern University Orthodontic Department and was in former private practice in Winnetka, Illinois. For information, contact the author at 950 Green Bay Road, Suite 205, Winnetka, IL 60093. Ortho-Tain, Inc., is the manufacturer of the Nite-Guide速 and Occlus-o-Guide速 appliances, RR-07 Box 11049, Toa Alta, PR 00953.

16 Orthodontic practice

Figure 2A

Figure 2C

Figure 2B

Figure 2D

Figure 2A and 2C: The initial of a patient 12.25 years of age showing the gummy smile and over-erupted maxillary incisors Figures 2B and 2D: Shows the final result with intrusion of the maxillary incisors to eliminate the gummy smile

showing can be acceptable.3 Since there are so many possible reasons for a high smile with gingival exposure, it is important to assess the primary cause or causes before any form of treatment is considered. Cases that have an excessively long lower face height (ANS-Me) are often most successfully treated with Le Fort 1 maxillary impaction surgery,5,6 while other procedures can be options such as reduction of the strong muscular effect of upper lip elevation7 and surgical elimination of a portion of the gingival tissue.8 The most common procedure, when

the cause is due to an excessive overbite with over eruption of the maxillary incisors with an increased distance from the incisal edges of the maxillary incisors to the palatal line (ANS-PNS) as outlined under (a) and (b) of the possible causes listed above, is to reduce the overbite by intruding the maxillary incisors. Such a procedure as shown in Figures 2A-2D was treated with fixed appliances. In order to correct the overbite, the maxillary incisors were intruded with forces from the maxillary arch wire combined with a high-pull headgear. At the same time, Volume 4 Number 4


the patient was instructed to clench the posterior teeth 200 times per day to prevent these teeth from erupting in order to gain the most incisor intrusion possible. Figures 2B and 2D show the final result with the reduction of the initial gummy smile. This procedure, although successful, is timeconsuming and must be done carefully to obtain as much intrusion of the maxillary incisors without erupting the posterior dentition. An efficient alternative to this procedure is to prevent these incisors from over erupting in the first place. In a study of 526 children by Keski-Nisula, et al.,9 24% of children whose average age was 5.1 years had gummy smiles exceeding 5 mm. Figures 3A-3F show a patient where the maxillary incisors were prevented from over erupting developing a deep overbite. The patient wore a preformed NiteGuide “C” series (Figure 4A) and an Occlus-o-Guide® “G” series (Figure 4B) while sleeping. Since this Nite-Guide procedure easily corrects gummy smiles, this study was designed to discover the mean changes of the contributing factors of gummy smiles with excessive overbites and over eruption of maxillary incisors during the transitional dentition period from 6 to 8 years of age compared to similar non-treated controls.

Figure 3A: The initial view of a 5.7-year-old patient

Figure 3C: Close-up of initial gummy smile

Figure 3E: Initial overbite with line drawn to show over eruption of deciduous incisors

Figure 3B: The final view after 27 months of passive Nite-Guide wear - 7.9 years of age

Figure 3D: Close-up of final smile

Figure 3F: Final view of correction

Method and materials The experimental sample consisted of 17 Caucasian patients of North European ancestry (13 females and 4 males) with a mean initial age of 5.9 years of age with deciduous overbites exceeding 1.5 mm and a mean overbite of 3.59 mm. Lateral cephalometric radiographs were taken initially and at the end of a mean period of 18 months after full contact of the mandibular permanent incisors with the maxillary permanent central incisors. The experimental group wore an Eruption Guidance® appliance (Nite-Guide “C” series if the first permanent molars were not yet erupted or an Occlus-o-Guide “G” appliance if these molars had already erupted) only while sleeping in order to guide the erupting permanent incisors into the arch. The serial control sample was obtained from the Denver Growth Sample of the Child Research Council of the University of Colorado (10) and consisted of 20 individuals with the same percentage distribution of females (N=15) and males (N=5) (as the treatment sample and as reported in the literature for the general population). The mean initial age of the Volume 4 Number 4

Figure 4A: The Nite-Guide “C” series for the deciduous dentition - worn passively while sleeping

control sample was 5.6 years, and the final mean age was 8.0 years. There were no significant differences between males and females in 85% of the variables in this study, and as a result, the sexes were pooled in the experimental and control groups to simplify the presentation of data. The mean initial overbite of the control group was 2.44 mm (+ 1.16), and the final permanent overbite was 4.16 mm (+ 0.97). The dimensions measured for both groups at the initial and final stages were the overbite, face height, and the incisal edges of the maxillary central incisors to the palatal line (ANS-PNS) and to menton. The tracing technique and accuracy

Figure 4B: The Occlus-o-Guide “G” series for the mixed dentition - worn passively while sleeping

of these measures have been previously described,10 and all measures were calculated to within 0.1 mm using magnification and a calibrated micrometer. Statistical comparisons were performed using the t-test, and all cephalometric measurements were compensated for enlargement.11 Clinical crown heights of maxillary central incisors were measured on six cross-sectional samples of plaster casts selected at random from the author’s practice at 6, 8, and 12 years of age. The means of the clinical crown height at 6, 8, and 12 years were 4.9 mm, 7.7 mm, and 8.9 mm respectively. The crown heights, Orthodontic practice 17

CLINICAL together with the overbite changes with age and the eruptive restriction of the maxillary permanent incisors, are required to estimate possible reductions in the gummy smile and to estimate future changes if no orthodontic interception is instituted.

Description of the preventive Eruption Guidance procedure with the Nite-Guide technique The Nite-Guide technique is based on the research of Moorrees.12 His sample consisted of mostly normal minimallycrowded dentitions from 3 to 17 years of age with 184 total developmental records. A summary of his findings applicable to the Nite-Guide development is: This arch enlargement occurs if the adult incisors erupt without rotations or displacements and force their way into the arch as a result of their own eruption pressure and exert pressure against the adjacent teeth which in turn expands the arch. This enlargement occurs only as the adult incisors erupt. When these erupting teeth are rotated or displaced, less or no expansion occurs. It was reasoned that if the incisors could be encouraged to erupt correctly instead of rotated or displaced, the arch could be enlarged in a similar way to that of Moorrees’ research12 of normal dentitions, providing a preformed appliance was large enough not to inhibit this enlargement. These preformed appliances (Figures 4A and 4B) come in two versions (NiteGuide “C” series and Occlus-o-Guide “G” series) and are both designed to advance the mandible, which corrects an abnormal overjet and can perfect the intercuspation. At the same time, these appliances prevent crowding and the development of an excessive overbite. The preformed tooth sockets are designed to capture the erupting upper and lower permanent incisors and prevent them from over erupting beyond the occlusal plane with an acceptable overbite of one to two millimeters (Figures 3E and 3F). In other words, the appliance is designed to guide the adult incisors into their appropriate preformed sockets, which prevents crowding, stops the maxillary and mandibular incisors from over erupting into a deep overbite, and advances the mandible to correct the overjet all at the same time. Each appliance is designed in equal increments of 0.8 mm for the mandibular incisors and 1.2 mm for the maxillary incisors. Two versions of appliances are available for use 18 Orthodontic practice

A compilation of Moorrees (12) research on bicanine arch enlargement

Mandibular Arch

Maxillary Arch



+2.4 mm

+2.7 mm

As laterals erupt

+0.9 mm

+0.8 mm

9.5 to 19 years


As centrals erupt

As canines erupt 8.710.7 years 13-19 years

Total bicanine enlargement

+.3.3 mm

Figure 5A

Total bicanine enlargement

+1.6 mm -0.5 mm +4.6 mm

Figure 5B

Figure 5A and 5B: Shows the measurement from the mesial of the maxillary left deciduous canine to the mesial of the maxillary right deciduous canine indicating a #3 appliance. The first appliance used is usually two half sizes larger than the lower measurement

Figure 5C

Figure 5D

Figure 5C and 5D: Shows the measurement from the mesial of the mandibular left deciduous canine to the mesial of the mandibular right deciduous canine showing a #4 appliane. The first appliance used is usually two half sizes larger than the lower measurement

in the deciduous and mixed dentition. The deciduous appliance comes in 11 sizes, while the mixed dentition appliance has 13 sizes. The main difference between the two series of appliances is that the Nite-Guide “C” series only has sockets in a posterior direction to include the second deciduous molars, and the Occlus-o-Guide “G” series has sockets posteriorly to include the first permanent molars. The procedure consists of taking a measurement of the maxillary and/or mandibular deciduous incisal area from the mesial of one canine to the other (Figures 5A-5D).

If clinicians anticipate future crowding, a larger size than measured is used, and is usually two to three half sizes larger than the measurement. Each half size increment amounts to 0.8 mm increase in the mandibular incisal area, and 1.2 mm increase in the maxillary. A jump of two half sizes, therefore, allows mandibular enlargement of 1.6 mm caused by the forceful eruption of the mandibular central incisors. Three half size increases allow an increase of 2.4 mm (3 x 0.8 = 2.4 mm). A maxillary increase by two half sizes allows an expansion of 2.8 mm, and three half size increases allow 3.6 mm (2 x 1.2 = Volume 4 Number 4

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• Corrects Crowding • Corrects Spacing • Corrects Overjet

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• Corrects Overbite

CLINICAL 2.4 mm and 3 x 1.2 = 3.6 mm). When the mandibular laterals begin to erupt, the second appliance is issued, which is two to three half sizes larger than the first and is an Occlus-o-Guide “G” series. The mean increases as the result of these appliances are 4.0 mm in the mandibular arch and 5.0 mm in the maxillary arch. Research from Turku University in Finland by Keski-Nisula, et al.,13 used a sample of 167 Nite-Guide patients compared to a control group of 104 both from 5 to 8½ years of age. That study found that 163 of 167 children (97.6%) had well-aligned mandibular incisors, and 164 of 167 (99.4%) had good alignment maxillary incisor. The overbite corrected to within 0.1 mm of the ideal sought at this early age (2.0 mm is considered ideal due to anticipated future mandibular growth) from a mean initial deciduous overbite of 3.2 mm. The experimental group’s mandibles increased (condylion-grathion) by 54.2% over that of the control sample. The overjet correction of the experimental group improved 105%, while the control group improved 41.4%.14 Candidates for this preventive procedure consist of those with mandibular closed deciduous incisal contacts (incidence of 32.3%9) or mild crowding of 1 or 2 mm, deciduous overbites exceeding 1.25 mm, and overjets over 3 mm. Ninetythree percent of children 5-6 years of age present with these three symptoms.9 A study by Methenitou, et al., at Tufts University of 43 patients treated with the Nite-Guide compared to a control sample of 5015 found that the overbite was corrected 96.4%, while the overjet corrected 111.7%. Of particular interest was that the maxillary permanent incisors were prevented from over eruption in the treatment group and resulted in an overbite of 1.4 mm from a mean initial deciduous overbite of 3.4 mm (6 to 7.5 years of age). During the same period, the control sample had an increase in the overbite from 3.0 mm to 4.3 mm There was no increase in the length of the face in either the total face height (N-Me) or the lower face height (ANS-Me) during the treatment period when compared to the control sample.

Results Three basic factors determine the future course of a gummy smile whether it is treated early with the Nite-Guide technique or not: 1. The difference in the clinical crown 20 Orthodontic practice

TABLE I: Maxillary central incisor to palatal line (ANS-PNS)




6 Years

23.31 mm



8 Years

23.13 mm






Change 6-8 Years

-0.18 mm

+1.72 mm


** = P< .01, *** = P< .001

TABLE II: Mean overbite in experimental and control samples




Deciduous 6 Years Initial

3.59 mm

2.44 mm


Permanent 8 Years Final

1.53 mm

4.16 mm





Change 6-8 Years

-2.06 mm

+1.72 mm


** = P< .01, *** = P< .001

TABLE III: Upper central incisor to menton




6 Years

30.12 mm

29.16 mm


8 Years

32.23 mm

28.85 mm





* = P< .05, *** = P< .001

heights of the deciduous and permanent maxillary central incisors. 2. The eruption of the maxillary permanent central incisor measured to the palatal line (ANS-PNS). 3. The deciduous overbite and how it will change with growth. In order for the gummy smile to reduce during an early preventive procedure, the maxillary adult central incisor has to be restricted in eruption and thereby reduce the overbite by considering the difference in crown heights that will occur between the deciduous and permanent maxillary central incisors. Other variables in a gummy smile are difficult to accurately measure in a young child of 5 or 6 years of age. Young children often smile differently on each command, and measurement cannot be done with any consistent precision. Also the growth

increments of the soft tissue lips are also difficult to study with any consistent accuracy. Deciduous clinical crown heights were measured from random casts since images from cephalometric images proved inaccurate from cephalometric radiographs. Since casts were not available for the control sample, random measurements of the experimental group were used for both classes of patients. The maxillary central incisal edges to the palatal line (ANS-PNS) were measured, and the results are presented in Table I. The distance from the incisal edge of the maxillary central incisor to the palatal plane (ANS-PNS) increased by a mean measurement of 1.72 mm in the control group and reduced by 0.18 mm in the experimental group between the ages of 608 years. The difference between the groups was significant by 1.9 mm (1.72 + Volume 4 Number 4


0.18). The control group’s mean overbite (Table II) increased from 2.44 mm at 6 years to 4.16 mm at 8 years of age for an increase of 1.72 mm, while the mean of the treatment group overbite reduced 2.06 mm during the same period for a significant difference between the two samples of 3.78 mm (1.72 + 2.06). Had the maxillary centrals in the treatment group erupted equally to the control sample, the treatment overbite might have developed a severity of 5.31 mm (3.59 + 1.72, Table II). Although the measurement from the maxillary central incisal edge to menton does not relate directly to the development of a gummy smile, it gauges the behavior of the maxillary incisor during treatment with the Nite-Guide. Table III shows that the maxillary central incisor in the control group is closer to menton than that of the treatment group by 3.38 mm (32.23 – 28.85 = 3.38), which indicates that the treatment central incisor has erupted less than the control central by 3.38 mm. Table IV shows the gingival tissue display reduction for the treatment and control groups. The treatment group, when measuring the gingival margin of the maxillary central incisor to the palatal line at 6 and 8 years of age, resulted in a display reduction of 2.94 mm versus 1.04 mm in the control group for a significant improvement of 1.9 mm (2.95 – 1.04). Table V reports the changes in overbite from 5 years to 12 years of age. This sample is from the Denver Growth Sample (10) of 36 longitudinal non-treated individuals. This chart is used for the predictive analyses of the gummy smile from 6 to 12 years.

TABLE IV: Gingival display




18.35 mm

17.26 mm


15.40 mm

16.22 mm




-2.94 mm

-1.04 mm

Ging. margin to ANSPNS 6 Years Ging. margin to ANSPNS 8 Years “t” Ging. tissue Reduction 6-8 Years


*** P = < .001 TABLE V: Overbite changes from 5 to 12 years of age





















































Males & Females N=36 From Denver Growth Sample Males vs. Females “t” = N.S., All Ages TABLE VI: Prediction of a gummy smile by 12 years of age that can be potentially reduced in a 6 year-old with eruption guidance (Nite-Guide procedure)

Deciduous Overbite (mm)

Addiction of effective crown difference

Gummy smile change


-1 Openbite


= +2 mm

Reduce gummy smile

0 End to End


= +3 mm

Reduce gummy smile

+1 Ideal Overbite


= +4 mm

Reduce gummy smile

+2 Minimal Overbite


= +5 mm

Reduce gummy smile

+3 Overbite


= +6 mm

Reduce gummy smile

+4 Overbite


= +7 mm

Reduce gummy smile

Discussion The current study along with that of Methenitou, et al.,15 has shown that the maxillary permanent central incisor eruptive force can be stopped and thereby prevent a deep overbite by using the NiteGuide. When early interceptive treatment is not instituted, the maxillary central incisor continues to erupt and develops a significantly deeper overbite (Table II). The easiest procedure to analyze whether early Eruption Guidance will help to reduce or eliminate a young child’s gummy smile is to simply measure the maxillary permanent central crown height estimated from the child’s panoramic film and measure this distance to the upper lip in a high smile. One measures this distance from an Volume 4 Number 4

Procedure: The deciduous overbite + the increase of the overbite from 6 to 12 years = 2 mm which you must reduce by 1 mm, which is an ideal overbite, then add the crown height difference between the deciduous and permanent central incisors Example: A 4 mm deciduous overbite +2 mm = a 6 mm adult overbite minus 1 mm to obtain the effective amount of overbite that will be reduced (3 mm) plus 4 mm, which is the amount of the permanent central’s increased height over the deciduous crown height = 7 mm (4+2-1+4=+7) Orthodontic practice 21

CLINICAL TABLE VII: Prediction of gummy smile by 12 years of age that will result if no orthodontic interception is initiated

Reduction of


effective crown




-1 mm Openbite


= -4 mm

Reduce gummy smile

0 End to End


= -3 mm

Reduce gummy smile

+1 Ideal Overbite


= -2 mm

Reduce gummy smile

+2 Minimal Overbite


= -1 mm

Reduce gummy smile

+3 Overbite



No change in gummy smile

+4 Overbite


= +1 mm

Increase gummy smile

Deciduous Overbite/Openbite


Procedure: The deciduous overbite + the increase of the overbite from 6-12 years = 2 mm which you must reduce by 1 mm, which is an ideal overbite, then subtract the crown height difference between the deciduous and permanent central incisors Example: a 4 mm deciduous overbite + 2 mm = a 6 mm adult overbite reduced by 1 mm to obtain the expected amount of overbite (5 mm) that offsets the effect of the (4 mm), which is subtracted from 5 mm which equals 1 mm

imaginary line between the level of the occlusal plane from left to right to see if the crown occupies the entire exposed space when the child performs a high smile (Figure 3E). If this is inconvenient, the mean adult crown height of 9 mm (8.6 mm female, 9.2 mm male) can be used in the same way. Table V indicates that the mean overbite increase between 6 and 8 years of age is 1.18 mm, and between 8 and 12 years of age it is 1.09 mm. As a result, the mean increase from 6 to 12 years is 2.27 mm, which is in agreement with most research studies. For simplification, the amount of 2.0 mm will be used in the following analyses. Another way to estimate changes in the gummy smile is to measure the deciduous overbite and add 2 mm to this measurement, which gives the projected adult overbite by 12 years of age, and considering that 1 mm is an ideal overbite relation, one subtracts 1 mm from this measure and adds the difference in crown height between a deciduous central and permanent central which is 4 mm. Therefore, the formula is: Deciduous overbite + 3 mm = possible reduction of a gummy smile with the preventive Nite-Guide procedure. 22 Orthodontic practice

Table VI can be used to estimate the possible improvement in gummy smile reduction with the Nite-Guide procedure. One will notice that as the deciduous overbite increases, the amount of possible gingival reduction tends to increase. Table VII gives an approximate estimate of the future gummy smile that will result when interceptive treatment is not a consideration. This chart increases the gummy smile as the deciduous overbite is increased. One must realize, however, that other variables too difficult to accurately measure must temper these estimates, such as lip growth, changes in musculature strength, patient cooperation, etc. In other words, predictions of future gummy smiles may approximate the changes but should not be considered precise measurements. In general, however, the greater the deciduous overbite is in a young child, the greater the amount of gummy smile that can be improved at a young age with preventive Nite-Guide use. The reverse occurs when interceptive treatment is not implemented.

Conclusions 1. The maxillary permanent central incisor eruption can be restricted from

occurring beyond a normal overbite relation with the Nite-Guide and Occluso-Guide therapy. 2. Nite-Guide use can prevent an excessive permanent overbite by restricting the eruption of the maxillary adult central incisor. 3. The distance from the maxillary central incisor to menton in the treatment sample is significantly less than that in the control sample. 4. A comparison between the treatment and control samples indicates a significant difference in the resultant overbite that is 3.8 mm more in the control group. OP

References 1. Hulsey CM. An esthetic evaluation of lip-teeth relationships present in the smile. Am J Orthod. 1970;57(2):132-144. 2. Peck S, Peck L, Kataja M. Some vertical lineaments of lip position. Am J Orthod Dentofacial Orthop. 1992;101(6): 519-524. 3. Peck S, Peck L, Kataja M. The gingival smile line. Angle Orthod. 1992;62:91-100. 4. Singer RE. A study of the morphologic, treatment, and esthetic aspects of gingival display [abstract]. Am J Orthod. 1974;65:435436. 5. Bell WH. Correction of skeletal type anterior open bite. J Oral Surg. 1971;29(10):706-714. 6. Willmar K. On Le Fort I osteotomy; A follow-up study of 106 operated patients with maxillofacial deformity. Scand J Plast Reconst Surg. 1974;12(0)(suppl 12):1-68. 7. Austin HW. Correction of the gummy smile – a plastic surgeon’s view. Dent Today. 1990;9(2):28. 8. Rosenberg E, Torosian J. Periodontal problem solving: interrelationship of periodontal therapy and esthetic dentistry. Dent Clin N Am. 1989;33(2):201-209, 221-261. 9. Keski-Nisula K, Lehto R, Lusa V, Keski-Nisula L, Varrela J. Occurance of malocclusion and need of orthodontic treatment in early mixed dentition. Am J Orthod Dentofacial Orthop. 2003;124(6):631-638. 10. Bergersen EO. The male adolescent facial growth spurt: its prediction and relation to skeletal maturation. Angle Orthod. 1972;42(4):319-338. 11. Bergersen EO. Enlargement and distortion in cephalometric radiography: compensation tables for linear measurements. Angle Orthod. 1980;50(3):230-244. 12. Moorrees CFA. The Dentition in the Growing Child. Cambridge, MA: Harvard University Press; 1959. 13. Keski-Nisula K, Hernesniemi R, Heiskanen M, Keski-Nisula L, Varrela J. Orthodontic intervention in the early mixed dentition: a prospective, controlled study on the effects of the eruption guidance appliance. Am J Orthod Dentofacial Orthop. 2008;133(2):254-260, 328. 14. Keski-Nisula K, Keski-Nisula L, Salo H, Voipio K, Varrela J. Dentofacial changes after orthodontic intervention with eruption guidance appliance in the early mixed dentition. Angle Orthod. 2008;78(2):324-331. 15. Methenitou S, Shein B, Ramanathan G, Bergersen EO. The prevention of overbite and overjet development in the 3 to 8 year old by controlled nighttime guidance of incisal eruption: a study of 43 individuals. J Pedod. 1990;14(4):219-230.

Volume 4 Number 4

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Treating vertical maxillary excess without surgery Dr. Stuart Frost presents a non-surgical adult case for treating vertical maxillary excess and mild crowding with VectorTAS™ and Damon® Clear™ Introduction In a world where people are motivated to look their best, it is important we educate potential patients on what makes a smile great. Many of my patients, and society in general, believe that straight teeth will create a great smile. For a few genetically gifted individuals that is indeed the case, but if it were simply a matter of straight teeth, my practice wouldn’t see the number of adult patients, previously treated as teenagers, still searching for that elusive perfect smile. So how do we enrich society’s perception of a perfect smile? You must be able to communicate your ability to make improvements not just by moving teeth, but the entire face, enhancing overall facial symmetry for improved midface esthetics and enhanced profiles. Also, highlight how a great smile shows a minimal amount of gingival tissue and can eliminate the dark buccal corridors within the corners of the mouth. While these may seem straightforward, they may be the messages that turn a potential patient into a new patient start. In the following case, I will illustrate how I implemented the combination of VectorTAS™, Ormco’s temporary anchorage device (TAD) system, and Damon® Clear™ brackets to treat a 33-yearold adult female who had an average orthodontic result and wanted to turn it into a Damon Smile.

Case presentation Diagnosis A 33-year-old, healthy female patient previously treated with orthodontics as a teenager presented Class I mild crowding, vertical maxillary excess (VME), and towed in cuspids and bicuspids. In addition to the

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

24 Orthodontic practice

Portrait smiling, before

correcting of VME, the patient vocalized the desire to have a broader smile that enhanced her smile arc and face midline. Treatment plan In assessing the case, it was determined that the best course of action was to use Damon Clear brackets on the patient’s upper arch and Damon Q™ brackets on the lower arch to correct mild crowding, upright the cuspids and bicuspids, broaden the smile, and efficiently enhance facial esthetics. I have exclusively used the Damon System for more than 13 years and am continuously amazed at the finished cases I can create. The passive self-litigating brackets combined with high-technology archwires and minimally invasive treatment protocols work together seamlessly, allowing me to move teeth with less binding and friction, and in most cases more comfortably. Because I was treating an adult female who wanted clear braces, the esthetics of Damon Clear were the standout choice. To address the patient’s VME, I turned to VectorTAS for its user-friendly protocols and mechanics. From end to end, every aspect of the VectorTAS miniscrew delivers maximum strength and stability. Using VectorTAS, I had the ability to intrude the maxillary arch and reduce the patient’s VME all without a surgical procedure. Treatment progress At the start of treatment, I bonded the patient with Damon Clear brackets and Damon Q. The teeth moved as planned, and after 9 months of treatment, I placed the TADs using an 8 mm miniscrew. VectorTAS comes with a wonderful color-

Portrait smiling, after

coded atlas guide to ensure proper screw selection, which I use during treatment planning as well as before my initial placement of the miniscrews. I followed my usual protocol for TAD placement — posterior to cuspid for optimal patient comfort — and applied topical Lidocaine for 3 minutes followed by the MadaJet (Mada, Inc.) needleless injector with 2% Lidocaine. By using the Mada-Jet needleless injector, orthodontists have the ability to place subtopical anesthesia where needed, without patient discomfort. To impact the maxilla, the actual treatment with VectorTAS for this case was unique to typical protocols for the following reasons: • Focus on the anterior Most protocols for maxillary impactions use four buccal TADs to get the full effect of intrusion. This patient had excessive gingival display of 4-5 mm in the anterior maxillae with only 2 mm in the posterior maxillae. I designed my TAD placement so that most of my maxillary impaction happened anterior to the cuspid. The posterior was not my primary focus. While many orthodontists will apply four TADs — two on the anterior between the lateral cuspids and two on the posterior between the first and second molars — I knew only two anterior miniscrews would be needed to achieve the result I wanted. As such, I placed the miniscrews between the upper right and left cuspids and first bicuspids. This would give me mostly anterior intrusion, while also having a slight, positive effect on posterior intrusion. • Metal brackets are not required Simply put, we as orthodontists, can be Volume 4 Number 4


Right intraoral photo with TADS

Frontal intraoral photo with TADs

Left intraoral photo with TADS

Right intraoral photo, final

Frontal intraoral photo, final

Left intraoral photo, final

confident that Damon Clear brackets will perform at the same level as metal brackets when using VectorTAS. Stainless steel wires are used when intruding teeth, and they are ideal due to their stiffness, making them a must for TADs treatments. I used VectorTAS with Damon Clear and did not encounter one instance when a bracket came off. With good bracket placement and positioning, the stainless steel wire can be used with the Damon Clear bracket. My patient was an adult, and the esthetics of clear brackets was a big selling point. I did not want to, and more importantly, did not have to rely on metal brackets to be successful with VectorTAS. After 3 months of active TAD intrusion, I started to notice a decrease in the amount of gingival display when my patient smiled. By month 5 of using TADs, there was a significant change in anterior gingival display, and after 7 months with VectorTAS, I was almost finished with the intrusion of the maxillae; however, I found that the left side was starting to intrude more than the right side. Because of this, I wire-tied the left side of the TAD to the wire and continued using my intrusion force on the right side. During the intrusion process, it is necessary to start elastics to help maintain the occlusion and maintain proper overjet/ overbite. At 12 months into treatment and 3 months into intrusion, box elastics

were started with 5/16 6 oz. elastics. At 20 months in treatment, a triangle elastic was added to keep the occlusion together at the upper cuspid and lower cuspid and bicuspid. Eleven months into using VectorTAS, I wire-tied the TADs on both sides to the stainless steel wire for 1 month to ensure a stable, proper finish. After 1 month, I discontinued the patient’s elastic wear.

architecture from the upper central incisors to the cuspids. I measure the clinical crown of the upper central incisors and compare it to the clinical crown of the upper lateral incisors. I then do the lasering needed to ensure the central incisors are 1 mm higher than laterals. I also work to match the height of the cuspids to that of the central incisors.

Finishing: Most maxillary intrusion cases will automatically flatten the smile arc, attributing to a beautiful intrusion case, but the clinician ends up with an unwanted flattened smile arc. To ensure an ideal smile arc in this case, I repositioned the upper 2-2 Damon Clear brackets slightly more gingival during the final 2 months of treatment. Orthodontists should not be afraid to reposition brackets during finishing stages of a maxillary intrusion case and should strive to get buccal cusps, marginal ridges, and contact points lined up and in occlusion before debond. Two months after repositioning the upper 2-2 brackets, the ideal smile arc was achieved, and the patient was ready to debond. After debonding and removing the VectorTAS miniscrews, it was time to contour. In addition to smoothing, shaping, and polishing the teeth, I used a diode laser to conduct gingival countouring. I follow a very methodical approach to get the correct proportions of the gingival

The result after 22 months of treatment — 13 months with the VectorTAS appliance — was more upright buccal segments, a broader smile without dark triangles, and better support in the patient’s midface. The difference in the midface was important, as this is one of the first facial areas to show signs of aging (typically in the early 30s).

Volume 4 Number 4


Conclusion Orthodontics is no longer a focus on just teeth; it’s a holistic approach for delivering an impeccable smile with enhanced facial esthetics that is unique to each individual patient. It is our job to educate these patients on the benefits of esthetic adult orthodontic treatment and the facial changes that are possible. Enlightening patients on this philosophy will help you grow your practice and drive demand. When the 33-year-old patient walked into my office, she had a nice smile, but by utilizing innovative treatment solutions like VectorTAS and Damon Clear, I gave her the Damon Smile that she desired. OP Orthodontic practice 25


Orthodontic Practice US congratulates the 18 winners of Pride Institute’s “Best of Class” Technology Awards


or 5 years, these prestigious awards have become renowned for recognition of products and services that impact clinicians and demonstrate excellence. Pride Institute’s “Best of Class” Technology Awards, created by Dr. Lou Shuman, President of Pride Institute, are determined through thoughtful, unbiased discussion by a panel of dental professionals. The distinguished panel of experts works all year assessing products, culminating in a spirited and honest debate and final decision process that occurs annually at the Chicago Midwinter Meeting. The winning technologies can have a profound impact on purchasing decisions by the dental community, leading to better patient care and more effective practice management. The Awards allow a variety of products — obscure, well-known, basic, and aspirational — the chance to be honored. “I am very proud of the integrity and unbiased selection process provided by our panel,” said Dr. Shuman. “Not every category has a winner – only those products that are truly differentiated from the competition. The purpose of these awards is to provide the dental community with products of excellence that will have the greatest impact.” OP

2013-2014 HONOREES • 3Shape TRIOS Color • ActionRun® Clinical Reactivator® • Align Technology Smart Track • DEXIS Imaging Suite and DEXIS go • Doxa Ceramir • Gendex SRT Technology • Glidewell Laboratories BruxZir Shaded • HealthFirst Tru-Align • Imaging Sciences Int’l i-CAT FLX • Isolite IsoDry • Kerr Dental SonicFill • Lexicomp Lexicomp® Online™ for Dentistry featuring VisualDx Oral • Liptak Dental DDS Rescue


• Orascoptic XV1 • SciCan STATIMG4


• Sesame Communications Sesame 24-7 • Ultradent VALO

• Lou Shuman, DMD, CAG — President

• Marty Jablow, DMD — Writer and

• John Flucke, DDS — Writer, speaker, and

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• Titus Schleyer, DMD, PhD — Associate

of Pride Institute, Best of Class founder

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speaker, and Technology Editor for Dental Economics


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Professor and Director, Center for Dental Informatics at the University of Pittsburgh, School of Dental Medicine

• Parag Kachalia, DDS — Vice-Chair of

Preclinical Education, Research and Technology, University of Pacific School of Dentistry

26 Orthodontic practice

Volume 4 Number 4


BioDigital Orthodontics: Outcome evaluation with SureSmile technology: part 4 Dr. Rohit C.L. Sachdeva describes some of the tools he uses in evaluating treatment outcomes Introduction The bedrock of BioDigital Orthodontics rests upon a culture of patient safety and continuous improvement. This necessitates commitment by the doctor to evaluate personal performance by evaluating treatment outcomes and gaining insight into how one may improve oneself and apply the learning to better serve his/her patients. In this paper, using the example of patient K.S. presented earlier,1-3 the author describes some of the tools he uses in evaluating treatment outcomes.

Outcome evaluation The initial and final treatment results with the cephalometric reanalysis and clinical activity, and treatment time for patient K.S are shown in (Figures 1A-1D and 2). They certainly demonstrate good control and a satisfactory result achieved in a reasonable time (Figure 2A and Table 1).

Figure 1A-1E: Patient K.S. A. Initial photographs. B. Initial ceph. C. Initial ceph tracing. D. Initial panoramic radiograph. E. Initial Virtual Diagnostic model (VDM) 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.

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Volume 4 Number 4


Final images. Total treatment time 12 months. SureSmile prescription archwires were used for 16 weeks.


Figures 2A-2F. Patient K.S. A. Final photographs; total treatment time 12 months. SureSmile precision archwires were used for 16 weeks. B. Final ceph. C. Final ceph tracing. D. Final panoramic radiograph. E. Virtual Final Model (VFM). F. Final versus initial superimposition; it can be seen that the patient showed a slight vertical growth pattern, and the vertical dimension was maintained with good sagittal control

Volume 4 Number 4

Active Treatment


Bonded upper and lower teeth with miniCLIPPY® brackets (Tomy™ Group, Japan) and .014” NiTi U/L initial archwires for alignment and space closure.


Patient was checked monthly over a period of 3 months


U/ .016” x .016” NiTi ; /L .016” x .016” NiTi and continue with space closure (sliding mechanics)

05/20/11 (7 mos)

Therapeutic scan

06/16/11 (8 mos)

SureSmile precision archwires. U/L .017”x.025” CuNiTi

08/11/11 (8 wks)

Checkup visit

09/08/11 (4 wks)

Checkup visit

10/03/11 (12 mos)

Debond Total Treatment time: 12 months

Table 1: Patient K.S. treatment activity and time audit

Orthodontic practice 29

ORTHODONTIC CONCEPTS However, the practice of BioDigital Orthodontics requires more than just this rudimentary analysis. It requires a personal commitment by the doctor and his team to go beyond the ordinary, driven by a culture of Continuous Quality Improvement (CQI).4,5 In order to sustain a CQI effort within a practice, a Plan, Do, Act, Study6 (Figure 3) operational cycle has to be embedded in all activities involving patient care in the practice. This requires that Key Quality Metrics (KQM)7 are identified and implemented to evaluate performance.8 There are a number of KQMs the author has developed that he uses regularly in conjunction with SureSmile9,10 and ABO measures.11,12 A discussion of some KQMs used to evaluate clinical operations, treatment outcomes, and professional performances for patient K.S follows. The delivery of “timely” care with as few interventions as possible is considered one dimension of quality by the Institute of Medicine.13 Therefore, it is important for an orthodontist to deliver care in the shortest time possible, with the fewest appointments, and least number of interventional episodes, e.g., archwire changes. Furthermore, it is imperative that the clinician measures his clinical performance against a benchmark of similarly treated patients by other doctors. SureSmile has a database of well over 60,000 patients treated conventionally and with SureSmile technology from 400 practices. This data provides information on the treatment attributes discussed above. It is accessible to any doctor in the SureSmile family of practices and can be used to measure one’s performance against peers. Figure 4 clearly demonstrates that for patient K.S., the total treatment time, number of appointments, and number of archwire changes tracked close to the benchmark practice. In further analyzing performance, it may be noticed that the pre-customized phase of treatment was longer by a month while the customized phase was shorter (Figure 5) by the same amount (when compared to the benchmark practice). This is probably because the entire space of the extraction site was closed during Phase I of treatment. This added to treatment time. Treatment time shortened in Phase II, because there was no need to close any space. Thus, Phase I of treatment was extended while Phase II shortened (Figure 5). Other measures that reflect the abilities of the doctor to manage care 30 Orthodontic practice

Figure 3: The Plan, Do, Act study cycle. This drives the continuous quality improvement initiative within any practice that subscribes to the practice of BioDigital Orthodontics

effectively include measures of how close the final outcome, i.e., Virtual Final Model (VFM) [Figure 2E], matched the initial treatment plan, i.e., VDS. In patient K.S, the lower archwidth was slightly expanded, but overall, the treatment outcome was very similar to what was planned, and the anchorage well controlled (Figure 6). Furthermore, comparing the VTS to the final outcome, i.e., VFM, clearly demonstrates that excellent control of orthodontic tooth movement was achieved (Figure 7). Note that the archwidth has been maintained. In summary, in Phase I, some archwidth control was lost but was well controlled during Phase II of the treatment.

Figure 4: A comparative analysis of treatment time, number of visits, and archwire changes for patient K.S. The “benchmark” practice is most efficient. The “average” practice represents the average treatment time. This data is compiled from the SureSmile database from a sample of 500 patients

Figure 5: A comparative analysis of pre-customized (Phase I), customized (Phase II), and the total treatment time for patient K.S. This data is compiled from the SureSmile database from a sample of 500 patients

Figure 6: Patient K.S. Virtual Diagnostic Simulation Model (VDS) superimposed on Virtual Final Model (VFM). Note the slight increase in intermolar width

Volume 4 Number 4


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Figure 7: Patient K.S. Virtual Target Setup (VTS) superimposed on Virtual Final Model (VFM). Note: Intermolar and intercanine width has been maintained

The ABO-OGS system of grading the final outcome is driven to looking at tooth to tooth relationships. SureSmile software automatically measures this score (Figure 8). A substantial reduction in this score was achieved in the Phase II of treatment, and a final score of 15 was achieved. This is well above the standard of 30 set by the American Board of Orthodontics. It should be noted that the lower the ABO-OGS score, the better the result. However, the final score did not meet the Virtual Target Setup (VTS) [Figure 8D]. This could be because of a number of reasons. Earlier removal of the archwire, or more plausible that the in vivo occlusion appeared sufficiently corrected, and there was no reason to proceed with further care. Furthermore, an ABO-OGS score of 10 versus 15 may not be clinically distinguishable. Generally speaking, in the author’s experience, when the final occlusion is evaluated clinically in comparison to the final model, it is more forgiving to scrutiny, and a clinical judgment has to be made in deciding whether the treatment goal has been accomplished. It should always be borne in mind that the VTS is a great navigational system for the clinician to use, but one’s clinical judgment should always prevail. In closely examining the occlusion clinically against the VTS, one can easily see how well the planned occlusal scheme (VTS) matches the final clinical outcome (Figure 9). Although, the torque in the canines resolved substantially, 32 Orthodontic practice

Figures 8A-8D: ABO-OGS grading system. In patient K.S., the buccal lingual inclination of the lower second molar is being evaluated. A. Initial therapeutic (VTM) score. B. Setup (VTS) score. C. Final (VFM) score. D. Summary of ABO-OGS scores

Figures 9A-9G: Patient K.S. A-C. Therapeutic stage. C. Shows the state of straightwire at the end of Phase I. D. Shows the occlusion at the end of Phase II. E. and F. Note how closely the final clinical occlusion matches the VTS. G. Shows the fine bends in the precision archwire that corrected the occlusion in the buccal segments

Volume 4 Number 4

ORTHODONTIC CONCEPTS Figures 10A-10J: A. and B. Therapeutic stage. C. SureSmile precision archwire at 12 weeks. D. Virtual Target Setup. E. and F. Final intraoral and VFM (frontal image). G-I. Shows closeup views of upper left canine through various stages of treatment from therapeutic to debond. J. Cross-sectional view of canine from the VTM. Note: The canine is torqued lingually. K. Superimposition of VFM to the VTS. Note: The upper canine was substantially torqued labially (compare Figure K. to J.). It could have benefitted from some additional labial crown torque

some overcorrection in the archwire would have been better (Figure 10).

Conclusions SureSmile is an all-digital technology that has transformational abilities to enable the doctor to cross the chasm from a reactive to a proactive care model. The choice to embrace this model of care is driven by the values and belief system espoused by the culture of BioDigital Orthodontics, which encompasses the practice of patient-centered care, patient safety, and continuous quality improvement.

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 Volume 4 Number 4

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. BioDigital orthodontics: Diagnopeutics with SureSmile technology: part 3. Orthodontic Practice US. 2013;4(3). In press. 4. Shortell SM, Bennett CL, Byck GR. Assessing the impact of continuous quality improvement on clinical practice: what it will take to accelerate progress. Milbank Q. 1998;76(4):593-624. 5. Heard SR, Schiller G, Aitken M, Fergie C, McCready Hall L. Continuous quality improvement: educating towards a culture of clinical governance. Qual Health Care. 2001;10(suppl 2):ii70-ii78. 6. Berwick DM. A primer on leading the improvement of systems. BMJ. 1996;312(7031):619622.

7. Pipino LL, Lee YW, Wang RY. Data quality assessment. Communications of the ACM. 2002;45(4):211-218. 8. Sheldon T. Promoting health care quality: what role performance indicators? Quality in Health Care. 1998;7:45-50. 9. Scholz RP, Sachdeva R. Interview with an innovator: SureSmile Chief Clinical Officer Rohit CL Sachdeva. Am J Orthod Dentofacial Orthop. 2010;138(2):231-238. 10. Sachdeva RCL. Measuring Outcome in Orthodontics. In preparation. 11. Shaw WC, Richmond S, O’Brien KD, Brook P, Stephens CD. Quality control in orthodontics: indices of treatment need and treatment standards. Br Dent J. 1991;170(3):107-112. 12. Moyers RE. Quality assurance in orthodontics. Am J Orthod Dentofacial Orthop. 1990;97(1):3-9. 13. Institute of Medicine - Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington DC: National Academy Press; 2001.

Orthodontic Care” discussion blog. Please contact improveortho@gmail.com for access information. Orthodontic practice 33


Instrument sterilization: the case for high velocity hot air sterilization in the orthodontic office Dr. Nelson S. Slavik delves into a sterilization method that can effectively sterilize instruments while increasing instrument life span Abstract Traditionally, steam sterilization has been the primary mechanism in which to sterilize orthodontic and dental instruments. However, advances in sterilization technologies have provided another thermal sterilization technology that uses high velocity dry heat to effectively sterilize instruments in significantly shorter time periods without the use of water, thus eliminating instrument drying, dulling, and corrosion. With concurrent advances in heat-resistant materials, most orthodontic instruments are compatible with the temperatures employed in this sterilization process. Shorter sterilization processing cycles result in reducing expensive instrument investment and assuring efficient instrument use. Eliminating instrument corrosion provides a longer useful lifespan of delicate, costly instruments, and lower orthodontic practice operating costs.

Introduction The use of steam sterilization is the predominant method to sterilize medical, dental, and orthodontic instruments having direct patient contact. The effectiveness of steam sterilization is, however, predicated on the adherence to the critical factors that allow steam to have direct contact with the instrument. Inattention to prescribed packing, packaging, or operational conditions can lead to ineffective sterilization, and put patient and practitioner at risk. Other factors such as instrument

Nelson S. Slavik, Ph.D., is senior vice president of Integrated Medical Technologies, Inc. His responsibilities include research and development of infection control, patient safety, and sterilization technologies. Academically, he holds dual degrees from the University of Illinois at Urbana-Champaign, which include a Ph.D. in Microbiology and Master of Science in Biochemistry. He served on the faculty of the Department of Health and Safety Studies at the University of Illinois at Urbana‑Champaign and as the Biological Safety Officer for the campus for over 10 years. He has authored over 80 articles on environmental and occupational safety legislation, regulations, and their application and has participated in over 100 healthcare workshops and seminars.

34 Orthodontic practice

Educational aims and objectives This article aims to define and discuss high velocity hot air sterilization and its effectiveness in the orthodontic office. Expected outcomes Correctly answering the questions on page 38, worth 2 hours of CE, will demonstrate the reader can: • Identify times for effective sterilization in several sterilization methods. • Recognize the compatibility of instruments and materials within the process. • See the differences in sterilization of wrapped and unwrapped instruments. • Realize the attributes of employing a high velocity hot air sterilization system.

turnaround time and instrument corrosion also make steam sterilization nondesirable for the orthodontic office where procedural timing and delicate instrumentation are required for an efficient and successful practice. Of other chemical and thermal alternatives to steam sterilization, only dry heat sterilization has gained any acceptance to the orthodontic practice. Each, including traditional dry heat sterilization, has its limitations to scope of usefulness and logistical ease in the orthodontic setting. For the chemical sterilization alternatives, sterilization time (minimum 10 hours), the toxicity of the chemical, and potential corrosiveness limit, if not exclude, chemical sterilization as a viable alternative. Traditional dry heat methodologies are limited by lengthy sterilization times (1 hour at 340ºF; 1 to 2 hours at 320ºF, dependent on device used), but they do not possess the problems of chemical toxicity or corrosion exhibited by chemical sterilization technologies. However, the lack of uniform sterilizing heat distribution and corresponding uneven temperature pattern in the sterilization chamber has combined to make validation of the sterilization process difficult. To overcome the deficiencies of traditional dry heat sterilization methodologies, a novel sterilization device was developed and patented by Dr. Keith Cox, DDS, for use in the sterilization of dental and orthodontic instruments and implants. Differing from the traditional dry heat sterilizer in which air remains

static (gravity convection) or minimally recirculated (mechanical convection) to enhance uniform heat distribution, this novel approach employed directed, uniform high velocity air across the surface of the instruments. This resulted in a marked reduction in time required for instrument sterilization from hours in a traditional hot air sterilizer to 6 to 12 minutes (unwrapped and wrapped, respectively) at 375ºF in a high velocity hot air sterilizer. The device was granted 510k status from the U.S. Food and Drug Administration (FDA) in 1987 and 1988 as a Class II (Performance Standards) device. High velocity hot air sterilization has since been recognized and validated for use in healthcare applications, including dental and orthodontic practices, medical offices, laboratories, ambulatory care clinics, and hospitals by the Centers for Disease Control and Prevention in their publications “Guidelines for Infection Control in Dental Health-Care Settings – 2003” and “Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008.”1,2 Standards for use and process validation have been issued under the auspices of the American National Standards Institute and the Association for the Advancement of Medical Instrumentation in standards ANSI/AAMI ST40:2004(R)2010 and ANSI/ AAMI ST50:2004(R)2010.3,4 As stipulated by the FDA, high velocity hot air sterilizers operate at 375ºF under varying time exposures, dependent on whether the instrument is unwrapped (6-minute exposure), wrapped (12-minute Volume 4 Number 4

Instrument and materials compatibility As with any thermal sterilization device, temperature compatibility of all intrinsic instrument components is imperative. For a high velocity hot air sterilizer operating at 375ºF, most of today’s orthodontic instruments and their components are constructed of materials that would not be subjected to damage at this elevated temperature. Standard handpieces, pliers, and cutters are typically composed of 440-C stainless steel or other hightemperature metals (including solders). For those instruments that contain plastic or other non-metal components, there may be susceptibility to repeated exposure to 375ºF, although most non-metal components compatible with a steam sterilization process are also compatible with exposure to 375ºF. Changes in color, cracking, or other alteration in physical appearance are visible indicators that the elevated temperature is affecting the material and could affect the instrument’s performance. This would be especially true for fiber optic handpieces or any instrument designed for single use. Before subjecting any instrument to treatment in which there may be doubt regarding thermal resistance, check with the manufacturer. To further ensure longer instrument lifetimes, instruments containing nonmetal components should be removed immediately from the sterilizer after the completion of the sterilization cycle to minimize their exposure to the elevated temperature. Significant with any hot air sterilization method are the hot, dry conditions that minimize or eliminate instrument corrosion. With any chemical or steam sterilization Volume 4 Number 4

method, chemical and/or water (steam) react with metals to corrode. Corrosion impacts on instrument efficacy and limits the effective lifetime of an instrument. To demonstrate any potential corrosive impact on instruments or other deleterious effects, tests involving high velocity hot air sterilization were conducted under prescribed sterilizing conditions. Dental and orthodontic instruments of various types, construction, and materials were subjected to rigorous testing to determine their ability to withstand exposure at 375ºF during repeated sterilization cycles. No visible or other physical alterations were observed as indicated in comparisons between new and sterilized instruments (Cox, MK, personal communication). The results of these tests are summarized in Table I.

Instrument turnaround To minimize expensive instrument inventory and assure efficient instrument use requires

a quick turnaround of instruments from one patient to the next. Often instrument sterilization is the most time-consuming operation in this preparatory process. All thermal sterilization processes are time and temperature dependent, and sterilization times cannot be shortened to expedite the process. Comparison of times required of steam sterilization and high velocity hot air sterilizers must accurately reflect the total time required of the sterilization process: from the time the instrument is placed into the sterilizer until the time it is removed. Complete steam sterilization processing time includes (1) the time necessary to achieve the required temperature and pressure; (2) the sterilization cycle time, and (3) instrument drying cycle time. Two types of steam sterilizers are typically found within an orthodontic practice: traditional vacuum-assist autoclave and cassette autoclave. These types of steam sterilizers both require 3 to 4 minutes to achieve required temperature

TABLE I: Summary of Instrument Condition After Repeated High Velocity Hot Air Sterilization Cycles at 375ºF

Number of Instrument Type

Cycles at 375 F 0

Physical Appearance

Tactile Feel


Dental Explorers





Orthodontic Pliers





Air Rotor Hand Pieces













Metal Impression Trays





Metal Implants













Burs: Stainless Steel and Tungsten-Carbide Endodontic Reamers, Files, Broaches

Stainless Surgical Instruments Glass Dappen Dishes

1. No observable alterations (NOA) 2. No apparent loss observed (NALO) 3. Expected useful life of such burs 4 Electron microscopy observations conducted (Adapted from data courtesy of M. Keith Cox, D.D.S.; 510k submittal to the FDA)

Orthodontic practice 35


exposure), or as unwrapped handpieces and medical drills (8 minutes). Dry heat functions to sterilize by the transfer of heat to the microorganism, causing dehydration and the organism’s inability to reproduce due to enzymatic damage (metabolic and genetic). Time-temperature profiles have been established for wrapped instruments, unwrapped instruments, and handpieces to deliver a Sterility Assurance Level (SAL) representing a microbial inactivation level of 12 logs of Bacillus atrophaeus spores as required by FDA and ANSI/AAMI standards. Attributes of employing a high velocity hot air sterilization system in an orthodontic practice are provided below.

CONTINUING EDUCATION and pressure before the sterilization cycle is initiated. For the vacuum-assist sterilizers programmed for operation at 270ºF, the sterilization times range from 4 to 8 minutes, unwrapped and wrapped instruments, respectively. These sterilization cycle times are roughly equivalent to those of the most commonly used cassette autoclave at 270ºF with unwrapped and wrapped instruments having a 3.5-minute and a 6-minute cycle time, respectively. However for both, the most critical time factor is the time required for instrument drying, 30 minutes for the vacuum-assist autoclave and 60 minutes for the commonlyused cassette unit (as prescribed in the sterilizer’s FDA 510k). Total instrument turnaround time, therefore, is considerable with vacuum-assist units taking from 37 to 42 minutes. For cassette autoclaves, the turnaround time is considerably longer, approximating 70 minutes. High velocity hot air sterilization is a dry heat process, and as such, does not require a drying cycle. Complete processing time includes the time required to attain 375ºF, usually 3 to 4 minutes and the sterilization cycle time of 6 minutes or 12 minutes for unwrapped and wrapped instruments, respectively, giving a total processing time of 10 to 16 minutes.

A comparison of total treatment times between stream sterilization and high velocity hot air sterilizers is shown in Table II.

Operational logistics



High velocity hot air sterilizers were developed for primary use within orthodontic and dental practices and as such, the sterilizers are small, designed for tabletop use, or to be portable by placement on a moveable cart (Figure 1). High velocity hot air sterilizers typically operate on 110120V and/or 220V and are energy efficient (e.g., 1100 watts for warm up stage and 300 watts during the sterilization cycle). High velocity hot air sterilizers require no water or stream for operation, making their placement contingent only on the availability of electricity. Standard controls minimize error and make the operation of the unit easy for orthodontic staff. Controls are limited to an on/off switch and for preprogrammed cycle time designations (e.g., wrapped, unwrapped, or handpieces). Operationally, the sterilizer is turned on at the beginning of the day and turned off at the completion of the day’s practice. Once the high velocity hot air sterilizer has been pre-heated for the

day, the sterilizer requires approximately 3-4 minutes to heat to operational temperature for each sterilization cycle. Once the unit is at temperature, it will automatically maintain that temperature throughout the day. As such, when instruments are ready to be sterilized, only 3 to 4 minutes are required to heat the chamber and the instrument load to temperature. Once the chamber is at operational temperature, the sterilization cycle is automatically initiated. The operator is notified at the completion of the cycle, and the instruments are removed from the unit and allowed to cool before use.

Wrapped versus instruments


Dental and orthodontic instruments can be processed either as wrapped or unwrapped, with sterilization cycle times increased for wrapped instruments. Standards for instrument placement and wrapping are contained within ANSI/ AAMI ST40:2004(R)2010 (Section 5.6 and 5.7).5 The decision to wrap or unwrap instruments is one that is dependent on requirements via state regulation (e.g., California, Nevada, Massachusetts) and clinical procedures requiring absolute instrument sterility.

TABLE II: Comparison of total treatment times between steam sterilization and high velocity hot air sterilizers

Sterlizing Cycle Time (Min)

Pre-Cycle Sterilizer Type




Time (Min)

Time (Min)

Total Elapsed Treatment Time (Min)


















Vacuum-Assist Autoclave @ 2700F Cassette-Type Autoclave @ 270 F 0

High Velocity Dry Heat Sterilizer @ 375 F 0

1. Unwrapped instruments 2. Wrapped instruments

36 Orthodontic practice

Figure 1: Example of a countertop high velocity hot air sterilizer (Courtesy CPAC Equipment, Inc., Leicester, NY)

Volume 4 Number 4

Evaluation of high velocity hot air sterilizers Although price does play a role in the selection of a sterilizer, the cost of sterilization equipment used in the orthodontic practice is relatively consistent between a steam sterilization alternative and high velocity dry heat sterilizers. This is demonstrated in Table III in a cost comparison analysis between sterilizers, both steam and high velocity dry heat, that are typically found in an orthodontic office. Selection of the sterilizer best suited for the practice, therefore, will be primarily made from an evaluation of the features that provide the most efficient, effective, and safe mode of operation. Presently, two manufacturers of high velocity hot air sterilizers supply the U.S. orthodontic and dental markets. Although both employ essentially the same sterilization technology, it is important that the prospective orthodontic practice evaluate both devices to ensure the unit’s performance, to meet the practice’s logistical needs, and to provide the features necessary to assure full user compliance. In this regard, questions that should be addressed would include: • Does the sterilizer provide for the collection of continuous time and temperature data for each sterilization Volume 4 Number 4

TABLE III: Cost comparison of typical orthodontic sterilizers

Sterilizer Type

Approximate Cost $US1

Tabletop Vacuum-Assist Autoclave @ 2700F


Tabletop Cassette-Type Autoclave @ 2700F


High Velocity Dry Heat Sterilizer A @ 3750F


High Velocity Dry Heat Sterilizer B @ 3750F


1. Manufacturer literature list price (as of 7-9-2013)

cycle, maintaining that data within internal storage for continuous or intermittent downloading for recording and recordkeeping purposes? • Does the sterilizer provide for multiple, pre-established sterilization cycles to accommodate wrapped instruments, unwrapped instruments, and handpieces? • Does the sterilizer provide a door interrupt mechanism that prevents the user from prematurely interrupting the sterilization process? • Does the sterilizer provide uniform chamber airflow and heat distribution to ensure reliable instrument sterilization? Documented answers to these questions will assure reliable sterilizer performance and provide the orthodontic practitioner with a sterilizer that meets the need for efficiency and efficacy. OP

References 1. Kohn WG, Collins AS, Cleveland JL, Harte, Eklund KJ, and Malvitz DM, Centers for Disease Control and Prevention. Guidelines for infection control in dental health-care settings – 2003. MMWR Recomm Rep. 2003;19(52)(RR-17):1-61. 2. Centers for Disease Control and Prevention. Guideline for Disinfection and Sterilization in Healthcare Facilities. Atlanta, GA: Healthcare Infection Control Practices Advisory Committee, Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2008. HYPERLINK “http://www.cdc.gov/hicpac/ Disinfection_Sterilization/toc.html” http://www. cdc.gov/hicpac/Disinfection_Sterilization/toc. html. Accessed June 6, 2013. 3. American National Standards Institute and the Association for the Advancement of Medical Instrumentation. Table-Top Dry Heat (Heated Air) Sterilization and Sterility Assurance In Health Care Facilities. Arlington, VA: ANSI/AAMI ST40:2004(R)2010. 4. American National Standards Institute and the Association for the Advancement of Medical Instrumentation. Dry Heat (Heated Air) Sterilizers. Arlington, VA: ANSI/AAMI ST50:2004(R)2010. 5. American National Standards Institute and the Association for the Advancement of Medical Instrumentation. Table-Top Dry Heat (Heated Air) Sterilization and Sterility Assurance In Health Care Facilities. Arlington, VA: ANSI/AAMI ST40:2004(R)2010. Sections 5.6, 5.7.1, 5.7.2, pages 17-18.

Orthodontic practice 37


Several states (via their state department of health) have made it a requirement that all instruments sterilized by hot air sterilizers be wrapped to avoid instrument exposure from microbial contaminants having environmental origin. All orthodontic and dental practices require instrument sterilization to eliminate exposure from microbial contaminants originating from the previous patient. Environmental contaminants play little or no role in disease transmission from instruments used in topical orthodontic or dental work in which the mouth is not sterile. For oral surgical procedures (endodontic), greater stringency in sterility practices may be required, and as such, wrapping instruments would be a requirement to avoid patient infection. A wrapped instrument typically implies that an instrument is placed in a heatresistant pouch, but sterile wrap may be also used to package the instrument. However in both instances, the material must be heat compatible with the elevated temperature used in high velocity hot air sterilization.


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



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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.





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.



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Instrument sterilization: the case for high velocity hot air sterilization in the orthodontic office 1. Advances in sterilization technologies have provided another thermal sterilization technology that uses high velocity dry heat to effectively sterilize instruments in significantly shorter time periods without the use of water, thus eliminating instrument ___________. a. drying b. dulling c. corrosion d. all of the above 2. The use of ______ sterilization is the predominant method to sterilize medical, dental, and orthodontic instruments having direct patient contact. a. steam b. dry heat c. bleach d. alcohol 3. Differing from the traditional dry heat sterilizer in which air remains static (gravity convection) or minimally recirculated (mechanical convection) to enhance uniform heat distribution, this novel approach employed ________air across the surface of the instruments. a. directed b. uniform c. high velocity d. all of the above 4. As stipulated by FDA, high velocity hot

38 Orthodontic practice

air sterilizers operate at ______ under varying time exposures, dependent on whether the instrument is unwrapped (6-minute exposure), wrapped (12-minute exposure), or as unwrapped handpieces and medical drills (8 minutes). a. 125ยบF b. 255ยบF c. 375ยบF d. 460ยบF 5. Significant with any hot air sterilization method are the hot, dry conditions that ______instrument corrosion. a. minimize b. eliminate c. encourage d. a and b 6. These types of steam sterilizers (traditional vacuum-assist autoclave and cassette autoclave) both require ________to achieve required temperature and pressure before the sterilization cycle is initiated. a. 1 to 2 minutes b. 3 to 4 minutes c. 10 minutes d. 30 minutes 7. High velocity hot air sterilization is a dry heat process, and as such, does not require ______. a. a drying cycle b. 375ยบF

c. any processing time d. none of the above 8. Once the high velocity hot air sterilizer has been pre-heated for the day, the sterilizer requires approximately ________ to heat to operational temperature for each sterilization cycle. a. 1-2 minutes b. 3-4 minutes c. 30 minutes d. 1 hour 9. Dental and orthodontic instruments can be processed either as wrapped or unwrapped, with sterilization cycle times ____for wrapped instruments. a. decreased b. increased c. the same d. unnecessary 10. Several states (via their state department of health) have made it a requirement that all instruments sterilized by hot air sterilizers be _____ to avoid instrument exposure from microbial contaminants having environmental origin. a. soaked in bleach b. unwrapped c. wrapped d. rinsed with alcohol

Volume 4 Number 4

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Impacted premolar — conservative management Dr. Runa Mowla-Copley details a case study requiring conservative management of an unerupted premolar during orthodontic treatment


n impacted tooth is one that is prevented from erupting in its normal functional position by bone, tooth, or fibrous tissue.1 Tooth impaction is a frequently observed anomaly of eruption in clinical practice. Mandibular second premolars rank third in frequency after third molars and canines in impacted or unerupted teeth. Ectopic maxillary second premolars are far less common. Thilander and Myrberg (1973) reported the prevalence of maxillary premolar impaction to be 0.1% to 0.3%.2 An impacted premolar may lead to esthetic concerns, masticatory inefficiency, and oral hygiene difficulties, as well as pathological developments such as cyst formation and destruction of adjacent structures, including neighboring teeth.3 The treatment of impacted premolars can be challenging and may even involve surgical exposure or removal. This paper describes a conservative approach to one such case.

Educational aims and objectives This article aims to show a conservative approach to a challenging condition. Expected outcomes • Correctly answering the questions on page 43, worth 2 hours of CE, will demonstrate the reader can: • Identify possible consequences of an impacted molar. • Determine possible conservative treatment options. • Recognize reasons for conservative treatment.

Figure 1: Initial presentation, centric

Case study A 14-year-old girl was referred by her general dental practitioner. Her presenting complaint was that her “front teeth stuck out.” She was medically fit and healthy. On examination, she presented in the permanent dentition with a Class II Division 1 incisor relationship on a Skeletal Class I base (Figures 1-5). Her Frankfortmandibular plane angle was average, and her lips were competent. She had an increased overjet of 5 mm and an increased and complete overbite. The molar relationship on both right and left sides was Class I. The canine relationship

Runa Mowla-Copley, BDS, DipOrth, graduated from Sheffield University in 1995 and currently works at Metamorphosis Orthodontics, London. She has also worked at a number of prestigious practices in London, including the award-winning Elleven Orthodontics in Devonshire Place. Dr. Mowla-Copley is a member of the British Orthodontic Society and the Faculty of General Dental Practitioners (UK). She has recently completed an MSc in orthodontics at Warwick. Her particular area of expertise is interceptive treatment in young children. www.metamorphosisorthodontics.com

40 Orthodontic practice

Figure 2: Initial presentation, right buccal

was a quarter unit Class II on the right and half a unit Class II on the left. Both upper and lower centerlines were centric and coincident. There was moderate crowding in the upper arch and mild crowding in the lower arch. The ULE was retained. UL5 was unerupted. A dental panoramic radiograph confirmed the presence of all secondary teeth including all 8s. UL5 was impacted with more than two-thirds root formation complete. The cementoenamel junction of UL5 was above the level of the apices of UL4 and UL6 (Figure 6).

Treatment options • Extract ULE followed by upper and lower fixed appliances

Figure 3: Initial presentation, left buccal

Figure 4: Initial presentation, upper occlusal

• Extract ULE and both upper first premolars followed by upper and lower fixed appliances. In view of the increased overjet and Volume 4 Number 4


Figure 7: Upper appliance

Figure 6: Initial presentation, OPG

Figure 5: Initial presentation, lower occlusal

Figure 8: Upper appliance, before extraction of ULE

Figure 9: Light spring coil maintaining space for eruption of UL5

Figure 10: OPG 6 months into treatment, showing position of UL5

Figure 12: Final result, centric

Figure 13: Final result, right buccal

upper fixed appliance only (Figures 7 and 8) and advised to have her ULE extracted by her dentist as soon as possible. A few months into treatment, the lower fixed Damon appliance was fitted. The reason for upper single arch treatment initially was to avoid longer than necessary time in the lower fixed appliance; a single upper arch appliance was not only easier for the patient to maintain but took into account the uncertain time frame for spontaneous eruption (if at all) of UL5. During sequential archwire changes (Figures 9-11), light spring coil in the UL5 space was activated to create and then maintain space for eruption of UL5. Six months into treatment, an orthopantomogram (Figure 12) was taken to confirm the position of UL5 this revealed UL5 was in a very favorable position for eruption. Nine months postbond up, UL5 erupted, and a bracket was bonded to it (Figure 13) soon after.

Further repositioning of UL5 bracket more gingivally as it erupted ensured good posterior interdigitation. A very pleasing result was obtained for this patient (Figures 14-18). A Class I molar and canine occlusion and good interdigitation will potentially enhance long-term stability. There was a 95% reduction in her PAR score, indicating a greatly improved outcome. Pre-treatment PAR was 20; post-treatment was 1. Total treatment time was 19 months. Retention was with a lower bonded retainer and upper and lower vacuumformed removable retainers.

Figure 11: UL5 erupted and bonded

upper arch crowding, the alternative treatment option of extraction of both upper first premolars would not only have been detrimental to the patient’s facial profile, there was a risk of failure of eruption of UL5, and the consequence would have been the loss of two units on the upper left.

Treatment A decision was made to extract ULE and fit the patient with upper and lower passive self-ligation Damon appliances to level and align the arches, relieve the crowding, create space for the spontaneous eruption of UL5, reduce the overjet and overbite, and coordinate the buccal segments. The patient was warned that should the UL5 fail to erupt 9-12 months after space had been created for its eruption, referral to an oral surgeon for exposure and bonding would be a possibility. The patient was fitted initially with the Volume 4 Number 4

Discussion The etiology of the impacted UL5 may be explained by the late development of the tooth germ itself4 together with overretention of the ULE. The ULE was in place beyond its normal shedding time, despite Orthodontic practice 41


Figure 14: Final result, left buccal

Figure 15: Final result, upper occlusal

Figure 16: Final result, lower occlusal

Figure 18

the presence of UL5 with more than threequarters root development. After extraction of ULE, had the UL5 failed to erupt, surgical exposure with or without orthodontic traction may have been necessary. Burch, et al., (1994), describe a very similar case in a 12-year-old girl with a Class II Division 1 malocclusion with crowding, where 4-1/2 months after extraction of the retained upper primary molar and space creation using fixed appliances, the upper second premolar erupted unassisted.5 Follow-up radiography was important in determining the position of UL5 and was 42 Orthodontic practice

Figure 17

justified, not only in reassuring the patient, but also in reconfirming the treatment plan being carried out. CT scanning would have been useful, and indeed, in any case with an ectopic tooth, CT scanning substantially increases detection of root resorption. This case highlights the importance of age-appropriate orthodontic screening radiographs. Contralateral teeth usually erupt within 6 months of each other; if this fails to occur, further investigation should be undertaken. In this case, earlier interceptive extraction of ULE may have prevented future impaction of UL5 and would certainly have shortened the patient’s time in fixed appliances. In practice, parents frequently question the need for taking radiographs for orthodontic purposes; they are often worried about any exposure of their child to dental radiation. And of course, as a profession, we are bound by regulation only to expose patients for dental radiography if it is absolutely necessary. However, when any permanent tooth is clinically missing,

a panoramic radiographic examination is essential. In cases of impacted premolars, good treatment planning, together with an understanding by all parties concerned of the procedures that are involved should the tooth not erupt into the arch spontaneously, can lead to a very successful outcome. OP

References 1. Andreasen JO. The impacted premolar. In: Andreasen JO, Peterson JK, Laskin DM. Textbook and Color Atlas of Tooth Impactions; Diagnosis, Treatment and Prevention. Denmark: Munksgaard; 1997:177-195. 2. Thilander B, Myrberg N. The prevalence of malocclusion in Swedish school children. Scand J Dent Res. 1973;81:12-21. 3. Lee PP. Impacted Premolars. Dental Update. 2005;32(3):152-157. 4. Leonardi R, Lombardo C, Barbato E. Delayed eruption of a maxillary second premolar due to a late bud. J Clin Orthod. 2007;41(10):597-600. 5. Burch J, Ngan P, Hackman A. Diagnosis and treatment planning for unerupted premolars. Pediatr Dent. 1994;16(2):89-95.

Volume 4 Number 4

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



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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.





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.



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

Impacted premolar — conservative management 1. An impacted tooth is one that is prevented from erupting in its normal functional position by _______. a. bone b. tooth c. fibrous tissue d. all of the above 2. Mandibular second premolars rank ______in frequency after third molars and canines in impacted or unerupted teeth. a. second b. third c. fourth d. fifth 3. An impacted premolar may lead to _______, as well as pathological developments such as cyst formation and destruction of adjacent structures, including neighboring teeth. a. esthetic concerns b. masticatory inefficiency c. oral hygiene difficulties d. all of the above 4. (In this case) The patient was warned that should the UL5 fail to erupt ______ after space had been created for its eruption, referral to an oral surgeon for exposure and bonding would

Volume 4 Number 4

be a possibility. a. 6 weeks b. 6 months c. 9-12 months d. 24 months 5. The reason for upper single arch treatment initially was to ______; a single upper arch appliance was not only easier for the patient to maintain but took into account the uncertain time frame for spontaneous eruption (if at all) of UL5. a. avoid longer than necessary time in the lower fixed appliance b. avoid the cementoenamel junction c. adjust the Frankfort-mandibular plane angle d. follow instructions of the oral surgeon 6. There was a 95% reduction in her PAR score, indicating a _______ outcome. a. disappointing b. fair c. greatly improved d. non-esthetic 7. (In this case) The etiology of the impacted UL5 may be explained by _______. a. the late development of the tooth germ itself b. over-retention of the ULE

c. both a and b d. none of the above 8. After extraction of ULE, had the UL5 failed to erupt, ______with or without orthodontic traction may have been necessary. a. root resection b. surgical exposure c. root canal d. removal of fibrous tissue 9. ______would have been useful, and indeed, in any case with an ectopic tooth ______substantially increases detection of root resorption. (For this question, the same answer is the correct answer for both blank spaces.) a. CT scanning b. Pulp testing c. Plaster study models d. Intraoral photographs 10. Contralateral teeth usually erupt within ______of each other; if this fails to occur, further investigation should be undertaken. a. 3 months b. 6 months c. 1 year d. 18 months

Orthodontic practice 43




Efficacy of a fluoride sealant and a fluoride varnish on demineralization around orthodontic brackets: in vitro study Drs. Cintia Santana Dias, Thais Aglaet Miranda, André Gasparetto, Adilson Luiz Ramos, and S. Jay Bowman explore the effects of a fluoride sealant and fluoride varnish Abstract Introduction: Enamel demineralization resulting from orthodontic treatment is a persistent problem in routine clinical practice. The use of fluoride-releasing sealants has been gaining popularity and is seen as a viable way to prevent this adverse effect. Objective: The aim of this study was to evaluate the efficacy of the sealant Opal® Seal to prevent demineralization around orthodontic brackets and to compare its effectiveness with a fluoride varnish. Methods: The sample consisted of 60 extracted bovine incisors with bonded metal brackets, randomly divided into three groups (Gos (Opal Seal): N = 20, Gct (control): N = 20, control, Gvz (fluoride varnish): N = 20). All teeth were subjected to alternating cycles of an artificial saliva and cariogenic solution for a trial period of 40 days. Sections of the dental specimens were prepared and analyzed under polarized light microscopy with 20x magnification. Results: ANOVA and post hoc Tukey tests showed statistically significant reduction in the mean depth of white spot lesions for both experimental groups: Gos (121.81 ± 48.69 µm) and Gvz (122.51 ± 67.27 µm), compared to the control Gct (178.79 ±

Cintia Santana Dias, DDS, is general dentist in private practice in Maringá, Brazil. Thais Aglaet Miranda, DDS, MScD, is an orthodontist in private practice in Maringá, Brazil. André Gasparetto, DDS, MScD, PhD, in an Adjunct Professor at State University of Maringá, Brazil. Adilson Luiz Ramos, DDS, MScD, PhD, is an Associate Professor at State University of Maringá, and is in private practice in orthodontics in Maringá, Brazil. S. Jay Bowman, DMD, MSD, is an Adjunct Associate Professor, Saint Louis University; an Instructor at The University of Michigan; an Assistant Clinical Professor at Case Western Reserve University; and in private practice in orthodontics in Portage, Michigan.

44 Orthodontic practice

Figure 1A: Exposition limits around bonded brackets. A rectangle was drawn 2 mm from the bracket base using a pencil to define the area of experimental focus

Figure 1B: Examples of teeth tested for each of the samples

46.53 µm; p<0.001). Opal Seal and varnish groups did not show statistically significant difference (p = 0.999). Conclusions: Opal Seal sealant has a similar effectiveness to fluoride varnish in reduction of in vitro demineralization around orthodontic brackets.

of light-cured materials seemed to solve this issue; however, some authors demonstrated no significant enamel protection when light-cured sealants were used.20,21 In contrast, several studies have demonstrated significant benefits in reducing decalcification with sealants.22-25 Recently, Ultradent introduced a specific orthodontic sealant, Opal Seal; a fluoride, light-cured material composed of 38% glass ionomer reinforced by nanoparticles. The intent was to produce an esthetic fluoride sealant to be used in conjunction with typical orthodontic adhesives that would be resistant to brushing and the oral environment. In addition, Opal Seal can be visualized on the tooth with UV light fluorescence to determine if reapplication is required. This fluorescence also facilitates the complete removal of any remaining sealant when the orthodontic adhesive is removed at the end of treatment. The present in vitro study was designed to compare the effectiveness of Opal Seal in reducing WSLs around orthodontic brackets compared to not only a control sample but also to 5% fluoride varnish.

Introduction Many materials with different fluoride release systems have been used in orthodontics to reduce the incidence of enamel demineralization (WSLs) during fixed appliance therapy.1-10 Since patient compliance with home care is unpredictable, the use of materials that do not require patient adherence (e.g., fluoride varnishes, adhesives, sealants) have become more prevalent.1-3,9-14 Fluoride varnishes applied in the orthodontic practice have gained popularity as adjuncts to home fluoride rinses. Varnishes require periodic reapplication during treatment, but they have demonstrated modest efficacy in reducing WSLs for orthodontics.1-3,11-16 Fluoride primers were introduced to bracket bonding to not only provide protection of etched enamel but also to resist abrasion. Composite sealants were shown to lack a perfect seal on the enamel surface, probably due to an oxygen layer within the material17,18,19. The introduction

Material and methods Enamel surfaces from 60 sound bovine incisors were selected for evaluation. The Volume 4 Number 4


Figure 2: Regions evaluated. a = gingival; b = incisal; Mb = demineralized area; Rb = remaining composite under bracket

teeth were stored in 0.1% Timol solution after extraction, disinfected with 0.12% chlorhexidine solution, and any remaining bone and tissue removed with a scalpel. The facial enamel surfaces were polished with rotary brush and pumice in distilled water. Specimens were randomly divided into three groups: Grt (control group; N = 20); Gvz (varnish group; N = 20); and Gos (Opal Seal group; N = 20). Small windows of exposed enamel were created by covering the rest of the facial surfaces of each tooth with adhesive tape (3M, Brazil) to limit the area that would be acid-etched to the size of the orthodontic bracket base. The enamel exposed by this window was then etched with 35% phosphoric acid for 30 seconds and then rinsed with distilled water for 30 seconds before drying. Standard metal, upper incisor orthodontic brackets (Morelli®, São Paulo, Brazil) were bonded using a light-cured adhesive (Ortholink® vlc), following manufacturer’s instructions. Any flash around the bracket base was removed with a dental explorer before the adhesive was light cured. Twenty minutes later, the tape around brackets was removed, and the teeth were cleaned with cotton imbibed in methanol. Then a rectangle was drawn on the enamel with a 0.5 mm HB graphite pencil, 2 mm from the bracket edges (Figure 1); thereby, defining the area of experimental focus. After bonding brackets in all groups, each specimen received an acid-resistant nail polish (Risquè®, Niasi, Taboão da Serra, São Paulo, Brazil) to protect the rest of the enamel surface, except the area of experimental focus. In the Gos group, Opal Seal sealant was applied within the 2 mm rectangular area following manufacturer directions. Fluoride varnish (50 mg NaF/1mL; Duraflur®, Dentsply, Petrópolis, Rio de Janeiro, Brasil) was applied to the enamel Volume 4 Number 4

Figure 3: Area of experimental focus. L2: maximum lesion depth; L1 and L3 correspond to measurement of depths taken 250µm away from the location of maximum lesion depth

within the defined “window” in the Gvz group, and the Gct control group did not receive either varnish or sealant to protect the experimental focus enamel within the rectangle. Later, teeth within each group were placed in a Becker’s glass containing 200 mL of artificial salivary solution (20 mmol/L NaHCO3; 3 mmol/L NaH2PO4 e 1 mmol/L CaCl2; balanced pH), one container for each group. After 12 hours, cycling of the teeth into an acidic environment was initiated. Twice a day (in 6-hour intervals), teeth were immersed in a 200 mL decay challenger solution (2.2 mmol/L Ca+2; 2.2 mmol/L PO-4; 50 mmol/L acetic acid; pH 4.4) for 1 hour. All teeth were stored at controlled temperature (37°C) with the storage solutions changed every 3 days during experimental period.16 After the 1-hour decay solution exposition, all teeth were washed in distilled water and brushed for 20 seconds (5 seconds each surface: mesial, distal, gingival, and incisal), using a soft brush Colgate® Professional Extra Clean (Colgate, Sanxiao, Yangzhou, Jiangsu, China) without paste. As they were immersed in

decay solution twice a day, they also were brushed twice a day. This cycle protocol was maintained for a 40-day experimental period. The Gos control group was checked every week using UV light to evaluate Opal Seal to determine if reapplication of sealant would be required. The Gvz group automatically received reapplication of fluoride varnish (Duraflur) on the 14th and 28th days. After 40 days, all the teeth were removed from the artificial saliva solution, dried, and brackets were removed using pliers (Schobell®, Rio Claro, São Paulo, Brazil). The teeth were then sectioned with diamond discs (Extec Corp.) mounted in an Isomet® 1000 (Buehler). The enamel of each specimen was then cut from incisal to gingival edge, resulting in a 450µm enamel slice, including: base bracket area, 2 mm cervical, 2 mm incisal, and at least 1.5 mm of sound enamel that was protected by acid-resistant nail polish. Sections were manually reduced to 150-200µm with sandpapers (wet-or-dry 400 3M, Sumaré, SP, Brazil). All specimens were then stored in deionized water. Orthodontic practice 45


















Control (µm)

141.6 (±68.00) 150.24 (±56.50) 0.333

Varnish (µm)

98.35 (±69.73) 109.05 (±62.54) 0.306







110.1 (±52.63)







Opal Seal (µm)

94.55 (±60.56)


Table 1: Paired t-test comparison between means and standard deviations of gingival and incisal region in all groups

Table 2: Data from mean demineralization depth of the experimental groups

Chart 1: Mean and standard deviations for the experimental groups

Microscopic evaluation was done under polarized light (Olympus BX 50), and images were digitized using an auxiliary camera (Pro Series 3CC). Two image captures were made from each specimen at 20x magnification with maximum brightness. The delineated experimental area of focus included 1000µm extensions near to the incisal and gingival bracket edges (Figure 2). All images were measured with Image Pro® Plus 1 (Media Cybernetics). Maximum depth of demineralized area was recorded for each teeth both at gingival and incisal areas. To assist, a line was traced from sound enamel and two more measurements were made 250µm from 46 Orthodontic practice

the location where the maximum depth of demineralization was noted (Figure 3). As a result, three measurements in each region were obtained in order to calculate the mean depth for each tooth.16,26 All records were repeated 1 week after first evaluation by the same examiner to check reproducibility.

Results Kolgomorov-Smirnov evaluation demonstrated data normal distribution. Recorded means, obtained at two different times (a 1-week interval), were not different as determined by a paired t-test. Mean depths obtained from gingival and incisal regions were compared using paired

t-test and demonstrated no differences (Table 1). Consequently, comparisons among groups were made using the highest mean reading obtained from each specimen (i.e., it could have been from either from the incisal or gingival area). Table 2 presents data from mean depth demineralization for all groups. Data was analyzed using one-way factor ANOVA and a Tukey post-hoc test. There were statistically significant differences among the groups (p = 0.0022; Chart 1). The mean demineralization depth of the control group (178.79±46.53 µm) was statistically larger than both the Opal Seal group (121.81±48.69 µm) and the varnish Volume 4 Number 4


group (122.51Âą67.27 Âľm); however, the Opal Seal and varnish groups did not differ from each other.


Discussion The present in vitro study evaluated the efficacy of a fluoride sealant (Opal Seal) in comparison to fluoride varnish in preventing demineralization around orthodontic brackets. Both sealant and varnish exhibited similar efficacy in reducing the mean depth of demineralization (Table 2, Chart 1) when compared to unprotected enamel surfaces in the control group. In the present study protocol, both the gingival and incisal enamel surfaces adjacent to the brackets were evaluated. Despite differences in directions of the enamel hydroxyapatite in those areas, there were no differences in mean depth between the gingival and incisal regions (Table 1). More caution is necessary for in vivo evaluations as the gingival region is the most affected by white spots.11,12,19 The present findings differ from other research22,24,25 that has reported better results from sealants compared with fluoride varnish. This includes Buren, et al.,22 who found 97% less decalcification when using Pro Seal sealant (Reliance Orthodontic Products). Pro Seal is said to have a modified catalyst system that provides for a more complete cure when set. Therefore, there may potential concerns in sealant investigations; namely, the lack of a homogeneous cure could lead to failure and/or microscopic cracks in the sealant layer. Interestingly enough, the percentage of filler content of the sealant does not appear to be a significant factor.26,27 Macroscopically, all Opal Seal specimens in this study appeared to exhibit a sound sealant layer. During the 40-day experimental period, no reapplication of the sealant was required as the material was examined for cracks using fluorescence (as recommended by the manufacturer) and none were noted; however, demineralization was found microscopically. Perhaps, microscopic fractures, not visible with simple clinical observation, resulted in any demineralization noted under the sealant. Preventive effectiveness of fluoride that is included in dental materials depends on its liberation in the oral environment; specifically into the enamel surface. In addition, the maintenance of a level of fluoride also assists enamel remineralization.6,8 It appears that if the Volume 4 Number 4

Figure 4A

Figure 4B


Figure 4C

Figure 4D


Figure 4E

Figure 4F

Figures 4A-4F: Polarized light microscopy photographs of some specimens. 4A and 4B. Opal Seal group (Gos). Note: the enamel surface is preserved in B, but exhibited some decalcification in A. 4C and 4D. Fluoride varnish group (Gvz). Enamel surface is preserved in D, but in C demineralization is present under the varnish layer. 4E and 4F. Control group (Gct). Noticeable enamel demineralization in both exposed areas

concentration of fluoride is less than 0.02 ppm that demineralization prevention is ineffective.28 Therefore, it is not clear that the fluoride concentration of a sealant, as well as its liberation capacity, is ideal. Perhaps, the mechanical barrier of the sealant is the most important factor and fluoride release is secondary. Further investigation is certainly warranted. Upon clinical examination of the fluoride varnish group, there was no noticeable remaining varnish on enamel

surface 7 days after application. In contrast, some specimens still had varnish on the enamel when evaluated microscopically (Figure 4C). In this Gvz group, two fluoride applications during the experimental period recharged fluoride levels and helped to reduce demineralization (Figure 4D). The exposure to the acid solution caused evident damage to the untreated enamel surfaces of the control group (Figures 4E and 4F) validating the demineralization model.16,29 Orthodontic practice 47

RESEARCH There are certainly risk factors for demineralization during orthodontic treatment, including white spots present before treatment, poor oral hygiene, and periodontal conditions.1-8 Despite the apparent lack of pre-treatment “risks,” some patients still develop WSLs. Certainly, the application of bonding adhesives that plaque have an inherent affinity for, etching the enamel surface, and adding braces that require more oral hygiene attention increase the patient’s risk.26 Consequently, the potential for developing enamel scars should be considered for all patients entering orthodontic treatment. Both fluoride varnish and Opal Seal may be applied at the outset or even some months later. Although both fluoride varnish and sealant presented similar effectiveness in reducing demineralization around brackets,

References 1. Sudjalim TR, Woods MG, Manton DJ. Prevention of white spot lesions in orthodontic practice: a contemporary review. Aust Dent J. 2006;51(4):284-289, 347. 2. Behnan SM, Arruda AO, González-Cabezas C, Sohn W, Peters MC. In-vitro evaluation of various treatments to prevent demineralization next to orthodontic brackets. Am J Orthod Dentofacial Orthop. 2010;138(6):712.e1–712.e7, 712-713. 3. Bergstrand F, Twetman S. A review on prevention and treatment of post-orthodontic white spot lesions – evidence-based methods and emerging technologies. Open Dent J. 2011;5:158-162. 4. O’Reilly MM, Featherstone JD. Demineralization and remineralization around orthodontic appliances: an in vivo study. Am J Orthod Dentofacial Orthop. 1987;92(1):33-40.

it is important to note that differences in the oral environment may reduce their effectiveness. For example, dietary, oral pH, mechanical, and chemical factors will differ for each patient, resulting in different balance between demineralization/ remineralization of the enamel. The present study did not evaluate the adhesive properties of Opal Seal as a “primer” when bonding brackets with lightcured adhesives, but previous evaluations of similar sealants did demonstrate favorable bond strength.29-31 In terms of cost-effectiveness, the initial application of a fluoride varnish is less costly than the sealant; however, varnish may need to be reapplied periodically. In contrast, Opal Seal can be considered part of a typical bonding procedure as it serves as a substitute for the adhesive primer, but it may need to be reapplied in some instances of significant

Ramos AL. The effectiveness of a fluoride varnish in preventing the development of white spot lesions. World J Orthod. 2006;7(2):138-144. 12. Demito CF, Rodrigues GV, Ramos AL, Bowman SJ. Efficacy of a fluoride varnish in preventing white-spot lesions as measured with laser fluorescence. J Clin Orthod. 2011;45(1):25-29, 40. 13. Bowman SJ. Use of a fluoride varnish to reduce decalcification. J Clin Orthod. 2000;34:377-379. 14. Derks A, Kuijpers-Jagtman AM, Frencken JE, Van’t Hof MA, Katsaros C. Caries preventive measures used in orthodontic practices: an evidence-based decision? Am J Orthod Dentofacial Orthop. 2007;132(2):165-70. 15. Todd MA, Staley RN, Kanellis MJ, Donly KJ, Wefel JS. Effect of a fluoride varnish on demineralization adjacent to orthodontic brackets. Am J Orthod Dentofacial Orthop. 1999;116(2):159-167.

brushing abrasion. Consequently, a combination method of initiating treatment with an application of Opal Seal when orthodontic brackets are bonded may be followed with regular, periodic treatments with a fluoride varnish may need to be reapplied every 3-6 months to “recharge” the sealant. This tandem approach may provide sufficient enamel protection for most demineralization; however, further investigation of the effectiveness of this combined approach is needed.

Conclusion In vitro evaluation demonstrated that Opal Seal sealant exhibits similar effectiveness in reducing enamel demineralization around orthodontic brackets as fluoride varnish (34% reduction in lesion depth) when compared to untreated controls. OP

Seal: an in-vitro study. Am J Orthod Dentofacial Orthop. 2008;133(4 suppl):S88-94. 23. Benham AW, Campbell PM, Buschang PH. Effectiveness of pit and fissure sealants in reducing white spot lesions during orthodontic treatment. A pilot study. Angle Orthod. 2009;79(2):338-345. 24. Hu W, Featherstone JD. Prevention of enamel demineralization: an in-vitro study using light-cured filled sealant. Am J Orthod Dentofacial Orthop. 2005;128(5):592-600, 670. 25. Shinaishin SF, Ghobashy SA, El-Bialy TH. Efficacy of light-activated sealant on enamel demineralization in orthodontic patients: an atomic force microscope evaluation. Open Dent J. 2011;5:179-186. 26. Hess E, Campbell PM, Honeyman AL, Buschang PH. Determinants of enamel decalcification during simulated orthodontic treatment. Angle Orthod. 2011;81(5):836-842.

5. Ogaard B, Rølla G, Arends J. Orthodontic appliances and enamel demineralization. Part 1. Lesion development. Am J Orthod Dentofacial Orthop. 1988;94(1):68-73.

16. Demito CF, Vivaldi-Rodrigues G, Ramos AL, Bowman SJ. The efficacy of a fluoride varnish in reducing enamel demineralization adjacent to orthodontic brackets: an in vitro study. Orthod Craniofac Res. 2004;7(4);205-210.

6. Cacciafesta V, Sfondrini MF, Tagliani P, Klersy C. In-vitro fluoride release rates from 9 orthodontic bonding adhesives. Am J Orthod Dentofacial Orthop. 2007;132(5):656-62.

17. Frazier MC, Southard TE, Doster PM. Prevention of enamel demineralization during orthodontic treatment: an in vitro study using pit and fissure sealants. Am J Orthod Dentofacial Orthop. 1996;110(5):459-65.

28. ten Cate JM. Current concepts on the theories of the mechanism of action of fluoride. Acta Odontal Scand. 1999;57(6):325-329.

7. Chin MY, Sandham A, Rumachik EN, Ruben JL, Huysmans MC. Fluoride release and cariostatic potential of orthodontic adhesives with and without daily fluoride rinsing. Am J Orthod Dentofacial Orthop. 2009;136(4):547-553.

18. Joseph VP, Rossouw PE, Basson NJ. Some “sealants” seal -- a scanning electron microscopy (SEM) investigation. Am J Orthod Dentofacial Orthop. 1994;105(4):362-368.

29. Bishara SE, Chan D, Abadir EA. The effect on the bonding strength of orthodontic brackets of fluoride application after etching. Am J Orthod Dentofacial Orthop. 1989;95(3):259-60.

19. Banks PA, Richmond S. Enamel sealants: a clinical evaluation of their value during fixed appliance therapy. Eur J Orthod. 1994;16(1):19-25.

30. Matheus PD, Demito CF, Sheibel PC, Bowman SJ, Ramos AL. Correlation between the microscopic evaluation and reading by laserfluorescence of enamel decalcification in bovine teeth: in vitro study. Odonto São Paulo. 2010;18(36):31-39.

8. Cohen WJ, Wiltshire WA, Dawes C, Lavelle CL. Long-term in vitro fluoride release and rerelease from orthodontic bonding materials containing fluoride. Am J Orthod Dentofacial Orthop. 2003;124(5):571-576. 9. Gorton J, Featherstone JD. In vivo inhibition of demineralization around orthodontic brackets. Am J Orthod Dentofacial Orthop. 2003;123(1):10-14. 10. Pascotto RC, Navarro MF, Capelozza Filho L, Cury JA. In vivo effect of a resin-modified glass ionomer cement on enamel demineralization around orthodontic brackets. Am J Orthod Dentofacial Orthop. 2004;125(1):36-41. 11. Vivaldi-Rodrigues G, Demito CF, Bowman SJ,

48 Orthodontic practice

20. Farrow ML, Newman SM, Oesterle LJ, Shellhart WC. Filled and unfilled restorative materials to reduce enamel decalcification during fixed-appliance orthodontic treatment. Am J Orthod Dentofacial Orthop. 2007;132(5):578.e1-6. 21. Leizer C, Weinstein M, Borislow AJ, Braitman LE. Efficacy of a filled-resin sealant in preventing decalcification during orthodontic treatment. Am J Orthod Dentofacial Orthop. 2010;137(6):796-800. 22. Buren JL, Staley RN, Wefel J, Qian F. Inhibition of enamel demineralization by an enamel sealant, Pro

27. Van Bebber L, Campbell PM, Honeyman AL, Spears R, Buschang PH. Does the amount of filler content in sealants used to prevent decalcification on smooth enamel surfaces really matter? Angle Orthod. 2011;81(1):134-140.

31. Varlik SK, Ulusoy C. Effect of light-cured filled sealant on shear bond strength of metal and ceramic brackets bonded with a resin-modified glass ionomer cement. Am J Orthod Dentofacial Orthop. 2009;135(2):194-198. 32. Kimura T, Dunn WJ, Taloumis LJ. Effect of fluoride varnish on the in vitro bond strength of orthodontic brackets using a self-etching primer system. Am J Orthod Dentofacial Orthop. 2004;125(3):351-356.

Volume 4 Number 4


lllllllllllllllllllllll OF EVENTS llllllllllllllllllllllllllllllllllllllllllllllllllll

Developing Pathways To Orthodontic Excellence: A Two-Day Update and Case Finishing Program Kay Gerety August 9-10, 2013 Tulsa, OK www.straightwireseminars.com/ orthodontic_courses.php Atlas Orthogonal Chiropractics Dr. Chris Chapman, DC, BCAO August 14, 2013 Beaverton, OR dnaappliance.com/schedule.php Session 103 – Fundamentals of SW Mechanics Dr. Jay Gerber August 15-17, 2013 The Center for Occlusal Studies Parkersburg, WV www.orthodonticstudies.com/courseschedule Level III/IV: Epigenetic Orthodontics August 16-18, 2013 New York, NY dnaappliance.com/schedule.php Ask The Expert… An Orthodontic Study Group For General Dentists Dr. Maurice Corbett September 5-6, 2013 Orange, CA www.straightwireseminars.com/ orthodontic_courses.php Case Finishing and Mechanics September 6, 2013 Toronto, ON www.rondeauseminars.com

Volume 4 Number 4

Technology Symposium September 6-7, 2013 Chicago, IL ormco.com Bridging the Orthodontic Gap for General Dentists Dr. Ralph Nicassio September 6-7, 2013 Carlsbad, CA www.straightwireseminars.com/ orthodontic_courses.php Level I – Introduction To Orthodontics Session #1 September 6-7, 2013 Toronto, ON www.rondeauseminars.com Level II – Advanced Orthodontics Session #1 September 7-8, 2013 Toronto, ON www.rondeauseminars.com General Dentistry With The DNA Appliance September 11, 2013 Beaverton, OR dnaappliance.com/schedule.php Session 203 – Advanced SW Mechanics Dr. Jay Gerber September 12-13, 2013 The Center for Occlusal Studies Parkersburg, WV www.orthodonticstudies.com/courseschedule

Robert G. Gerety Comprehensive Orthodontic Education Program Kay Gerety September 13-15, 2013 Tulsa, OK www.straightwireseminars.com/ orthodontic_courses.php Dentists Role in Snoring and Sleep Apnea September 14-15, 2013 Chicago, IL www.rondeauseminars.com Kozlowski Mentoring Program September 19-20, 2013 New London, CT ormco.com Level II: Epigenetic Orthodontics September 20, 2013 New York, NY dnaappliance.com/schedule.php 2013 Comprehensive Orthodontic Education Dr. Jordan Balvich Dr. Joseph R. Schmidbauer September 20-22, 2013 Atlanta, GA orthodontics.com/course/catalog Session 104 – Essentials of Case Finishing Dr. Jay Gerber September 26-27, 2013 The Center for Occlusal Studies Parkersburg, WV www.orthodonticstudies.com/courseschedule

Orthodontic practice 49


Integrating technology in orthodontic practice for pain relief, TMJ/D, and headache Dr. Sheila Birth uses a systematic therapy approach for life-changing care


rthodontists are, by profession, specialists. We have chosen to narrow our scope of care to those patients requiring additional treatment to perfect their smiles. However, as I quickly learned, practicing a specialty does not limit our ability to provide life-changing care. Rather, broadening the application of relevant treatment technologies that can be used in orthodontic practice can prove beneficial not only to patients, but to practitioners as well. I am an orthodontist with multiple practices in Texas. Orthodontics is my passion, not just my profession. The greatest reward is transforming the smiles of any child or adult who selects my practice. I know I’m not just improving their smiles, but their self-esteem, also. My practice began in one location in Fort Worth, Texas, but demand subsequently led to expansion to four other locations in Arlington, Burleson, and Keller, Texas. After practicing orthodontics for more than 25 years, I longed to do more for my patients, despite the fact that our practices were thriving and our staff welltrained and extremely efficient. In particular, addressing the needs of patients suffering from temporomandibular joint disorder (TMJ/D) and associated headaches was of interest, but we were unsure and uncomfortable with how to proceed given the level of difficulty these cases often present.

Sheila Birth, DDS, MS, received her DDS degree from Baylor College of Dentistry and her Master’s Degree in Orthodontics from the University of Oklahoma. Recognized as a Top Doctor in Fort Worth Magazine and a Top Orthodontist in Texas Monthly, Dr. Birth is also an Invisalign® Premier Elite Provider, People-to-People Ambassador, and Fort Worth Star Telegram Reader’s Choice Award Top Orthodontist. A member of several professional associations, including the American Board of Orthodontics, American Association of Orthodontists, and the American Dental Association, she actively participates in ongoing continuing education to remain abreast of the latest advances for successful, efficient, and effective orthodontic treatments.

50 Orthodontic practice

What I felt was needed was an established and integrated technology system with proven results before I would feel ready to begin treating patients with TMJ/D. It wasn’t until 2012, while attending an orthodontics conference, that I discovered the TruDenta system (www.drsdoctor.com). Incorporating this technology-based, systematic approach to assessing and treating dentomandibular sensorimotor dysfunction proved to be the answer we were seeking.

What is TruDenta, and how does it work? TruDenta (TruDenta, Dental Resource Systems, Inc.) is a comprehensive system of education, technology, and training. The assessment technologies include devices to digitally measure cervical range of motion and dynamic as well as static bite forces. The therapeutic technologies (e.g., ultrasound, microcurrent stimulation, low level laser) are designed to resolve dentomandibular sensorimotor dysfunction (DMSMD). This can be a very painful disorder that encompasses the head, neck, temporomandibular joint (TMJ), jaw, and dental forces. Caused by misalignment in the skull and mandible, it can result in problems with bite force, muscles, and joint balance.1,2 Many patients who suffer from these issues display myriad symptoms, including jaw clenching, TMJ/D, clicking and popping of the jaw, tooth damage or fracture, and bruxism. Other symptoms indirectly related to DMSMD include chronic headaches, migraines, tinnitus, vertigo, and sleep disorders.1-3 Sufferers of DMSMD may experience other challenges, particularly in the case of orthodontics. Force distortion can adversely affect the stability and reliability of dental restorations or appliances that patients are using to treat unrelated conditions. Such a distortion could require additional treatment to achieve and retain function and balance.1,2 According to the National Institute of Dental and Craniofacial Research,

Dr. Birth performing a TMJ assessment on a staff member

anywhere from 10 to 45 million individuals may suffer from TMJ/D and similar problems.4 Perhaps more alarming is that nearly 90% of the United States population has headaches, and more than 29 million Americans suffer from migraines.5 The TruDenta system can offer relief to many of these patients. The system’s therapeutic modalities are cleared by the Food and Drug Administration (FDA) and represent a highly conservative but effective solution to managing and treating the causes of DMSMD pain and discomfort. TruDenta enables a customizable treatment plan for each individual to restore motion and function, stabilize the mouth, head, and jaw, and, perhaps most importantly for the patient, treat inflammation and pain.6

Training and integration Once I learned about the TruDenta system and how we could use it to care for our patients, I knew that I had to implement the systematic, technology-based assessment and treatment approach into our practice. Many of our patients were suffering from Volume 4 Number 4

TECHNOLOGY TMJ/D and associated pain, especially headaches. However, because we weren’t confident treating their pain, more often than not, I had been referring them to physicians. Unfortunately, treatments were usually difficult, painful, and expensive. I wanted to offer a cost-effective, efficient headache and pain treatment alternative that requires no drugs or needles within my own practices. A company executive worked with us to explain the benefits of the TruDenta system, visited the practice to discuss integrating the system, and spoke with staff members about their questions and concerns. The transition would require a leap of faith, but I was determined to move forward and remove any staff doubts about incorporating this technology and type of care. I was committed to helping them understand it first-hand. The first TruDenta system was purchased for the Keller practice in October of 2012. Although we were anxious to fully integrate it into the practice, we allowed ourselves ample time to learn the intricacies of the system and participate in the 3-day hands-on training. By March of 2013, everyone felt comfortable with the assessment and therapies, as well as recommending the treatment to patients experiencing painful symptoms. Based on the success and patient response in the Keller practice, I purchased another system for the Burleson office within a month. I’m now considering purchasing a third system to add to one of the other offices, since so many patients have experienced positive results.

Success realized Once my team and I began treating patients with TruDenta, that’s when we realized the magnitude of what we are doing in terms of patient care, especially for those who had resigned themselves to lives of chronic, unending pain. Our first patient was a young woman who suffered with severe facial and TMJ pain. Within the course of five treatments, her pain had disappeared. Another patient was a young girl who suffered from weekly migraines who required a melatonin prescription to help her sleep. She is still completing treatment, but her migraine frequency has been significantly reduced, and she no longer requires melatonin. One of our greatest success stories is the mother-in-law of one of my dental assistants. A lifelong migraine sufferer, 52 Orthodontic practice

Dr. Birth performs the ultrasound therapy—one component of the customizable TruDenta treatments for relieving dental headaches and TMJ/D pain

the patient tried every treatment available for over 25 years, but to no avail. She estimated having spent more than $45,000 in treatments searching for relief. It wasn’t until she underwent the TruDenta therapies that she finally experienced pain relief. She is now nearing the end of her course of treatment, and her headaches have become much shorter and more tolerable.

also. For example, my orthodontic patients have the option of incorporating a pain management component into their orthodontic treatment.7 For those unsure whether incorporating this type of treatment is right for them, I wholeheartedly recommend exploring it further, and for one simple reason: it works! OP

Discussion Although my staff and I began treating only our orthodontic patients, word of our TruDenta treatment success spread, and soon we began treating family members of current patients, as well as new patients who had heard of this effective headache pain therapy and wanted to experience it for themselves. We now treat orthodontic patients, those suffering from DMSMD, and those who need care for both. In fact, we have begun a marketing campaign for headache sufferers, hoping to raise awareness of the type of dental headache pain relief that people can receive from orthodontic practices like ours. Financially, incorporating this systematic, technology-driven approach to the assessment and treatment of dental force imbalance related pain has proven to be a worthwhile investment for me. It has helped me attract new patients and offer pain relief to current orthodontic patients,

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. National Institute of Dental and Craniofacial Research. Adults. National Institute of Dental and Craniofacial Research. http://www.nidcr.nih.gov/ DataStatistics/ByPopulation/Adults. Accessed December 7, 2012. 5. National Headache Foundation. Migraine. National Headache Foundation. http://www. headaches.org/education/Headache_Topic_ Sheets/Migraine. Accessed July 3, 2012. 6. DiMatteo A, Montgomery M. Understanding, Assessing and Treating Dentomandibular Sensorimotor Dysfunction. Provo, UT: Dental Resource Systems, Inc.; 2012. 7. Bicakci AA, Kocoglu-Altan B, Toker H, Mutaf I, Sumer Z. Efficiency of low-level laser therapy in reducing pain induced by orthodontic forces. Photomed Laser Surg. 2012;30(8):460-465.

Volume 4 Number 4


Lythos Digital Impression System TM


elcome Lythos! Inspired by the word “lithography”— the process of replicating or producing a mirror image of data within the exact confines from which it was taken — Ormco’s Lythos™ Digital Impression System takes digital impressions and treatment to the next level. Designed with both the doctor and patient in mind, Lythos allows orthodontic practices to made traditional PVS impressions a thing of the past. Capturing patients’ accurate and detailed intraoral data is critical to orthodontic diagnosis and treatment. However, capturing a high-quality traditional PVS scan can be difficult, requires several retakes, and results in added inventory and storage costs. By harnessing the power of today’s digital technologies, Lythos makes the transition to digital impressions easy, rewarding, and both cost- and timeefficient.

Simply capture data Unlike point-and-click technologies that are limited to single image capture, the Lythos Digital Impression System uses Fluid Convergence™ Technology to capture data in real time (vs. post-process stitching). The result is high-definition detail at all angulations of the tooth surface scanned. An entire, high-resolution dual-arch scan can be completed in as little as 7 minutes. With the ability to complete a scan in about the same time as a PVS impression, Lythos is easily integrated into any practice workflow, allowing the professional team to transition quickly to digital impressions while keeping chair time to a minimum.

Create a comfortable experience for patients and staff The lightweight, compact, and ergonomic Lythos wand is comfortable to hold in varying positions and light enough to use throughout the day. Similarly, the wand easily reaches the posterior of the mouth for maximum patient comfort and scanning convenience. The scanner’s intuitive platform offers an easy-to-clean touch screen for fast rotation of models on screen and when entering patient data. Adding another level of convenience, the scanner allows operators to rescan anytime during the process. Data is reviewable at any point Volume 4 Number 4

during or after processing the scan, and the model can be rotated in an infinite number of ways for the ultimate in data visibility. Once scans are complete, staff can wirelessly upload data to the cloud and access scans from any computer in the office — ensuring files are properly cataloged and always just a click away.

Make a smart investment New treatment technologies are often directly associated with high costs. Not with Lythos! Ormco has implemented a unique rebate program, helping ensure that the Lythos scanner is a sound financial

“The fundamental technology inside Lythos is an accurate, noncontact metrology (the science of measurement) system. The handheld medical device was adapted from innovations used in the aerospace industry, where meticulous measurement detail is needed.” ~ Olaf Krohg, Lythos Research & Development

investment. When scan data is used for Ormco products, practices earn a direct rebate towards the system payment. The more cases you do, the more you can earn — no limits! In fact, offices that treat eight or more Insignia™ or Clearguide™ Express cases per month can earn rebates that can cover the cost of Lythos completely.

A streamlined workflow Lythos’ open system allows data to be easily integrated with orthodontic labs and manufacturers to produce a variety of custom appliances and/or study models— including compatibility with Insignia, Clearguide Express, and AOA lab. Unlike other digital impression systems, Lythos creates STL (stereolithography) files of patient data that can be downloaded and used in any manner and at no additional charge. By tapping into available integration with Ormco’s digital platform, there is an opportunity to increase profitability and elevate workflow. With Lythos, you can

move towards a fully integrated, 100% digital workflow — from scanning to customized brackets and treatment. By bundling with Insignia interactive treatment, data indicates that 30% more efficient treatment is achievable.

Start taking exceptional digital scans At the heart, Lythos is a cutting-edge tool with the ability to fuel continued practice success in a competitive industry. With a focus on meeting both patient and staff demands, Lythos Digital Impression System is intraoral imaging designed around your needs — with incredible detail, speed, and unmatched ability to streamline orthodontic procedures. OP To learn more about Lythos visit www. Ormco.com. This information was provided by Ormco.

Orthodontic practice 53


Accelerate orthodontic treatment with AcceleDent® Aura OrthoAccel offers groundbreaking technology to speed bone remodeling

AcceleDent Aura is a simple-to-use, hands-free device designed for faster orthodontic treatment with only 20 minutes daily use. This FDA-cleared, Class II medical device uses SoftPulse Technology™ to deliver gentle micropulses that enhance the movements directed by orthodontics and accelerate bone remodeling. This groundbreaking technology, which allows teeth to move up to 50% faster, is based on sound biological and clinical research and on the same principles used in the most current treatment of osteoporosis.

AcceleDent Aura Components Activator AcceleDent Aura’s small, lightweight Activator generates gentle micropulses to safely accelerate bone remodeling. It includes a USB interface that may be inserted directly into a computer to view patient usage history via the FastTrac Usage Report.

Mouthpiece AcceleDent Aura’s Mouthpiece provides a comfortable fit and snaps easily on and off the Activator for transport and cleaning. The orthodontist determines the optimal Mouthpiece size and profile for each patient. AcceleDent Aura Mouthpieces are available in two sizes (small and large) based primarily on the anatomical dimensions of the patient’s dental arches. Each size is available in three profiles based on the type of malocclusion (anterior open bite, anterior deep bite, and normal flat plane occlusion).

CASE STUDIES Female, Age 49 Projected Treatment Time: 18 months Actual Treatment Time: 12 months 2 weeks

Photos courtesy Dr. Straty Righellis, Oakland, CA

Male, Age 18 Projected Treatment Time: 18 to 24 months Actual Treatment Time: 10.5 months

Photos courtesy Dr. Sharon Ortin-Gibbs, Surrey, UK

USB Extension Cable AcceleDent Aura’s USB extension cable with power adapter allows for easy, convenient charging.

Travel Case AcceleDent Aura’s Travel Case keeps all components safe, clean, and secure. OP

54 Orthodontic practice

AcceleDent Aura can be used for all orthodontic patients regardless of their malocclusion. Orthodontists and their patients worldwide are experiencing expedited cases with AcceleDent Aura and also reporting less discomfort during orthodontic treatment. Please contact OrthoAccel Technologies, Inc., at 1-866-866-4919 or visit acceledent.com. Information provided by OrthoAccel Technologies, Inc.

Volume 4 Number 4


Dentronix LED 3000


ith the entire orthodontic world going digital, the purely analog process of bonding brackets to teeth is still a key function of orthodontic treatment. Even in the 21st century, bonding can be a procedure fraught with variables, and those variables can make the difference between success and failure in bond integrity. Over the years, there has been much discussion regarding specifics on bonding agents, etchants, and etching procedures, as well as adjunct elements such as sand blasting and bracket base designs, but according to Zachrisson and Buyukyilmaz1, good bond strength depends primarily on (a), avoiding moisture contamination, and (b), undisturbed setting of the bonding adhesive. Both of these factors can be minimized by reducing the overall time of the bonding procedure. With 3250mW2 in High Power mode, the Dentronix LED 3000 was developed specifically to provide the orthodontist with a light that will safely compress the curing process to the minimum time available with camphorquinone photoinitiators. The High Power setting is especially useful for indirect bonding, where penetration of tray materials can be an issue in bond strength and integrity. In addition to enhancing bond quality, shorter cycle times produce improved efficiencies in revenue. Our own data indicates over 8 hours of time savings per 100 patients bonded when compared to the use of 20-second halogen curing cycles. An automatic ORTHO mode cycles the light at 3-second intervals with an audible beep and a 1-second rest. This allows navigating the entire arch mesiodistally with consistent 6-second per bracket cure times. Individual 1, 2, and 3second cycles are also selectable at the push of a button, as well as toggling to a Standard Power mode of 1600mW2 when lower power is indicated. Dentronix has been a manufacturer of premium orthodontic instruments since the late 1960s, and the LED 3000 fits into our tradition of high-quality materials and great handling balance. Made from extruded aircraft aluminum, the all metal construction is extremely durable, yet light in weight at only 4.4 ounces. The cordless design features a user-replaceable polymerion battery, removing it from the realm of Volume 4 Number 4

Dentronix has been a manufacturer of premium orthodontic instruments since the late 1960s, and the LED 3000 fits into our tradition of high-quality materials and great handling balance.

disposable-type products. It will provide years of reliable service – backed by the Dentronix factory team for any service or support that you may require. This curing light is delivered with an 8 mm optical turbo tip and an orthodontic light shield that is rotatable a full 360°. The handle stores in its own charger base so it is always ready for use at full power. OP This information was provided by Dentronix.

For more information, please call 800523-5944 or email info@dentronix.com.

Reference 1. Graber L, Vanarsdall R, Vig K. Orthodontics/ Current Principles and Techniques, 4th Edition, Chapter 14, 2005.

Orthodontic practice 55


The doctor-patient relationship Dr. Laurance Jerrold discusses the legal aspects of the dentist-patient connection Abstract There is no duty owed a patient unless a doctor-patient relationship has been established. This article deals with the establishment of this relationship as well as how to legally and ethically terminate it. The related issues of abandonment and discontinuing treatment are also addressed.

The contract A tort is a civil wrong, based on a special relationship or implied by law. In orthodontics, this relationship is the one between the doctor and the patient that forms a pseudo contract, wherein a patient seeks professional services from a doctor with the expectation that their professional needs will be addressed, hopefully resulting in a “cure” of some type. Doctors, on the other hand, consensually agree to treat the patient expecting to affect such a “cure” and receive compensation for professional services rendered. Like most contracts, there exist responsibilities and obligations on the part of each party. The real and implied “contractual “duties” that orthodontists owe their patients are: • The doctor and staff will be properly credentialed/licensed/registered. • Neither the doctor nor staff will practice beyond the scope of duties allowed. • Employees will be appropriately trained and adequately supervised.

Laurance Jerrold, DDS, JD, is the President of Orthodontic Consulting Group and the former Dean and Program Director of the School of Orthodontics at Jacksonville University in Jacksonville, FL. He received his Undergraduate and Postgraduate dental education at NYU, his JD from Touro University, and his Certificate in Bioethics and the Humanities from Columbia University. Integrating over 30 years in the private practice of orthodontics, with more than 25 years teaching dental risk management, coupled with 20 years in the practice of law, over 15 years teaching clinical bioethics, and 10 years in full-time academia and educational administration, Dr. Jerrold offers a unique and practical perspective on risk management for the dental practitioner and has been recognized nationally for his contributions to the field of dental risk management education. He has presented risk management courses for six of this country’s major dental malpractice carriers and has presented or written well over 200 lectures, articles, or multi-media presentations dealing with risk management and/or ethics for dental organizations nationwide.

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• Experimental procedures will not be performed without patient consent. • The doctor will not perform procedures for which he is not qualified. • Doctors will maintain their skills through continued dental education. • Doctors will obtain the patient’s informed consent prior to treatment. • Doctors will be available for emergencies and will not abandon the patient. • Doctors will complete care in a timely manner. • The doctor will keep patients informed as to their clinical progress. • Doctors will keep appropriate and accurate records of treatment rendered. • The doctor and staff will maintain the confidentiality of the patient. • Appropriate consultations and referrals will be made. • The doctor and staff will comply with all regulatory rules and regulations pertaining to their scope of practice as defined by applicable law. • Doctors will abide by the Code of Ethics. However, there are only five duties and obligations that patients owe their doctors; they are: • All instructions regarding treatment will be followed. • Appointments will be kept. • Fees for services will be paid. • Patients will conform to generally accepted modes of behavior.

• Patients will be truthful about their health history and administrative inquiries.

Establishing the doctor-patient relationship It is quite easy to establish a doctor-patient relationship. It can occur at informal settings such as a cocktail party or a sporting event. If you offer professional advice intending the patient to rely on it, and he/she does so, you have just established a legally recognized professional relationship with the patient requiring you to adhere to the standard of care regarding the diagnostic or professional opinion rendered. This is regardless of whether or not you formally examined the patient, whether or not the patient was seen in the office, or whether or not you charged a fee for your services. Must we accept everyone who presents themselves to our offices for treatment as a patient? No, you do not! Courts have routinely stated that doctors are not in the same category as common carriers or innkeepers, and need not open their doors to all who seek their services. However, you cannot discriminate against accepting patients based solely on the fact they might be members of one of many legally protected classes of people, such as a person’s race, religion, gender, sexual orientation, national origin, handicapping condition, etc. It is legal to discriminate regarding the provision of services based Volume 4 Number 4

Terminating relationship



One of the more difficult risk management issues is terminating the dentist-patient relationship and often leads to legal problems if not handled appropriately. There are five recognized legal justifications for terminating the doctor-patient relationship; they are: • both parties agree to end it; • the patient is cured, or a course of treatment is completed; • the dentist or the patient dies; • the patient decides to unilaterally terminate the relationship; • the dentist decides to unilaterally terminate the relationship. An example of the first is when a patient moves out of the area. The second and third are both self-explanatory. In the fourth scenario, the patient essentially abandons the doctor, usually over fiscal, administrative, management, or personality issues, as well as unhappiness with the results of the treatment rendered. However, it is the last one that causes practitioners the greatest degree of consternation. In order to unilaterally terminate a patient from your practice and not run the risk of abandoning the patient, the following procedure should be followed. First, the patient must be given sufficient notice of the doctor’s intent to withdraw as the practitioner of record. A letter to this effect should be sent both by certified mail, return receipt requested, as well as by regular mail using a certificate of mailing. Using both methods ensures that the patient was either notified or a valid attempt to do so was made. Second, this letter should inform the patient of the reason(s) you are terminating your professional relationship with him/her; essentially that he/she breached one of the legally accepted obligations he/she owed you stemming from the doctor-patient relationship. Next, if the patient is at a point in treatment such that continued care is still required, he/she should be strongly urged to seek it. State in the letter that you will Volume 4 Number 4

provide him/her with adequate time and assistance to seek substitute or alternative care for a specific time frame during which he/she should seek out a new dentist, i.e., 45 days, and that during this period of time you will only be available for emergency care, consultations, or to offer a referral if necessary. Finally, inform the patient that upon request, a copy of his/her records will be forwarded to him/her or to a subsequent treating practitioner. While you may legally be entitled to charge the patient a reasonable fee for the duplication of his/her records, various states address this by statute. A good rule of thumb is that the fee for copying X-rays, models, etc., should not exceed the original cost of each record. It is important to appreciate that when you are attempting to terminate the doctor-patient relationship, it may not be prudent to place a financial stumbling block such as a records duplication fee in the patient’s way. While patients may reticently accept being dismissed from your practice because of their actions, attempting to collect a fee for record duplication may be a sufficient enough impetus for them to consider retaliatory litigation for any perceived wrong, which up to this point, was not that important. This brings us to a tangential factor relating to what should be done when a potential subsequent treating practitioner contacts your office to find out the reason(s) behind the patient seeking a new doctor. Neither you nor your staff should badmouth the patient regarding such matters as his/her financial status with your office, his/her behavior while a patient, his/her level of cooperation, etc., even if truthful, because these facts might in and of themselves interfere with the formation of a new, substitute doctor-patient relationship. Prudent risk management dictates that you merely state that there were administrative differences to which you and the patient could not agree upon, sans the details.

Abandonment of the patient One question that always looms is that if a doctor does dismiss a patient from his/ her practice, doesn’t that act in and of itself constitute the tort of abandonment? The answer is a qualified no. Abandonment may be defined as first, not giving the patient any further appointments or refusing to treat him/her before his/her course of treatment is completed without having a legally recognized reason to do so. The exception is the patient who is in

extremis. Thus, unless a patient of record is bleeding, is suffering from significant swelling, is in excruciating pain, etc., you have a legally recognized right to terminate the doctor-patient relationship upon providing proper notice and following accepted protocol. The second definition is not being available to a patient who requires continued or follow-up therapy such as being unavailable for whatever reason and not providing for substitute or emergency coverage. Finally, there is a doctrine called constructive abandonment that occurs when doctors refuse to give the patient anymore appointments; or, they extend or prolong treatment for non-clinical reasons such as past due accounts. Terminating the doctor-patient relationship is not the same thing as discontinuing treatment.

Discontinuing active treatment Doctors have the unfettered right to discontinue active treatment if, in their best judgment, the patient’s best interests are served by doing so. This can be done without running the risk of having abandoned the patient. Classic examples of this are: if during active treatment, the doctor discovers negative sequellae occurring such as decalcifications, periodontal breakdown, root resorption, caries, TMD, etc. The doctor may decide that it is in the patient’s best interest to discontinue active treatment rather than to stay the course, risk exacerbation of the negative sequellae, and subsequently cause severe injury to the patient. In this circumstance, treatment is discontinued, but the patient continues to remain a patient of record. Rather than dismissing him/her from the practice, the doctor may follow the patient with the intention of reinitiating treatment once the patient’s status warrants the resumption of care; or, if treatment has to be stopped indefinitely or permanently, a decision has to be made to forego or employ a specific retention modality. In other words, the doctorpatient relationship is still ongoing. The patient must of course give his/her consent to the discontinuation of treatment. If he/ she refuses, then the doctor always has the option of terminating the doctorpatient relationship based on the patient’s failure to follow medically necessary recommendations. In summary, it is the existence of a doctor-patient relationship that gives rise to the duty to adhere to a given standard of care. OP

Orthodontic practice 57


on such criteria as limiting one’s practice to a particular specialty or subspecialty; the inability of the patient to assume the financial obligations associated with treatment; as well as a patient’s inability to abide by reasonably constructed office protocol, rules, and regulations, etc. even if the patient is a member of a protected class since the discrimination is such that it would apply to everyone evenhandedly.


Maximizing practice profits Terri Zeringue explores ways to effectively manage office expenses “Why am I taking home less money even though my collections continue to grow?” This is a question we hear all the time. Increasing collections is just one component of improving your practice’s profitability. The other key driver is controlling expenses. How much of the revenue collected can you realistically expect to find its way to the bottom line? A good goal to set would be 50%. While expenses can vary based on a variety of factors, the chart to the right is a general guideline on the percentage of your practice’s revenue that should be allocated to specific costs. You may be saying, “WOW! Nearly a quarter of my revenue goes to my staff.” Keep in mind that while your employees are by far your largest expense, they are also your most valuable asset. If you are staffed adequately, schedule your employees appropriately, and if your team is working efficiently, you will be able to keep your cost under 24% of revenue. Employee expense is inclusive of all costs related to your staff including travel, medical insurance, 401k, employee education, uniform allowance, and employer taxes in addition to salaries. It’s not just about having the right number of people on your team, but having the right people on your team. Excessive turnover will negatively impact your expense in this area as well. Determining how much money to invest in advertising depends greatly on where your practice falls in its life cycle. Whether you are newly in practice or already established in your community will determine not only the amount you should spend on advertising your practice, but also how those dollars should be spent. Always be sure to take advantage of extremely low

Terri Zeringue has served as Vice President of Practice Accounting and Reporting at OrthoSynetics for over 20 years. She currently supervises the Practice Accounting group whose responsibilities include financial statement preparation and analysis for practices, cash reconciliations, cash management, practice theft controls, and doctor profit distributions. She is committed to promoting practice growth through financial and statistical analysis. She received her Bachelor of Science Degree in Business with an Accounting Concentration from Troy University in 1985.

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Employee Expenses






Clinical Supplies


Lab Expense


General and Administrative Operating Income

cost or free marketing resources such as social media. Numerous factors affect the cost of clinical supplies, the most relevant being the brackets used. Shop and compare prices, take advantage of specials, or consider joining a buying group. But before you purchase a year’s supply of brackets, evaluate the savings versus the impact of having your money sit on the shelf for 12 months. While large bulk purchases often seem appealing, they may not be the best option. Building a budget for your practice can also help to control your costs. Review your budget at the beginning of every month, and think about how you will stay within those spending limits. Review again at month’s end. Look at the variances in your actual costs when compared to your budget. Why were you over budget? Was it just a timing issue, or do you expect this overage to continue in subsequent months? Closely monitor the trends and adjust your budget when necessary. Quick cost saving tips: • Take advantage of all early payment discounts. Vendors will often reduce the total invoice by a predetermined percentage if payment is received by a certain date. • Always pay invoices timely to avoid interest and/or late fees. If you do incur a late fee, contact the vendor and ask him/ her to reverse it. If you are not a habitual late payer, vendors will usually forgive the late fee in exchange for a prompt payment.

8-10% 55-42%

• While we all like to use our credit cards for payment to rack up points, be sure to pay your credit card bill in full each month or the interest charges will likely offset any rewards earned. Always weigh the value of the credit card rewards against other potential discounts or savings. Vendors may offer a discount for cash payments that outweigh the points you would receive from your credit card company. • Don’t leave money on the table when renewing your lease. Landlords will almost always throw in some tenant improvement money that you can use to give your office a face lift. • Evaluate the pros and cons of leasing equipment versus buying. • Monitor for lost revenue from posting errors. Anyone can hit that zero key one too many times. If you accidentally post a $100 payment as $1,000, you have just reduced the patient’s balance by $900 that they did not pay and lost $900 that you will never collect. Balance your bank statement monthly comparing the amounts deposited to the amounts posted in your patient financial software to identify and correct any posting errors. Most importantly, never take your eye off the ball. Annual financial reviews are not sufficient. Prepare financial statements each and every month, and address excessive expenses; those over your budgeted amounts or higher than the benchmarks referenced here. This simple process will put you on the road to financial success! OP Volume 4 Number 4


The removable orthodontic market is alive and kicking Dr. Neil M. Warshawsky discusses MTM® In-Office Minor Tooth Movement


he past few years have been a rollercoaster for small businesses as well as the orthodontic market place. Esthetic services like plastic surgery, cosmetic dentistry, and even orthodontics saw a reduction in the need for services as average consumers halted much of their elective spending to conserve income and prepare for the unknown. Business owners, as well as practitioners, readily adapted to the new economy where growth was all but impossible to achieve. It is this distressed economic climate that led me to embrace the MTM® In-Office Minor Tooth Movement from Dentsply Raintree Essix. The new economic climate suggested weathering the storm was the goal, and maintaining your existing level of business was good enough. At times, depending on who you talked to, even that was/is challenging. So consumers needed to have options that cost less, yet potentially yielded similar results to fixed comprehensive solutions. The truth of the matter is that in these times of business distress and economic turmoil, most of the business consultants are suggesting the need to invest in your business infrastructure and reinvent your practice to stimulate new growth. If you can better yourself in this economy, you will flourish when the economy decides to make a turn for the better. I would like to introduce a new concept to your practice. This idea has the potential to bring frenzied growth back to your camp, at a time when business growth is all but nonexistent. I believe in giving individuals customized care to correct their malocclusions. If I determine that a patient desires a removable custom esthetic option to correct his/her

Neil Warshawsky, DDS, MS, PC,, is the founder and owner of Get It Straight Orthodontics, a leadingedge orthodontic practice in the Chicago area. A board-certified orthodontic specialist since 1992, he has over 18 years of experience with cleft palate and craniofacial cases, and is a Diplomate, American Board of Orthodontics. His practice uses state-of-theart orthodontic treatments to deliver healthy, esthetic results. Dr. Warshawsky is a featured speaker for Dentsply Raintree Essix on MTM® In-Office Minor Tooth Movement.

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Figure 1: Broad Surface Contact across multiple/adjacent teeth can deform the plastic and compromise fit of the margins of an aligner if the tooth movement of the setup model is excessive

malocclusion, I still recommend Invisalign®. However, many of these cases are not really “full comprehensive care.” They tend to be failed orthodontic cases that are displaying minor relapse where the individual is concerned with the anterior teeth and not necessarily the entire occlusion. So if they do not need a lot of tooth movement or they cannot afford the cost of a full comprehensive custom appliance, I now recommend Dentsply’s MTM® In-Office Minor Tooth Movement as an effective yet efficient option for the correction of their issues. When I see a new patient examination that has a minor malocclusion, I will always give him/her more than one option to treat the problem. Based on esthetics and cost, the patient will make a decision on what system he/ she would like me to use to help correct their malocclusion. My new knowledge has really helped as I am able to offer Minor Tooth Movement as the sole treatment modality for some of the easier cases I am currently screening. My experience over the last 12 years has allowed me to add an additional dimension to my practice, which is teaching. I have learned a great deal over the past decade regarding Dentsply’s MTM® In-Office Minor Tooth Movement and now travel for Dentsply to teach handson classes. I believe 100% that all dental personnel can learn something from Minor Tooth Movement regardless of their title and role. It has been a fun and satisfying journey to bring such a simple concept to a group of educated people, and yet amaze them with what can be achieved with a simple sheet of plastic. MTM® In-Office Minor Tooth Movement is an economical solution to offer patients

Yellow color within the blue tooth region indicates where a specific force point has been applied to place direct pressure upon a specific tooth. Controlled movement of a single tooth will result preventing aligner deformation

Figure 2: Tooth velocity, i.e., how fast teeth will move, will be determined by the depth of the force point. For my monthly activations, I routinely make my force points approximately 0.5 mm in depth

a custom-made removable aligner to correct minor malocclusions. Limited to the anterior six teeth, the name MTM® says it all. The purpose of this system literally is to focus on the alignment of the anterior teeth, frequently referred to as “the social six.” MTM® In-Office treatment builds on the existing successful empire that Dentsply has been marketing for over a decade. The foundation is Sheridan’s concept of interproximal reduction where applicable, a simple well-fitting clear aligners made with Essix® plastics, and force points created using the Hilliard Thermopliers® to cause tooth movement. When speaking about clear aligner therapy, one needs to appreciate what is causing the tooth movement. In general, handmade aligner systems rely upon broad surface contact of the plastic to create tooth movement (Figure 1). The MTM® InOffice Minor Tooth Movement is a unique departure from all other clear aligner systems. The MTM® system is a departure from historical aligner design. Instead of focusing on the setup to create the malocclusion, the MTM® system focuses on FIT FIRST. Successful tooth movement is achieved by following very direct but simple “staging” Volume 4 Number 4

First: Space needs to be made between the teeth. Your choices are air rotor stripping (handpiece) or Interproximal Reducation (hand performed) options for creating space within the arch: Figure 3: Tooth alignment achieved in under 5 months using a single MTM® aligner. IPR was performed to create interproximal space around the right central incisor and the mesial of the left canine


Figure 5A: Initial Malocclusion

of tooth movement. Alignment of the teeth will be obtained utilizing integrated force points to provide direct and targeted pressure. Unique to this system, the Hilliard Thermoplier® Pliers have unique shapes that can be utilized to guarantee that the force point is exactly matched to the desired type of tooth movement (Figure 3). The pliers are broken into two types of groups. The first group increases the retention of a tooth borne appliance, meaning an appliance where there is no palate. The second group of pliers is activators that will create force points over a period of time to move the teeth. The vertical position of the activation point will determine if the tooth will tip or torque. The mesial distal position will determine the range of tooth movement from clockwise/ counter clockwise rotation, tipping, torquing, bodily movement, and space closure (Figure 4; note position of the activation points). MTM® In-Office Minor Tooth Movement follows what we refer to as Sheridan’s first law for predictable results. It is comprised of four things: • Mild force points specifically created by the Hilliard Thermoplier® Pliers. • Space underneath the custom aligner created by the doctor by placing block Volume 4 Number 4

Abrasive strips

Abrasive discs

Figure 5B: Occlusion as a result of 6 months of MTM® therapy

out material on the working model to prevent the custom aligner from impeding tooth movement. • Space between the teeth to prevent dental collisions when the teeth move. If the teeth are in contact, the spaces may be engineered using interproximal reduction. If spaces are already present, these spaces may be closed. • Time, a repeatable cycle to allow the teeth to express the intended movement that is being created from the force point. An analysis of the two images shows quite clearly that the patient was able to benefit cosmetically simply by wearing an Essix® style retainer and activating it to achieve the desired result (Figure 5). The model to build the aligner was prepared by placing blockout on the original malocclusion so that the plastic of the aligner would not impede the desired tooth movement. The blockout of the aligner may be done using various materials such as flowable composite, Triad® Gel Light Cure Material, Barricaid® Light Cure Periodontal Dressing, and blockout putty. Once the force points have been properly placed into the initial aligner, the goal would be to have the patient return

Figure 4: An actual clinical picture of an MTM® patient in “midflight” indicating the teeth are moving. Note the pressure point at the gingival lingual indicative of a torqueing move. Notice the space in front of the tooth, showing that the tooth still has not achieved the desired final position

Figure 5C: The green areas represent the FINAL position of these 2 teeth. Grey represents the initial position. 0.67 represents how far forward the incisal edge of the right lateral incisor moved 0.53 mm indicates how much the diastema closed between the central incisors. 0.77 mm represents the how much the mesial edge of the maxillary left central incisor came in

Figure 6: The image depicts the stair step appearance of multiple activations points in the same area aka “wedding cake” pressure point

on a 4-week cycle to reactivate the aligner opposite of where the blockout areas are. When the patient returns to be reactivated, the desired move will determine the position of the force point. Again, the position of the force point will determine whether the patient’s tooth will rotate clockwise/ counter clockwise, tip, torque, or have bodily movement. When reactivating a tooth in the same area the following month, it is important to understand that the plastic has been fatigued. In the event that the tooth activation on the subsequent month needs to be in the same area of the aligner, it is important to understand that the force point may NOT be in the exact same location as before. To make sure that the tooth gets Orthodontic practice 61


MTM® Concept is simple: Space + Force + Time = Tooth Movement (Sheridan’s First Law of Biomechanics)


Initial malocclusion presenting with a square arch form and crowding

Mandibular arch form was changed from square to oval arch form using MTM® aligners and IPR over a 7 month period. Note the fixed retainer bonded to the teeth guards against further relapse of the teeth

Figure 7: Typical orthodontic relapse where a tooth has tipped forward, giving it the appearance that it looks shorter than it really is. Note the tooth is straighter and appears longer at the end of 7 months using MTM®

62 Orthodontic practice

a proper activation, the second, third or fourth activation point must be surrounding the original force point. In this manner, it creates a wedding cake-like effect. You should observe that with frequent monthly activations of the aligner, I believe that a patient can typically see tooth movement within 3 months. I think arch form can be permanently altered within 6 months if a patient is cooperative (Figure 6). In closing, I believe that the Dentsply MTM® In-Office Minor Tooth Movement is an asset for any dental office to use to address minor orthodontic relapse, as well as to resolve minor spacing or crowding. It is a focused solution for an individual who seeks to achieve a limited orthodontic result of the anterior teeth. This cost effective solution, combined with its ability to be constructed quickly, is a very attractive feature to help capture a patient’s excitement. Properly used, MTM® In-Office Minor Tooth Movement will please your patients and help you grow your practice at a time when economic uncertainty is abounding, and practice growth is anything but common (Figure 7). OP

Volume 4 Number 4

MATERIALS lllllllllllll & lllllllllllll EQUIPMENT ClearCorrect now accepts intraoral scans ClearCorrect, LLC, is now accepting intraoral scans. Doctors can now choose to send either traditional PVS impressions or digital intraoral scans to ClearCorrect when submitting a clear aligner case. Unlike some labs, ClearCorrect will not restrict doctors to any particular scanner model or brand. ClearCorrect expects all-digital cases to get turned around days faster, and with more accuracy. Doctors should verify that their scanner allows them to export STL files. If not, they can contact the manufacturer of the scanner or the reseller to find out whether it is possible to upgrade to a version that allows this feature. For more information, visit www.clearcorrect.com or call 888-331-3323.

Dentronix LED 3000 Orthodontic Curing Light Dentronix introduces a new and powerful cordless curing light for the efficiency-driven orthodontic practice. A high-power mode of 3250mW/cm2 of LED power translates to fast bracket cure times and high-quality, consistent bonds. A convenient automatic ORTHO mode delivers programmed 3-second increments of high-powered light with a 1-second rest and an audible beep, allowing easy mesiodistal navigation of the entire arch. The handle’s all-aluminum construction means extremely lightweight (4.4 oz.) with excellent balance engineered to minimize fatigue. The 8 mm optical glass turbo tip optimally focuses light energy and is fully autoclavable. For more information on Dentronix, call 800-523-5944 or visit www.dentronix.com.

Netsertive: Local patients rely on the Internet Local patients rely on the Internet to find the right clinician for their needs. Practices can now increase production and attract qualified patients with Netsertive’s Digital Extend™ marketing programs that combine the power of search, display, mobile, retargeting, and other online tactics to ensure that practices and top services are highly visible to patients doing research in specific local markets. The company’s experts will review the practitioner’s marketing goals and estimate what can be achieved within budget using the firm’s patent-pending technology. For more information, visit www. netsertive.com/dental or call 800-940-4351.

64 Orthodontic practice

MacroCab + self-contained dust and grinding cabinet Danville’s new MacroCab + is a compact unit offering an efficient and comfortable design where you only insert your fingers with a handpiece to work. Bright, LED light provides ideal illumination. Featuring a built-in dust collection/filtration system, it is easy to clean, and the filter lasts for years. A 50% higher flow fan for better suction power! New window design for a better fit less powder leakage! For more information on Danville Materials, call 800-827-7940 or visit www.danvillematerials.com.

NDC brings revolutionary Phocal to U.S. market National Distribution & Contracting, Inc. (NDC), representing the largest network of independent medical and dental distributors in the United States, has reached a distribution agreement with Colldent to distribute the revolutionary new Phocal fluoride disks in the United States. NDC represents 56 independent dealers focused on the dental market. Collectively, these dealers have an estimated 11% of the North American dental retail market. Phocal disks provide a significant breakthrough in the treatment and prevention of interproximal caries. Phocal’s thin, round disks are designed to fit between the teeth and deliver a concentrated dose of fluoride to previously inaccessible areas. The product helps dentists combat the growing concern over interproximal caries by effectively breaking the isocap barrier between the teeth and directly depositing fluoride. The action prevents dental caries on intact surfaces, arrests the progress of incipient caries, and enhances remineralization. For more information about Phocal, visit www.phocaltherapy.com or call 888-PHOCAL-3 (888-746-2253).

Clean Over, under and around with the new Easy Braces™ toothbrush Brought to you by the makers of the Channel-Trim toothbrush, Tess Oral Health announces the Orthodontic Easy Braces™ toothbrush. This is the first-ever toothbrush designed specifically to clean underneath the arch wire thereby REDUCING OR ELIMINATING unsightly decalcifications. The hollow well of the brush-head hugs the brackets while longer bristles massage the gums and teeth. A separate set of bristles serves to clean underneath the arch wire. Invented, tested, and patented by an orthodontist, the Easy Braces™ brush is proven to succeed. Available in five bright colors! Get it personalized*. Why? Because personalized toothbrushes promote your practice. Call 800-762-1765 or visit www.tessoralhealth.com to order. *Free Personalization with case order.

Volume 4 Number 4

ProMax® S3 PLANMECA’s ProMax has won Townie Choice Awards for its pan/ceph model 2006-2012

ProMax S3 cephalometric image ProMax S3 anatomically accurate extraoral bitewing (above) and adult panoramic (below) from same patient

Enter for your chance to win a FREE ProMax S3-2D panoramic machine!

ProMax S3... Unlimited Imaging Potential • Using the ALARA radiation safety principle, ProMax enhances patient safety with features designed to minimize dosage: - Horizontal and vertical segmenting tool and four-bladed collimation focus radiation only to areas of interest - Pediatric mode reduces radiation by 35% - Pulsed radiation for lower dose verses continuous exposure

Schedule a free in-office demo and be entered automatically for a chance to win a FREE ProMax S3-2D panoramic machine!

For a free in-office consultation, please call


• Patented SCARA arm allows unlimited movement to accommodate complex and unique jaw shapes • Integrates with Dolphin, Ortho II, and other ortho imaging programs • Advanced imaging program includes improved interproximal pan program for better spacing and root positioning during TAD placement

or email

WinProMaxS3@planmecausa.com Winner will be announced live at the 2014 Chicago Midwinter Dental Conference!!!

• Upgrade to 3D at any time • Mac OS compatible and DICOM compliant


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

Implantologists Endodontists

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

General Practitioners will achieve greater diagnostic accuracy for routine cases.


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

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

The advantages of 2D & 3D in one comprehensive unit ORTHOPHOS XG 3D is a hybrid system that provides clinical workflow advantages, along with the lowest possible effective dose for the patient. Its 3D function provides diagnostic accuracy when you need it most: for implants, surgical procedures and volumetric imaging of the jaws, sinuses and other dental anatomy. For standard 2D images, it offers the most comprehensive selection of pan and ceph programs to meet virtually all needs, from standard panoramic programs for adults and children, to extraoral bitewing, sinus, TMJ options and many more.

Automatic patient positioning The new Auto-Positioner measures the exact tilt of the patient’s occlusal plane and automatically adjusts the height for an optimal panoramic image within the sharp layer, thereby preventing incorrect positioning and reducing re-takes.

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